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Prescribing in general practice

Cannabis-based medicinal products

July 2018, the Home Office announced plans to reschedule cannabis-based medicinal products in order to widen their availability within the NHS. The new regulations came into effect on 1 November 2018.

Read our FAQs

 

Increase for NHS prescription charges - 1 April 2018

The charge for a single prescription increased by 20p from £8.60 to £8.80 for each medicine or appliance dispensed from 1 April 2018. The BMA believes it would be best to abolish prescription charges in England - they have already been abolished in Northern Ireland, Scotland and Wales.

Read the full details on GOV.UK

 

Our guidance for prescribing in general practice

The GP committee's prescribing policy group has published guidance to help with the clinical rights and responsibilities in relation to prescribing.

Download this guidance

 

In detail

  • GPC policy

    Drug switching

    The GPC is aware that in some areas practices are being encouraged by their PCO to switch patients from one drug to a less expensive drug. The prescriber must assess each patient individually when taking the decision to change a patient’s medication. Any changes must be made in the patient’s best interests and must be fully explained to the patient.

    Where a bulk switch is made at the request of the PCO or CCG they should provide adequate resources to facilitate the switch including the input of the pharmacy advisor and resources to inform patients of the change. Where it is reasonable to switch a patient then practices may agree to do so. However, GPs must always use their clinical judgement and, where they can make a clinical case for not switching a patient, they have every right to continue to prescribe as they feel is clinically appropriate. GPs continue to carry responsibility for their prescribing decisions.

    Repeated switching on the basis on cost savings alone can irritate patients and can erode trust and compliance. These detrimental effects need to be borne in mind.

    A related issue is the confusion patients can experience when the colour and shape of their tablets are changed as a result of pharmacists changing supplier. With some pharmacists this can happen frequently. Continuity in prescribing for individual patients is safer and will improve compliance.

     

    Exemptions from prescription charges

    People with certain medical conditions can get free NHS prescriptions, and in April 2009 cancer was added to the list of conditions that give exemption from prescription charges. Patients receive an application form which needs to be countersigned by their GP or hospital doctor (or, at their GP's discretion, a member of the practice who can access their medical records). The full list of exempted conditions is available on the NHS Business Services Authority website, including further guidance.

    The BMA has long called for a review of the prescription charge system and believes that prescriptions should be free of charge for all patients in England as they already are in the rest of the UK.

     

    Excessive prescribing

    The GPC is aware that some PCOs have in the past attempted to misuse Annex 8 of the 2006/07 GMS contract (‘Excessive and inappropriate prescribing: guidance for health professional on prescribing NHS medicines’) to control prescribing or threaten termination of GMS contracts. The GPC has produced further guidance on this topic: Focus on excessive prescribing.

     

    Medicine shortages

    In 2011, the GPC produced joint guidance with the Department of Health (DH), Pharmaceutical Representatives and MHRA via a Medicines Supply Chain group, Best practice for ensuring the efficient supply and distribution of medicines to patients, that sets out the key legal and ethical obligations on manufacturers, wholesalers, NHS Trusts, registered pharmacies and dispensing doctors in relation to the supply and trading of medicines. However, this remains a problem for both patients and doctors, and the GPC continues to be in discussion with England’s Department of Health.

     

    Non-GP prescribing

    When a non-GP prescriber initiates a new drug, they accept responsibility for that prescription, but usually have no method of reissuing repeats and so that responsibility invariably falls on GPs. When faced with a request from the patient for a repeat prescription initiated from outside the practice, GPs should review the patient and set up a repeat prescription if appropriate or refer the patient back to initial prescriber.

    Good working practice would advise that anything prescribed for long term prescription should be notified to those likely to continue the medication (i.e. the GP). The responsibility for checking interactions remains with the prescriber who should take a full drug history if they do not have access to the main clinical record. [See also FAQs on supplementary and independent prescribers]

     

    Prescribing numbers for GPs

    Following pressure from the GPC, from 2007 salaried GPs have been entitled to have their own prescribing number. When a salaried GP joins a new practice, they would need to fill in an NPL 2/3 form [change to circumstance or status] and send to their local NHS England team, to obtain an individual unique prescribing number. We continue to make representations for all prescribers to have a unique identifier for their prescribing consisting of an individual number combined with a location code.

     

    Prescribing incentive schemes

    Prescribing incentive schemes are implemented in some areas to reward practices for cost effective prescribing. GPs should be aware of the costs involved and ensure ethical consideration when signing up to schemes. The GPC supports prescribing incentive schemes where they are evidence-based and introduced with the support of local GPs. For further advice see the GMC guidance Good Medical Practice about good clinical care and Good practice in prescribing and managing medicines and devices.

     

    Working with pharmacists

    The GPC is working together with the Pharmaceutical Services Negotiating Committee (PSNC), on issues relating to community pharmacists. Guidance on community pharmacy is available on the webpage for dispensing doctors and community pharmacy.

     

    Community Drug Charts

    There is no need for a GP to complete a community drug chart (MAR Chart) as a prescription is all that is legally required for a nurse or other community worker to administer medication.

    We believe that there is widespread confusion about the role of a medicines administration record. Many people believe that this is an instruction for the medication to be administered, whereas it ought to be regarded as a record that a medication has been given, with the instruction being provided by the information provided by the prescriber on the prescription and recorded by the dispenser on the original packet. We do have concerns that many organisations that use MAR charts use them inappropriately as an authority to administer, rather than as a record of that administration.

    If the employer of the community nurse (or other worker) requires any additional documentation then the responsibility for completing that resides with the organisation whose staff are using it, compiled from the information provided by the prescriber, and completed by staff trained in the process. The drugs themselves should be given according to the prescription as recoded on the original packet, with only the fact that it was given (or not) entered on the MAR chart.

  • Prescription intervals FAQ

    Is there a standard prescription interval?

    Doctors should provide prescriptions for intervals that they feel are clinically appropriate, taking into account such factors as possible reactions, the stability of the treatment, patient compliance, and any necessary monitoring. Sometimes a doctor may give six or even twelve months supply on one prescription (for example the contraceptive pill, or thyroxine, with a regular review in surgery once the patient is safely stabilised) as this is cost-effective and convenient for patients.

    A report on prescribing durations recognises that blanket instructions to only give 28 days’ supply are associated with significant increases in dispensing and other transaction costs, together with reductions in compliance in previously stable patients, and an increase in dissatisfaction amongst patients because of travel costs and time to obtain regular medicines. It can also place significant and unnecessary workload on the doctor and surgery staff.

     

    What should we do about seven-day prescribing for MCA dispensing?

    The request for seven-day repeat prescriptions to defray the pharmacist’s costs for the filling of MCAs has become an increasing pressure for GPs. Our advice is to resist such demands unless there is a clinical reason for restricting supply to seven days. Length of prescriptions should be specific to the status and condition of the patient and their particular clinical needs. Consistency of size, shape and colour of the medication could be more effective than using MCAs, as it can be confusing for patients to receive medication that appears different every time that it is prescribed. There are also some storage problems involved in using MCAs, such as possible deterioration of drugs after being taken out of the packet.

    There are also alternative ways to support patients taking medication, such as medicine advice charts, which allow the drugs to then be retained in their original packaging with advice sheets.

    The GPC supports the Pharmaceutical Services Negotiating Committee (PSNC) in that both pharmacists and dispensing doctors issuing MCAs should be properly reimbursed for the services they provide to patients.

  • Travel vaccinations FAQ

    Guidance on travel vaccinations can be found in our Focus on travel immunisations.

  • Supplementary and independent prescribing FAQ

    What is a supplementary prescriber?

    Supplementary prescribing involves a voluntary partnership between an independent prescriber and a supplementary prescriber (a trained nurse, midwife, pharmacist, physiotherapist, diagnostic and therapeutic radiographer, or optometrist who has completed the relevant training programme) to implement an agreed patient-specific Clinical Management Plan with the patient’s agreement. However, this arrangement is becoming less common, with the broadening of the group of professionals that can be independent prescribers (see below).

     

    What is an independent prescriber?

    Currently independent prescribers include nurses, pharmacists and optometrists; and chiropodists, physiotherapists and podiatrists who were added to the list of independent prescribers in 2013.

    Nurse independent prescribers include district nurses and health visitors who can prescribe in their own right. Independent nurse prescribers can prescribe any medicine for any medical condition within their competence, including some controlled drugs listed in schedules 2-5 except diamorphine, cocaine, dipipanone for the treatment of addiction.

    Qualified and registered pharmacist independent prescribers can prescribe any medicine for any medical condition within their competence, including any controlled drugs listed in schedules 2-5 except diamorphine, cocaine, dipipanone for the treatment of addiction.

    Optometrist independent prescribers are able to prescribe any licensed medicine for ocular conditions affecting the eye and surrounding tissue, but cannot prescribe any controlled drug independently.

    Although all independent prescribers have access to the full range of medicines listed in the BNF, they have an overriding professional duty to prescribe within their knowledge and competency.

    The PSNC has a useful list of which different prescribers can prescribe.

     

    Does this mean that doctors bear no responsibility for the actions of independent prescribers?

    Independent prescribers are professionally responsible for their own actions. However, where a nurse is appropriately trained and qualified as an independent prescriber and prescribes as part of his or her nursing duties with the consent of their employer, the employer may also be held vicariously responsible for the nurse's actions. All independent prescribers should ensure they have professional indemnity and the employing GP should be satisfied that any employee has the relevant skills and training.

     

    Have prescribing by podiatrists, chiropodists and physiotherapists now been introduced?

    In 2011, the Department of Health consulted on the introduction of prescribing by podiatrists, chiropodists and physiotherapists. The BMA believes that appropriately trained physiotherapists, chiropodists and podiatrists should be permitted to prescribe independently from a list of specified medicines for a specified list of conditions, as is the case for dentists, unless under supervision of a named consultant. As of 2013, podiatrists, chiropodists and physiotherapists have been added to the list of independent prescribers, and the Health and Care Professions Council will be their regulator.

  • Private prescriptions FAQ

    If a patient has been seen privately in secondary care and is given a private prescription, is it acceptable for them to come to their GP and ask for it to be converted to an FP10?

    If a patient is being seen as an NHS patient in a private facility (e.g. through eRS), they should be provided with NHS prescriptions by the clinician responsible for their care.

    If a GP receives a letter from a private consultation advising/suggesting a course of action then it may be appropriate for a script to be issued on an FP10 if the GP agrees with the advice. The prescriber takes clinical responsibility for monitoring, so the GP must ensure that they are able to accept this responsibility.

    If the drug is one that a GP would not normally initiate, then it may be prudent to await a full communication from the private consultant. Even then, replacement of the private prescription with an FP10 may not be appropriate and the patient may need to be advised of this.

     

    Can I prescribe drugs which are available on the NHS and are cheaper than the prescription charge, e.g. amoxicillin, on a private script to save the patient money?

    GPC has obtained legal advice that in case of treatment under the primary care contract, GPs may not issue private prescriptions alongside as an alternative to FP10s. In any case where a GP is obliged to issue an FP10, the concurrent issue of a private prescription will be a breach of this obligation.

     

    Are CCGs allowed to request that GPs issue private prescriptions of branded medicines where a patient has requested a brand but there is no clinical reason why the generic should not be prescribed?

    GPC has obtained legal advice which confirms that GPs cannot issue private prescriptions alongside NHS prescription forms (FP10s), including in the context of locally commissioned services outside the core GMS/PMS contract, as this would be a breach of the GMS Contract Regulations.

    Clause 14.2.2. of the GMS contract state that, subject to specific exceptions, a prescriber “shall order any drugs, medicines or appliances which are needed for the treatment of any patient who is receiving treatment under the contract by issuing to that patient a non-electronic prescription form”.

    The medicine must be ordered on an FP10, and to supply it via a private prescription would be a breach both of the requirements of the Regulations and the terms of the contract.

  • Charging patients FAQ

    May GPs charge their own patients?

    The GMS contract prevents contractors from charging their patients for most services. There are however instances were charges may be made. Schedule 5 of GMS Regulations 2004 lists the strictly limited circumstances in which GPs may charge fees for providing treatment to their NHS patients. Similar arrangements apply to the other contractual options.

     

    May GPs charge for issuing a private prescription?

    GPs may write private prescriptions for patients which they may wish to do for drugs not available through the Drug Tariff. However, GPs may not normally charge their registered patients for providing such a prescription, although a dispensing doctor may charge for dispensing the prescription. The only occasions when a doctor may charge for a private prescription 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.

     

    May GPs charge for dispensing a private prescription for ‘black/grey listed’ drugs?

    Prescribing doctors may not charge. Dispensing doctors can supply ‘black/grey’ listed drugs and charge for the supply of the drug as set out in schedule 5, section 24 of the GMS Regulations 2004.

  • Patients and prescribing rights and responsibilities FAQ

    Am I right, that as an NHS patient my GP must prescribe for me whatever I want?

    Under the NHS regulations your GP must prescribe for you any drugs that he or she feels are needed for your medical care. A patient is entitled to drugs that the GP believes are necessary, not those which 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 list 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, 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 gluten free foods or sunblocks, 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, these include Evening Primrose Oil, many vitamins, bath preparations, cough syrups and expensive brand names of some drugs.

     

    If a drug is not available on the NHS, can my GP 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:

    1. 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. Drugs issued for the prevention of malaria.

     

    Can my GP 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 most 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 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.

    Malaria chemoprophylaxis - The Department of Health has issued guidance that medication for malaria prophylaxis may not be reimbursed under the NHS and so this should be prescribed privately. A GP may make a charge for the provision of prescriptions for malaria tablets if these are not available ‘over the counter’ at a pharmacy.

    A GP, even a dispensing GP, is not allowed to sell any ‘over the counter’ medicines.

     

    Can my GP refuse to give me a prescription that my consultant asked them to provide?

    Yes, your GP may refuse because the person who signs the prescription is legally liable for the prescribing and the consequent effects of that drug.

    Some drugs which may be very familiar to consultants in a specialised area of medicine can be potent drugs of which a GP will have little experience (for example many cancer drugs or specialised treatment for diseases such as rheumatoid arthritis – the group called ‘biologicals’). Where a GP considers that it is inappropriate for them to issue a prescription on the advice of a third party, responsibility for provision will rest with the doctor making the recommendation.

    As part of the 2017-18 NHS standard contract for secondary care trusts, new requirements on hospitals has been placed to reduce inappropriate bureaucratic workload shift onto GP practices. As a result, the GPC has published template letters in the event that hospitals are not implementing the changes, as well as template letters to CCGs to highlight where there has been a breach of the standard contract, for the CCG to take action.

     

    A friend’s GP wrote them a similar prescription on a consultant’s 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. Some doctors might have special training or knowledge of a particular area of medicine which makes them comfortable to prescribe and monitor a drug where many GPs would not.

    Clearly, a GP should be aware of their limitations as well as their skills and must ensure that they are not prescribing beyond their knowledge or their ability to ensure patient safety.

    GPs are not obliged to provide every possible medical service to their patients, only those for which they have been contracted for, and these contracting arrangements may vary between practices.

     

    What is a shared care agreement?

    Sometimes the care of a patient is shared between the two doctors, usually a GP and a specialist. There should be a formalised written agreement/protocol setting out the position of each, to which both parties have willingly agreed, which is known as an ‘shared care agreement’. It is important that patients are involved in decisions to share care and are clear about what arrangements are in place to ensure safe prescribing.

    In some cases, a GP may decline to participate in a shared care agreement if he or she considers it to be inappropriate. In such circumstances the consultant would take full responsibility for prescribing and any necessary monitoring. Guidance covering these issues was published in 2018, on the NHS England website.

     

    I live abroad for six months of the year and my GP has refused to give me a prescription.

    The NHS accepts responsibility for supplying ongoing medication for temporary periods abroad of up to three months. If a person is going to be abroad for more than three months then only a sufficient supply of his/her regular medication should be provided to enable them to get to the destination and find an alternative supply.

    NHS prescriptions must never be obtained by relatives or friends on behalf of patients who are currently abroad, irrespective of such factors as owning a house in the UK or paying UK taxes. Patients are responsible for ensuring that any drugs they take into a country conform to local laws.

  • Useful resources

    BMA guidance on drugs and prescribing

    General Medical Council (GMC) - Good practice in prescribing and managing medicines and devices

    NHS Prescription Services - For the monitoring, processing and information feedback related to NHS prescribing.

    The Medicines and Healthcare Products Regulatory Authority - Relating to drug licensing, yellow card reporting, drug and device safety and medicine consultations.

    The Royal Pharmaceutical Society of Great Britain - Guidance on controlled drugs and the Misuse of Drugs Act, and on medicines use and storage.

    The Dispensing Doctors Association - Guidance for dispensing doctors, including legal requirements for storage and use of controlled drugs.

    NHS England - Responsibility for prescribing between primary and secondary / tertiary care

    NHS (General Medical Services Contracts) (Prescription of Drugs etc.) Regulations 2004

    British National Formulary (BNF) - Practical information on the selection and clinical use of medicines for UK healthcare professionals.

    The Human Medicines Regulations 2012

    Electronic Prescription Service (EPS)

    NICE Medicine and prescribing support - Comprehensive advice and support for delivering quality, safety and efficiency in the use of medicines.