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Can GPs refuse medicines because they are available OTC?

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David Reissner: GPs must make prescribing decisions on the basis of their contracts
David Reissner: GPs must make prescribing decisions on the basis of their contracts

Recent weeks have seen clinical commissioning groups (CCGs) make increasingly public efforts to reduce the prescribing of medicines available over the counter.

The Royal Pharmaceutical Society published guidance last week in response to “some CCGs” looking to reduce the routine prescribing of medicines that have been assessed to be “readily available for over-the-counter (OTC) purchase”.

It came three weeks after Dudley CCG stopped the routine prescribing of “self-care medicines” – including paracetamol and headlice lotion. A poster (below) produced by the CCG states that “prescriptions for self-care medicines are no longer available from your GP” and instead encourages patients to “buy these [medicines] over the counter at your local pharmacy”.

 

So are CCGs within their rights to tell the public that prescriptions of OTC medicines are now off-limits?

CCGs “don’t have that power”

David Reissner, senior healthcare partner at law firm Charles Russell Speechlys LLP, stresses that CCGs “do not have the power to say what GPs can or cannot prescribe”.

“CCGs are legally entitled to try to influence prescribing, but they cannot insist that GPs cease prescribing medicines that can be bought over the counter,” he tells C+D.

“GPs must make their decisions on the basis of their contracts, which require them to prescribe treatment if this is clinically appropriate.”

Mr Reissner echoes concerns raised by GP Azeem Majeed earlier this month when he says: “In my opinion, a statement by a CCG to the public saying that self-care medicines are no longer available from their GP is not lawful.”

“GPs could be sued”

It begs the question: what would happen if GPs followed CCGs’ recommendations to their logical conclusion, and refused to prescribe these OTC drugs and treatments?

“A GP who refused to prescribe because the required item could be bought over the counter would probably be in breach of contract, and could be sued or made the subject of a complaint under the NHS complaints procedures,” Mr Reissner adds.

15 Comments
Question: 
What do you think about CCGs restricting prescriptions of OTC medicines?

Helen Robertshaw , Community pharmacist

 

I would add to locum pharmacist’s point about selling within license. It’s all well and good to send people to the pharmacy for acute pain, but how much time do we spend with people coming in every week for co-codamol who are using it for chronic arthritis? And that’s just the ones who are really taking it for chronic arthritis. Don’t get me started on the ones who tell you anything that sounds plausible.  Personally I think anything that is chronic should be treated through the NHS even if it is just with paracetamol. How else would the GP know the condition existed. The same applies to indigestion; fine if it’s acute, but how many repeat purchasers of ranitidine should really get a proper diagnosis. 

 

A Rashid, Locum pharmacist

Having recently been refused Dicofenac gel (100g) for osteoarthritis by a nurse, I found this whole leaflet infuriating. According to her it was cheaper to buy than prescription; which it isn't. And secondly degenerative disc disease is a minor ailment to her; funny because I've been suffering for 6 years and will do so for rest of my life. And it didn't mater if I had a maternity certificate now, I should pay. This advice allows some healthcare professionals to follow blindly and without thinking what impact it has on patient.

janet maynard, Community pharmacist

We just need a new blacklist with itmes not allowed on script- my personal bug bear is olive oil drops!

Ilove Pharmacy, Non Pharmacist Branch Manager

When will the multiples push for a new NHS advanced bottom wiping service for all patients( to carried out in the consultation room or home visits available on request). Should be interesting when some stubborn pharmacists/locums refuse and a patient reminds them that they're entitled to it 'free' on the NHS. I presume that will involve a trip to Canary Wharf for a swift striking off followed by the usual write in the C&D and the multiple absolved of all blame.

Valentine Trodd, Community pharmacist

When a service or product is provided free of charge it will be abused. This is the case for free prescriptions, free GP visits, free delivery, free MDS, etc. In the Rep. of Ireland for example, only those that can't afford to pay for prescriptions (over 70s, unemployed, etc - the rest of us must stump up for private prescriptions, but that's another story...) have them paid for by the state - BUT, they must still pay a levy of 2 euros per item, up to a maximum of 20 euros/month. Perhaps, this is something the UK needs to start thinking about?

Jonny Johal, Pharmacy Area manager/ Operations Manager

Valentine, need I point out that pharmacies are providing free delivery services voluntarily ... are you arguing these should be withdrawn? My personal view, should never have started in the first place.

Gerry Diamond, Primary care pharmacist

It is a difficult problem, as I get free prescriptions and always buy my own gaviscon, ranitidine, lactulose, pain killers without going to my GP. And so don't have too much of a problem when prescribing as a practice pharmacist to recommend people buy paracetamol, cough meds, and head lice products.

Jonny Johal, Pharmacy Area manager/ Operations Manager

Hi Gerry, I wonder if you can say what your legal position is should you be challenged by a patient? As Mr Reissner seems to think that prescribers are contractually bound to provide treatment, including free treatment to those who are entitled, or risk legal action. I assume you are professionally insured, and do you know if your insurer has a view on this subject?

Jonny Johal, Pharmacy Area manager/ Operations Manager

I totally agree with David Reissner on this issue, while we all have an opinion as to whether patients should be punished for going to their GPs for items like paracetamol, or for wasting what was supplied free of charge, the legal situation is quite clear, certain sections of the community are entitled to free treatment under the various NHS Acts, doctors are obliged to prescribe and pharmacists are obliged to dispense. Whether an item is cheap or whether there is a likelihood that it'd be wasted is not part of the equation.

Until parliament changes the rules (which I hope they won't), this sort of discussions are futile. I am a patient's advocate, and when I see doctors sending pregnant ladies to my pharmacy to purchase iron tablets, I do ring them up and remind them of their obligations (and to date, I have not had any refusals from any doctors). As a pharmacist, I don't see my job as the cost control officer for the NHS. 

Meera Sharma, Community pharmacist

I suggest you raed up your "NHS Acts" - GPs can recommend purchasing OTC products if clinically appropriate. There is nothing in the "NHS Acts" that says a patient can demand/is entitled to a script, if the GP does not think so. Secondly, this is the current path - have you seen the list of low-value clinical items that are proposed to be no longer provided on prescription? It's the way it will be going, if the NHS is to survive for anyone posting on this forum!

Jonny Johal, Pharmacy Area manager/ Operations Manager

Did you not post earlier " I agree that GPs legally cannot refuse " ?

Jonny Johal, Pharmacy Area manager/ Operations Manager

The vast majority of the NHS budget is spent on salaries and wages Meera, all I say is to compare the salaries of the NHS professionals with the global average ... now, are patients a burden on the NHS? Your post reminds me of an episode of "Yes, Minister".

Alan WHITEMANN, Communications

I think every community pharmacist is acutely aware of the tremendous waste within GP's prescribing regimens and maybe one solution would be to precribe such small amounts eg, 5 days supply that the patients would eventually give up and buy their own ( we can only hope anyway )

Meera Sharma, Community pharmacist

While I agree that GPs legally cannot refuse - we are living in an age of unprecedented cost pressures. Its going to be a case of "if we carry on the way we are going, we will be in bigger problems". Doing something rational now seems sensible, and articles like these fail to address this point. Why is it unreasonable to ask someone to buy a 20p box of paracetamol as opposed to queuing up at the GPs (appt blocking, waste of GP time and resource)?? Let's be pragmatic about the NHS, otherwise there will be no NHS by the time we need it!- not a good scenario for anyone. Let's have more balanced articles that come up with pragmatic solutions as opposed to veiled threats - with the current pressures on GPs and lack of GPs, articles like these are not thinking about the long-term problems we could be facing. Like all pharmacists, you witness wanton abuse of "free deliveries/meds etc". Unless there is a value attached to items, most people do not appreciate it - this concept does need to shift. Guess what is the top item that ends up as medicines waste nationally - paracetamol!

Locum Pharmacist, Locum pharmacist

I think I partially support this move but with a few major concerns. I have worked in pharmacies providing the minor ailment scheme where patients frequently demand paracetamol etc under the scheme and act as though the pharmacy have no right to refuse. Some pharmacies have discontinued this service due to patients unreasonable attitudes. It is not just this- it's the same with any free service provided by the pharmacy such as deliveries, MDS, pharmacy 'loans' etc. Patients develop a sense of entitlement and fail to recognize that they are not the only patients at the pharmacy and that others may need to be prioritized over them. I expect they are the same with staff at GP surgeries so I can understand taking steps to make them take some responsibility for their self-care.

The main downside for me is that pharmacies have strict rules to follow when it comes to selling medicines OTC and GPs/nurses/midwives are unaware of these. They frequently send patients to buy co-codamol/hayfever tablets for use in pregnancy, hydrocortisone cream for use on face and we are put in the difficult position of having to refuse the sale. Patients generally don't take this well as so-and-so said they could get the medicines from the pharmacy and they don't realise that pharmacists are independant professionals in their own right.

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