Safe prescribing for adult patients with ADHD following discharge

Dr Ben White offers prescribing guidance for GPs treating adult patients with attention deficit hyperactivity disorder

Medical Protection has been receiving a large number of queries to our advice line from members seeking guidance on prescribing to adult patients with attention deficit hyperactivity disorder (ADHD). Specifically, where there is a limited adult ADHD service and patients are discharged back
to their GP once stabilised on treatment, with a request to continue
this treatment.

GPs are concerned that they are being asked to continue the prescribing of medication for ADHD without ongoing follow-up in secondary care.

There are several issues to consider when deciding whether to accept the ongoing prescribing and monitoring of these medications including the needs of the individual patient, relevant guidelines, and a doctor’s professional obligations and liability should something go wrong.

GPs are concerned that they are being asked to continue the prescribing of medication for ADHD without ongoing follow-up in secondary care

Consider patients on a case-by-case basis

When deciding whether it is appropriate to prescribe in the absence of ongoing adult services specialist input, each patient needs to be considered on a case-by-case basis. Doctors should consider the risks of continuing to prescribe in the absence of a shared care arrangement versus the risks to the patient if the medication were discontinued.

In making any decision about what best serves the patient’s requirements, doctors need to consider relevant guidelines, such as those produced by NICE or the HSE. Of course, patients should also be involved in any decision-making regarding their treatment plan.

Where the prescription for ADHD is a controlled drug, it is also important to consider the Medical Council’s Guide to Professional Conduct and Ethics for Registered Medical Practitioners (‘the Guide’), which states:

35.1 When prescribing controlled medications, you must comply with applicable legislation and follow applicable guidelines.

In line with the Guide, doctors need to ensure that they have “adequate knowledge of the patient’s condition and believe that such a prescription
is indicated”.

The Guide further states that doctors should “ensure that any treatment, medication or therapy prescribed for a patient is safe and evidence-based.”

Doctors will also need to have adequate knowledge of the potential risks of any medication, any monitoring requirements, and actions to take if side-effects occur. If considering prescribing, where a clinician requires more information about the medication, it may be necessary to seek advice from an appropriate specialist, such as the clinician who is asking to share or handover care.

Shared care arrangements

The initial diagnosis and management of ADHD is usually carried out by a doctor with a specific expertise in this area, typically a consultant psychiatrist or a specialist ADHD service. GPs can then be asked to take over prescribing, usually sharing the care with the specialist who initiated the medication.

In a situation where a doctor is being asked to prescribe on the recommendation of secondary care colleagues, the Guide is relevant. Section 36 deals with the issue of transcribing. This is defined in the Guide as “…transferring a medication order from an original prescription to another type of prescription”.

It states that the act of transcribing incurs the same responsibility as prescribing (as detailed earlier in this article). It is recommended that if the doctor transcribing has any issues or concerns about the prescription, they should contact the original prescribing doctor or a member of their team for clarification before proceeding.

If deciding to continue prescribing, a doctor must ensure that they remain informed about the medicines and the side-effects, and that appropriate monitoring and review appointments are put in place.

If doctors feel that patients are being put at risk – for example, due to the availability of specialist services, the local policy on prescribing for patients, or where they feel they are being asked to prescribe inappropriately – then it may be necessary to consider raise concerns in line with local policy and as detailed in paragraph 3 of the Guide.

Potential liability

Doctors are understandably concerned regarding their liability in the event that something goes wrong when prescribing. Ultimately, if a doctor decides to prescribe, they assume responsibility for that decision and should contact their medical defence organisation for assistance if any issues arise.

It is, of course, also true that if a doctor declines to continue prescribing, and an adverse event occurs, they will need to be prepared to justify the decision they took.

In summary, when considering whether to prescribe for a patient no longer under secondary care, doctors must take into account the patient’s needs, relevant medical guidelines, and their own competence in prescribing and monitoring the medication.

In the final analysis, the doctor who signs the prescription takes responsibility for that prescription.