There is “limited national assurance” that lithium monitoring is being carried out “in line with guidance”, particularly within primary care, a healthcare body has warned.
A report published by the Health Services Safety Investigations Body (HSSIB) yesterday found that monitoring arrangements “vary across primary and secondary care”.
It cited reports of people taking lithium “having to organise their own blood tests or remind services when their monitoring was due”.
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The HSSIB called on NHS England and the Department of Health and Social Care to establish “national oversight and assurance processes to measure and improve the quality and safety of lithium treatment across care settings”.
It said these processes, covering prescribing and adherence to recommended monitoring, would promote “greater confidence for people with bipolar disorder and prescribing clinicians”.
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The HSSIB undertook its investigation to understand why lithium is not always offered by clinicians to people with bipolar disorder, despite having the “largest evidence base for efficacy in bipolar disorder compared to any other treatment” and the National Institute for Health and Care Excellence recommending it as a first-line medication for long-term treatment.
It found that some patients had tried “several other medications before the option of lithium was raised with them”, and that the “practical requirements of lithium monitoring can affect whether clinicians feel confident about starting a patient” on the drug.
“These requirements include arranging blood tests, reviewing results, adjusting doses and ensuring follow-up,” it added.
“Unknown” monitoring effectiveness
The report noted that despite the majority of lithium being prescribed in primary care, there was “no regular audit of lithium monitoring” in the sector.
And while the Community Pharmacy Quality Scheme high-risk medicines audit report for 2019/20 included lithium monitoring and found that “95% of patients reported having had their lithium levels monitored”, the HSSIB said the audit has not been repeated and so “the current effectiveness of monitoring in primary care is unknown”.
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The investigation was also “unable to identify any primary or secondary healthcare provider that had a comprehensive lithium patient register”, despite the 2026 Specialist Pharmacy Service guidance stating that healthcare professionals should “ensure there are defined responsibilities” for compiling and managing one.
“National stakeholders told the investigation that maintaining lithium registers had been problematic for some providers due to information governance concerns, and this could depend on the technology in use,” the report noted.
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It comes after the HSSIB recommended in June that independent prescribing organisations should have access to patients’ health records to improve the safety of online prescribing.
And it follows a coroner in July saying there is a “lack of national guidance” on monitoring and prescribing for hepatitis B reactivation, which poses a “significant risk of future deaths”.
