Prescribing issues in primary care

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Prescribing issues in primary care

• A series of cases and learning tasks

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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

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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.

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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

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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

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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

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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?)

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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

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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.

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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.

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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)

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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.

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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. Maviss 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

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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.

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Prescribing responsibility what are the rules?

• BMA But my friends GP wrote them a similar
  prescription on a consultants advice, why wont
  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.

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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 nurses recommendation, but
  would others visit Mavis themselves and make
  their own assessment before prescribing?

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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

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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 consultants 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

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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.

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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.

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BMA advice

• What is shared care between consultants and
  GPs?Sometimes GPs will come to an arrangement
  with a consultant regarding a patients 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.

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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

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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

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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 isnt methadone.

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Allocation of Learning prescriptions! for
second session

• Group A Andys group
• Group B Davids group
• Group C Malcolms group
• Group D Wills group

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Group A. tasks 1,2,3
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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?

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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?

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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?

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Group B. tasks 4,5,6
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Group task 4.Role of PCT prescribing advisor

• Find out about the role of the PCT prescribing
  advisor

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Group task 5PACT reports

• What are PACT reports?
• How are they obtained?
• How are they used?

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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

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Group C. tasks 7,8,9
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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?

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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

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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?

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Group D. tasks 10,11,12
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Group task 10Relationship with pharmaceutical
advisors pharmaceutical company employed nurses
for practice based audits

• What are the issues?
• What is the guidance?
• Dont upset your trainers, but find out what they
  think, what is their experience?

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Group task 11ACBS regulations/ SLS scheme

• What are these?
• What do they cover?

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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?