In recent times there has been a noticeable increase in advertising of online medical services. We have also seen a number of doctors being referred to the General Medical Council (GMC) as a result of concerns relating to online prescribing, in particular, the prescribing of medications with abuse potential.
The attractions of online prescribing services are obvious. They offer convenience and accessibility, particularly for those who work away from home or those who struggle to make an appointment with their GP. However, they also carry risks and they have come under increased scrutiny from the media and regulators. Some of the identified concerns include a lack of corroboration of the patient’s reported symptoms, a lack of communication with the patient’s own GP and uncontrolled prescribing of medications of potential abuse.
Care Quality Commission (CQC)
In an article dated 3 March 2017, the CQC advised patients to take care when using online primary care services. Whilst acknowledging such services can present convenient ways for people to access advice, treatment and medication, it notes that some services may put patient safety at risk.
Following inspections of two services, it highlighted the following concerns:
- No (or minimal) identity checks for patients
- No way of identifying whether or not patients lacked capacity to consent or understand their prescribed treatment or medical advice or if there were any safeguarding concerns
- No systems or processes to contact the patient’s regular GP, including when medication was prescribed that required monitoring or follow up
- Prescribing practice that did not take account of the patient’s clinical condition or consider differential diagnoses
- Inadequate medical history-taking to inform appropriate prescribing
- No assurance that clinicians had relevant skills or qualifications for the role they were performing
Recognising that the use of technology to deliver regulated activities remotely is increasing, the CQC also published guidance setting out how it will regulate digital healthcare providers in primary care. The approach to be used is based on the CQC’s existing operating model.
The CQC’s inspections will be directly related to five key questions about whether services are:
- Responsive to people’s needs
- Well led
The CQC will use answers to these questions to judge whether providers are meeting the relevant regulatory requirements.
General Medical Council
Online prescribing poses risks to practitioners as well as patients. The GMC has produced guidance relating to prescribing for patients based on consultations by telephone, online and video link. Whilst the guidance focuses on prescribing, it sets out good practice for carrying out any remote consultation.
The guidance emphasises that prescribers must have ‘adequate knowledge of the patient’s health’ and must be satisfied that the medicines ‘serve the patient’s needs’. Practitioners are required to consider:
- The limitations of the medium through which [they] are communicating with the patient
- The need for physical examination or other assessment
- Whether they have access to the patient’s medical records
The guidance sets out a mandatory requirement to undertake a physical examination of patients before prescribing non-surgical cosmetic medicinal products. It also requires that practitioners seeing patients who have not been referred by their GP without access to their medical records and who have not previously provided face to face care, must follow the advice in paragraphs 30-34 on sharing information with colleagues.
This includes an obligation that practitioners who prescribe for a patient but are not a general practitioner ‘should check the completeness and accuracy of the information accompanying a referral’ and
‘when an episode of care is completed, must tell the patient’s general practitioner about changes to the patient’s medicines, length of intended treatment, monitoring requirements and any new allergies or adverse reactions identified, unless the patient objects or if privacy concerns override the duty, for example in sexual health clinics.’
The guidance emphasises the importance of considering ‘whether the information you have is sufficient and reliable enough to enable you to prescribe safely’; for example, whether:
- ‘you have access to their medical records or other reliable information about the patient’s health and other treatments they are receiving
- you can verify other important information by examination or testing’
The guidance states that the doctor should ‘ask for the patient’s consent to contact their general practitioner if you need more information or confirmation of the information you have before prescribing. If the patient objects, you should explain that you cannot prescribe for them and what their options are.’
What should doctors do?
Doctors who choose to work in the online sector must make sure that they are following the relevant guidance. They must be alert to the reality that not all patients will choose to use online services for bona fide reasons. Some may seek to exploit weaknesses in the model to subvert proper prescribing stewardship. The obvious risk is that patients seeking drugs which can be abused may obtain multiple prescriptions if systematic checks are not carried out.
The risk of patients seeking inappropriate prescriptions is not new but online prescribers operate with relatively limited information. Doctors must be astute to safeguard patients and their own professional position. They should take appropriate steps to ensure they have sufficient information to justify any prescription given, both in respect of the medication and the quantity prescribed. Whilst convenience may be a key driver in the provision of online services, it must not be the overriding consideration.