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HOW DO I RESPOND TO A NON-COMPLIANT PATIENT WANTING A REPEAT PRESCRIPTION?


Dr Gail Gilmartin Medical and risk adviser at MDDUS I


HAVE a diabetic patient on insulin who has not attended for review for well over a year. When he last requested a repeat prescription for insulin he agreed to attend but then failed to turn up for an appointment. The practice has sent letters reminding him to attend but to


no avail. He has now requested another prescription. How should I proceed? Non-attendance for prescription review


can be a tricky problem and, although this scenario involves insulin, the same issues can occur with many types of repeat prescriptions for essential treatment in conditions that need regular monitoring. Doctors worry that prescribing for


patients who refuse to engage adds to the potential harm that the patient faces. Sometimes doctors feel almost blackmailed into prescribing in an unsafe way where patients request their medication but fail to accept monitoring or follow-up. All doctors are responsible for the


prescriptions they sign and so must be prepared to justify their actions should something go wrong. The same applies if they decide not to prescribe. What factors should be considered and


what is the best way to proceed? The GMC offers detailed guidance (Good


practice in prescribing and managing medicines and devices 2013) about repeat prescribing and in particular states that as with any prescription you should “agree with the patient what medicines are appropriate and how their condition will be managed, including a date for review. You should make clear why regular reviews are important and explain to the patient what they should do if they suffer side effects or adverse reactions, or stop taking the medicines before the agreed review date (or a set number of repeats have been issued). You must make clear records of these discussions and your reasons for repeat prescribing.” Initial discussions with patients on repeat


medication should always include information about the importance of follow-up. At MDDUS we often have cases that arise where patients claim they were not fully advised of the importance of follow-up and review. Their non-compliance is blamed on the doctor for not providing sufficient information in a way the patient could understand. Discussions about review


20 / MDDUS INSIGHT / Q2 2017


form a central part of good care and need to be documented in the patient’s notes should problems arise at a later date. In all cases where there are significant


health risks to the patient from non- compliance, it is the doctor’s responsibility to pursue this. Communication with the patient should ensure they receive the message that review is necessary and why. This can be by personal letter or electronic means if email addresses and mobile numbers are known. Occasionally more urgent contact is needed. Some members are concerned about


possible breaches of confidentiality if messages are left. Care should be exercised, but if there is a significant risk of harm, the risk of breaching confidentiality must be balanced against the risk of harm to the patient if they are not contacted. Take care regarding how much information is left in case someone other than the patient might pick up a message. But again this needs to be balanced because if a message is too vague its importance may be ignored. It is essential to act in a way you can


justify based on the information you hold and the risk to the patient. If in any doubt


ring MDDUS and speak to one of our advisers. Often the simple act of talking things through can be very helpful. Should you continue to prescribe in this


case? You must consider the risks and benefits of the different courses of action. Is it less potentially harmful to prescribe as before or to adjust a dosage? You can also consider prescribing for a limited time to allow the patient to attend and be reviewed. Should the risks of prescribing – or not


prescribing – be unclear then discuss the case with your colleagues and any secondary care doctors involved so that you have a full picture of risks and benefits. It is essential to be adequately informed before making these decisions. Again, we always advise keeping a careful note of the information you have gathered and the way you have used this information to make a decision. These types of dilemmas are quite


common and require careful assessment. Preparing a patient for regular review at the time treatment starts can help to avoid these problems but should such a situation arise the practical steps outlined above can help.


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