The PDA has previously issued a series of articles highlighting the pitfalls associated with online prescribing when using a questionnaire model (also known as asynchronous prescribing). PDA specialist pharmacists have provided detailed feedback about this guidance to the DiCE network participants, based upon the experience of prescriber members who are or have been under investigation by the GPhC. The PDA believes the final guidance conflicts with the expert opinion which underpins the GPhC’s prosecution strategy towards pharmacist prescribers under investigation.
The PDA’s concerns about questionnaire-based prescribing include the following:
- In most cases, there is no interaction between the patient and prescriber.
- In some cases, prospective patients can select the medicine they want at the start, making the interaction more of a commercial transaction rather than a professional clinical consultation with shared decision-making.
- On some systems, patients can subsequently alter the answers they provide on the questionnaire resulting in them being able to obtain a medicine when supply was previously declined.
- False information can be provided to ensure a supply is obtained when the patient does not fit the supply criteria, without sufficient safeguards to detect this.
- The lack of access to the patient’s clinical record means that prescribers cannot be assured that a supply is safe and appropriate.
- The failure to inform patients’ GPs about the medicine that has been supplied exposes patients to potential harm and leaves GPs unaware of what additional medication their patient is taking.
- To optimise the efficacy of GLP1-RA medicines, NICE guidance and marketing authorisations require patients to receive regular diet and exercise support and monitoring in addition to the medication – the asynchronous model can usually only provide leaflets and further periodic online supplies.
When a clinical expert was asked by the GPhC to consider whether online questionnaire-based (asynchronous) provision of weight loss medications, including Glucagon-like Peptide-1 Receptor Agonists, was appropriate, the expert stated that in “my opinion weight loss medications should not be prescribed from an online questionnaire”.
The expert also said, “…prescribing from a questionnaire without a face-to-face consultation is not and cannot be in a patient’s best interests as the prescriber does not have a full and complete clinical picture of the patient, only self-reported information. Therefore, the prescriber cannot assess the patient clinically, assess their emotional and mental health, or have any kind of meaningful therapeutic dialogue with them.”
DiCE Guidance
The guidance includes many recommendations about how to provide an asynchronous weight management service, including relatively detailed guidance on prescribing decisions (to be found at the end).
It notes the measures that can be taken to try to verify information provided by patients but admits that “it is the consensus of the DiCE Working Group that there is no completely foolproof way to safeguard against wilful misuse of GLP-1RA in the context of digital asynchronous prescribing”.
Despite this clear risk, whilst advising prescribers that they should employ a combination of verification methods to confirm information volunteered by prospective patients, the guidance stops short of advising prescribers that they must undertake any specific mitigating actions to enhance patient safety, leaving this for individual clinicians to decide, on the grounds that it does not seek to be ‘overly prescriptive’.
Conclusion
Pharmacists prescribing GLP1-RA medication based upon an asynchronous model expose themselves to the risk of possible regulatory action should their practice come to the attention of the GPhC because of a routine inspection, complaint, or patient safety incident.
Our view is that this guideline cannot be regarded as ‘best practice’ when it promotes a questionnaire-based prescribing model which is described as unsuitable in a GPhC clinical expert’s report specifically commissioned to consider online pharmacist prescribing.
The PDA calls upon the GPhC to issue unambiguous guidance about its expectations of prescribers who use questionnaire-based/asynchronous models to provide online prescribing services.
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