Greater Glasgow and Clyde Medicines

Medicines Policies

last updated 23/12/2022

NHSGGC Medicines Governance Arrangements during the COVID-19 Pandemic

In light of the COVID-19 outbreak, ADTC had cancelled its meetings between April and July 2020.  The temporary medicines governance arrangements NHSGGC had in place during that time is summarised HERE.

Policies relating to the management of medicines, and the terms of reference of ADTC and other group in the medicines advisory structure are noted in this section.  The information contained at this site is issued on the understanding that it is the best available from the resources at our disposal at the time of issue.

    Expiry Date or Comments
  Structure and General  
1.1 Medicines Advisory Structure Under review
1.2 Managed Introduction of New Medicines and Managed Introduction of New Oncology Medicines Dec 2023
1.3 Medicines Governance - Interim Processes during COVID-19 June 2025
  ADTC and Subcommittees  
2.1 Area Drug and Therapeutics Committee: Terms of Reference Under review
2.2 Medicines Utilisation Subcommittee: Terms of Reference Sept 2022
2.3 Prescribing Interface Subcommittee: Terms of Reference Sept 2023
2.4 Non-Medicines Utilisation Subcommittee: Terms of Reference April 2025
2.4.1 Non-medical Prescribing Policy  Under review
2.4.2 Processes related to the Non-Medicines Formularies  Dec 2023
2.4.3 Non-Medicines Utilisation Sub-Committee Guideline/ Formulary Checklist Sept 2021
2.5 Communications Subcommittee: Terms of Reference May 2024
2.6 Antimicrobial Utilisation Subcommittee: Terms of Reference Nov 2021
2.7 Safer Use of Medicines Subcommittee: Terms of Reference Nov 2025
2.8 Patient Group Direction Subcommittee: Terms of Reference March 2024
  Formulary Management  
3.1

Formulary Management Policy 

You may also wish to refer to the Formulary process for non-prescription medicines and medical devices

June 2024
  Prescribing Management Group (PMG) and Subgroups  
4.1 Prescribing Management Group: Terms of Reference Feb 2020
4.2 Acute Services PMG: Terms of Reference Jan 2019
4.3 Primary Care PMG: Terms of Reference Jan 2022
4.4 PMG Finance Subgroup: Terms of Reference Feb 2020
4.5 PMG Mental Health: Terms of Reference Sept 2020
  Access to Medicines   
5.1 Non-Formulary Prescribing Policy  August 2023
5.2 Peer Approved Clinical System (PACS Tier Two) Policy For related info and documentation, see HERE October 2023
5.3

Peer Approved Clinical Systems (PACS Ultra-Orphan) Policy

Please Note: The Scottish Government published guidance about a new Ultra-Orphan Pathway in April 2019.  This guidance affects the applicability of the PACS UO process for many medicines.  For further information, see the Non-Formulary page of this website (click here)

August 2023
5.4  Management of Individual Patient Treatment Requests (IPTRs)

December 2025

5.5 Individual Patient Treatment Request (IPTR) Appeal process  December 2025
5.6 Co-payment Policy for patients receiving aspects of care privately August 2025
5.7 Acute Unlicensed Medicines Policy (ULM Policy) Oct 2024
5.8 Medicines Access Scheme Policy (also see 5.8.1) Dec 2024
5.8.1 Medicines Access Scheme Interim Arrangements during COVID-19 Aug 2021
5.9 Ultra-Orphan Pathway New: In development
5.10 Supply of Medicines Following Specialist Review or Clinic Appointments Dec 2023
5.10.1 Supply of Medicines Following Specialist Review - Additional Guidance for Mental Health Aug 2022
  Clinical and Handling of Medicines Policies  
6.1 Safe and Secure Handling of Medicines Policy and Guidance  
6.2 Administration of Intravenous (IV) Medicines and Flush Policy Nov 2023
6.3 Policy for Supply and Administration of Cytotoxic Intrathecal Systemic Anticancer Therapy

Via StaffNet

Nov 2024 

6.4 Policy for Non-Cytotoxic Intrathecal and Intraventricular Injections Under review 
6.4.1 Register of Authorised Non-Cytotoxic Intrathecal and Intracentricular Injections (Nov 2022) Nov 2025
6.5 Medicines Reconciliation in Hospital  June 2023 
  Clinical Guidelines  
7.1 Clinical Guidelines Framework Via Clinical Guidelines 
7.2 Development and Review Process and Clinical Guideline Title Page Via Clinical Guidelines
7.3  Electronic Checklist for submission of Clinical Guidelines Via Clinical Guidelines
7.4  AUC Antimicrobial Guideline Approval Process  May 2021 
  Miscellaneous  
8.1 Suspected Medicines Defect Policy Jan 2026
8.1.1 Suspected Medicines Defect Reporting Form (for use by acute pharmacy staff) Jan 2026
8.2 Symptomatic Relief Policy (Adults) April 2024
8.3 Drug Alerts Procedure August 2021
8.4 PPSU Medicines Shortages Guidance Via StaffNet