Rules for prescribing drugs remotely
The GMC’s updated prescribing guidance and its impact on independent doctors is discussed by medico-legal adviser Dr Kathryn Leask.
The GMC’s updated prescribing guidance Good practice in prescribing and managing medicines and devices – effective from 5 April – places more emphasis on remote prescribing and consent.
Throughout the pandemic, more and more consultations have been held remotely and while there will inevitably be patients who need to be seen face to face, remote consultations are very likely to continue.
The guidance makes clear that it applies to all prescribing regardless of the setting. Where remote consultations are used, prescribing must be compatible with the guidance and you need to have the appropriate knowledge and skills to use the technology required for your role.
While the guidance does not distinguish between NHS and private prescriptions, there are some areas which may particularly impact those working in private practice.
Firstly, there is more emphasis on establishing a dialogue with patients. Not only does this allow you to obtain the information you need to prescribe safely, the dialogue should provide an opportunity for the patient to ask questions to help them decide whether or not to have the care or treatment you are offering.
Questionnaire issue
The guidance specifically mentions the need to raise concerns if you are prescribing remotely based on a questionnaire, which provides no opportunity for a two-way dialogue with the patient.
You should take a proportionate approach when obtaining a patient’s consent to prescribe. Verbal consent is generally adequate providing the patient has been given all the information they need to make a decision and has had the opportunity to ask questions.
There may, however, be occasions when a patient’s signature is required; for example, to comply with a Medicines and Healthcare products Regulatory Agency drug safety alert about a medicine with serious side-effects.
Assessing capacity
As with all treatments, it is important to ensure the patient has capacity to make decisions about their care. Assessing capacity is a core clinical skill and you should be able to draw reasonable conclusions about your patient’s capacity during the dialogue you have with them.
During a remote consultation, you will need to consider whether you should physically examine the patient.
Some forms of examination and assessment can take place during a video consultation. However, this won’t be adequate in all cases and the need for a physical examination should be considered to ensure prescribing is done safely.
Additionally, you need to consider whether you have all the information you need to prescribe safely. As a private clinician, you may not have access to the patient’s clinical records and may not be in a position to verify the information you are given.
Patient’s permission
If you are not the patient’s regular prescriber, you should ask for the patient’s permission to contact their GP or other treating doctors to obtain or confirm relevant information. If the patient refuses, you must be able to justify your decision to prescribe.
In doing so, you have to consider any medication the patient is obtaining from other sources, such as the internet.
As well as obtaining information you need to prescribe safely, you should obtain the patient’s consent to allow you to share information with their GP.
If the patient refuses, you should explain the risks associated with not sharing information to other potential prescribers and those involved in their care.
This discussion and any decisions you make should be documented in the records. If you decide that you are not able to prescribe safely, you should provide the patient with other options and alternative services.
Under pressure
During a remote consultation, you should also consider whether the patient is able to talk to you freely. In some situations, you will need to consider whether they are being put under pressure by others who may be present with them or who may be in the room but not visible to you.
Furthermore, in some instances, a patient will ask for treatment which you don’t believe is clinically appropriate for them. You should discuss this with the patient so that you can understand their reasons and expectations.
If, after discussion, you do not believe the treatment is appropriate, you should not prescribe it and explore other options that may be available. This may include offering the patient a second opinion.
The GMC’s guidance also makes specific reference to controlled drugs and other medicines where additional safeguards are needed. The GMC advises that if you do not have access to a patient’s medical records, you must not prescribe controlled drugs or medicines that could be open to abuse, overuse or misuse.
This includes where there is a risk of addiction and the need for monitoring is important. The exception to this is when there is no other person with access to the patient’s records available and prescribing is necessary to avoid a serious deterioration in the patient’s health or it is necessary to avoid serious harm.
Limited quantity
It may also be necessary to prescribe to ensure continuity of treatment where a patient is unexpectedly unable to access medication for a limited time. If such a situation arises, you should provide a limited quantity to allow treatment to continue until the patient is able to access suitable care from a professional with access to their records.
You will also need to consider whether the patient is also obtaining medication from other sources.
Some private clinicians may be consulting remotely with patients abroad. It is important to consider how the patient’s condition will be monitored and whether there are any differences in the licensed name of the medication and the recommend dose.
It is also important to ensure you have the appropriate insurance or indemnity in place to cover your practice in another country and also whether you need to be registered with the regulatory authority where the patient is based. If the service provider you work for is based outside the UK, you need to be aware that there may not be established local mechanisms to provide effective systems of regulation and this may have an impact on patient safety.
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Dr Kathryn Leask (right) is medico-legal adviser at the Medical Defence Union