Richard Armitage is a GP and Honorary Assistant Professor at the University of Nottingham’s Academic Unit of Population and Lifespan Sciences. He is on X: @drricharmitage
While over one billion items are prescribed each year in primary care in England alone,1 patients are also provided with a large number of various other regular medications that are prescribed elsewhere. Source of these ‘outside’ prescriptions include outpatient departments, hospital day case units, drug and alcohol services, community mental health teams, sexual health clinics, and private healthcare providers. Outside prescriptions that are consumed by patients on a long-term and regular basis include disease-modifying anti-rheumatic drugs (DMARDs -such as IM/SC/IV methotrexate, etanercept, adalimumab, infliximab, and anakinra), anti-psychotic depots (such as zuclopenthixol decanoate, olanzapine embonate, and risperidone), opioid substitution therapy (such as methadone hydrochloride and buprenorphine), HIV treatments (such as emtricitabine, tenofovir disoproxil, and dolutegravir), weight management medications (such as SC semaglutide), and chemotherapy agents.
…it is critical to quality of care and patient safety that GPs are aware that their patients are receiving these products.
Although outside medications are neither prescribed by GPs nor dispensed by community pharmacists, it is critical to quality of care and patient safety that GPs are aware that their patients are receiving these products. This for two major reasons: firstly, troublesome symptoms that the patient presents to their GP with might constitute some of the recognised side-effects of these outside medications, the accurate diagnosis of which is rendered more likely if the GP is aware that the patient receives these medications; secondly, the introduction of new medications (both acute and repeat) by the GP must be preceded by a review of the patient’s existing medication regimen to identify potential interactions, a process which is stymied if the GP is unaware of outside medications (this is especially the case with HIV treatments, of which the potential interactions with other medications are so numerous that a dedicated website has been created to help identify them).2
While some patients will inform their GP that they are receiving an outside medication at the point they present with troublesome symptoms or when the GP proposes introducing a new medication, many patients will assume the GP is already aware of this fact and so will not volunteer the information spontaneously during the consultation. It is, therefore, extremely important that a strategy is put in place to ensure the GP holds this knowledge at the outset of the consultation. The most convenient method to achieve this is to incorporate any outside medications into the patient’s list of repeat medications on their primary care clinical system at the point the GP practice learns about them (such as through clinical letters or emails from outside prescribers). This method is useful as the list of repeat medications is immediately available to the GP and avoids the much less reliable strategy of the GP trawling through the (potentially hundreds of) clinical letters for information about the existence of any outside medications. Another benefit of storing and presenting this information in this manner is that it is automatically shared with other healthcare providers (such as 111, ambulance, Emergency Departments, Minor Injury Units/Walk In Centres/Urgent Treatment Centres, GP out of hours, etc) via the patient’s Summary Care Record,3 which serves to improve quality of care and patient safety in these settings for the same reasons as above.
The most convenient method to achieve this is to incorporate any outside medications into the patient’s list of repeat medications on their primary care clinical system…
The major limitation to this strategy is the patient’s willingness for information regarding their outside medications to be shared with the GP. If consent is not provided, the GP practice will not be informed by the outside prescriber of this information (and, presumably, the patient will not share the information themselves), meaning these outside medications cannot be added to the patient’s list of repeat medications in the primary care clinical system. This lack of transparency is a hard problem which threatens quality of care and patient safety in primary care. The potential consequences of this must be discussed with the patient by the outside prescriber if the patient withholds their consent for this information to be shared.
A practical guide on how to add outside medications to lists of repeat medications is provided by NHS Digital,4 which includes explanations for the EMIS Web, TPPSystmOne, and Vision clinical systems. To minimise the risk of these medications being prescribed by GPs or dispensed by community pharmacists once they have been added to the list of repeats, the quantity field could be set to 0.001, and the dosage field could be populated with a message such as ‘NOT TO BE PRESCRIBED BY GP OR DISPENSED BY COMMUNITY PHARMACY.’ GP practices could improve the implementation of and compliance to this strategy by conducting regular audits cycles.
References
- NHS Digital. Electronic prescriptions reach one billion a year. 28 February 2023. https://digital.nhs.uk/news/2023/electronic-prescriptions-reach-one-billion-a-year#:~:text=The%20Electronic%20Prescription%20Service%20is,in%20the%20last%2012%20months[accessed 20 August 2024]
- HIV Drug Interactions. https://www.hiv-druginteractions.org/checker [accessed 20 August 2024]
- NHS Digital. Summary Care Record. https://digital.nhs.uk/services/summary-care-records-scr [accessed 20 August 2024]
- NHS Digital. Recording medicines prescribed elsewhere into the GP practice record. https://digital.nhs.uk/services/summary-care-records-scr/recording–medicines–prescribed–elsewhere-into-the-gp-practice-record [accessed 20 August 2024]