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GMC tightens rules on self-prescribing as fitness-to-practise cases treble in two years

The number of doctors hauled in front of the GMC for self prescribing has trebled in two years, according to figures released by the regulator.

The GMC said the number of closed fitness-to-practise cases featuring allegations of self-prescribing, self-treatment or informal treatment of family and colleagues had increased from 36 in 2010 to 82 in 2011 and 98 in 2012.

The rise in cases comes as GMC guidance on self-prescribing and treatment of close family or friends is tightened up.

The latest guidance from the GMC, Good practice in prescribing and managing medicines and devices (2013), says GPs ‘must’ avoid prescribing for themselves or ‘anyone with whom they have a close personal relationship’.

It also adds that doctors must immediately make a clear record justifying why there was no other alternative, and also inform their own, or the other person’s, GP about which medicines have been prescribed.

Previous guidance only said doctors ‘should’ avoid self-prescribing and there was no requirement to inform the relevant GP.

Analysis: Accusations of self prescribing can have serious consequences

Medical defence experts warned the strengthened wording puts even greater pressure on GPs to justify their actions, or potentially face fitness-to-practise proceedings.

It comes as the BMA also published new warnings over self-prescribing earlier this month.

The GMC confirmed that the cases of self-prescribing over the last two years had resulted in 13 voluntary erasures, 10 undertakings, 12 warnings and 28 cases referred to fitness-to-practise hearings.

A further 111 cases involved giving advice to the doctors to avoid similar actions in the future. Out of the 28 cases referred to hearings, 10 resulted in suspensions and five in erasure.

The GMC said that while the guidance will only come into effect later this month, it expected that doctors to be ‘aware of’ and ‘familiarising themselves with’ the new guideline. It did not specify why it believed the number of cases had gone up but it told the BMA that it was likely related to an overall rise in fitness-to-practise proceedings.

The GMC told Pulse: ‘With regards to self-prescribing, the guidance is clear. Wherever possible you must avoid prescribing for yourself or anyone with whom you have a close personal relationship.

‘The new guidance comes into effect on 25 February 2013, but we would expect doctors to be aware of it and to be familiarising themselves with it.’

The rise in cases statistics comes despite previous warnings to doctors that the problem was on the rise, and after a Pulse survey in 2007 found 43% of GPs self-prescribe.

A spokesperson from the Medical Defence Union said that opiates and benzodiazepines remained the most commonly self-prescribed substances among doctors, and these would be banned under the advice from the GMC that controlled drugs can only be self-prescribed or prescribed to someone close to you in order to save a life, avoid serious deterioration in health, or alleviate ‘otherwise uncontrollable pain or distress’.

Dr Claire Macaulay, MDU medico-legal adviser, said: ‘There may be rare situations where a GP considers there is little or no choice but to self-prescribe, but the GMC expects doctors to comply with the standards of good practice set out in their guidance and any GP who does chose to self-prescribe must be prepared to explain and justify their decision as a failure to do so can lead to their fitness to practise being called into question.

‘Treating friends and family should also be avoided if possible. One exception is in an emergency situation where there is no one else available, in which case a GP has an ethical obligation to provide immediate medical care to anyone who requires it.’

Dr Mary Hawking, a GP in Dunstable, Bedfordshire, said: ‘GPs can always see another GP for antibiotics - and often have odd boxes returned by patients: other disciplines not so fortunate. If there is an increase in benzos (not so easily obtained from colleagues), might the ever-increasing stress produced by the changes in the NHS for all groups of doctors be involved?’

The new guidelines

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

- 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. the treatment is immediately necessary to:

i save a life

ii avoid serious deterioration in health, or

iii alleviate otherwise uncontrollable pain or distress.

 

- 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.

Source: Good practice in prescribing and managing medicines and devices, GMC, 2013

Readers' comments (18)

  • Whilst I, mostly, agree with the above article, no consideration has been taken to the good GP who spots an issue with a friend or close relative and avoids further unecessary work for the NHS by just getting on with dealing with it.
    A mechanic might fix their own brakes?
    I'd hate to have a GMC 'mark' against my record for getting some fluclox for an ingrowing toenail!
    Further regulation/rules that trap the whole profession to stop a few bad eggs.

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  • It is unfortunate that common sense seems to have gone out of the window here. Clearly it is inappropriate to prescribe benzos or opiates for myself or family, but why I should not be able to prescribe a tube of acne cream for my teenage son that could also be bought OTC beats me. If my father finds he has left his insulin at home when visiting me, should I really have to go to the out of hours centre to get a prescription for him simply to maintain probity?
    Should we not have a limited list which is deemed appropriate to prescribe, or a larger set of circumstances that are permissible rather than this draconian ruling that bans all prescribing?

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  • This is madness.

    I sometimes prescribe fybogel for myself - I suspect my constipation is due to lack of fluid intake caused by unreasonably busy working days allowing no breaks at all. I also occassionally need omeprazole (no, I don't drink more than 1/2b wine/week), again I suspect it's due to irregular eating habits and late dinners at 8pm when I come home from work (yes, I know what upper GI red flag symptoms are and no, I don't have any. I dont need another clinician to tell me that).

    So from now on, I have to either face panishment from the organization that takes over £400 each year and pushes various work including revalidation to me, or take time off work to see my own GP to have this prescribed.

    The pen pushers have gone utterly mad!

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  • completely over the top regulation. I despair that there is no room for even a hint of common sense or pragmatism from the GMC. We are now to be treated as irresponsible criminals for prescribing an emollient for a family member. Crazy world - feel I am the last sane person left in the medical profession. Yet more cracking nuts with sledgehammers!

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  • Have they've gone far enough? Those rural GPs that live in the village areas that they serve shouldn't be allowed to prescribe for the patients they live close to. After all these neighbours may have close, neighbourly, relationships with the village GP. These patients should have to go to a different GP in a different village. In fact why stop there why not make it a requirement to have every prescription signed by 2 doctors (who have no relationship or financial interest in each other) to ensure that only justified prescriptions are prescribed. What the hell - have every prescription electronically justified by a panel at the GMC - it's easy enough - I prescribe something it gets sent to the GMC panel, patient waits in waiting room and if it's OK to prescribe flucloxacillin for a paronychia for that patient then it gets authorised and printed. This way no bad apple will get away with it!

    OR

    Maybe they could just some common sense and stop this madness!

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  • More balderdash. I agree it is not OK to self prescribe drugs of addiction etc, but it remains OK in my book to prescribe other medications (much of it available OTC) for self and relatives if this is supported by documentation and appropriateness. I shall continue to self diagnose and treat either OTC or by prescription including antibiotics occasionally; they work really well sometimes and I know when, same as some patients do (I have never had a day off work, I'm now 57). I'd better post anonymously since there are some prats in our profession, some of them making stupid rules, idiot authoritarians, others liable to shop me.

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  • I am glad that I am retired and no longer on the medical register. When my children were young I often prescribed for minor illnesses, and I did the same for my grandchildren.
    The lunatics are definitely in charge of the asylum.

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  • EC

    It is believed that doctors may not be inclined seeking help for several reasons. Patients want healthy doctors and doctors feel there is enormous pressure on them not to ‘give in’ to ill health and there is a view that doctors who do take time off sick are perceived as a “problem”.
    One of the reasons behind self-prescribing is convenience and feeling duty of being helpful to both family and patients.
    Beauchamp and Childress’ Four Principles framework (respect of autonomy, beneficence, non-maleficence and justice) had been respected.
    From the detailed review of the cases I was not able to find a clear dilemma between convenience and ethics. In fact, it is likely that the convenience for the self-prescriber was also convenient to the society.
    Kant believes only actions performed for the sake of duty have moral worth. He seems to suggest that the greater one's disinclination to act for the sake of duty, the greater the moral worth of the action. Moral value is essentially established by the intention of the person acting.
    Although convenience is often what drives physicians either to curbside or to self-prescribe, the question remains what motivates doctors to curbside rather than simply self-prescribe. One explanation for curbside requests is the physician’s concern about the legality of self-prescribing. Some regions in the USA and other countries have restrictions on self-prescriptions. A second reason may be that the provider wants to avoid the appearance of impropriety from the pharmacist. This concern is particularly valid if the prescription is for a controlled substance that is more closely monitored for inappropriate prescribing patterns (3).
    A third reason to curbside is that the request is a way to obtain a second opinion. However, curbside requests rarely include a full medical history or physical examination. To ensure the appropriate prescribing of any medication requires access to information often considered highly sensitive and not readily shared by colleagues (eg, whether the patient smokes, uses oral contraception or consumes significant amounts of alcohol). In a formal encounter, the prescribing physician would have access to a patient’s full medication list, medical history and social practices that may affect the metabolism or side effect profile of the prescribed drug. In the practice of curbside prescribing, however, there may be an implicit assumption that the requesting physician has accounted for these factors when making the request, so these details are rarely asked of the requesting physician. In addition, because of the social stigma and sensitivity of some information, prescribing physicians should be sceptical about whether they have received complete answers even when brazen enough to request relevant information. The requesting physician may leave out information because of fear that the curbside encounter may not be protected by typical confidentiality constraints, yet again underscoring the ways in which it is different from a formal encounter.
    Furthermore, it would be most difficult for the pharmacist questioning the prescription (4).
    To resolve the dilemmas that may arise from self-prescribing, prescribing to family members, and curbsiding prescriptions, one option could be just not allowing all together this kind of prescribing, no matter the circumstances and the type of medication prescribed. Somehow this type of intervention, which seems to have been embraced by some Health Authorities, would simplify the decision for doctors.
    However, this intervention may be obviously of nocument to patients in case of emergency. If the emergency situations are exempted, then doctors would be once again called to judge is there is an emergency or not. One of the main accuses to self-prescribing and prescribing to family members is that judgment can be impaired. It is therefore likely that judgment could be affected in emergency situations involving the own person or family members.
    Ultimately, it appears that everything may be reduced to best judgment in the given circumstances and not allowing this type of judgment implies limitation of freedom and it can be detrimental for patients and the society.
    With the Hippocratic Oath doctors swear they will prescribe for the good of patients according to their ability and judgment and never do harm to anyone. If the judgment is not obscured, or there is no reason to think that the judgment can be obscured, then it should be considered appropriate self-prescribing and prescribing to family members.
    Mill argued that the burden of proof is supposed to be with those who are against liberty; who contend for any restriction or prohibition; the a priori assumption is in favour of freedom.
    Joel Feinberg, American political and social philosopher, appears to agree with this concept, which is also echoed by later works from Stanley I. Benn and John Rawls, arguably the most important political philosopher of the 20th century.
    For Gerald Gaus freedom is normatively basic, and so the responsibility of justification is on those who would limit freedom, especially through coercive means. It follows from this that regulations and laws must be justified, as they limit the liberty.
    Further studies are necessary to investigate wheter if, how, and when, limitations of self-prescribing and prescribing to family members may be beneficial to patients and society alike.






    REFERENCES

    1. La Puma J, Priest ER. Is there a doctor in the house? An analysis of the practice of physicians' treating their own families. JAMA.1992;267:1810-1812
    2. Kuo D, Gifford DR, Stein, MD. Curbside consultation practices and attitudes among primary care physicians and medical subspecialists. JAMA. 1998;280:905-909.
    3. Myers JP. Curbside consultation in infectious diseases: a prospective study. J Infect Dis. 1984 Dec;150(6):797-802.
    4. Bake K. Should you dispense to M.D.s who self-prescribe? Drug Topics Nov. 17, 2003;147:57.

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  • EC

    Just a couple of additional considerations: many drugs may be on prescriptions, but are available OTC. The decision to take or not to take them is already a "medical decision" . It can be argued that many of them may be actually dangerous if taken not in an appropriate way. So is the decision to take or, no to take, yourself or a relative, to see a colleague. Unfortunately it is technically impossible to "revert " to a non-medical doctor status. In the other hand, the new position of the GMC makes the situation clearer, rightly or wrongly so. As such, it is welcome.

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  • Oh dear. I have been off sick for a few years and was considering coming back. But what with revalidation and now this and the micromanagement of PCT and the ungrateful rudeness of some patients and the increasing threats of complaints, I don't think I'll bother.

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