Prescribing issues in primary care

1. Prescribing issues in primary care A series of cases and learning tasks

2. Prescribing issues in primary care Background • This is an extremely important topic • There are prescribing rules and guidelines, some of which are precise and rigid, others are very flexible • We will look at some issues using role play followed by feedback and consolidation of knowledge • Other issues will be covered by way of assignments to each group, with a view to brief presentations from the groups next term

3. Learning objectives • To familiarise you with the current issues around prescribing in primary care and help you identify practical strategies to deal with any problems.

4. Learning outcomes (first session) By the end of this session you will: • Be aware of the importance of determining who has prescribing responsibility • Have recognised how prescribing decisions can have a profound effect on the workings of a practice and the doctor-patient relationship

5. Learning outcomes second session By the end of this session you will • Know who is entitled to free prescriptions • Be aware of the varying mechanisms by which patients receive repeat prescriptions • Be aware of various incentives/influences over GP prescribing • Know the role of PCT prescribing advisors, pharmacists and dispensing practices • Have considered new innovations such as nurse, pharmacist and electronic prescribing • Be aware of some regulations/guidelines e.g. ACBS regulations, SLS scheme, notification of adverse events

6. Prescribing in primary care; key issues 1 • Prescription duration • Prescribing responsibility • High cost; high tech; high risk or off-licence prescribing • Prescribing for substance abuse

7. Prescribing in primary care; key issues 2 • FP10 Entitlement to free prescriptions on socio-demographic/health grounds • Repeat prescription systems • Prescribing Incentives • Role of PCT prescribing advisor • PACT reports • Role of pharmacists in primary care • Dispensing practices, relationship between a practice and an in-house pharmacy • Nurse prescribing • Electronic prescribing • Relationship with pharmaceutical advisors; pharmaceutical company employed nurses for practice based audits • ACBS regulations/ SLS scheme • Drug interactions, notification of adverse events • Keeping up to date with new drugs (self evident?)

8. Case 1.Doctor informationPrescription duration • Fred is a 72 year old widower who is going to Thailand for 8 months. He has a history of ischemic heart disease having had a CABPG 5 years ago. He normally has a repeat prescription every 2 months. He has very few symptoms and is taking the following drugs: • Atenolol 50mg daily • Aspirin 75mg daily • Atorvastatin 80mg daily • Imdur 60mg daily • Valsartan 160mg daily • His biochemical profile and lipids were normal 3 months ago and his BP is well controlled

9. Case 1.Patient informationPrescription duration • You are Fred, a 72 year old widower who is going to Thailand for 8 months. You have a history of ischemic heart disease, having had a CABPG 5 years ago. You normally have a repeat prescription every 2 months. You have very few symptoms and are taking the following drugs: • Atenolol 50mg daily • Aspirin 75mg daily • Atorvastatin 80mg daily • Imdur 60mg daily • Valsartan 160mg daily • Your biochemical profile and lipids were normal 3 months ago and your BP is well controlled. • You would like your GP to give you a prescription for 6 months worth of tablets, otherwise you will have to buy the drugs in Thailand. You have paid lots of taxes, the NHS is supposed to be free, you did national service etc.

10. BMA advice I live abroad for six months of the year and asked my doctor to give me six months worth of prescription to cover this period but they refused. Can this be right?The NHS accepts responsibility for supplying ongoing medication for temporary periods abroad of up to 3 months. If a person is going to be abroad for more than three months then all that the patient is entitled to at NHS expense is a sufficient supply of his/her regular medication to get to the destination and find an alternative supply of that medication.

11. Prescription duration • ‘NHS guidance that a prescriber writes a prescription that does not exceed a maximum quantity of 30 days supply for tablets’ (p99 in Cases and concepts for the new MRCGP, P. Naidoo)

13. Case 2.Doctor informationPrescribing responsibility • Mavis is an 88 year old diabetic who has made a reasonable recovery from a stroke, but is immobile • She has an indwelling urinary catheter • She has regular carers and the district nurse visits on a daily basis to give Mavis her insulin • Lynn, one of the district nurses wants to see you in the middle of a hectic surgery. Two of your partners are on holiday and another has phoned in sick.

14. Case 2.Patient informationPrescribing responsibility • Mavis is an 88 year old diabetic who has made a reasonable recovery from a stroke, but is immobile • She has an indwelling urinary catheter • She has regular carers and the district nurse visits on a daily basis to give Mavis her insulin • You are Lynn, an experienced district nurse. You have been to see Mavis who complains of abdominal pain and feels hot. Mavis’s urine is smelly and you think she has a urinary tract infection • You know the doctor is very busy and offer to deliver a prescription for antibiotics. You will send a urine sample to the lab, but the carer had already emptied the leg bag when you went this morning

15. GMC Good Practice in Prescribing Medicines (2006) • 7. If you prescribe at the recommendation of a nurse or other healthcare professional who does not have prescribing rights, you must be satisfied that the prescription is appropriate for the patient concerned and that the professional is competent to have recommended the treatment.

16. Prescribing responsibility; what are the rules? • BMA But my friend’s GP wrote them a similar prescription on a consultants advice, why won’t mine? I think this is discriminatory.Each GP will make prescribing decisions based on what they are or are not prepared to take clinical responsibility for. There are cases, where one GP is prepared to take responsibility, whereas another GP may not. Sometimes a patient may feel that the doctor is behaving in a discriminatory manner. An example might be a refusal to prescribe sex hormones for a transsexual. Sometimes a drug is known to be expensive e.g. Interferon, and the patient might believe the refusal to prescribe is because of cost-prejudice. This should not be the case. The refusal to prescribe indicates that the GP, as is his/her right, is not prepared to take the clinical responsibility in the particular circumstances. Expensive drugs and drugs for complex and unusual conditions are those with which the GP is unlikely to have significant experience. However, some GPs will have specialised experience and will be confident to prescribe drugs that other GPs would not have the knowledge to use safely. A patient has the right to request to change NHS GP if they are unhappy with the treatment their GP provides, and an alternative GP is available.

17. Prescribing responsibility • If you sign a prescription, even under the direction of another person, you will be held liable for the consequences. • In the case of Mavis, some doctors would prescribe on the nurse’s recommendation, but would others visit Mavis themselves and make their own assessment before prescribing?

19. Case 3.Doctor informationHigh cost; high tech; high risk or off-licence prescribing • George is a delightful 63 year old man who has been a patient of the practice for many years. He is a retired teacher and his ex pupils include many of the children of the doctors in the practice. • He was diagnosed as having metastatic renal cell carcinoma just over 2 years ago and has been treated with chemotherapy. • He is starting to deteriorate

20. Case 3.Patient informationHigh cost; high tech; high risk or off-licence prescribing • You are George, a delightful 63 year old man and have been a patient of the practice for many years. You are a retired teacher and your ex-pupils include many of the children of the doctors in the practice. • You were diagnosed as having metastatic renal cell carcinoma just over 2 years ago and have been treated with chemotherapy. • You are starting to deteriorate and it was a struggle to get to the surgery today. • Your consultant has mentioned a new drug called Aldesleukin, which he thinks may help. This is licensed for the treatment of your condition, but the consultant’s Trust will not let him prescribe it because it is new and very expensive. • Your consultant says that your GP could prescribe the drug for you and suggests that you approach the GP personally

21. GMC: Prescribing medicines for use outside the terms of their licence (off-label) • You may prescribe medicines for purposes for which they are not licensed. Although there are a number of circumstances in which this may arise, it is likely to occur most frequently in prescribing for children. Currently pharmaceutical companies do not usually test their medicines on children and as a consequence, cannot apply to license their medicines for use in the treatment of children. The use of medicines that have been licensed for adults, but not for children, is often necessary in paediatric practice.

22. GMC: When prescribing a medicine for use outside the terms of its licence you must: • Be satisfied that it would better serve the patient's needs than an appropriately licensed alternative • Be satisfied that there is a sufficient evidence base and/or experience of using the medicine to demonstrate its safety and efficacy. The manufacturer's information may be of limited help in which case the necessary information must be sought from other sources • Take responsibility for prescribing the medicine and for overseeing the patient's care, monitoring and any follow up treatment, or arrange for another doctor to do so (see also paragraphs 25-27 on prescribing for hospital outpatients) • Make a clear, accurate and legible record of all medicines prescribed and, where you are not following common practice, your reasons for prescribing the medicine.

23. BMA advice • What is shared care between consultants and GPs?Sometimes GPs will come to an arrangement with a consultant regarding a patient’s care where in essence the clinical responsibility is shared between the two doctors. There will usually be a formalised written agreement/protocol setting out the position of each, and to which both parties have willingly agreed. This is known as ‘shared care’ agreement. It can be an enhanced service that the GP provides. There are some drugs (eg: certain growth hormones, erythropoietin) which it would not be appropriate for a GP to take sole responsibility for without sharing the care with a consultant. A GP can refuse a ‘shared care’ agreement if he or she is not happy with it, and then the consultant must take full responsibility for prescribing and any necessary monitoring. Pressure on a GP, where it may be inferred that a patient will not receive a treatment such as Interferon or Erythropoietin, if a GP does not agree to prescribe is not acceptable.

24. MTRAC (Midlands Therapeutics Review and Advisory Committee) view on Aldesleukin (this is an old example) Not appropriate • Patients have to be rigorously selected and treatment very carefully monitored, because of toxicity. It is therefore not appropriate for GPs to prescribe aldesleukin irrespective of the route of administration

26. Case 4.Doctor informationPrescribing for substance abuse • Carl is a 20 year old man who used to be your patient till 3 years ago. • He is re-registering today and insists on an appointment with you • Your receptionist has made him wait till the end of surgery and it is now 6.30pm

27. Case 4.Patient informationPrescribing for substance abuse • You are Carl, a 20 year old man who used to be a patient of the practice until 3 years ago. You have moved around a lot and spent 9 months in prison last year following a conviction for burglary. • You are currently having methadone 60 mils daily on a weekly pick up basis. This was prescribed by your last GP in Leeds, but you have had to leave the area in a rush because a drug dealer is ‘out to get you’ (you owe him money from last year). • You were smoking heroin, but not for the last 2 months. • You take cannabis at weekends. • You have insisted on an appointment with your doctor today when you are registering. The receptionist has made you wait till the end of surgery. It is now 6.30pm and you are feeling very ‘rattly.’ • You have not had any methadone today and would like the doctor to give you a prescription for something, even if it isn’t methadone.

29. Allocation of ‘Learning prescriptions!’ for second session • Group A Andy’s group • Group B David’s group • Group C Malcolm’s group • Group D Will’s group

30. Group A. tasks 1,2,3

31. group task 1.FP10 Entitlement to free prescriptions on socio-demographic/health grounds, season tickets • Outline the eligibility for free prescriptions • Consider if there are any areas of uncertainty • Find out about season tickets?

32. Group task 2.Repeat prescription systems • Outline how repeat prescription systems work in your practices • Are there any rules and are they documented? • Discuss examples of what you consider to be good or bad practice. • What is the usual duration of repeat prescriptions for drugs such as amlodipine 5mg given to patients with stable hypertension?

33. Group task 3.Prescribing Incentives from PCTs • Investigate which prescribing incentives have previously been offered to, and are currently offered to your practice? • Find out what the doctors feel about them?

34. Group B. tasks 4,5,6

35. Group task 4.Role of PCT prescribing advisor • Find out about the role of the PCT prescribing advisor

36. Group task 5PACT reports • What are PACT reports? • How are they obtained? • How are they used?

37. Group task 6.Role of pharmacists in primary care Increasingly pharmacists have a role in primary care which is in excess of their traditional dispensing and advisory one • What new roles do pharmacists have? • Carry out a SWOT analysis (from the GP perspective) about the new roles

38. Group C. tasks 7,8,9

39. Group task 7.Dispensing practices, relationship between a practice and an in-house pharmacy • What are dispensing practices? • What are the guidelines about links between GPs and pharmacies? • What are the issues?

40. Group task 8Nurse prescribing • Increasingly practice nurses have a role in primary care which is in excess of their traditional one • What new prescribing roles do practice nurses have? • Carry out a SWOT analysis (from the GP perspective) about the new roles

41. Group task 9Electronic prescribing • What are the new proposals for the electronic linkage of practices to pharmacies? • How does this relate to ‘Connecting for Health’?

42. Group D. tasks 10,11,12

43. Group task 10Relationship with pharmaceutical advisors; pharmaceutical company employed nurses for practice based audits • What are the issues? • What is the guidance? • Don’t upset your trainers, but find out what they think, what is their experience?

44. Group task 11ACBS regulations/ SLS scheme • What are these? • What do they cover?

45. Group task 12.Drug interactions/notification of adverse events • How do we avoid/recognise drug interactions? • Where are the problem areas/situations? • How do we notify adverse events?