In January 2018, the Medical Defence Union (MDU) published guidance on prescribing,1 explaining that prescription errors are one of the most frequent reasons for a claim reaching the MDU.

Indeed, of closed cases between 2011 and 2015, 217 concerned prescription errors. The errors related primarily to the following:

  1. Prescribing to a patient with a known allergy, particularly penicillins
  2. Prescribing an incorrect medication, as a result of similar sounding drug names
  3. Prescribing the wrong drug dose.

Remote prescribing in the GP out of hours setting is informed by BNF and NICE guidelines, and governed by GMC guidance. Additionally, clear prescribing policies should be in place at individual GP out of hours’ services.

When contemplating prescribing in the GP out of hours setting during a remote consultation, one should determine the level of urgency, i.e. whether the medication is required, or will be dispensed, in the out of hours setting, or could wait until the patient can contact their own GP. If the out of hours GP is issuing a script, rather than dispensing, the patient may only obtain the medication in hours, and it may be preferable for the patient to see their own GP for review. One should also consider whether the medication could be obtained from a pharmacy, if it is a repeat prescription, or over the counter medication.

For repeat medication requests, which are a common presentation in the out of hours setting, it is important to clarify when the medication was last taken, at what dose, and the circumstances of the medication having been stopped, or if the patient no longer requires a supply of this medication. If it is clear that there are no contraindications to continuing with the medication requested by the patient, it is advisable to verify whether the patient has some of this medication left over, which may be sufficient until the patient can be reviewed by their own GP in hours.

The potential for abuse when medication is requested by patients should be considered. Previous out of hours’ encounters may highlight whether the patient often contacts the out of hours’ service for repeat or acute prescriptions, in preference to seeing their own GP, which then carries risk in terms of ongoing patient review, and appropriate monitoring. The possibility of fabricated and induced illness may need to be considered in the case of parents or carers attempting to obtain medication(s) for a child from an out of hours’ service.

In the case of drugs with the potential for abuse, GPs caring for patients in the out of hours’ setting should consider prescribing the minimum possible dosage and quantity of drugs. For drugs such as antibiotics, it is usually advisable to issue the full course of treatment.

In light of the fact that prescription related queries, and requests, form a significant proportion of GP out of hours’ patient encounters, pharmacists play an important role in the GP out of hours setting.

Pharmacists have some discretion in issuing supplies of prescription-only medication at a patient’s request, in accordance with guidance on emergency supply published by the Royal Pharmaceutical Society (RPS): https://www.rpharms.com/resources/quick-reference-guides/emergency-supply#patient.

The RPS guidance states as follows: “As a pharmacist, you can supply prescription only medicines (POMs) to a patient without a prescription in an emergency at the request of a prescriber or a patient. You should consider each request on a case by case basis, using your professional judgement to decide which course of action you believe will be in the best interest of the patient and support patient care.”

The RPS guidance further states: “You are able to make an emergency supply even when the surgery is open and out of hours’ services are available. Trying to obtain a prescription may sometimes cause undue delay in treatment and potentially cause harm to the patient.”

Since 2006 regulations permitting those pharmacists who have undergone specific training programmes accredited by the General Pharmaceutical Council to prescribe independently, have been in place,2 meaning that they are able to prescribe medication autonomously for conditions within their clinical competence, which affords them a growing role when working in Primary Care out of hours.

The GMC guidance on remote prescribing is set out in Good Practice in prescribing medicines and devices.3 The GMC states that prior to prescribing remotely by telephone, video-link or online, the doctor should be satisfied that an adequate assessment can be made, that a dialogue can be established with the patient, and that it is possible to obtain the patient’s consent, in accordance with GMC guidance.

The guidance stipulates that the doctor can only prescribe when he/she has “adequate knowledge” of the patient’s health, and is satisfied that the medicines serve the patient’s needs. The doctor must consider the following: “The limitations of the medium through which you are communicating with the patient; the need for physical examination or other assessments; whether you have access to the patient’s medical records.” In this guidance, the GMC highlights the fact that non-surgical cosmetic products, e.g. Botox, cannot be prescribed remotely, as a physical examination of the patient must be undertaken prior to prescribing these preparations.

If the doctor has decided to prescribe to a patient in a care or nursing home or hospice, he/she should communicate with the patient, or if this is not possible, with the person caring for the patient, in order to make an assessment, and deliver the appropriate information and advice.

The GMC guidance further states that the doctor should ensure that any instructions, such as regarding administration or monitoring of the patient’s condition, are understood, and that written confirmation is sent as soon as possible.

The GMC states that if the patient has not been referred by their GP, there is no access to their medical records, and the doctor has not previously provided the patient with face-to-face care, doctors MUST also:

  1. Give their name and, if prescribing online, their GMC number
  2. Explain how the remote consultation will work, and what to do if they have any concerns or questions
  3. Follow the advice on sharing information with colleagues, issued by the GMC in the guidance (paragraphs 30-34).3

 

The GMC states that doctors should not: “Collude in the unlawful advertising of prescription only or unlicensed medicines to the public via websites that breach advertising regulations.”

The GMC emphasises that continuity of care is a key patient safety issue when conducting remote consultations, and that when the episode of care ends, the doctor must handover the following to the patient’s own GP:

  • Changes to the patient’s medication (existing medication changed or stopped, and new medication commenced), with reasons
  • Length of planned treatment and any monitoring requirements
  • If any new allergies or adverse reactions have been identified, unless the patient objects or if privacy concerns override the duty, for example, in sexual health clinics.

 

It is worth highlighting that patients accessing GP care remotely may be located overseas, in which case doctors should consider how they, or healthcare professionals locally, will monitor the patient’s condition. Further considerations for doctors include local differences in a product’s licensed name, indications, and recommended dosage regimen. One may also need to consider MHRA guidance on import/export requirements and safe delivery; doctors’ indemnity cover; and whether one must be registered with the regulatory body in the country in which the prescribed medication is to be dispensed.

The MDU advises as follows with respect to remote prescribing:1 “Remote prescribing is only appropriate for some drugs and treatments, and for some patients. The GMC stresses that doctors must consider the limitations of electronic communication (phone, internet, Skype etc) when consulting remotely.”

 

Remote prescriptions should only be made when:

  • You are satisfied that you are in a position to prescribe safely
  • You are prepared to ask the patient to come in for a physical examination
  • You have adequate knowledge of the patient’s health
  • You are satisfied that the medication you prescribe serves the patient’s needs.

 

As GPs, we have a duty to understand the nature of the drug we are prescribing, including contraindications, side-effects and monitoring requirements. We are responsible for the prescriptions we sign, and must be sure that both the drug name, dose and frequency are correct. We should be sure that the drug we prescribe is the best option for the patient, and the GMC requires that we should explain the risks and benefits of treatment, including side-effects that may arise; what to do if side effects occur or symptoms persist or worsen; when and how to take the medication, and how to change the dose if appropriate; the intended length of treatment; and the plan for monitoring, follow-up and review of the patient.

 

OUT OF HOURS GP REMOTE PRESCRIBING: Chart for guidance

References:

  1. https://www.themdu.com/guidance-and-advice/guides/prescribing (last accessed July 2018)
  2. https://www.pharmacyregulation.org/education/pharmacist-independent-prescriber (last accessed July 2018)
  3. General Medical Council, Good practice in prescribing and managing medicines and devices, 2013.  https://www.gmc-uk.org/-/media/documents/Prescribing_guidance.pdf_59055247.pdf (last accessed July 2018).

Dr Sharon Raymond

Experienced out of hours GP, GP appraiser and independent trainer