I can see that this practice rarely reviews its methadone prescriptions, and the practice manager has just threatened to refer me to the GMC if I don’t sign 30 of these prescriptions before I head off to my next practice this afternoon. What should I do?
Dr Justine Hall: Only prescribe within your competence
A doctor must work within the limits of their competence and must only prescribe drugs or treatments where there is adequate knowledge of the patient’s health, as stated in the GMC’s document ‘Good practice in prescribing and managing medicines and devices’. You must keep your skills up to date therefore unless you had recent training or experience in substance misuse it is unlikely you would feel confident in this subject and I would advise refusing to sign the prescriptions. The RCGP’s ‘Guidance for the use of substitute prescribing in the treatment of opioid dependence in primary care’ might help.
The person who signs the prescription is the one who would be held accountable if something goes wrong. You also need to check dosage, contraindications, consent and ensure appropriate follow up as well as good record keeping, as emphasised in MPS’, ‘Safe Prescribing’. It is unlikely in this context you could do all these things so it is probably best not to sign them.
Liaising with another GP in the same practice or a practice pharmacist may provide enough information for you to be able to feel confident in signing such prescriptions however the onus is on you to ensure you meet GMC guidelines so if you have doubts, do not sign. As long as you stick to GMC guidelines you have nothing to fear if the practice did report you to the GMC. You have done nothing to breach GMC guidelines by refusing to sign.
The GMC also states where you have concerns you should question any action you consider to be unsafe. The practice should respond constructively to any concerns raised about their own practice. There are various policies both local and nationally on whistleblowing in the NHS but I would seek advice from your indemnity provider and/or the BMA if a member before doing so.
In many areas there are dedicated substance misuse centres where methadone prescriptions are provided and administered. It is worth asking for advice from the CCG and LMC here especially if you have concerns about the safety of prescribing within the practice.
Lastly it is important to never be bullied in the workplace and the BMA has recently published a document to help doctors in this situation.
Dr Justine Hall is a GP in Guildford and planned care clinical lead at Guildford and Waverley CCG
Dr Edward Farnan: Balance the risks of signing and not signing
Although the prescriptions may have been authorised by the patients’ regular GP and printed off by a receptionist for signing, you are responsible for the prescriptions you sign.
The GMC says you must recognise and work within the limits of your own competence. If you don’t feel competent to sign a prescription for methadone, for example because you have no experience with this particular medication or feel you need to know more about the patient’s medical history before doing so, you should explain the reasons for this to the practice manager. Even though it may be a difficult conversation to have with the practice manager, you need to ensure that the prescriptions are safe.
When issuing repeat prescriptions, you need to determine in each case, whether you can safely prescribe the medication, including whether you have adequate knowledge of the patient’s health and are satisfied the drug serves the patient’s needs.
You will need to balance the risks and benefits of signing the prescription against the risks of not doing so – are patients more likely to come to harm in the short term by continuing medication without an appropriate review, or by having such medication declined thereby running the possible risk of withdrawal symptoms pending an appropriate review? Document carefully what you have done and explain why.
If you decide that you cannot sign all or some of the prescriptions, you may want to check if another doctor in the practice who is more familiar with the patients or with methadone prescribing is willing to do so. If not, there may need to be alternative arrangements put in place in the short term to ensure that patients are not disadvantaged.
If you have concerns about the practice’s policies or procedures then you should raise these within the practice, initially, and externally if you are not satisfied that appropriate action has been taken. Keep a careful record of this for future reference.
Dr Edward Farnan is a medicolegal advisor at the Medical Defence Union