Guidance

Good Practice in Prescribing

This guidance was published by the GMC on 31st January and came into effect on 25th February 2013.

In “Good Medical Practice” it is stated – in providing care you must:

  • Prescribe drugs or treatment including repeat prescriptions, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs.
  • Provide effective treatments based on the best available evidence.
  • Keep clear, accurate and legible records, reporting the relevant clinical findings, the decisions made, the information given to patients, and any drugs prescribed or other investigation or treatment.
  • Make records at the same time as the events you are recording or as soon as possible afterwards.

It is important to remember that you are responsible for the prescriptions you sign and your decisions and actions when you supply or administer medicines or devices or authorise or instruct others to do so. You must be prepared to explain and justify your decisions and actions when prescribing, administering and managing medicines.

The guidance makes the following statement “Serious or persistent failure to follow this guidance will put your registration at risk”.

“Good Medical Practice” says you must recognise and work within the limits of your competence and you must keep up to date both in your knowledge and skills.

You must not prescribe medicines for your own convenience or the convenience of other health or social care professionals (for example, those caring for patients with dementia in care homes)

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Duration of Prescriptions and 7 Day Prescribing

This is a recurrent issue and something that we are contacted about at the office on a regular basis with GPs and practices asking whether or not there is any obligation to provide prescriptions for seven days of medication. The answer is no – but never say never.

There will be times when a seven day prescription is appropriate e.g. in managing drug addictions or where a patient is starting  a new medication and there might be the need for an early dosage change.

With regard to requests for seven day prescriptions from either patients or pharmacists there is no requirement for GPs to comply. The provision of Domiciliary Medication Dosage Systems (DMDS) is included within the essential services component of the pharmacy contract. We are all required by the Disability Discrimination Act (DDA) to make reasonable and appropriate adjustments to our services so as to ensure that a disabled person is not discriminated against. For pharmacists this will include making medication available with suitable instructions or in a suitable container. The pharmacy contract recognises the increased work and costs of meeting this legal obligation and there is an additional payment per prescription item to help with these costs.

The decision of what adjustments are appropriate in each individual case is the responsibility of the community pharmacist. Seven day prescriptions are not a requirement but it must be remembered that if a prescription is written for 28 days then all 28 days will be provided to the patient at the same time. Community pharmacists are only obliged to provide support to patients who are eligible under the act. Ineligible patients have the option of paying themselves for any requested support.

We are frequently asked for guidance on the appropriate duration of prescriptions and thought it would be helpful to set out our advice and also consider the issue of weekly prescriptions and monitored dosage systems (MDS).

We would advise that the appropriate duration of a prescription should be decided by the prescriber, in conjunction with the patient, taking into account the medicine being prescribed, its monitoring requirements, the condition being treated and the individual patient’s needs.

We would also advise that a shorter duration is appropriate when a new medicine is first started or when a patient’s condition or medicines regimen is likely to change. The quantities on a prescription should reflect the required frequency of dispensing. The quantity (and cost) of wasted medicines is significant and the duration of prescriptions is one factor that affects this.

With regard to the issue of weekly prescriptions the Local Pharmaceutical Committee has produced a useful briefing document on the issue of MDS and the Disability Discrimination Act (DDA). The guidance covers the adjustments that a dispenser (pharmacy or dispensing practice) might be required to make under the DDA and the fact that funding for such adjustments is included in their contract.

It is the dispenser’s decision as to what is the appropriate adjustment, not a carer or another healthcare professional. The guidance is available at: https://cpsc.org.uk

The LPC website also has a number of useful resources to help pharmacists assess and support patients with disabilities.

I would like my patient to receive their medicine on a weekly basis (for reasons of safety).

In this situation it is necessary to prescribe weekly prescriptions. The quantity on a prescription should reflect the required frequency of dispensing.

A care home has asked the pharmacist to provide medicines in a MDS and the pharmacist is asking for weekly prescriptions to help cover the cost of the MDS.

We can see no justification for practices to prescribe weekly prescriptions for patients in care homes unless the patient’s clinical condition justified a weekly supply. GPs should not prescribe weekly prescriptions as a way of subsidising the cost of MDS and the pharmacist and home can enter into a private arrangement for the supply of medicines in a MDS.

A patient requires an MDS because of their disabilities should I write weekly prescriptions?

The pharmacist is responsible for assessing a patient’s needs and making appropriate and reasonable adjustments to their services so that the patient would not be prejudiced against. The supply of medicines in a MDS might be one of the possible adjustments (other examples might be large print labels or a medicines administration record sheet). Funding is included within the pharmacy contract to recognise the additional work and costs of this requirement and therefore weekly prescriptions would not be appropriate (unless clinically indicated).

A patient does not qualify for an MDS, should I write weekly prescriptions?

If the pharmacist has assessed the patient and does not believe they are eligible under the DDA then the patient and pharmacy are free to enter into a private arrangement to provide the support requested

Unlicensed Medicines

The term ‘unlicensed medicine’ is used to describe medicines that are used outside the terms of their UK licence or which have no licence for use in the UK.  Unlicensed medicines are in common use especially in paediatrics, psychiatry and palliative care.

You may prescribe unlicensed medicines where, on the basis of an assessment of the individual patient, you conclude for medical reasons that it is necessary to do so to meet the specific needs of the patient.

Para 69 and 70 of the GMC Guidance state:

69:

Prescribing unlicensed medicines may be necessary where:

a. There is no suitably licensed medicine that will meet the patient’s need. Examples include (but are not limited to), for example, where:

i. there is no licensed medicine applicable to the particular patient. For example, if the patient is a child and a medicine licensed only for adult patients would meet the needs of the child; or

ii. a medicine licensed to treat a condition or symptom in children would nonetheless not meet the specific assessed needs of the particular child patient, but a medicine licensed for the same condition or symptom in adults would do so; or

iii. the dosage specified for a licensed medicine would not meet the patient’s need; or

iv. the patient needs a medicine in a formulation that is not specified in an applicable licence.

b. Or where a suitably licensed medicine that would meet the patient’s need is not available. This may arise where, for example, there is a   temporary shortage in supply; or

c. The prescribing forms part of a properly approved research project.

70:

When prescribing an unlicensed medicine you must:

a. be satisfied that there is sufficient evidence or experience of using the medicine to demonstrate its safety and efficacy

b. take responsibility for prescribing the medicine and for overseeing the patient’s care, monitoring, and any follow up treatment, or ensure that arrangements are made for another suitable doctor to do so

c. make a clear, accurate and legible record of all medicines prescribed and, where you are not following common practice, your reasons for prescribing an unlicensed medicine

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Electronic Prescribing EPS and eRD inc. Remote Consultations

Electronic Prescribing Service – EPS

NHS Digital are continuing to drive  Electronic Prescribing.

Electronic Prescribing Service – Phase 4 was deployed from 18th November 2019, initially to TPP SystmOne following a pilot in 2018. The roll out plans for EMIS, Vision and Microtest will follow.

Phase 4 of EPS allows prescriptions for patients without an EPS nomination to be signed, sent and processed electronically.

The electronic prescription is sent to the Electronic Prescription Service, where it can then be downloaded by a dispenser who has also upgraded their computer system to use EPS.

Patients have the option to choose, or ‘nominate’ a dispensing contractor to receive their electronic prescription automatically ­ without the need for any paper.

Patients without an EPS nomination will be given a token (patients may refer to this as a paper copy of their prescription) to present at a community pharmacy or Dispensing Appliance Contractor (DAC) to obtain their medication. This token will contain a unique barcode which can be scanned at any community pharmacy or DAC in England to download the prescription from the NHS Spine and retrieve the medication details.

Paper prescriptions will continue to be available in special circumstances, but almost all prescriptions will be processed electronically.

Prescribers will have the ability to cancel electronic prescriptions at any point up until they are dispensed and record the reason why they were cancelled. Also, prescriptions for nominated dispensing contractors will no longer need to be sent by post in situations where this was previously necessary.

Phase 4 – Information for GP Practices contains details on how it works in practice along with resources and templates.

Sign up to receive NHS Digital bulletins to your inbox.

Prescribing in Remote Consultations

GMC updated guidance (Feb 2021)

With more and more remote consultations the GPC thought it important to highlight that the GMC have published updated guidance on prescribing, to support doctors who are increasingly seeing patients via remote and virtual consultations.

Key updates include:

  • New advice for doctors not to prescribe controlled drugs unless they have access to patient records, except in emergencies.
  • Stronger advice on information sharing, making it clear that if a patient refuses consent to share information with other relevant health professionals it may be unsafe to prescribe.
  • Alignment with the GMC’s updated Decision making and consent guidance, highlighting the importance of good two-way dialogue between patients and doctors in all settings.
Electronic Prescription Service in Remote Consultations

NHS Digital Updated Guidance – April 2020

Updated guidance has been published by NHS Digital and the key points to note are:

If the patient has an EPS nomination in place already, the prescribing system will automatically default to send the prescription to that dispenser.

  • You should check whether a patient’s nominated pharmacy is suitable for the prescription before prescribing. If not, for example if the nominated pharmacy is closed or the patient is not able to get there, then consider changing the nomination or using a one-off nomination (if this is available in your prescribing system) – see below.
  • If the patient does not have a nomination in place, encourage them to choose a pharmacy that is convenient to them and set the nomination on their record.

Changing a Nomination

If a patient wishes to make a temporary change of nomination, it is important to tell the patient that:

The change of nomination will apply to future prescriptions and may also affect any that they have not yet collected from their pharmacy.

Once they have received their medication from the ‘temporary’ pharmacy, they should ask the pharmacy to change their nomination back to their usual pharmacy. Alternatively, they can contact the practice or their usual pharmacy when they wish to re-set their nomination. They can also change it themselves if this functionality is available to them via their patient-facing service or app.

If the prescriber changes the nomination back or removes it too soon (i.e. before the intended pharmacy has downloaded the prescription), then that pharmacy will not receive the prescription in their routine download.

One-off Nomination

This is only available in some prescribing systems but, if available, can be used to override the patient’s regular pharmacy for this prescription without affecting future prescriptions which will continue to be sent to the patient’s regular nominated dispenser. The one-off prescription would be affected if the regular nomination is changed before it is collected.

EPS Phase 4 (non-nominated) Prescriptions

Currently only available in some prescribing systems.

If an EPS nomination is not a suitable option and if EPS phase 4 is enabled, send the prescription as a non-nominated EPS prescription. The prescription will be signed electronically and sent to the Spine. The prescribing system will default to print a token, which would be given to the patient if they were present, to take to a pharmacy of their choice.

In scenarios where the patient is not present to collect the token, they can still go to a pharmacy to ask them to download and dispense the prescription.

It is important to:

  • Provide the patient with the prescription ID, if possible.
  • If this is not possible, ensure the patient knows their NHS number or knows where to find it.
  • Advise the patient to give the pharmacy their Prescription ID or NHS number.

Nominations – Consent and Recording

Patients must be informed and given their consent before a nomination is recorded. The consent doesn’t have to be in writing but you do need to have an auditable process.

The patient’s nomination should be recorded in the Pharmacy Medicine Record (PMR) system or GP system, and it is then updated on the NHS Spine.

Once updated, the nomination will be visible to both the patient’s GP practice and their pharmacy. The patient’s prescriptions will then be sent via EPS to their nominated pharmacy, unless they request otherwise.

Increasing Electronic Repeat Dispensing

The NHS Business Services Authority has launched a service to help GP practices increase electronic repeat dispensing (eRD). You can request the NHS numbers of patients who may find the service useful, based on their prescribing data.

The whole repeatable prescription can be set up for as long as a year but each repeat should not be for longer than the patient has now.

For example, if the patient has prescriptions for a month’s supply now, then the repeat dispensing should be set up as up to 13 x 28 days’ supply.

Guidance for Practices

The NHSBA will:

  • contact GP practices to confirm whether they have an active nhs.net email address.
  • once confirmed, send the practice an email with a password-protected ZIP file. This will contain the NHS Number and the name of item prescribed for every patient that is potentially eligible for eRD.
  • A clinician should then review the patient records of those patients to ensure that they are appropriate for eRD.

The practice can then arrange for verified patients to be moved to eRD. All requests for NHS Numbers as part of the COVID-19 response should be made to nhsbsa.epssupport@nhs.net .

Information for Patients
To help explain eRD to your patients, the NHSBSA and Wessex AHSN have created a poster for practices’ entrances. To download the poster, visit the NHSBSA website .

Further Guidance

For further guidance, go to: https://www.nhsbsa.nhs.uk/pharmacies-gp-practices-and-appliance-contractors/prescribing-and-dispensing/electronic/erd-information-gp-practices

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Self Prescribing & Family Members

The LMC has been made aware of a number of GPs who have been reported to the GMC for self-prescribing. The LMC would strongly advise GPs not to prescribe for themselves or their family, except in exceptional circumstance.

The areas of high risk are controlled drugs, psychiatric medication and drugs for erectile dysfunction.

The GMC Guidelines for Good practice in prescribing and managing medicines and devices are quite clear:

17. Wherever possible you must avoid prescribing for yourself or anyone with whom you have a close personal relationship.

18. Controlled medicines present particular dangers, occasionally associated with drug misuse, addiction and misconduct. You must not prescribe a controlled medicine for yourself or someone close to you unless:

a. no other person with the legal right to prescribe is available to assess and prescribe without a delay which would put your, or the patient’s, life or health at risk or cause unacceptable pain or distress, and

b. That treatment is immediately necessary to:
i. Save life
ii. Avoid serious deterioration in the patient’s health, or
iii. Alleviate otherwise uncontrollable pain.

19.  If you prescribe for yourself or someone close to you, you must: a make a clear record at the same time or as soon as possible afterwards. The record should include your relationship to the patient (where relevant) and the reason it was necessary for you to prescribe. b tell your own or the patient’s general practitioner (and others treating you or the patient, where relevant) what medicines you have prescribed and any other information necessary for continuing care, unless (in the case of prescribing for somebody close to you) they object.

We are aware of GPs who have been reported to the GMC for self-prescribing antibiotics. Pharmacists will often challenge self-prescribed medication and some will refuse to dispense the prescription.

The LMC has been involved in some cases where a GP has prescribed for themselves using a false name.

Prescribing for yourself or your family using a false name is fraud and a criminal offence and your registration with the GMC  will certainly be at risk.

Please all remember issuing a prescription for yourself on an FP10 for a drug that should be issued as a private prescription is also fraud.

A small number of Wessex GPs have been contacted by the NHS Counter Fraud Service about prescriptions written for family members.  This is partly because treating family members is not ideal but also because a common way for doctors to obtain drugs by deception is to issue a prescription in the name of a family member.

The Counter Fraud Service therefore target prescriptions written by doctors for patients with the same surname or home address.  Although most such prescriptions are innocent (e.g. for antibiotics) the issue can cause embarrassment, as Counter Fraud may inform the GMC of their findings (and this has already happened in some cases).

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Temporary Residents

A person visiting your practice area is entitled to be registered as a temporary patient.

They may not be aware that they can usually order their repeat prescription from their “home” surgery enclosing a stamped addressed envelope (SAE) and an explanation that they are temporarily away on holiday. They are often unaware that the temporary GP does not have all their records, and that safe prescribing is best done routinely by the GP who has the entire record. However, with the advent of Electronic Prescribing Services (EPS) which allows for an electronic prescription to be sent to the Electronic Prescription Service, where it can then be downloaded by a dispenser, this makes it possible for a patient to ask for their repeat prescription from their permanent registered surgery to then be “sent” to a dispenser where they are temporarily away on holiday.

You might find it useful to have a poster with this idea at the reception desk.

It is best to inform them of these (preferred options) but if nonetheless they express a need for their medication then the temporary GP should put themselves in a position to judge whether a prescription is necessary. If it is necessary then a prescription should be issued.

If you are uncertian about the genuine nature of an urgent request, you may wish to prescribe a short course only whilst enquiries are made with their home practice.

Special care should be taken with regard to benzodiazepines and analgesia. See our section on Counter Fraud – Drug Seekers.

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Nurseries, Schools and OTC Medications

Non-prescription (OTC) medication does not need a GP signature/authorisation in order for the school/nursery/childminder to give it.

It has been brought to the attention of the GPC Clinical and Prescribing Subcommittee that the revised ‘The Early Years Foundation Stage Statutory Framework’, which governs the standards of institutions looking after and educating children, includes a paragraph under specific legal requirements – medicines, that states:  ‘Medicines should only be taken to a setting when this is essential and settings should only accept medicines that have been prescribed by a doctor, dentist, nurse or pharmacist.’  We are aware that in some areas this is resulting in parents making unnecessary appointments to seek a prescription for an OTC medicine, just so it can be taken in nurseries or schools.

The Clinical and Prescribing Subcommittee wishes to remind GPs that the MHRA licenses medicines and classifies them when appropriate as OTC (P or GSL).  This is to enable access to those medicines without recourse to a GP.  It is appropriate for OTC medicines to be given by parents, as they consider necessary, in the home or nursery environment.  It is a misuse of GP time to take up an appointment just to acquire a prescription for a medicine, wholly to satisfy the needs of a nursery/school.  The Clinical and Prescribing Subcommittee wrote to the Department of Children, Schools and Families seeking an amendment to this paragraph in the Statutory Framework and we have now heard from that Department.  They will amend their guidance to stay consistent with current national standards for day care and childminding, whereby non-prescription medication can be administered where there is parents’ prior written consent.  Should any practice find that this continues to be a problem in their area we have produced a Template letter for schools requesting OTC medicines which can be downloaded and sent to the Nursery/School.

The Early years foundation stage (EYFS) statutory framework – GOV.UK (www.gov.uk) outlines the policy for administering medicines to children in nurseries/preschools 0-5 years.

The following has been taken from Statutory framework for the early years foundation stage, Setting the standards for learning, development and care for children from birth to five, page 33

3.45.   The provider must promote the good health, including the oral health, of children attending the setting. They must have a procedure, discussed with parents and/or carers, for responding to children who are ill or infectious, take necessary steps to prevent the spread of infection, and take appropriate action if children are ill.

3.46.   Providers must have and implement a policy, and procedures, for administering medicines. It must include systems for obtaining information about a child’s needs for medicines, and for keeping this information up-to-date. Training must be provided for staff where the administration of medicine requires medical or technical knowledge. Prescription medicines must not be administered unless they have been prescribed for a child by a doctor, dentist, nurse or pharmacist (medicines containing aspirin should only be given if prescribed by a doctor).

3.47.   Medicine (both prescription and non-prescription55) must only be administered to a child where written permission for that particular medicine has been obtained from the child’s parent and/or carer. Providers must keep a written record each time a medicine is administered to a child, and inform the child’s parents and/or carers on the same day, or as soon as reasonably practicable.

Statutory guidance for governing bodies of maintained schools and proprietors of academies in EnglandSupporting Pupils at School with Medical Conditions – December 2015

  • “No child under 16 should be given prescription or non-prescription medicines without their parent’s written consent – except in exceptional circumstances where the medicine has been prescribed to the child without the knowledge of the parents. In such cases, every effort should be made to encourage the child or young person to involve their parents while respecting their right to confidentiality. Schools should set out the circumstances in which non-prescription medicines may be administered
  • A child under 16 should never be given medicine containing aspirin unless prescribed by a doctor. Medication, e.g. for pain relief, should never be administered without first checking maximum dosages and when the previous dose was taken. Parents should be informed”.

This website is also a useful resource: https://www.gov.uk/government/publications/supporting-pupils-at-school-with-medical-conditions–3 

Further information can also be found on Prescribing over-the-counter medicines in nurseries and schools (bma.org.uk)

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Requests to Convert Private Prescriptions to NHS FP10

Under NHS GMS Regulations the patient is entitled to receive any drug which is available on the NHS, via an NHS prescription.

Therefore, GPs can convert a private script to an FP10 if the patient requests this.

However, the GMC duty to prescribe only in the best interests of the patient and only within your level of competence, takes priority.

There are a number of circumstances when prescribers will decline the request or offer to prescribe an alternative medicine.

He or she may decline to prescribe if:

  • A letter explaining the full rationale for the treatment has not been provided by the consultant in the private sector.
  • He or she feels the medicine is not clinically necessary.
  • The medication is unlicensed.
  • The medication is prescribed outside of its licensed indication.
  • The medication is not one he or she would normally prescribe.
  • The medication needs special monitoring and he or she feels they do not have the expertise to do this.
  • The use of the medication conflicts with NICE guidance or locally agreed protocols.
  • An equivalent but equally effective medicine is prescribed locally under prescribing advice from the CCG. In this situation you will be offered the equivalent medicine.

In any of these circumstances the patient will retain the option of purchasing the recommended medicine via a prescription from their consultant in the private sector.

There is also no provision for refunding any money already spent on private treatment, including medicines.

We have some template letters for patients requesting prescriptions following outpatient appointments:

Prescribing following assessment or treatment in the private healthcare sector

Prescribing following assessment or treatment under the NHS

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Last Reviewed Date
13/12/2023