The scene

A GP member contacted the MDU advice line after a patient with chronic fatigue syndrome (CFS) had come into the practice. The patient had said she had seen a specialist doctor who had recommended she take thyroxine, and she wanted the GP to prescribe it.

She produced a headed letter from the specialist with a handwritten note saying "thyroxine 50 micrograms", but there was no further information or a reason why the specialist wanted this given. The GP had taken blood for thyroid function tests and arranged to see the patient with the results in a week's time.

The GP had looked at NICE and NHS guidance which said that thyroxine should not be used in CFS. He said the thyroid function tests were normal, and that he had looked up the 'specialist' on the GMC website and found he was not registered with the GMC. The GP asked what he should do as the patient was insistent that he prescribe thyroxine.

MDU advice

The MDU's medicolegal adviser explained that doctors are responsible for prescriptions they sign and that they should be satisfied that the medicine serves the patient’s needs.

While patients with capacity can refuse any treatment if they choose, they cannot demand specific treatment unless the doctor feels it is suitable for their needs. In its guidance on prescribing the GMC sets out a process for handling patient requests for medicines that the doctor does not think will benefit them.

In line with this guidance, the adviser recommended that the GP explore why the patient wanted the medication, their understanding of the risks and their expectation of the benefit. If after this discussion the doctor still thinks the treatment would not serve the patient’s needs, then he should not prescribe it.

The GP was advised to explain to the patient that national guidance from both NICE and the NHS says that thyroxine and other drugs should not be used for CFS, and that an individualised approach to other treatments should be made up. He should also offer the patient a referral to an NHS CFS specialist.

The adviser said the GP may wish to explain that as far as they can see, the 'specialist' is not on the GMC register - which is in the public domain - and therefore cannot work as a doctor in the UK. They also cannot prescribe medication in this country or demand anyone else prescribe the medication on his behalf.

The outcome

Following the conversation with the MDIU's adviser, the GP declined to prescribe the thyroxine after a discussion with the patient about the risks. The patient then made a complaint via NHS England, which the GP answered with the further assistance of an MDU adviser. NHS England did not uphold the complaint.

The patient was referred to an NHS specialist in CFS and an individualised management plan was formulated for their treatment.

Good practice in prescribing and managing medicines and devices, GMC 2021

Refusal to prescribe off-label

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