Direction of prescriptions 2015
Definitions ............................................................................................................................................... 1
Direction .............................................................................................................................................. 1
Contractor ........................................................................................................................................... 1
Health Care Professional ..................................................................................................................... 2
Prescription ......................................................................................................................................... 2
Why is direction wrong ........................................................................................................................... 2
Patient choice ..................................................................................................................................... 2
Patient confidentiality ......................................................................................................................... 2
Data Protection Act ................................................................................................................................. 2
Examples of direction of prescriptions ................................................................................................... 3
GP practice .......................................................................................................................................... 3
Community nursing ............................................................................................................................. 3
Hospital dietician ................................................................................................................................ 3
Care home ........................................................................................................................................... 4
How can I avoid a patient complaint of direction? ................................................................................. 4
Individuals ........................................................................................................................................... 4
Pharmacists ......................................................................................................................................... 4
GP practices ........................................................................................................................................ 4
References .......................................................................................................................................... 4
Direction of prescriptions is the term used to describe the exercise of undue influence by a health care professional over the choice of where a patient takes or sends their prescription to be dispensed. The influence may be intentional, or may be because any positive comment by a health care professional that is likely to be taken by a patient to be an endorsement.
A contractor is a GP practice, a pharmacy, an appliance contractor or supplier of enteral feeds
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Direction of prescriptions 2015
This includes all hospital doctors, general practitioners, practice nurses, community nurses, hospital nurses, community and hospital pharmacists, practice pharmacists, dieticians, podiatrists, physiotherapists or other allied healthcare professional and would also, in this context, extend to those staff employed by contractors e.g. GP practice staff and pharmacy staff.
A prescription is a legal written request intended as an instruction to a dispensing contractor to supply a medicine, appliance or enteral feed to the patient named on the prescription.
The direction of prescriptions contravenes the NHS constitution in two ways:
A patient is entitled to be involved in every decision taken about their healthcare, and this would include taking decisions about where they want their prescriptions to be dispensed.
The NHS Constitution contains a number of principles, including principle 4:
The NHS aspires to put patients at the heart of everything it does. It should support individuals to promote and manage their own health. NHS services must reflect, and should be coordinated around and tailored to, the needs and preferences of patients, their families and their carers. Patients, with their families and carers, where appropriate, will be involved in and consulted on all decisions about their care and treatment. The NHS will actively encourage feedback from the public, patients and staff, welcome it and use it to improve its services.
This makes clear that the preferences of patients must be reflected in NHS services, and if a patient prefers to use a particular pharmacy, the NHS should ensure that this preference is respected.
The Constitution also sets out a number of rights, one of which is related to confidentiality:
You have the right to privacy and confidentiality and to expect the NHS to keep your confidential
information safe and secure.
The information set out on a prescription is confidential information. Forwarding a prescription to a particular contractor without the patient’s consent will breach this confidentiality. Confidentiality is also covered by the Data Protection Act.
The information set out on a prescription is confidential, and because it is often possible to deduce the condition for which a patient is being treated, the information is sensitive personal information.
The first principle in the Data Protection Act requires those who ‘process’ personal data to process it lawfully. To assist data processors, the Act sets out in Schedule 2 the conditions that apply to
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Direction of prescriptions 2015 processing personal data and in the case of sensitive personal data, additionally at least one of the conditions in Schedule 3 must be met for the processing to be lawful.
In respect of sensitive personal data, the conditions in Schedule 3 are as would be expected, drafted to provide maximum protection for the individual whose data is being processed. Sensitive personal information can be disclosed where the individual has given explicit consent to the processing. There are exceptions, for example where it is in the best interests of the patient but the patient’s consent cannot reasonably be obtained. There is also an exception where the process is for medical purposes and is undertaken by a health professional or by someone who is subject to an equivalent duty of confidentiality. This allows pharmacies to maintain patient medication records for use within the pharmacy without obtaining the consent of the patient. This exemption may also apply where a patient is referred within the NHS (for example referred by the GP to hospital for treatment). Whilst it might be expected that this could allow a GP to pass information to a community pharmacy without explicit consent, it should be noted that with repeat dispensing, the GP is required, as part of the setting up of repeatable prescriptions, to obtain consent from the patient to have the relevant exchanges between the GP and pharmacy. This suggests that GPs and pharmacists do not have a general authority to discuss a patient without their consent (hence the need for consent forms for
MUR and NMS consultations).
Healthcare organisations are often the subject of enforcement action by the Information
Commissioner’s Office (ICO), where sensitive personal information is disclosed inappropriately, especially if the processes of the organisation are inadequate to protect the data. The ICO now has the power to levy fines of up to £500,000.
Most GP practices operate collection arrangements where repeat prescriptions may be collected by the patient’s chosen pharmacy. Practices must have robust processes to ensure that prescriptions are forwarded to the correct pharmacy. If a patient’s prescription has been sent to a pharmacy without that patient’s explicit consent, then the matter may be one that could be referred (with the patient’s consent) to the ICO. If a prescription was sent to a particular pharmacy, thereby disclosing sensitive personal information, in circumstances where the patient had expressed a preference to use another pharmacy, then this is likely to be viewed extremely seriously by the Information
Commissioner.
A member of the practice staff gives a prescription to a pharmacy for dispensing without checking that this is the patient’s preferred pharmacy.
A community nurse sends a prescription for urinary drainage equipment to an appliance contractor of their choice without asking the patient/carer.
The dietician sends patient details to an enteral feed supplier to arrange for on-going supply of feeds without informing the patient that their supplies could be obtained elsewhere.
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A care home manager sends all their patients’ prescriptions to one pharmacy without consulting the individual patients or relatives.
The best way to avoid an accusation of direction of prescriptions is to make sure that you always ask the patient (or carer) where they want their prescription dispensed and to make a note of this choice; as with any consent it can be withdrawn or changed without notice so it is necessary to ask the patient on each occasion.
Make sure you have valid consent to both collect and deliver prescriptions.
GP Practices should have a robust process to ensure that prescriptions are only forwarded to the patients chosen pharmacy, appliance contractor or enteral feed supplier.
Avoid the following activities to in order to maintain good practice:
1.
Providing a practice endorsement for a pharmacy
2.
Allowing a practice database to be used to facilitate the promotion of a pharmacy, or any other promotional activity
3.
Suggesting that the practice/GP/member of staff would like a patient to use a particular pharmacy
4.
Allowing a patient to believe that the level of care they receive from their medical practice could be influenced by their choice of pharmacy
5.
Recommending that the patient collects a prescription from a certain pharmacy which is not the pharmacy that the patient had chosen
6.
Manipulating the prescription management process in favour of a particular pharmacy, including, but not limited to, offering a pharmacy privileged access to prescriptions generated by the practice
7.
Failing to be equitable when liaising with pharmacies, by offering differing levels of cooperation such as for repeat prescriptions
8.
Ignoring a patient’s freely stated choice of pharmacy
9.
Misrepresenting a practice’s relationship with a pharmacy
10.
Showing a lack of candour when providing information about dispensing and pharmacies
(including, for example, making unsubstantiated or misleading claims about a particular pharmacy)
11.
Failing to be transparent about a financial relationship between a practice and a pharmacy
12.
Any other practice, which is designed to unduly influence a patient’s choice of pharmacy

PSNC Briefing 095/13: Direction of Prescriptions September 2013
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
GMC. Financial and commercial arrangements and conflicts of interest 25.3.13

BMA, PV, PSNC. Prescription direction. October 2013
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