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. 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 well as communication difficulties.
Prescribing medication without a face-to-face consultation also needs careful consideration and documentation. With that in mind, the GMC's new guidance Good practice in prescribing and managing medicines and devices places greater emphasis on remote prescribing and the importance of dialogue and patient consent.
When to see a patient in person
One of the main changes is a specific requirement (at paragraph 20(a)) to consider the appropriate mode of consultation the doctor is using. Despite the fact that this is contained in a GMC publication about prescribing, under a heading 'Deciding if it is safe to prescribe', this requirement will apply to all consultations - regardless of whether a prescription is anticipated or generated.
Similarly, the list of circumstances in which a face-to-face consultation may be more appropriate (in paragraph 22), also applies to all consultations.
The new guidance emphasises the need to have sufficient information to prescribe safely, stating in paragraph 38 that "If it's not possible to clarify or ask for more information from the patient in the environment you are working, you should consider whether it is safe to prescribe".
This may include information that needs to be gained from a physical examination of the patient, or other assessments that may not be possible remotely. Because of this, we would also advise doctors to consider whether an alternative means - such as a face-to-face appointment - should be offered to complete the consultation. This might be appropriate if communication is poor for technical reasons, for example, or where it becomes evident a patient is unfamiliar with the hardware/software needed for an online video appointment.
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 make sure 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 get patient consent 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 can't 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.
The new guidance emphasises the need to have sufficient information to prescribe safely
Making detailed notes of a remote consultation is key. Consider making a note to summarise details such as:
- why a remote consultation was deemed appropriate
- the options offered to the patient, eg whether face-to-face was also offered
- a record of their consent to consult remotely
- that aftercare has been discussed and agreed
- information about their agreement to share info with other local health professionals, or justification for proceeding if they decline to provide that consent.
Linking in with the GMC's guidance on consent, the prescribing guidance emphasises the importance of establishing a dialogue with the patient. When getting 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; this is a core clinical skill. 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, but you must be satisfied the patient has the opportunity to consider any relevant information.
If patients request medicines that 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 you do not believe is appropriate.
Want to know more?
Watch the MDU's free on-demand webinar explaining the new GMC guidance on prescribing.
Prescribing without examining the patient
The following fictional example, based on MDU cases, illustrates the type of dilemma doctors may face.
A GP contacted the MDU for advice because she was concerned about prescribing diazepam to a patient following a phone 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 thought she could hear another voice in the room despite the patient saying 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 to see if there had been any improvement. 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 doctor whether she could be sure that the patient had provided all the relevant information the doctor 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 who was 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.
With the increased use of remote consultations and remote prescribing, you are advised to familiarise yourself with the new GMC guidance before it takes effect in April.
This article was first published on GPonline in March 2021, and has been edited for re-publication.
Dr Ellie Mein
Dr Ellie Mein
MB ChB MRCOphth GDL LLM
Ellie joined the MDU as a medico-legal adviser in 2013. Prior to this she worked as an ophthalmologist before completing her Graduate Diploma in Law in Birmingham.
See more by Dr Ellie Mein
Dr Catriona James
Dr Catriona James
Catriona graduated from Glasgow University and trained as a GP in the West of Scotland, before joining the MDU in 2001. Since that time she has completed an LLM in the Legal Aspects of Medical Practice and become a foundation member of the Faculty of Forensic and Legal Medicine. Catriona is based in Glasgow.
See more by Dr Catriona James