Johnathan Laird
IN the United Kingdom (UK) pharmacists are the gatekeepers of medicines. They fulfil the traditional supply function and this is in the majority of cases quite straight forward. There are of course constraints and varying degrees of control on supply of medicines as there are in other countries around the world.
It is worth at this point mentioning that there are several classifications of medicines in the UK. They are as follows:
1. General sales medicines (GSL)– can be sold in any retail outlet. Limitations apply in terms of quantities available for sale.
2. Pharmacy only medicines (P) – must only be sold under the direct supervision of a pharmacist from a registered pharmacy.
3. Prescription only medicines (POM) – must only be supplied against a valid prescription written by an authorised prescriber. Information on practitioners authorised to prescribe is available in the Royal Pharmaceutical Society’s Medicines, Ethics and Practice. Details of individuals authorised to prescribe are annotated on the relevant regulators websites.
4. Controlled drugs – These are subject to the greatest controls. For example prescriptions must be written in words and figures and they are only valid for 28 days from the date they are signed (not 6 months like all other prescriptions).
I will focus on the emergency supply of POMs.
Legal framework
In certain circumstances, pharmacists working in a registered pharmacy are permitted to supply a prescription only medicine to patients without prescriptions. Requests for emergency supplies can come from patients or prescribers and there are different . Slightly different rules apply to each scenario.
The decision pharmacists need to make is whether to supply or not supply. For both types of emergency supply, pharmacists must ensure that the supply is legal and the decision they make is in the best interests of patients.
I find that emergency supplies can be one of the more interesting areas of practice, because they test the pharmacist’s professional and ethical judgement. Although legal restrictions apply, as I will describe later, it is important to make sure that patient welfare is at the centre of any decision.
Emergency supply at the request of the prescriber
There are a number of legal regulations that apply with this type of emergency supply request. The pharmacist must first satisfy himself that the prescriber requesting the emergency supply is an appropriate prescriber.
The list of appropriate prescribers includes the following professionals:
- Doctors
- Dentists
- Independent and supplementary prescribers:
- Community practitioner nurse prescribers
- Nurses
- Optometrists
- Pharmacists
- Physiotherapists
- Podiatrists
The regulators for each profession maintain a list of registrants and this details their prescribing ability.
Pharmacists must satisfy themselves that the situation is a genuine emergency and that a prescription cannot be obtained. Again, the impact of not supplying to the patient should be considered.
This is one such occasion where professional judgement may be required. This type of emergency supply is required to be supplied in the way stipulated by the prescriber at the time of request. Once the process is triggered the doctor agrees to furnish the pharmacist with a prescription to cover the supply.
Controlled drugs cannot be supplied in this way. The only exception to this is the medicine Phenobarbital. The usual prescription labelling requirements apply throughout as well as the additional ones required for emergency supplies.
In everyday practice I encounter this type of emergency supply in a number of circumstances. For example a doctor may be visiting a patient at home and phone the pharmacy to request an urgent delivery of an antibiotic. The patient is at the centre of things here and will receive the medicine in a timely fashion. The prescriber has to agree to furnish the pharmacist with a prescription within 72 hours.
Another example of emergency supply at the request of the prescriber are faxed prescriptions. These are arguably the safest type of this version of emergency supply because the information, although copied, is written and not just verbal. Remember, a fax is not a legally valid prescription, but it does indicate that one exists.
Emergency supply at the request of a patient
Community pharmacies in the UK are very accessible for patients to access. A patient can see a patient without appointment. One of the unique services offered is emergency supply at the request of a patient. A patient may be on holiday and left home without their medicine. That patient can present to the pharmacy and request a small supply of their medication so that they do not run out.
The pharmacist must again satisfy himself of a number of factors before making the supply. The first requirement is that the patient has previously been prescribed the requested medicine by one of the named prescribers above. There is a requirement for the pharmacist to interview the patient. This requirement was introduced in 2012 as part of the Human medicines regulations.
The pharmacist must establish that there is an immediate need to supply the medicine. This introduces some rather interesting scenarios. For example the law states that pharmacists can legally complete an emergency supply even if the doctor’s surgery is open – something that some pharmacists forget.
On the face of it pharmacists could be well justified in refusing supply in this case, however there may be circumstances for example when timing is critical and the supply perhaps needs to be made quicker than the time it would take for the patient to source a prescription. A good example of this is the supply of insulin if the patient knows that blood sugars are running high.
The frequency of supply is important especially if the drug in question is liable to abuse. For example a pharmacist would be expected to use their professional judgement to decide if there was potential abuse happening after repeated requests. The strength and dose is critical, so pharmacists are expected to consult either the patient medication record, the prescription repeat slip or if the patient is away from home, perhaps phone the patient’s usual pharmacy to confirm.
As with emergency supplies, at the request of the prescriber, controlled drugs may not be supplied in an emergency at the request of the patient. Phenobarbital again is the only exception in controlled drug supply. An entry must be made in the prescription only register in the pharmacy and must include the following particulars: Date of supply, name of drug, form of drug, quantity of drug supplied, name and address of the patient supplied and interestingly the reason for supply. The emergency supply must be labelled in the normal way.
Scotland CPUS
Interestingly the emergency supply rules apply to the whole of the UK, but Scotland has a slightly different additional process. Here, there is a patient group direction in place that allows pharmacists to write prescriptions for a normal cycle of medication that the patient has been supplied with previously. More information can be found here. This patient group direction is currently not available in England or Wales.
The only other regional variation is the use of the summary care record in England to improve the efficiency and safety of emergency supplies. Quite simply the summary care record is a brief version of the patient record which can be accessed then used to inform the pharmacist what to safely supply.
What if the pharmacist decides not to supply?
There can be many reasons why pharmacists refuse to supply a medicine in emergency circumstances. Perhaps the legal requirements have not been met, or perhaps the pharmacist suspects that the patient is abusing the medicine requested. Whatever the reason for non-supply, pharmacists have a professional obligation to direct the patient further help. This may involve referral to a doctor, or to an accident and emergency centre.
Patients can suffer harm from not receiving a medicine, so it is of critical importance that while being cognisant of the relevant laws, pharmacists use their clinical judgement when deciding whether to supply or not. I find that making these clinical decisions, often when the prescriber is unavailable can make my job feel very rewarding. Non-prescribing pharmacists rarely have such autonomy and should therefore use this autonomy wisely.
Johnathan Laird is a community pharmacist independent prescriber with a special interest in asthma. He is based in based in Aberdeen.
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References and further reading
RPS Medicine ethics and practice. 2015. (login required)
RPS support. Emergency supply – Quick reference guide. 2011. (login required)
Amin R. Emergency supply: law vs ethics. The Pharmaceutical Journal. 2011. Volume 286, page 598.
Community Pharmacy Urgent Supply (CPUS)
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