Hello,
Can anyone give some advice or guidance around the issue of a GP signing a nurse generated script in a substance mis-use setting.
The GP presumably takes full responsibility for the script; but how common is this practice in primary care. The situation has arisen where "non-prescribing" nurses are reviewing patients and producing the script, but need a GP to sign,
Thanks,
Alastair

Hasn't this always happened? I think a lot is to do with the relationship the Doctor and Nurse have, if it's good it works.
The Nurse would still have to take responsibility for generating the prescription and 'Advising' the Doctor to sign that rx. You can't get away scott-free just because you didn't sign it if something goes wrong.

this is oten how all the scripts are generated in primary care, in particular in some of the older shared care scheme, it was partly as an incentive to GPs in terms of reducing workload (in the days before theywere paid to do it).

I have a feeling its less common now but I'm not sure. The GP is still responsible for what they sign and should check the scripts are OK and have the competance to do so (this was not always the case)

Scripts for methadone and buprenorphine can be treated in just the same way as scripts for insulin or antihypertenive medication, with a decision on how frequently they need a medical review. This period may appropriately turn out to be be anything between 24 hrs up to a maximum of three months.

The GP will agree with the patient and drugworker how often they need to review the patient themselves, and in between the script can be printed by anybody (receptionist, admin person, drug worker, nurse), for signature by the GP. Of course every GP signs large numbers of prescriptions each day,for all their patients and has to check every single one for appropriateness and safety before signing (eg has this warfarin patient had her clotting time checked? Has this methotraxate patient had their blood tests checked? Should this person still be taking iron?) and our scripts can fit into the same system.

The Guidelines, and also good sense, suggest that each patient on methadone or buprenorphine should be seen for medical review at a minimum each 3 months. The GP should also be able to see the latest care plan made by the patient and the keyworker each 3/12s.

Especially during the initial induction and engagement stages, the GP may well see the patient much more frequently, and may print all the scripts themselves, but once a maintenance dose is established it may be much more productive for them to see another worker, and for the scripts just to churn out boringly in the background somewhere.

Judith
Thanks for your reply - its taken a while to get back to you!!
Do you inevitably end up pre-signing scripts in advance of the patient coming in to collect their script?
If so, how long in advance would you sign?
It seems such a simple issue, but the Home Office, I have been informed, are adamant that "pre-signing" scipts for methadone is "illegal" - cant quite see it myself, but...
Alastair

One way to keep within the Home Office's view of what is 'illegal' (not always the same as actually illegal),is to have the scripts start sometime after seeing the drug worker. The script can be printed and signed anytime after the appointment and before the commence date. If they are also sent direct to the dispensing pharmacy the client just goes there to collect. It also avoids the 'lost my script' scenario. I have dome this with scripts up to a week ahead with established stable clients. It is reassuring all round.

Hi Alistair,
As you suspect, We are pre-signing scripts all over birmingham. Will the Home Office come and close us down? I could do with a holiday.

As I have described elsewhere, at the CDTs scripts for maintenance doses are printed in batches for 6 weeks at time, and we prescribers are asked to sign them in big piles, without the case notes. We have a precribing card only, with each person's scripts, on which is recorded their medication doses, and the date they were last seen by a Doctor for medication review. If this is recorded to be within the last 12 weeks, i sign the scripts, and they are posted to the person's pharmacy.

I have come to accept this sytem, which was thrust upon us in order to deal with the numbers and safe organisation of scripts, though i still feel it not ideal. I would prefer to sign them with the patient in front of me, or imediately after seeing them, as i do in my own surgery. The downside of doing the scripts during the appointment is that you sit printing and signing scripts, rather than listening to the latest installment of the patient's life, and attempting the latest version of motivational interviewing. . I don't suppose there is an ideal solution. Important just to make it safe and efficient and auditable for all of us.

Hi Judith
scripts in big piles, no case notes... seen a doctor for a 'medication review'...( did that CDT review include a record of alcohol intake?)
are you sure this 'system' , (which was thrust upon you -whilst you continue to take personal responsibility for every script in that pile) accords with http://www.gmc-uk.org/guidance/current/library/prescriptions_faqs.asp#5h ?
Several threads on the SMMGP site support my view that systematic reviewing & recording in SMS is at about the same stage GP asthma reviews were in the late 1980s.
If prescribers arent happy with their systems they can change them; say words like 'governance' and 'clinical responsibility' audibly in meetings with commissioners, or better still get a role in PBC and ensure that services are only commissioned if they satisfy proper governance requirements.
Regards
Graham

Oh to be in Bradford where clinical governance reigns supreme. Unfortunately we work in a world where substance misuse services are dealing with thousands of individuals outside of the remit of PBC, where chronic disease management is largely undertaken by practice nurses and where pragmatism and professional judgement are occasionally brought to bear.

I am afraid that I cannot accept for a minute an alleged Home Office position that 'pre-signing' of scripts is illegal. I have had an interminable number of discussions with different PCT prescibing advisors that FP10 (MDA) scripts can be legally signed in advance of the first dispense on the script, and a signed script merely becomes 'live' on the day of that first dispense.

I also agree with the implied pragmatic positions of Judith and Pat that it is impossible to organise a clinic which may prescribe for hundreds of patients over the course a rolling fortnight so that a medic will see every patient on the day their script is due to be signed. It may be possible to have that arrangement in a primary care setting where there are relatively few patients being prescibed but it just can't work like that as the numbers go up.

Cheers
Simon

crossed wires & threads here I think.
1.Secondary signing of scripts ;this is really a form of repeat prescribing. I clarified the legality of this with the MPS in response to another thread.According to them there appears to be 'no technical bar to (repeat) prescribing in this way'.
They are continuing to make more detailed enquiries.
The MPS does however strongly reiterate the GMC advice about signing repeat prescriptions
2.I've not suggested that clinical governance reigned supreme in Bradford.SMS (I think everywhere) has a lot to learn from Primary Care where systematic IT based reviews have been the norm for over a decade, allowing practices like my own to care for > 10, 000 pts with 3 FTE docs;in the real world without compromising standards.
there's massive potential to safely increase capacity in SMS by adapting this approach; unfortunately there's minimal understanding of the concepts at a commissioning level.
3.I hope all Clinicians would agree that to disregard (or remain ignorant) of the advice of the GMC or their indemnity body would be a touch unprofessional.
If I worked in an SMS which couldnt operate without me doing so I'd be doing a pragmatic Foxtrot Oscar out the front door.
Regards
Graham

quote:

Originally posted by graham sanderson:
"Several threads on the SMMGP site support my view that systematic reviewing & recording in SMS is at about the same stage GP asthma reviews were in the late 1980s.
If prescribers arent happy with their systems they can change them; .......,"
Graham

"

hi graham,
I do agree with all your statements about the importance and need for clinical governance and responsibility. However i do not agree that our present sytems are like "GP asthma reviews in the 1980s". I think you may have misunderstood the sytem i was describing, or probably I was not being clear.Just like the other areas of chronic disease management, we have guidelines which we follow, and templates which trigger regular reviews, and sytems for safe repeat prescribing which are of course in line with the GMC guidelines in your link.

When I check , before signing any script, that one of my trusted prescribing colleagues have seen the patient within the pre-decided review date period (usually either 6 or (a maximum)12 weeks for maintenance patients) that is exactly the same procedure I follow for signing repeat scripts every day for diabetics, asthma etc in the surgery, checking that it is not past the due date for their review, before signing, and taking steps to get them in to be seen , or making sure they have an appointment, if the review date is approaching.

One of the attempts we have made, all of us with the help of this web site, is to make sure these or similar systems are applied for the improved care of this group of patients all over the country, aiming to reduce post code lottery levels of care. In general I have seen enormous improvements over the last ten years in clinical governance in this area. Cetainly ten years ago in this area it was common in what was then an overwhelmed and poorly organised hospital based service, for "maintenance" patients to continue to get scripts without any kind of medical review for six months or more . This has now stopped,and there are regular care plans and reviews,and more structured work by the drug workers (following a modified texas model) http://www.ibr.tcu.edu

I was anxious about the suggestion that we could not have any kind of post dating or signing of CD scripts without seeing the patient on the start date of each script, but hopefully , as Simon says, that is not the case.

This message has been edited. Last edited by: judith yates,

I just thought I would add a link here to the other thread we are using to discuss these issues, so that if people read this later, via a search, they will be able to hop to the other thread...

http://smmgp.groupee.net/eve/forums/a/tpc/f/9954030241/...341055562#7341055562

and answering my own question above, the quote from the BNF controlled drug prescribing section: (quote)
"9) The prescriber may forward-date the prescription; the start date may also be specified in the body of the prescription."

This message has been edited. Last edited by: judith yates,

i don't "post-date" Rx's i must admit since i thought that like any legal document, the date that appears beside your signature has to be the date that you actually signed it.......if i want it dispensed at a later date i write "to be dispensed from......" on the script. i presume that's what people mean.

Yes. wel that's what I mean anyway with regards to FP10(MDA)s: the script can be printed and signed weeks in advance of the first dispense date.
Simon

Don't forget the 28 day validity for CD scripts, 'weeks in advance' can only be 4 weeks from the date you signed it as I understand it. Can cause problems at holiday time.......

The 28 day clock starts ticking either at the date of signing or at the start date specified on the script. Most methadone/subutex scripts will have a start date for interval prescribing.

Yes, pat is absolutely right.
FP10 (MDA) scripts - which necessarily have a first dispense date - can be signed ANY number of weeks prior to that start date.

That's not to say that would always be a sound clinical position mind...

Simon

Seems to cause a lot of confusion. If I postdate them I write the start date in the date box next to the signature. Other prescribers sometimes put the start date in the text of the script and date the script as the date on which they have written it - one pharmacist rejected it done that way last week. Needs to be clarified!

Pharmacists have just as miuch right to be wrong as the rest of us.