Updated guidance from the General Medical Council (GMC) on Good practice in prescribing and managing medicines and devices came into force in April, which emphasises limits on the prescribing of controlled drugs to reduce the risk of harm.
This guidance is important to address concerns about inappropriate prescribing of controlled drugs, especially since the majority of GPs are now conducting many consultations remotely. When prescribers cannot assess the patient in person, and particularly when they do not know the patient, there may be increased risk of inappropriate prescribing.
The new GMC guidance provides clarity about prescribers’ responsibilities in this context. It applies equally to all prescribing, in any setting, including remote consultations.
Follow relevant clinical guidance on controlled drugs
Controlled drugs are subject to high levels of regulation and restrictions on how they are prescribed, supplied, stored and destroyed because they pose a risk of serious harm or are associated with dependency and misuse. Prescribers have responsibilities to ensure that they are managed and used safely.
GMC guidance states that “When prescribing, you should follow relevant clinical guidance, such as drug safety updates on the risk of dependence and addiction associated with opioids.”
Avoid prescribing controlled substances without access to patients’ records
The GMC guidance states “If you don’t have access to relevant information from the patient’s medical records you must not prescribe controlled drugs or medicines that are liable to abuse, overuse or misuse or when there is a risk of addiction and monitoring is important.”
The only exceptions are “when no other person with access to that information is available to prescribe without unsafe delay” and it is necessary:
- “to avoid serious deterioration in health or avoid serious harm”
- or “ensure continuity of treatment where a patient is unexpectedly without access to medication for a limited period.”
Additionally, you must not prescribe controlled drugs to yourself or someone close to you, unless the above exceptions apply, in which case clear records should be made of the reasons for action.
Understand the risks when you do not know the patient
Be mindful that there are particular risks when patients are unknown to the prescriber. Some patients may be seeking controlled drugs from multiple sources. Where it is essential to prescribe controlled drugs without access to the patients’ records, only a limited quantity and dose should be prescribed, until the records can be verified.
Reinforcing this need for caution, the Care Quality Commission (CQC) notes a worrying increase in the number of coroners’ reports where large quantities of Schedule 4 and 5 controlled drugs (not subject to the same monitoring as Schedule 2 and 3 drugs) have been prescribed and led to a patient’s death.
Contact us at Medical Defense Society for legal advice if you are concerned about an incident related to prescription of controlled drugs.
Ensure safeguards are in place for appropriate prescribing
Especially if you are prescribing remotely, GMC states “you must also be satisfied that appropriate safeguards are in place to support safe prescribing”. If you cannot be sure of this, it may be appropriate to offer an alternative mode of consultation.
Safeguards include robust identity checks, ensuring you have the patient’s consent for sharing information with their regular prescriber, and making relevant information about the prescription known to their GP or adding it to the primary care record. Notably, the guidance says that it may be unsafe to prescribe if the patient refuses consent to share this information.
As always, dialogue and clear communication are essential for safe prescribing. CQC’s review of the safer management of controlled drugs also stresses that healthcare professionals should consider the individual needs and wishes of their patients and understand that a blanket approach to prescribing is inappropriate, especially in end of life care.
Whenever prescribing controlled drugs, make sure to plan for appropriate monitoring, follow-up and review. Give the patient the names and contact details of people who will be involved in their care and who they can contact if they have questions or concerns.
Further information and guidance
BNF guidance on controlled drugs and drug dependence includes:
- The five Schedules of controlled drugs and regulatory requirements that apply.
- Prescription requirements for controlled drugs (all preparations in Schedules 2 and 3).
- Responsibilities of the prescriber to avoid causing drug dependence and misuse.
- Precautions to prevent stealing and misuse of prescription forms.
At Medical Defense Society, we are available 24/7 to provide members with advice about legal matters related to prescribing of controlled drugs.
The UK formally left the EU on 31 January 2020, entering into a tense transition period during which a long-term trade relationship was negotiated. After much uncertainty, the two sides eventually struck a deal and the EU-UK trade and co-operation agreement took effect from 1 January 2021.
With this arrangement, free movement of labour between the UK and European Economic Area (EEA) countries came to an end and a new points-based system of immigration was introduced. However, the majority of health care professionals with an NHS job offer are exempted from the points-based system and can apply for a Health and Care Worker Visa. GPs with relevant European qualifications can also apply to the General Medical Council (GMC) for entry to the GP Register.
Despite concerns before Brexit, the new system is intended to streamline international recruitment into health care roles. Greater clarity over the arrangements should now boost efforts to recruit GPs from overseas.
GPs with relevant European qualifications can apply to register in the UK
Firstly, GPs coming from Europe to practice in the NHS will need to apply to the GMC for entry to the GP Register. From 1 January 2021, they will need a qualification awarded in the EEA or Switzerland that is classed as a relevant European qualification; they do not have to be a national of the EEA.
GMC guidance summarises the steps for GPs to follow:
Qualifications that are classed as relevant European qualifications will be recognised in the UK for two years from 1 January 2021. The UK government is now working with professional regulatory organisations to determine future registration arrangements from January 2023.
For qualifying Swiss applicants, the Citizens’ Rights Agreement signed by the UK and Switzerland means that the process will remain the same as before the transition period, until at least the end of 2024.
For queries about indemnity insurance for GPs working in the UK, please contact us at Medical Defense Society.
Next steps to practice as a GP in the NHS
The British Medical Association (BMA) offers advice about the step-by-step process to work in the NHS. After applying to join the GP register:
- Apply to join the national performers list of approved GPs.
- Register on the NHS GP induction and refresher scheme. This provides practical support and assessments such as placements and simulated surgeries.
- Apply for a job. NHS Jobs is a useful place to start.
Qualified GPs from overseas need a Health and Care Worker Visa
Qualified health care workers arriving in the UK from 1 January 2021 need to obtain a Health and Care Worker Visa. This allows medical professionals with a job offer to come to the UK to work in the NHS or with an NHS supplier or in adult social care. Note that Irish nationals can continue to live and work in the UK without needing permission.
Workers from the EEA who arrived in the UK by 31 December 2020 can apply under the EU Settlement Scheme until 30 June 2021 to be granted pre-settled or settled status, depending on how long they have lived in the UK.
NHS Employers offers this guidance for employers seeking to recruit from Europe: Preparing for the end of the EU transition: workforce guide for employers.
European doctors in the NHS
The opportunity to work in the NHS remains a draw for international health workers seeking to join one of the world’s leading health care systems.
Despite the uncertainty around Brexit before the agreement, the proportion of NHS GPs trained in the EEA stabilised and retention was improving in the years up to 2020. About 5% of NHS staff reportedly came from EEA countries in 2020 – among GPs, the largest groups were from Ireland, Germany and Spain.
GMC chief executive Charlie Massey said: ‘We’re grateful to the thousands of European and international doctors who choose to live and work in the UK and make a huge difference for patients. Despite uncertainty over the UK’s future relationship with the EU, we have observed steady growth in recent years. But we must not be complacent as the long-term impact of both Brexit and the pandemic on travel and decisions to emigrate and settle in the UK remain largely unknown.’
Our team of experts can help members who need advice about legal matters related to international recruitment, including indemnity insurance – please get in touch at Medical Defense Society.
The Additional Roles Reimbursement Scheme (ARRS) is designed to expand the primary care work force and enable more proactive, personalised and integrated health and social care. Through the scheme, Primary Care Networks (PCNs) are entitled to access funding to recruit staff for additional roles that will provide multi-disciplinary support according to local needs.
Expanding the primary care workforce is a priority to enhance patient care. With demands on GP practices likely to remain high due to the ongoing pandemic, backlog of patient needs and COVID-19 vaccination campaigns, recruitment of additional staff will also help to relieve some of the pressure.
The update to the GP Contract Agreement 2020/21-2023/4 introduces extra investment in the scheme and more roles for PCNs to choose from. Here’s what you need to know.
Which roles are funded through ARRS in 2021?
With the update to the GP Contract Agreement, a further 6000 staff are being funded through ARRS, meaning a total of 26,000 additional staff by 2023/24. More flexibility has also been introduced with the addition of more roles: nursing associates and trainee nursing associates from October 2020, plus paramedics, advanced practitioners and mental health practitioners from April 2021.
This means that from April 2021, PCNs are able to recruit staff for the following roles, to be reimbursed through ARRS: social prescribing link worker, clinical pharmacist, first contact physiotherapist, physician associate, pharmacy technician, community paramedic, occupational therapist, dietitian, chiropodist/podiatrist, health and wellbeing coach, care coordinator, nursing associate, trainee nursing associate, and mental health practitioners (including Improving Access to Psychological Therapy [IAPT] practitioners).
Advanced Practitioner roles include: clinical pharmacist, physiotherapist, occupational therapist, dietitian, podiatrist, and paramedic.
PCNs can decide which roles are required depending on their existing workforce and local needs.
How will additional roles be funded?
ARRS funding will increase from £430m in 2020/21 to a maximum of £746m in 2021/22. For most roles, the reimbursement is 100% of the aggregate Full Time Equivalent (FTE) salary, including on costs (Employer NI and Employer Pension) up to a maximum reimbursable amount.
From April, PCNs are entitled to a FTE mental health practitioner. These roles will be jointly funded by the PCN (through ARRS reimbursement) and the local mental health provider, each providing 50% of the cost.
All PCNs are urged to use 100% of their available funding, which should allow the average PCN to recruit an additional 20 FTE staff by 2023/24. However, many PCNs raised concerns that they would miss out on their full share of funding during the last financial year. Issues included lack of time for planning and recruitment, lack of available staff and inflexibility of the scheme. With the update introducing more flexibility, this should help PCNs to claim their full share of the funds.
What other schemes can boost GP practice expansion?
In March, NHS England announced a new £120m General Practice Covid Capacity Expansion Fund for six months from April. This money is to make further progress on the priorities set out in the COVID-19 support fund announced in November, such as boosting GP capacity and tackling the backlog in chronic disease management. Spending is prioritised for PCNs committed to deliver the COVID-19 vaccination enhanced service.
Also keep in mind the GP Retention Scheme, designed to help doctors who are thinking of leaving the profession to remain in clinical general practice. The scheme provides financial support to the retained GP and the practice that employs them. It also offers more flexibility and educational support than a ‘regular’ salaried GP post. In GPonline, Dr Sarah Matthews explained how the scheme works for her.
Helpful resources for the ARRS
Guidance on the ARRS is available from NHS England and NHS Improvement, including the process for claiming reimbursement for additional staff.
Expanding our Workforce details the additional roles that are funded.
The Additional Roles Reimbursement Scheme (ARRS) new online portal provides a simple way for PCNs to claim, and CCGs to approve, reimbursement for the roles hired.
FutureNHS provides recruitment support and guidance for ARRS roles.
Medical Defense Society is on hand 24/7 to help members needing advice about legal matters related to staff recruitment and expansion of GP practice teams.