Paragraph 98 and remote consultations

by TheEditor

Categories: Investigative, Medicine

This blog has considered a number of issues relevant to prescribing of medications. Paragraph 98 is one of the most powerful. It is squarley designed to protect patients.

You are responsible for any prescription you sign, including repeat prescriptions for medicines initiated by colleagues, so you must make sure that any repeat prescription you sign is safe and appropriate. You should consider the benefits of prescribing with repeats, and where possible, reduce repeat prescribing.

GMC’s standards on prescribing.

At first glance it may seem to be what ‘everybody’ is supposed to know. A deeper think about it reveals its power. The following are suggested:

You” – means a person registered with a licence to practice medicine.

Sign” – means authorise because a signature of any sort means an authorisation. Authorisation is sometimes given by word of mouth in certain situations.

Must” – the word means a duty of care as defined by the GMC.

Make sure” – means take reasonable effort to make relevant checks required by other parts of the Standards – and the associated documentation so that in months ahead, ‘you’ can evidence that you ‘made sure’.

Safe” – means reasonably safe having considered all relevant aspects of the patient, in paras 99 to 102 – as nobody can be near 100% safe.

Appropriate” – the GMC has not defined what they mean by the word in para 98. It means various things captured by paras 99 to 102 (and other parts). Capacity & Consent would fall into this, as well as prescribing of unlicenced medications (defined by the GMC) at para 103 (See 103 to 109).

Scenario

A consultant psychiatrist was asked in a remote consultation via MS Teams, by a health worker to prescribe for a patient, s/he had no previous knowledge of. This arose from administrative difficulties due to the prescribing psychiatrist being off on leave. There were no other substitute prescribers who could help. The psychiatrist who went on leave previously prescribed 36 mg of methylphenidate for ADHD. The remote consultation was a request to increase the dose to 54mg which reportedly was part of the treatment plan.

It was established that if the dose was not increased it would continue at 36mg/d and could be increased at a later stage. Due to lack of access to records and no immediate access to the patient, it was not possible to properly evaluate: the condition and diagnosis, consent/capacity, risks to the patient by increasing the dose, concurrently prescribed medications, the patient’s physical health, relevant investigations, nor any follow-up arrangements.

The consultant psychiatrist ascertained from knowledge and experience of treating ADHD cases, that there was minimal risk to the patient (or others) by not increasing the dose immediately. There was no urgency or immediacy. The advice was to continue the dose at 36mg/d and arrange for the dose to be increased at a later stage, perhaps when the original prescribing psychiatrist returned from leave or at an outpatient clinic. Paragraph 98 was appropriately applied.

Meaning

No rubber stamping

The overall context of para 98 means that even if a medication has been previously prescribed multiple times, the guidance mandates that doctors review factors such as:

  • Current medical conditions
  • Other medications risking drug interactions
  • Appropriate dosing based on latest status
  • Monitoring plans for potential adverse effects
  • Alignment with therapeutic goals and standards of care

This underscores that repeat prescribing is not a perfunctory task but requires an active re-assessment and deliberation by the prescriber each time to uphold their professional responsibilities.

The key points from paragraph 98 that highlight why repeat prescribing cannot be taken lightly are:

  1. “You are responsible for any prescription you sign, including repeat prescriptions for medicines initiated by colleagues.” This makes it clear the prescribing doctor retains full accountability.
  2. “You must make sure that any repeat prescription you sign is safe and appropriate.” The use of “must” indicates an obligatory requirement to ensure safety and appropriateness is verified for each repeat.
  3. “You should consider the benefits of prescribing with repeats, and where possible, reduce repeat prescribing.” This suggests repeat prescriptions should be limited where feasible, rather than reflexively continued.

In essence, paragraph 98 does not allow doctors to simply “rubber stamp” repeat prescriptions.

Safe and appropriate

Safe means:

  1. Having sufficient information about the patient’s current medical conditions, other medications, potential drug interactions/contraindications to assess risks.
  2. Ensuring the medication is still clinically indicated and the intended benefits outweigh potential adverse effects.
  3. Determining if the dosage/formulation remains suitable based on the patient’s latest health status.
  4. Establishing a plan for monitoring the patient’s response and any potential side effects.

What is safe is captured in aggregate by the following paragraphs.

  1. Paragraph 1 (Good medical practice): Doctors must work within the limits of their competence and follow professional standards.
  2. Paragraphs 8-14: Keeping up to date with knowledge and skills, using electronic and other systems, and following guidance to improve prescribing safety.
  3. Paragraphs 21-26: Considering the suitability of the mode of consultation (e.g., face-to-face vs. remote) for safe prescribing.
  4. Paragraphs 27-33: Ensuring sufficient information is available to prescribe safely, especially when not the patient’s regular prescriber.
  5. Paragraphs 59-66: Exercising caution when prescribing controlled drugs, drugs that are liable to misuse, or those requiring additional safeguards.
  6. Paragraphs 93-97: Monitoring, follow-up, and review arrangements to ensure ongoing safety of prescribed medicines.
  7. Paragraphs 99-102: Ensuring secure procedures for repeat prescriptions to maintain patient safety.

Appropriate means:

  1. The repeat prescription aligns with the intended therapeutic goal and standard of care for the patient’s condition.
  2. Non-pharmacological alternatives have been considered where relevant.
  3. The duration of the repeat prescription is reasonable based on the clinical situation.
  4. The patient has been properly counselled on the medication’s use, precautions, etc.
  5. Prescribing the repeat remotely does not compromise the physician’s ability to properly evaluate the ongoing need/suitability.

What is appropriate is captured in aggregate by the following paragraphs:

  1. Paragraphs 20 and 35-40: Assessing the patient’s needs, establishing a dialogue, and obtaining consent before prescribing.
  2. Paragraphs 41-44: Assessing the patient’s capacity to make decisions about treatment.
  3. Paragraphs 45-52: Providing sufficient information to patients about their medicines and considering their preferences.
  4. Paragraphs 76-79: Ensuring prescriptions are appropriate when based on recommendations from other healthcare professionals.
  5. Paragraphs 80-82: Ensuring competence and considering the patient’s needs when sharing prescribing responsibilities in shared care arrangements.
  6. Paragraphs 103-109: Prescribing unlicensed medicines only when necessary to meet the patient’s specific needs.

Essentially, “safe and appropriate” imposes a duty of care on the prescriber to ensure repeat prescriptions, even remotely, are still clinically justified, carry an acceptable risk-benefit profile specific to that patient, and follow best practice guidelines as much as possible. Documenting the decision rationale would also be prudent.

Remote consultations

A remote consultation, also known as a telemedicine consultation or virtual visit, refers to the practice of providing healthcare services and medical advice to patients remotely, without the need for an in-person encounter. It involves the use of telecommunication technologies, such as video conferencing, telephone calls, or secure messaging platforms, to facilitate real-time or asynchronous communication between healthcare providers and patients who are geographically separated. The GMC has given supplementary guidance on remote consultations.

Remote consultations, especially over the telephone, can present several potential pitfalls or limitations compared to in-person consultations. Here are some key areas of concern:

  1. Lack of visual cues: Over the phone, the physician cannot observe the patient’s physical appearance, body language, or non-verbal cues that can provide important clinical information about their condition or distress levels.
  2. Limited physical examination: Remote consultations preclude the ability to perform a hands-on physical examination, which is often crucial for accurate diagnosis and assessment of many medical issues.
  3. Diagnostic uncertainty: Without being able to directly inspect the affected area or perform relevant tests, there is a higher risk of missing important clinical findings or arriving at an incorrect diagnosis remotely.
  4. Communication barriers: Telephone consultations may pose challenges for patients with hearing impairments, cognitive deficits, or language barriers, impacting the physician’s ability to obtain an accurate history or convey instructions effectively.
  5. Privacy and confidentiality concerns: Depending on the patient’s environment during the remote consultation, there may be privacy issues or distractions that compromise the necessary focus and confidentiality.
  6. Establishing rapport: Building a strong patient-doctor rapport, which is essential for trust and adherence, can be more difficult without the benefits of in-person interaction.
  7. Technology limitations: Connectivity issues, poor audio quality, or unfamiliarity with the technology platform can hamper the effectiveness of remote consultations. Electronic or paper records may not be available.
  8. Inability to directly observe medication administration or side effects: For certain medications or conditions, being unable to witness in-person how the patient takes the medication or manifests side effects poses a monitoring challenge.

While remote consultations offer convenience, these potential pitfalls highlight the need for careful screening of cases suitable for this mode, clear communication protocols, and an understanding of the inherent limitations compared to traditional in-person evaluations.

Para 98 and remote consultations

To uphold the duties outlined in paragraph 98 when engaging in remote prescribing or authorising repeat prescriptions remotely, prescribers must ensure they have robust processes in place to:

  • Access complete and up-to-date medical records
  • Verify patient identity and obtain proper consent
  • Assess the ongoing clinical necessity and appropriateness
  • Establish clear monitoring and follow-up plans
  • Comply with relevant regulations and documentation requirements

Thorough documentation of the decision-making process, including any limitations or deviations from the ideal, would also be prudent to demonstrate accountability per paragraph 98.

Limited traction of para 98

There are probably hundreds of thousands of prescriptions that need to be repeated in the UK every day. Quite a fraction of those repeats would be done by junior doctors, and another fraction done by doctors who are covering for absences of other doctors. To put such high duties of care on the repeat prescriber means that the burden of scrutiny of another doctor’s prescribing practice is too high, cumbersome, time consuming in scrutiny and time consuming in diligent documentation. Junior doctors for example will lack the expert knowledge to address safety and appropriateness. Doctors have to be able to trust other doctors.

Some doctors will object to such a high standard because every day doctors are required to repeat prescribe for patients they have not been involved with. The duties of care are serious. A not unfamiliar argument is that if every doctor had to obey the GMC standards in para 98, health services would melt down due to lack of human resources and time impact. Furthermore, any deviation from the standard requires brutal documentation of the factors balanced in order to be accountable at some date in the future which could be 6 months or more – or less if something untoward happens in what could have arisen from a remote consultation and remote prescribing.

Adhering strictly to the high standard set by paragraph 98 for every repeat prescription, especially in a remote context, would indeed place a significant time burden on doctors and potentially overwhelm the healthcare system’s capacity.

Some key considerations:

  1. In routine practice, doctors often have to re-prescribe medications initiated by colleagues without being able to do a full reassessment each time. This is an acknowledged reality.
  2. Aiming to fully satisfy paragraph 98 for every repeat remote prescription would require extensive documentation of the doctor’s clinical reasoning, risk/benefit analysis, review of patient records, etc. This is extremely time-consuming.
  3. Intentionally disregarding the guidance also opens up legal/ethical risks if adverse events occur from inappropriate remote prescribing.
  4. Imposing such rigorous duties of scrutinising the initial prescribing decision and diligently documenting the rationale for every single repeat prescription would create immense administrative and time burdens on doctors.
  5. This could significantly impede workflow efficiency and potentially diminish patient access to needed medications if the repeat prescribing process becomes overly cumbersome.

Pragmatics

  1. There is an inherent need for doctors to be able to reasonably trust the clinical judgment and prescribing practices of their colleagues, at least for stable, low-risk medications.
  2. The duty of care and primary liability should arguably lie more with the doctor who initiated the original prescription, after a comprehensive patient assessment.
  3. For the repeat prescribing doctor, a reasonably diligent review of available records and the patient’s current status, within the constraints of their practice environment, may be more pragmatic.

Summary and takeaway points

Paragraph 98 of the GMC’s standards on prescribing places a significant duty of care on doctors when it comes to authorising repeat prescriptions, even in the context of remote consultations. The paragraph states that doctors are responsible for ensuring any repeat prescription they sign is safe and appropriate for the patient.

In remote consultation scenarios, fulfilling this duty can be challenging due to potential limitations. Doctors may lack access to complete medical records, inability to perform physical examinations, and challenges in verifying patient identity or obtaining informed consent. There is also a risk of missing crucial clinical information or signs that could impact the appropriateness of the repeat prescription.

Furthermore, remote consultations may involve technological limitations, communication barriers, or regulatory complexities that could hinder a doctor’s ability to gather sufficient information to make a fully informed decision aligned with paragraph 98’s requirements.

Failure to adhere to the standards set forth in paragraph 98 when authorizing repeat prescriptions remotely could expose doctors to legal and ethical risks, particularly if adverse events occur due to inappropriate prescribing practices.

To mitigate these risks and uphold their professional responsibilities, doctors engaged in remote prescribing must implement robust processes to access comprehensive medical histories, establish clear monitoring and follow-up plans, comply with relevant regulations, and thoroughly document their decision-making process, including any deviations from the ideal standard due to the remote nature of any consultation.

Ultimately, paragraph 98 underscores the importance of ensuring repeat prescriptions, even in the remote setting, are clinically justified, carry an acceptable risk-benefit profile for the specific patient, and align with best practices in prescribing. Doctors must exercise diligence and prioritise patient safety when navigating the potential pitfalls of remote consultations involving prescribing or repeat prescribing.


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