Information and guidance on prescribing in general practice
September 2004
Patients and prescribing: rights and responsibilities
Am I right, that as an NHS patient my doctor must prescribe for me whatever I want?
Under the NHS regulations your GP must prescribe for you any drugs that he feels are needed for your care. This decision of what or whether to prescribe will be a clinical decision based on the presenting symptoms and history. A patient is entitled under the NHS to drugs that the doctor believes are necessary, not what the patient feels should be prescribed. GPs are responsible for all prescribing decisions they make and for any consequent monitoring that is needed as a result of the prescription given.
The Department of Health lists all drugs that the NHS is prepared to pay for in a book called the Drug Tariff. It is likely that most, if not all, the drugs you need are available through the NHS, however the Drug Tariff does have exceptions. Some drugs, like Viagra, listed in Schedule 11 will only be offered on the NHS to patients suffering from specified conditions. Similarly some products other than drugs, such as high energy or gluten free foods, are listed as ‘Borderline Substances’ and may only be prescribed at NHS expense in defined circumstances. Other drugs or substances, listed in Schedule 10, cannot be prescribed at all on the NHS. Examples are Evening Primrose Oil, many vitamins, bath preparations, cough syrups and expensive brand names of some drugs.
(Viagra and “single” mumps, measles and rubella vaccines will be discussed in detail in questions below)
If I would like a drug that is not available on the NHS can my doctor write me a private prescription for it?
Any doctor can write a private prescription for a patient if they feel it is clinically appropriate and they are happy to take responsibility for that prescribing decision. Under the NHS regulations, a GP or his deputy can write a private prescription for a patient but cannot charge the patient for writing a private prescription if the patient is registered for NHS care with that GP or any other GP in the same practice.
The only exceptions to this rule are when an NHS GP writes either a private prescription for drugs that are requested by the patient “just in case” of the onset of illness while outside the UK, or else when a private prescription is required for the prevention (chemoprophylaxis) of malaria.
Can my doctor supply me with drugs directly rather than going to a pharmacist?
The supply of drugs in the NHS is highly regulated. NHS prescriptions must be dispensed at pharmacies except where a doctor has been granted permission to be a dispensing doctor. This is likely to happen when there are few, if any, pharmacies in a rural or semi-rural area. The area is then known as a ‘Controlled Area’ and a dispensing doctor is allowed to supply drugs to named patients who live more than one mile by road from a pharmacy. Many dispensing doctors can only dispense to some of their patients depending on the position of a pharmacy. All patients have the right to take their prescription to a pharmacy of their choice if they wish to do so. Dispensing doctors are never found in areas defined as being non-rural (i.e. ‘urban’) where the proximity of pharmacies is guaranteed. Out of hours a doctor may supply a patient with immediately necessary emergency drugs when the pharmacy or dispensary is likely to be closed. (It is envisaged in the ‘Carson Report’ that in the near future instead of limited supply or a ‘starter pack’ plus a prescription, an Out-of-Hours doctor should supply a complete course of any necessary emergency medicine to the patient, and charge a prescription charge where the patient is not exempt.)
The only situations in which an NHS GP can supply his/her NHS patient with drugs privately are:
1. For drugs which are being issued solely in anticipation of the onset of an ailment whilst outside the UK, but for which the patient does not require treatment when the medicine is prescribed.
2. For drugs issued for the prevention of malaria.
Malaria chemoprophylaxis -There is no NHS Regulation that prevents a GP prescribing drugs for the prevention of malaria at NHS expense. An ‘Executive Letter’ from the NHS encourages doctors to prescribe privately.
A GP, even a dispensing GP, is not allowed to sell any ‘over the counter’ medicines.
Why can’t my doctor give my child single vaccines for measles, mumps and rubella?
There are some drugs (see above) that the government has not been prepared to provide on the NHS. The single vaccines for measles, mumps and rubella are included in this category. The Department of Health believes that on the basis of currently available evidence the MMR vaccine is the most effective and safe means of ensuring protection against measles, mumps and rubella, and therefore this is the only treatment it will provide for on the NHS. The three vaccines combined in MMR boost the effects of one another, whilst there are doubts about the efficacy of single vaccines. Some patients given single vaccines have now been advised to have reimmunisation.
If I choose to pay for it, can my GP give my child single measles, mumps and rubella vaccines?
Under the NHS regulations an NHS GP is not allowed to charge an NHS patient registered with any doctor in his/her practice for anything which is not specified in Regulation 24, Schedule 5 of the National Health Service (General Medical Services Contracts) Regulations 2004,(previously paragraph 38, Schedule 2 ‘Terms of Service for Doctors’). Single vaccines for measles, mumps, or rubella are not specified in Schedule 5. NHS GPs cannot therefore charge NHS patients of their own practice for supplying or for administering these vaccines without breaching their terms of service.
I have seen a consultant who wrote to my GP and asked that they write a prescription for me; however my GP refuses to give it to me. Why?
It is the doctor who signs the prescription who carries legal responsibility, not the doctor who may suggest it. A consultant will often advise a GP to prescribe a particular medicine for a patient. This can be the case whether the patient has seen the consultant privately or on the NHS. GPs will often write a prescription based on the consultant’s advice, but should only do so if they are in agreement that the medicine is appropriate, and if they are sufficiently knowledgeable about the use/interactions/side effects of the particular medicine to take personal legal responsibility for writing the prescription for it. Many complex illnesses may be monitored in primary care, with the GP accepting responsibility for some of the necessary prescribing, but then referring back when necessary under ‘shared care’ agreements for a consultant to prescribe treatment with which the GP cannot be expected to be familiar. In general the doctor who has the clinical control of any aspect of the patient’s management should accept the responsibility for prescribing, except where another doctor has willingly agreed to take some of that responsibility under a ‘shared care agreement’. There is no reason why prescriptions cannot be issued by a hospital doctor and posted to a patient who lives at a distance from the hospital.
A consultant may see a patient privately in order to give an opinion to an NHS GP on diagnosis or further management. Alternatively the consultant may treat a private patient for whom he/she will then continue to have the clinical responsibility, and will personally determine the ongoing treatment for a particular condition. In the latter case the consultant should prescribe privately for his/her private patient. A GP may well refuse to prescribe on the NHS in such a situation, because he does not have the clinical responsibility for managing that particular condition. He must, however, continue to provide NHS treatment and prescription for other conditions for which he does take clinical responsibility.
Sometimes treatments are new, experimental, for unlicensed indications, or are not normally in the area of knowledge in which a GP would be expected to have competence. Any GP has the right to refuse to prescribe a drug that they are not prepared to take clinical responsibility for. An example, which commonly causes problems, is the prescription of Ritalin for a hyperactive child.
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.
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, erythropoetin) 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 Erythropoetin, if a GP does not agree to prescribe is not acceptable.
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.