I HAVE a diabetic patient on insulin who has not attended for review for well over a year. When he last requested a repeat prescription for insulin he agreed to attend but then failed to turn up for an appointment. The practice has sent letters reminding him to attend but to no avail. He has now requested another prescription. How should I proceed?
Non-attendance for prescription review can be a tricky problem and, although this scenario involves insulin, the same issues can occur with many types of repeat prescriptions for essential treatment in conditions that need regular monitoring.
Doctors worry that prescribing for patients who refuse to engage adds to the potential harm that the patient faces. Sometimes doctors feel almost blackmailed into prescribing in an unsafe way where patients request their medication but fail to accept monitoring or follow-up.
All doctors are responsible for the prescriptions they sign and so must be prepared to justify their actions should something go wrong. The same applies if they decide not to prescribe.
What factors should be considered and what is the best way to proceed? The GMC offers detailed guidance (Good practice in prescribing and managing medicines and devices 2013) about repeat prescribing and in particular states that as with any prescription you should "agree with the patient what medicines are appropriate and how their condition will be managed, including a date for review. You should make clear why regular reviews are important and explain to the patient what they should do if they suffer side effects or adverse reactions, or stop taking the medicines before the agreed review date (or a set number of repeats have been issued). You must make clear records of these discussions and your reasons for repeat prescribing."
Initial discussions with patients on repeat medication should always include information about the importance of follow-up. At MDDUS we often have cases that arise where patients claim they were not fully advised of the importance of follow-up and review. Their non-compliance is blamed on the doctor for not providing sufficient information in a way the patient could understand. Discussions about review form a central part of good care and need to be documented in the patient’s notes should problems arise at a later date.
In all cases where there are significant health risks to the patient from non-compliance it is the doctor’s responsibility to pursue this. Communication with the patient should ensure they receive the message that review is necessary and why. This can be by personal letter or electronic means if email addresses and mobile numbers are known. Occasionally more urgent contact is needed.
Some members are concerned about possible breaches of confidentiality if messages are left. Care should be exercised but, if there is a significant risk of harm, the risk of breaching confidentiality must be balanced against the risk of harm to the patient if they are not contacted. If someone other than the patient could pick up a message take care regarding how much information is left. But again this needs to be balanced because if a message is too vague its importance may be ignored.
It is essential to act in a way you can justify based on the information you hold and the risk to the patient. If in any doubt, ring MDDUS and speak to one of our advisers. Often the simple act of talking things through can be very helpful.
Should you continue to prescribe in this case? You must consider the risks and benefits of the different courses of action. Is it less potentially harmful to prescribe as before or to adjust a dosage? You can also consider prescribing for a limited time to allow the patient to attend and be reviewed.
Should the risks of prescribing – or not prescribing – be unclear then discuss the case with your colleagues and any secondary care doctors involved so that you have a full picture of risks and benefits. It is essential to be adequately informed before making these decisions. Again, we always advise keeping a careful note of the information you have gathered and the way you have used this information to make a decision.
These types of dilemmas are quite common and require careful assessment. Preparing a patient for regular review at the time treatment starts can help to avoid these problems but should such a situation arise the practical steps outlined above can help.
Dr Gail Gilmartin is a medical and risk adviser at MDDUS