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A supra-regional specialist wrote to a GP asking her to prescribe for a neonate with complex problems. The GP was not familiar with the medication, which was unlicensed for use in children. She found that there was no guidance for this age group in the BNF for Children. The GP emailed the specialist asking for more information.
The consultant responded with reassurance that as the prescription was to be at his recommendation, he would take full responsibility. He gave no more information about experience of the drug in this age group or possible side effects, nor who would undertake the required monitoring and what that would comprise. It was not clear, either, what the family had been told.
The GP called the MDU for advice.
The adviser confirmed that the GP was correct in believing that she would bear responsibility for any prescription she wrote, even if she prescribed at the recommendation of a specialist. GPs are not obliged to provide prescriptions if they do not believe they have sufficient information and are not competent to do so.
The GMC guidance Good Practice in prescribing and managing medicines and devices (2013) makes clear that the onus is on the specialist to explain the use of unlicensed medicines and departures from the accepted regimen. The specialist should also provide the GP and patient with sufficient information 'to permit safe management of the patient's condition'.
When recommending a medication which is not well known, the specialist should agree a protocol for treatment with the GP and specify the dosage and means of administration.
The adviser directed her to the GMC guidance on prescribing, which is available on the GMC website.
The GP discussed the situation with the prescribing lead for the Local Area Team of NHS England. They liaised with the trust to produce a protocol for cases where unusual and off-licence drugs are recommended by secondary and tertiary specialists who wish to share ongoing prescribing with GPs.
With knowledge of potential adverse effects and the rationale for treatment, and with a written agreement in place which included a clear plan for monitoring and a copy for the records, the GP felt sufficiently informed to provide further prescriptions.
The prescriber has a duty to understand any drug they prescribe, including adverse effects and appropriate monitoring, even when prescribing on the advice of a specialist. When the regimen is unusual, the specialist is best placed to provide that information and must do so.
A formalised process for shared care which makes clear what is expected in primary and secondary care and what the essential elements of the process are, will help safeguard patient safety. A written record is essential for good communication between healthcare professionals, and helps prevent one doctor mistakenly thinking that the other has addressed some aspect of the process. In all cases, the overriding priority must be patient safety.
Dr Christine Walker
MDU medico-legal adviser
This page was correct at publication on . Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.