What a GP cannot see on a screen may be just as important as the image in plain sight when prescribing medication to a patient via an online consultation.
Having a keen awareness of potentially unseen factors such as body language is absolutely critical in preventing harm, ensuring patient safety, and managing the risk of prescribing errors. This is becoming increasingly salient as more and more people choose to access GP services online or by phone.
The harm caused by incorrectly prescribed or unmonitored medication can be serious and long lasting. Prescribing errors constitute one of the top risk areas for general practice and last year accounted for 9% of all GP claims closed by MDDUS.
Rapid changes in healthcare mean that more patients are choosing to access healthcare online, so it was reassuring to see healthcare organisations including the GMC and royal colleges issue ten high level principles for good practice to protect patients online, which are particularly related to prescribing.
The guidance has a strong focus on mitigating against the risks associated with clinicians treating patients remotely when they have little or no access to their medical records.
The principles advise UK-based healthcare professionals on important considerations should they be asked to provide remote services to patients overseas, emphasising the potential indemnity and regulatory difficulties with this.
Risks of remote consultations
In our experience, when a GP hasn’t previously met the patient in person, issues can arise with remote consultations because safeguarding clues can be missed. For example, a GP doesn’t know who is standing behind the camera – is the patient making this call under duress? Are they being manipulated? Do they understand the risks associated with the prescription they want?
A GP must take responsibility for the prescriptions they issue. However, when it comes to online prescribing, GPs may not have access to a patient’s relevant medical history or usual medications. It may also be difficult to ensure the consultation is accurately recorded in the patient’s usual medical records – and this can significantly increase the risk of inappropriate prescribing.
Without access to medical records, a GP is solely reliant on what the patient tells them, making it even more important to take detailed notes to justify any prescribing decisions taken. The MDDUS therefore recommends GPs develop a separate framework to remote prescribing in comparison to a face-to-face consultation.
In short, it is reasonable for a GP to decline to prescribe, or to err on the side of caution, when involved in an online consultation. It is also important for GPs to be mindful of the risk of medication abuse.
In circumstances where the GP hasn’t physically seen the patient they need to be alert to the risk of people purporting to be someone else. Extra due diligence, such as requiring patients to provide their CHI or NHS number may be appropriate. As technology moves on, so does the way GPs prescribe, and the GMC’s guidance Good Practice in Prescribing and Managing Medicines and Devices includes a section on remote prescribing.
If relevant information is difficult to obtain or not forthcoming from a patient, then a GP should not feel pressurised into prescribing. They should also consider seeking the support of their MDO.
Ensure robust systems are in place
There may be a risk of patients seeking online prescriptions from several sources. It is important all doctors prescribing online are alert to this risk, particularly if the medication requested has the potential for abuse or causing serious side effects.
Abuse of prescribing is taken very seriously by the GMC because of the adverse consequences for both the doctor and patients involved. Ensure that robust systems are in place for the issuing and review of prescriptions, particularly for drugs which may be abused. These systems should cover all prescriptions and should include regular tailored audits.
It’s important that GPs conducting remote consultations do not feel anxious about signposting a patient to another source of care. That could be to the patient’s own GP for a face-to-face consultation or even to their nearest walk-in centre or A&E department. No GP involved in remote consultations should feel 'It’s me or nothing'.
If a GP is worried about an online consultation and not sure whether to prescribe they should consider whether they are able to defer the decision. You may wish to take this time to discuss with colleagues or contact your MDO for further support and guidance.
Your MDO can also help you work out where else you can signpost a patient to, especially if the call is out of hours.
- Dr Nazem is a medical adviser for MDDUS