Patient non-compliance with requests for monitoring can present a difficult dilemma for GPs and we regularly receive advice calls on the subject. Whether it be for INR monitoring, disease-modifying anti-rheumatic drugs (DMARDs) or diabetic reviews, the GP will have to make a decision as to whether to continue to prescribe the medication or not.
Many types of repeat prescriptions for essential treatment in conditions need regular monitoring. Sometimes doctors feel pressured into prescribing in an unsafe way where patients request their medication but fail to accept monitoring or follow-up.
The first thing to be aware of is the GMC’s supplementary guidance 'Good practice in prescribing and managing medicines and device's. The following paragraphs are particularly pertinent here.
'You are responsible for the prescriptions you sign for and your decisions and actions when you supply and administer medicines and devices or authorise or instruct others to do so. You must be prepared to explain and justify your decisions and actions when prescribing, administering and managing medicine.' (paragraph 3)
This applies even if you are simply signing a repeat prescription that you did not initiate:
'You are responsible for any prescriptions you sign including repeat prescriptions initiated by colleagues so you must make sure that any repeat prescription you sign is safe and appropriate.' (para 55)
Therefore, should any medical mishap arise out of a side effect from a medication and you signed the prescription, you must be prepared to justify the decision, including in situations where monitoring didn’t take place: 'Whether you prescribe with repeats or on a one-off basis, you must make sure that suitable arrangements are in place for monitoring follow-up and review, taking account of the patient’s needs and any risk arising from the medicine.' (para 51)
Suitable call-recall arrangements should be standard practice in all GP practices. It is therefore very important when signing repeat prescriptions that you are aware of your practice’s review procedures and make sure that you are following them.
Check the patient’s contact details and then send a letter asking them to attend for monitoring. Most practices have a standard template letter for this purpose. It is also advisable to set an alert to remind you to check whether they have attended or not.
If the first routine letter does not work then send a follow-up letter. If that fails then send a personal letter from the GP inviting the patient to attend an appointment to discuss their medication and its continued supply. The time between each letter will depend on the risks involved. It may also be appropriate to contact the patient by telephone.
It is not enough, however, to simply say: 'I sent a letter and the patient did not attend'. The guidance states you must take account of the patient’s needs and any risks arising from the medicine.
Speak to the patient
Often the most efficient and best way to fully understand the patient’s needs is to speak directly to them to try to understand their reluctance to attend for the monitoring. For example, the patient may not be able to attend for a review appointment during the working day or have travel issues in which case it may be appropriate to arrange near-patient testing or a home visit review.
Perhaps the patient simply does not understand the significance and importance of the monitoring and a conversation outlining the risks involved in continuing to prescribe the medication would be helpful. Initial discussions with patients on repeat medication should always include information about the importance of follow-up.
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.
Whilst you shouldn’t set out to frighten the patient, it is important to make them aware of the dangers involved and potential risk they are exposing themselves to by not attending.
It is also important to clearly document in the patient’s records the steps you have taken to contact and invite them for monitoring. Should they attend the surgery for another matter, the clinician seeing them will be alerted to the need to discuss these issues.
Explain the risks
If the patient still refuses to attend then the next step would be to write to them, clearly outlining the risks of continued prescribing in the absence of monitoring. You can also consider issuing shorter prescriptions that they will be forced to collect, or advise them that, due to the risks involved, you will have no choice but to discontinue the medication should they fail to attend for review within a given time limit.
This last option is rarely necessary as most patients by this point do realise it is in their interests to comply with your request. However, on the rare occasions it does occur it would be advisable to involve your secondary care colleagues in this decision and have a case conference to discuss the pros and cons of continuing/discontinuing the medication.
It is very important to also involve the patient in this decision-making process and make sure they have the capacity to understand, weigh and retain the consequences of their decision to refuse monitoring. If a competent patient understands the risks of refusing to attend for monitoring it is for the doctor to decide whether continuing to prescribe poses more risk to the patient than not prescribing.
- Dr Susan Gibson-Smith is a medical adviser for MDDUS