Prescribing is a routine part of everyday medical practice and is mostly safe and effective. But it can be the source of a wide range of problems, from simple and harmless errors, to significant fatal mistakes and serious ethical dilemmas about patient safety.
Because prescribing is carried out so frequently even a small rate of error can lead to a large number of issues and, from our perspective, a significant amount of contact from members.
In terms of ethical dilemmas, we receive many enquiries about patients who won’t comply with potentially life-saving treatment or monitoring. Members also often raise concerns when disagreements arise over the best therapeutic option, for example when there is conflict between specialist and GP or patient wishes. These cases are very individual and specific and cannot be addressed here but it is useful to revisit some of the GMC’s guidance on prescribing to reinforce general principles which always apply.
Good Medical Practice, the GMC’s core guidance for the medical profession, clearly states that you must only prescribe when you have adequate knowledge of the patient’s health, and that the treatment prescribed must be appropriate for your patient’s needs.
More detailed and expansive guidance can be found in the GMC’s additional guidance Good practice in prescribing and managing medicines and devices. Each doctor can of course review the regulator’s position on prescribing for themselves but it is nonetheless useful to highlight some key areas here which are relevant to many of the enquiries we receive.
Each doctor is responsible for the prescriptions they sign. This applies even when a prescription is issued on the advice of a colleague, for example when GPs prescribe in line with specialist advice. You must therefore make sure you can justify your actions when doing this and be able to explain why a prescription was appropriate. The reasons can of course include information from specialist colleagues, but where necessary this should be reviewed before issuing a prescription. Issuing a prescription solely on the basis that a colleague asked you to do so is not of itself sufficient justification.
It is essential to keep up-to-date in relation to pharmacology and therapeutics in your own field of expertise. The GMC guidance specifically refers to the BNF and BNFC stating that you “must” be familiar with the guidance from these publications.
When doctors do not believe a prescription should be issued (because it will not be of overall benefit) they are often concerned that this refusal will upset the patient.
The GMC advises: “… the doctor should discuss the issues with the patient and explore the reasons for their request. If, after discussion, the doctor still considers that the treatment would not be of overall benefit to the patient, they do not have to provide the treatment.”
The guidance goes on to confirm that this should be explained to the patient along with other options, including obtaining a second opinion.
The GMC’s guidance makes clear that prescribing involves the agreement of the patient and when explaining the proposed treatment, risks, benefits and side effects should also be explained. Patients should be advised of what to do in the event of an adverse reaction. They should also be advised clearly how to take any medication, for how long and if monitoring or specific follow-up is required.
After initial prescribing, review of medication may also be necessary and should not be overlooked.
There are many situations when patients require ongoing monitoring for safe prescribing, for example with warfarin. But when they disengage and decline to be monitored, refusing to prescribe may not be an option because of the risk to the patient. These difficult situations require very careful consideration of the risks and available options. Such dilemmas are best considered on a case-by-case basis and we encourage members to seek specific advice if necessary.
When prescribing errors occur the GMC says: “You should question any decision or action that you consider might be unsafe.” In this regard doctors are also reminded that where concerns are raised about their own prescribing a reflective and constructive response is expected.
The guidance also devotes a specific section to remote prescribing via telephone, video-link or online, which is becoming increasingly important in modern medical practice. If you are involved in this you must familiarise yourself with this guidance.
So, as a final reminder, to understand the regulator’s stance on prescribing we recommend review of the full guidance, and remember this applies to all doctors who prescribe – whatever their grade or speciality.