Risk reduction: stopping medicines when patients default from review

In a previous blog I illustrated the importance of robust processes that ensure any patient with a condition requiring clinical monitoring is added to practice recall systems, so that an alert is prompted should they fail to attend for review.

In their 2013 guidance Good practice in prescribing and managing medicines and devices the GMC state that:

You should reach agreement with the patient on the treatment proposed, explaining… arrangements for monitoring, follow-up and review, including further consultation, blood tests or other investigations, processes for adjusting the type or dose of medicine, and for issuing repeat prescriptions.

But what do you do when a patient for whom you are prescribing consistently defaults from review? Should you withdraw access to the medicine? If so, how should this be done, and when?

MDDUS analysis of GP claims shows two common problem areas in the monitoring and review of patients on repeat medicines:

(1)  failure to adequately monitor long term prescriptions or

(2)  failure to effectively manage patients who default from review. Such cases, where medicines may be continued or stopped, can lead to the patient or their family blaming the practice for not adequately explaining the risks to them.

We receive a significant number of calls from members requesting advice on how to deal with patients who default from review. In most cases several attempts have already been made to arrange a review but the patient has either declined and continued to request repeat prescriptions, or failed to attend appointments as promised. This often occurs when the GP offers to provide another script if the patient agrees to make a review appointment.

Members are often looking for guidance to ensure their actions will not be criticised should the patient come to harm.

In our experience, many practices have a range of processes in place to deal with patients who default from review appointments. Some examples of these are below:

• Send further invitations to attend a review appointment
• Contact the patient by telephone to try to arrange an appointment
• Place an alert in the patient’s record saying they need to be reviewed in case the patient attends for another matter
• Write to them – once via registered post - warning that if they continue to default from their review appointments their medicine will be stopped, including the potential risks of this
• Issue shorter prescriptions that the patient is forced to collect (and pay for in some areas) so that it is easier to attend the review
• Refuse to issue a prescription after a deadline date unless the patient attends before this

Although it may be helpful to implement one or more of these actions within a practice system for dealing with those who default for review, the most important consideration is the individual needs of the patient in the specific circumstances.

The GMC advise that:

“…you must make sure that suitable arrangements are in place for monitoring, follow-up and review, taking account of the patients’ needs and any risks arising from the medicines. Reviewing medicines will be particularly important where:

a. patients may be at risk, for example, patients who are frail or have multiple illnesses

b. medicines have potentially serious or common side effects

c. the patient is prescribed a controlled or other medicine that is commonly abused or misused

d. the BNF or other authoritative clinical guidance recommends blood tests or other monitoring at regular intervals”

In carrying out an individual needs assessment, and creating a shared action plan for the team, in our experience you may wish to consider the following:

• Some prescriptions have adverse long-term effects. MDDUS regularly assist members with claims related to alleged lack of appropriate monitoring of these medicines which are perceived as ‘lower risk’ but can have significant long-term adverse effects.
• Some prescriptions require monitoring to assess response to the drug treatment. If you continue to treat without understanding the effect and adjusting the dosage as indicated, there is the potential for the patient to suffer a range of adverse effects.
• Some prescriptions require monitoring to adjust dosage and the risk increases very quickly if prescriptions are continued without results information.
• For some medicines you may wish to withdraw treatment slowly rather than just stop prescribing.

You should also consider why the patient might be defaulting from review – might they be worried about results? Might their circumstances make it difficult to attend (e.g. working hours and loss of income / working away from home)? What is the state of the patient-doctor relationship / patient-nurse relationship? Might the patient be worried about something else (e.g. they don’t want to come in for BP / blood check as avoiding a smear test)?

Reducing risk

The practice should have processes in place to deal with patients who default from review, but it is also essential to ensure the patient is looked at as an individual rather than just a name on a recall list

Where possible, discuss the patient’s case with your colleagues and come to a shared view about how to proceed with that individual patient – along with reasonable timescales dependent on the case. Communicate this decision clearly to administrative staff acting on your behalf.

If the patient continues to default, the risks and benefits of continuing to prescribe without review should be weighed up and a decision made and fully documented.

Whatever the decision, it is always best to try to speak to the patient yourself before taking action – this is particularly important for those patients at a greater risk of harm.