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GPs go forth

Do we continue prescribing BP drugs without review?

Three experts advise on whether a GP should stop the medication of a patient who repeatedly fails to attend the practice

A patient with severe hypertension taking regular treatment is repeatedly failing to attend for his review, despite a number of requests from the practice. His usual GP says she is not comfortable continuing to prescribe without any form of monitoring. Should we cancel his medication?

Dr Jessica Garner: Threaten to halt prescriptions

The first rule all of us must abide by when considering patient care is ‘do no harm’. In this scenario the decision has to be made as to what would cause greatest harm to the patient: allowing hypertensives to be continued in the absence of monitoring or stopping them?

My concern would be prescribing medications such as an ACE inhibitor without appropriate monitoring, due to the potential iatrogenic effects.

It sounds as if more could be done to engage with the patient. GMC guidance states that doctors must work in partnership with their patients and this cuts both ways. If standard recall letters have been ignored, a more personalised approach may be required.

Writing to the patient yourself, spelling out the reason for annual monitoring as well as the long-term benefits of the medications, may be helpful. It may unearth logistical reasons for the patient not attending appointments, such as caring duties or being housebound. I would also state clearly that if they fail to attend for monitoring, prescriptions will be temporarily halted.

Should your letter fail to garner a response, stopping antihypertensive treatment until they attend for important blood tests would seem an appropriate balance of risks in this case. An appropriate next step would be to raise it at a practice meeting. Establishing a practice policy on such matters would be sensible.

Dr Jessica Garner is a GP in Worcestershire and a health blogger

Professor Azeem Majeed: Try to negotiate with the patient

Patients such as this can be very frustrating for GPs and their teams as a lot of time can be tied up in chasing them.

If he is not keen to attend for regular checks, he could buy an automated sphygmomanometer and could pass the results to your practice. Information on validated devices is available from the British Hypertension Society. The patient does, though, still need an annual medication review and measurement of parameters such as renal function.

If he still refuses to attend these checks, you should contact him to try to understand his reasons and aim to negotiate a mutually agreeable review schedule. He needs to be informed that long-term prescribing of combination therapy for his high blood pressure without monitoring is unsafe, and something you cannot do for medicolegal reasons. Give this information in a way he can understand, and keep records of your discussion and the reasons for your decision. If he still refuses to attend, I would not be able to condone prescribing his medication. Patients do need to take responsibility for their own health and people with long-term conditions should ensure they are appropriately reviewed.

Professor Azeem Majeed is a GP in Lambeth and head of the primary care and public health department at Imperial College London

Dr Beverley Ward: It is the responsibility of the prescribing doctor

In its guidance on prescribing the GMC is clear that a doctor who prescribes for a patient takes responsibility for that prescription, and doctors are required to ensure that prescriptions are safe, appropriate and in the patient’s best interests. The GP signing the prescription should ensure they are happy to issue the prescription in the circumstances.

In making a decision, the prescribing GP will need to satisfy themselves that the patient understands the need for monitoring, and the risks associated with the treatment. Review the information provided to the patient and ensure he has been given the information in a way he can understand to enable him to make an informed decision. The GP may wish to write to the patient, reminding him of the importance of regular reviews. The GP could explain that only a limited supply of tablets will be provided until he attends a review, if this action is considered safe and appropriate.

If the patient still refuses to attend, the prescribing GP will need to balance the risks associated with a failure to monitor against the needs of the patient to receive medication, and choose the least risky option. It would be important to document the information given to the patient, the patient’s response and your rationale for the decision made.

The practice should have arrangements for repeat prescriptions that include provision for monitoring a patient’s condition. Many practices have clinical templates for this.

Dr Beverley Ward is a medicolegal adviser at the Medical Defence Union

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Readers' comments (11)

  • Another way is to type on the directions on the prescription to attend for review. The pharmacist is obliged to type this on the prescription dispensed. If this doesn't work reduce the quantity of tablets prescribed. Most patients respond to this.

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  • Azeem Majeed

    David Simpson | GP Partner 24 Feb 2016 11:25am

    Thanks David. That's a useful intervention that we can add to the others given in this article.

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  • Or perhaps get the pharmacist to take the patients BP and give them relevant forms for other monitoring? The patient may have something as inconvenient as a JOB,and not all employers are as understanding as the NHS!

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  • I work in a GP practice on the 1st reminder of medication review is overdue we half the quanitity to 28 then to 14 and then to 7 day prescriptions. It works well. The GP meets the obligation to do no harm as the patient still recieves the prescription and some level of understandable inconvenience to themselves

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  • Too much debating and patient contentedness. The approach should be no monitoring = no prescription. Simple!

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  • Rather than wasting time and money sending multiple letters, just phone patient. Much quicker usually. Although I agree with all points above. Prescribing 7 days at a time usually irritates the patient sufficiently to comply....

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  • I understand all of the above points and wouldn't want to imply they are not valid. I particularly like the reduction but still prescribing element, but I would add, how does a practice monitor how often a patient rings to make an appointment, with nothing available time after time? I am sure there is some monitoring apart from patient completed surveys that looks at this in a very general way, but i am equally sure there is nothing that monitors who is repeatedly trying and not succeeding to get an appointment, I'm not sure its as 'simple as' no attendance = no medication. Maybe this could be looked at in conjunction with decisions to stop medication for those who don't attend, i.e. could a receptionist ring and negotiate an appointment time with the patient? If there is then non-attendance that then gives a clear indication that the patient is being non-compliant with requirements as opposed to we don't know why they are not coming but it must be their fault and a choice. I think if it is something the practice is wasting a lot of time on, evidencing different ways of trying to contact the patient is a good protective factor if medication is stopped and the patient then suffers serious health consequences.

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  • Should self monitoring and providing the results not be the most encouraged option with some basic education on what to do and the importance of it? Make sending in the results by email to a dedicated account easy and you may well see good results.(no one except GPs have fax machines these days).

    I have the problem, it's what I do and OK, I may understand more than the average person about the need for this and I also understand the responsibility of the GP to ensure prescribing is safe.

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  • We have a nurse who runs a hypertension clinic dedicated to reviewing all QOF patients who are not seen by a GP due to another co-morbidity. I'll also review these patients too as a part of the medication reviews that I do. This releases extra capacity and frees up GP appointments. My appointments and the nurses appointments are readily available and so patients not getting an appointment isn't really an excuse for patients not coming in to get their Blood Pressure and U&E's checked

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  • Most of the repeat prescriptions are ordered by chemist and secondly we have no record of patients taking them unless patients are reviewed 3-6 monthly.

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