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This scenario is a reasonably frequent one we encounter via our advice line, and there are some common issues around repeat prescriptions which come up regularly including:
Patient won’t have the tests necessary to ensure the medication is being used safely
Patient won’t attend consultations to ensure the medication is still appropriate and safe
Patient won’t pay, but still wants on-going scripts
A specialist started this medication, but I don’t consider it’s in my scope to continue to prescribe it
All these situations leave the doctor with a dilemma – do we take the risk and prescribe despite not being able to monitor appropriately, or when we are not being paid, or do we withhold the script and risk that the patient will come to harm as a result of the lack of the medication?
Often there is not a clear answer, and we would suggest you call Medical Protection (or your own indemnifier) to discuss your options. But below I will go through some of the considerations to take into account when deciding whether or not to provide a repeat prescription.
Let’s start by looking at the New Zealand Medical Council’s statement on prescribing and what it says about repeat prescribing:
‘It is important that any system for issuing a repeat of an earlier prescription issued to a patient takes full account of the obligations to prescribe responsibly and safely and that the doctor who signs the prescription takes responsibility for it. Before signing a repeat prescription, you must be satisfied that secure procedures are in place to ensure that:
The patient is issued with the correct prescription
Each prescription is regularly reviewed so that it is not issued for a medicine that is no longer required
The correct dose is prescribed for medicines where the dose varies during the course of the treatment
You have appropriate information available (which may include access to the patient’s clinical records) so that you can review the appropriateness of the repeat prescription
Any subsidy conditions that have changed since the last prescription (such as a change to subsidised medicines or a change to the patient’s dispensing frequency requirements) are amended by you on the prescription
You review all relevant information before completing the prescription, and ensure that the patient record is maintained and updated
Repeat prescriptions should include details about the number of the repeats allowed within a given time frame and, for the patient’s benefit, clear instructions relating to the dosage including quantity, frequency, and route i
Patients receiving repeat prescriptions should be assessed in person on a regular basis to ensure that the prescription remains appropriate, adverse effects are monitored, and the patient is taking or using their medicines as intended. Patients who need a further examination or assessment should not receive repeat prescriptions without being seen by a doctor. This is particularly important in the case of medicines with potentially serious adverse effects. It is at the doctor’s discretion whether a patient is given a repeat prescription. Decisions not to issue a repeat prescription should be explained to the patient and documented accordingly.’
This makes it clear that repeat prescriptions are not the patient’s right – they are given at the discretion of the prescriber and prescribers should be able to insist on a consultation, if they consider that is necessary to ensure the safety and appropriateness of the script.
It also makes clear that prescribers should not issue repeat prescriptions if the patient needs further examination or assessment. However, this puts the doctor in an awkward position, when the patient refuses to do the necessary blood tests, or come in to be examined, but clearly is likely to suffer harm if they do not continue with their medications.
In practice, when in this situation, the doctor needs to weigh up the potential harm of prescribing without appropriate monitoring versus the harm of the patient not having the medication at all. In this scenario we usually suggest there are several factors the doctor should take into account:
The seriousness and imminence of harm should the prescription not be issued. For example, not prescribing allopurinol may increase the chances of a patient getting gout, but that is not as serious as withholding insulin, where the patient would be at risk of developing ketoacidosis.
Whether the patient is being monitored or reviewed at another service. For example, if you know a patient is under a renal specialist and having their blood pressure and blood tests monitored regularly by that service, there may be less of a concern if you yourself are not able to check their blood pressure or get your own blood tests done.
Whether the patient is likely to have significant withdrawal effects if the prescription is not issued. In situations where withdrawal effects could be severe, you may consider providing a weaning script, rather than stopping a medication suddenly.
Whether there is a good reason why the patient cannot present for monitoring and whether you are able to arrange some other service to assess them. For example, a house-bound patient may have their blood pressure checked by the district nurse, or an outreach service.
Whether the prescription includes controlled drugs, or any medication with a risk of addiction or misuse or any psychotropic medication. The New Zealand Medical Council makes it clear that extra care needs to be taken with these types of medication.
All these are points to take into account when considering whether you will provide a repeat prescription when the patient is due an assessment or bloods but refuses to attend. However, making the decision yourself, in isolation, can increase your medicolegal risk in this situation. Medical Protection often suggests that you consider:
Discussing the case anonymously with your peer group, or with colleagues, to see what your peers feel the risks of prescribing are, versus the risks of not prescribing.
Writing to a specialist for advice regarding the risks of prescribing without monitoring, versus the risks of not prescribing. This is a common scenario in patients with mechanical heart valves who are on warfarin and who refuse to have their international normalised ratio (INR) checked. It is good to get a specialist opinion on the risk of an adverse outcome if you don’t prescribe their warfarin versus the risk of prescribing warfarin without monitoring.
Making sure you have discussed the risks of not monitoring with the patient and documented in detail that discussion in the notes. This can be challenging if the patient refuses to come in for a consultation, but in that case you should write the patient a detailed letter of why you wish to see them/wish them to have tests done, and what the risks of prescribing are without that monitoring.
In the end, if you decide the risks to the patient of not prescribing are higher than the risks of prescribing without monitoring, and therefore decide to prescribe, it may be appropriate to offer short prescriptions, which will give you the opportunity to engage with the patient again in a short time and again try to persuade them to attend for monitoring.
If you decide not to prescribe you should write to the patient explaining your reasons for not prescribing, what their alternatives would be for getting a prescription and letting them know what conditions need to be met for you to resume prescribing – such as a face-to-face consultation, or further blood tests.
If a patient refuses to pay prescription charges, but still requests repeat scripts, you need to go through the same process of considering the risks to the patient of withholding the script, and if that risk is high, it is likely the appropriate course of action is to continue to prescribe. It would be appropriate to explore other possible means of helping the patient with payment, including WINZ disability allowances, or any other local programmes that can help patients who are struggling to pay the practice fees. However, you are entitled to be paid for your services and should have a practice debt policy which allows for several contacts with the patients informing them of the debt and the possible consequences of non-payment. This may include disenrollment as a final step. If it gets to that and having completed an appropriate debt programme, the patient is disenrolled, we would suggest that you contact the local PHO to let them know that this patient requires prescriptions, which you will no longer be providing, and ask them to find a new provider for the patient.
A further situation to consider is where a GP is being asked to prescribe a medication which is normally provided in secondary care, which the GP is unfamiliar with and where the GP believes it is outside of their area of expertise to monitor. Unfortunately, as hospital services become ever more stretched, this is becoming a regular occurrence and something which makes GPs feel very uncomfortable. A similar situation happens for hospital doctors, where a patient is seen in a specialist clinic and the patient asks the specialist to prescribe all their regular medications (not just those related to their speciality). The specialist is not in a position to know background information about the patient’s other conditions, or do the routine monitoring which is normally done by the GP prior to prescribing. The New Zealand Medical Council make it clear that doctors are expected to:
‘Be familiar with the indications, adverse effects, contraindications, major drug interactions, appropriate dosages, monitoring requirements, effectiveness and cost-effectiveness of the medicines that you prescribe.’ ii
When prescribing a medication which is normally outside your scope of practice, there is a significant risk that you may not be aware of the appropriate doses, monitoring requirements, or the common side effects of that medication. If you consider it is not safe for you to prescribe, then you can decline to do so and refer them back to the specialist to do so.
An alternative is to write to the specialist asking for a detailed plan of care, including monitoring, consideration around dose adjustments, when to refer back, etc. With a clear plan from a specialist, the GP may be more willing to take on prescribing a medication which they are less familiar with. Similarly, if a specialist is asked to prescribe medications which are outside their scope of practice, they need to be careful to ensure that the necessary monitoring has taken place and that the script is appropriate and they should also let the GP know exactly what medications, and in what quantity they have prescribed.
In conclusion, it is important to remember that repeat prescriptions are not a patient’s right and that prescribers need to carefully consider whether a repeat prescription is safe and appropriate. If not, they should ask the patient to come in for review. If the patient refuses to engage with appointments or other monitoring, the prescriber needs to carefully weigh up the risks of prescribing versus not prescribing and this calculation is very much dependant on the facts of each particular case. As always, documentation is key.
If you have any concerns in this situation, we advise you to contact Medical Protection, or your own indemnifier, to discuss the medicolegal implications of the particular case.