One of the positive developments to have arisen from the pandemic is the way in which both doctors and patients have embraced telephone and video consultations.
However, as well as the benefits of consulting with patients remotely, including increased convenience and reduction in DNAs, there are of course some drawbacks. These include the potential for delayed diagnoses, as highlighted in our previous GPonline article, as well as communication difficulties
Prescribing medication without a face-to-face consultation also needs careful consideration and documentation. With that in mind, new GMC guidance Good practice in prescribing and managing medicines and devices places greater emphasis on remote prescribing and the importance of dialogue and patient consent. The new guidance comes into effect on 5 April 2021
When to see a patient in person
The new guidance emphasises the need to have sufficient information to prescribe safely. This may include information that needs to be gained from a physical examination of the patient or other assessments which may not be possible remotely.
Other circumstances where a remote consultation may not be the best option are also identified. These include where you are uncertain of a patient’s capacity to decide about treatment or where you may be concerned that a patient does not have a safe or confidential space for the consultation to take place, such as where a patient’s decisions may be being influenced by others or where there is domestic abuse.
You are expected to ensure you have enough information about the patient before prescribing, considering the mode of the consultation and whether you have access to the patient’s medical notes.
Check whether the patient is also obtaining medication from other sources. This may have implications for safe prescribing or, in extreme cases, may create a risk of serious harm or death.
If you are not the patient’s regular prescriber you should get consent from the patient to contact their GP or other treating doctors to allow you to obtain all the information you need for safe prescribing. If the patient refuses to allow you to do this you need to ensure you can justify prescribing without this information.
If you believe prescribing poses a risk you should explain why you cannot prescribe and advise the patient of their options and what alternative services are available. This discussion with the patient and any decisions made should be carefully documented.
Linking in with the GMC’s guidance on consent the prescribing guidance emphasises the importance of establishing a dialogue with the patient. When obtaining consent your discussion with the patient should include the likely benefits and risks, serious and common side effects and what to do if they occur, how to take and adjust the medicine and arrangements for follow up and review.
Where necessary, assess the patient’s capacity. If an adult lacks capacity, or in accordance with mental health legislation, medicines can be prescribed if it is likely to be of overall benefit to the patient.
For most decisions verbal consent will be sufficient, however, you must be satisfied that the patient has the opportunity to consider any relevant information.
If patients request medicines which you don’t think will benefit them, discuss the reasons for the request and their expectations. If you still think the treatment does not meet the patient’s needs, you should explain the reasons for this and advise them of other options including their right to a second opinion. You should not prescribe medication which you do not believe is appropriate.
The following fictional example, based on MDU cases, illustrates the type of dilemma GPs may be faced with.
A GP contacted the MDU for advice because she was concerned about prescribing diazepam to a patient following a telephone consultation.
The patient complained of back pain and spasm after exercising. The records showed she had complained of back pain before and been prescribed a short course of diazepam. The patient insisted she needed diazepam again. The GP noted that the patient seemed distracted and she thought she could hear another voice in the room, although the patient said she was alone.
After questioning the patient further and excluding any red flags symptoms, the GP agreed to prescribe the diazepam and arranged a follow-up phone call the next day. She also gave safety netting advice to ensure the patient knew what to do if her symptoms deteriorated. On ending the call, the doctor felt uneasy about prescribing remotely and rang the MDU for advice.
The MDU adviser discussed with the GP whether she could be sure that the patient had provided all the relevant information she needed for safe prescribing. Had the patient understood what was discussed and had a proper dialogue taken place to obtain consent?
The GP noted a history of domestic abuse and that, coupled with concerns that another person may have been present in the room possibly coercing the patient or influencing her request for diazepam, raised the issue of whether the back pain could have been the result of an assault.
An examination would be needed to fully assess the cause of the pain. On reflection, the doctor felt that a face-to-face appointment was indicated and rang the patient back to request they attend the surgery.
The GP saw the patient alone later that day. The patient confessed that she did not have a bad back and her partner had made her call the practice to ask for diazepam. After a long supportive discussion, the patient agreed for the GP to contact adult safeguarding due to ongoing domestic abuse.