Deciding if it is safe to prescribe
You should only prescribe medicines if you have adequate knowledge of the patient’s health and you are satisfied that the medicines serve the patient’s needs. You must consider:
- the suitability of the mode of consultation you are using, for example face to face or remote, taking account of any need for physical examination or other assessments (see paragraphs 21 to 26)
- whether you have sufficient information to prescribe safely, for example if you have access to the patient’s medical records and can verify relevant information (see paragraphs 27 to 33)
- whether you can establish two-way dialogue, make an adequate assessment of the patient’s needs and obtain consent (see paragraphs 34 to 38)
- whether you can share information appropriately after an episode of care (see paragraphs 53 to 58).
Does the mode of consultation meet the individual needs of the patient and support safe prescribing?
Patients may prefer to access healthcare services face-to-face or through remote consultations via telephone, video-link or online, depending on their individual needs and circumstances.7 Where different options exist, and when it is within your power, you should agree with the patient which mode of consultation is most suitable for them.
Circumstances in which a face-to-face consultation may be more appropriate than a remote consultation include when:
- you are unsure of a patient’s capacity to decide about treatment (see paragraphs 41 to 44)
- you need to physically examine the patient
- you are not the patient’s usual doctor or GP and they have not given you consent to share their information with their regular prescriber; this is particularly important if the treatment needs following up or monitoring, or if you are prescribing medicines where additional safeguards are needed (see paragraphs 59 to 66)
- you are concerned that a patient does not have a safe and confidential place to access healthcare remotely, for example due to domestic abuse
- you are concerned that a patient may be unable to make a decision freely because they are under pressure from others (see paragraphs 69 to 75 of ‘Decision making and consent’).
If you are not the patient’s regular prescriber, such as a GP, you should:
Before you prescribe, you must be satisfied that you can make an adequate assessment, establish a dialogue and obtain the patient’s consent through the mode of consultation you are using (see paragraphs 34 to 44).
You must also consider and respond to the patient’s communication needs and make reasonable adjustments to your practice, where necessary, so they can receive care that meets their needs.8
You must carry out a physical examination of patients before prescribing non-surgical cosmetic medicines, such as Botox, Dysport, Vistabel or other injectable cosmetic medicines. Therefore, you must not prescribe these medicines remotely.
Do you have enough information about the patient to prescribe a treatment that meets their needs?
You must only prescribe if it is safe to do so.
- It’s not safe to prescribe if you don’t have sufficient information about the patient’s health or if the mode of consultation is unsuitable to meet their needs.
- It may be unsafe if relevant information is not shared with other healthcare providers involved in the patient’s care – for example because the patient refuses consent.
Before prescribing, you must consider whether the information you have is sufficient and reliable enough to enable you to prescribe safely.
For example, whether:
- you have access to the patient’s medical records or other reliable information about their health and other treatments they are receiving
- you can verify other important information by examination or testing
- the patient would be at risk of death or serious harm if they are also obtaining medication from other sources.
If you are not the patient’s regular prescriber, you should ask for the patient’s consent to:
- contact their GP or other treating doctors if you need more information or confirmation of the information you have before prescribing
- share information with their GP when the episode of care is completed.9
In some circumstances, such as in the provision of sexual health services, privacy concerns may override the need to share information.
If the patient objects to information being shared with you, or does not have a regular prescriber, you must be able to justify a decision to prescribe without that information.
If the patient refuses to consent to you sharing information with their GP, or does not have a GP, you should explain to the patient the risks of not sharing this information. This should be documented in their medical records.
If failing to share information could pose a risk to patient safety, you should explain to the patient that you cannot prescribe. You should outline their options and signpost them to appropriate alternative services. You should clearly document your reasons for any decisions made.
When treating vulnerable patients in any setting, such as children’s homes, care homes or prisons, take particular care to follow relevant national protocols. You should support appropriate and effective information sharing between the setting and the community in order to ensure continuity of care.
Can you establish a dialogue and obtain consent?
Establishing a dialogue
You must establish a dialogue with your patient to help them consider information about their options and so they can decide whether or not to have care or treatment. Good dialogue should give both you and your patient the opportunity to ask questions to get the information you both need.
Together with the patient, you should assess their condition before deciding to prescribe a medicine. You must have or take an adequate history, which includes:
- any previous adverse reactions to medicines
- current and recent use of other medicines, including non-prescription and herbal medicines, illegal drugs and medicines purchased online or face to face
- other medical conditions.
You should encourage your patient to be open about their use of alternative remedies, illegal substances and medicines obtained online or face to face, as well as whether or not they have taken prescribed medicines as directed in the past.
If you need more information to help you decide which options would serve the patient’s needs, you must ask for it before recommending an option or proceeding with treatment.
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, and raise concerns as appropriate. For example, it may be appropriate to raise concerns if the system in which you’re working involves prescribing remotely on the basis of a questionnaire and there is no mechanism for two-way dialogue or communication with patients.
Assessing the patient’s needs
You should identify the likely cause of the patient’s condition and which treatments are likely to meet their needs.
You should reach agreement with the patient on the proposed treatment,10 explaining:
- the likely benefits, risks and impact, including serious and common side effects
- what to do in the event of a side effect or recurrence of the condition
- how and when to take the medicine and how to adjust the dose if necessary
- how to use a medical device
- the likely duration of treatment
- any relevant arrangements for monitoring, follow-up and review, including further consultation, blood tests or other investigations, processes for adjusting the type or dose of medicine and for issuing repeat prescriptions.
Assessing a patient’s capacity
You must begin with the presumption that every adult patient has capacity to make decisions about their care. Assessing capacity is a core clinical skill and doesn’t necessarily require specialist input. You should be able to draw reasonable conclusions about your patient’s capacity during your dialogue with them.
If you are unsure if a patient has capacity to make a decision, you should assess their capacity using the test under the relevant legislation. Our guidance on ‘Decision making and consent’ gives detailed advice on assessing capacity and making decisions where a patient is known not to have capacity, at paragraphs 76 to 91.
Medicines may be prescribed without consent if it is likely to be of overall benefit to adults who lack capacity, or in accordance with mental health legislation.
For patients under 18 this guidance should be read alongside ‘0–18: guidance for all doctors’.11
Giving information to patients
The amount of information you give to each patient will vary according to the nature of their condition, the potential risks and side effects, and the patient’s needs and wishes. You should check that the patient has understood the information and encourage them to ask questions to clarify any concerns or uncertainty. You should consider the benefits of written information, information in other languages and aids for disabled patients to help them understand and consider and retain information in a way suited to their needs.
It is sometimes difficult, because of time pressures, to give patients as much information as you or they would like. To help with this, you should consider the role that other members of the healthcare team, including pharmacists, could play. Pharmacists can undertake medicine reviews, explain how to take medicines and offer advice on interactions and side effects. You should work with pharmacists in your organisation and/or locality to avoid the risks of overloading or confusing patients with excessive or inconsistent information.
You should refer patients to the information in PILs and other reliable sources of information.12 PILs are useful supplements to the information you give patients about their medicines, but they are not a substitute for that information.
With the patient’s consent, you should provide patients’ carers with information about the medicines you prescribe. If the patient lacks capacity to consent, you should share this information with carers where, in your opinion, it would be of overall benefit to the patient.13
The concept of overall benefit is consistent with the legal requirements to consider whether treatment ‘benefits’ a patient (Scotland), or is in the patient’s ‘best interests’ (England, Northern Ireland and Wales). General Medical Council (2020) ‘Decision making and consent’ London, General Medical Council (paragraph 87).
Also see ‘Confidentiality: Good practice in handling patient information’ (paragraphs 44 to 49).
Some patients do not take medicines prescribed for them, or they do not follow the instructions as to the dose or the time medicines should be taken. You should try to understand the reasons for this and address them by providing reassurance and useful information. You should try to reach agreement with the patient on an appropriate course of treatment that they are able and willing to adhere to.14
Obtaining a patient’s consent
You should be proportionate when obtaining a patient’s consent. For most prescribing decisions, you can rely on a patient’s verbal consent, as long as you are satisfied that they’ve had the opportunity to consider any relevant information and decided to go ahead. Sometimes a patient’s signature is required on a form, for example to comply with an MHRA drug safety alert about a medicine with serious side effects.
Handling patient requests for medicine you don’t think will benefit them
Sometimes, patients will ask for treatment or care that you don’t think is in their clinical interests. In these situations, you should explore the reasons for their request, their understanding of what it would involve and their expectations about the likely outcome. This discussion will help you take account of the factors that are significant to the patient and assess whether providing the treatment or care could serve the patient’s needs.
If, after discussion, you still think the treatment or care would not serve the patient’s needs, you should not provide it. You should explain your reasons to the patient and explore other options that might be available, including their right to seek a second opinion.