Why we're horrified by OTC chloramphenicol
Treating temporary patients can often cause confusion among GPs Dr Nicholas Norwell of the MDU gives advice
Imagine the scene. Yours is a pretty seaside practice, you have just finished your morning surgery and are enjoying a cup of tea and the view of the harbour when the receptionist asks if he can send a woman in who has just arrived with her young son. They are not patients but the mother says her son needs to see a doctor urgently.
Being in a seaside practice, you are used to seeing temporary patients who have run out of medication on holiday or become ill while away and so ask the receptionist to send them in. The mother explains her son is on methylphenidate for attention deficit hyperactivity disorder and needs a repeat prescription.
Usually the family's own GP prescribes the drug but they are visiting friends in the area and ran out two days ago. Since then, the mother explains, her son's behaviour has deteriorated and they cannot wait until they return home to get more supplies. You have never prescribed the drug for this condition before. What do you do?
It is indeed a problem. Temporary patients can provide GPs with some medicolegal dilemmas, not least because they are not known to the doctor who does not have access to their records.
Contractually, GPs can refuse to treat temporary patients provided they have 'reasonable grounds for doing so that do not relate to the applicants' race, gender, social class, age, religion, sexual orientation, appearance, disability or medical condition' (clause 181, standard GMS contract). GPs have a contractual duty to provide immediate necessary treatment and an ethical duty to treat if it is an emergency, however.
The GMC's frequently asked questions on prescribing medicines make it clear that if you accept a patient for treatment without a referral from their GP then you must explain to them the importance and benefits of keeping their GP informed. And that you should, where possible, inform the patient's GP before treatment is started, unless the patient objects. (www.gmc.org.uk Prescribing Medicines FAQ, Q 3).
In any event, it may be prudent to contact the patient's GP to check history, dose of drugs, etc, and to make a note of the conversation.
It is also advisable to ask the patient if they have any allergies or are taking any other medications, either prescribed or over the counter. If necessary, you can follow up any information they give you with their GP, with their permission.
Checking with the patient about whether they are suffering from a medical condition or taking any medications may be even more crucial if the patient does not have a GP or does not wish them to be informed of the treatment you are providing. In these circumstances, the GMC says that as well as making these checks, you should 'take responsibility for providing all necessary aftercare for the patient'.
If a patient refuses to give permission for you to contact their GP, you may decide to ask the patient why. In it's guidance on confidentiality, the GMC says: 'You must respect the wishes of any patient who objects to particular information being shared with others providing care, except where this would put others at risk of death or serious harm' (paragraph 10).
The GMC also advises doctors to recognise and work within the limits of their professional competence.
If the doctor above signed the prescription, he would take responsibility for it, so he has a choice of either familiarising himself with the drug, declining to prescribe it, or perhaps asking a colleague with more experience of the drug to prescribe it.
Aside from holidaymakers, patients with drug addictions do sometimes sign up as temporary patients and in these cases, communication with the patient's own GP is particularly important in order to establish full details of their past medical history.
It is desirable wherever possible to gain the patient's consent before contacting their GP.
When prescribing treatment to new or temporary patients with drug addictions, it might be advisable to consider giving them limited supplies of drugs unless it is possible to confirm the necessary information from the patient's GP.
Contacting a temporary patient's own GP can sometimes prove vital as the fictional example shown far right, based on the MDU's files, illustrates.
Nicholas Norwell is an MDU medicolegal adviser
The case mentioned is fictitious, but is based on cases from the MDU's files. Doctors with specific concerns are advised to contact their medical defence organisation for advice.
Case history: when police are investigating
A GP working in a seaside town called the MDU 24-hour advice line after he received a visit from a 22-year-old man who explained he was on holiday in the town and came to see him with an infected toenail.
During the consultation the patient asked for a repeat prescription of temazepam. He said his GP usually prescribed him a course of 50 and showed a repeat prescription printout saying the last issue was two months previously.
The GP was advised that if he had concerns he could contact the patient's registered GP before issuing a prescription. He did so and was told the patient had been issued with a prescription for 50 temazepan just a week earlier and that the police were investigating him as he was suspected of supplying the drugs to others. This GP was disturbed by this revelation and sought the MDU's help again when he received a call from the investigating officers asking for confirmation that he was a temporary patient and requesting access to his records.
Generally information should not be disclosed to third parties without the consent of the patient and it would be a breach of confidentiality even to confirm that the man is a patient. However, GMC guidelines state that you may be able to justify disclosing information in the public interest 'where failure to disclose appropriate information would expose the patient or others to risk of death or serious harm'. The GP was advised that if he decided to disclose the information to the police he could release the minimum information necessary for the purpose, eg stating that the patient had been a temporary patient between certain dates. He was also advised that he might consider explaining to the patient what he intended to do and making a note of his reasoning.