Prescribing Dilemmas—A Guide for Prescribers

Overview

This Guidelines summary of the All Medicines Strategy Group guideline, Prescribing dilemmas—a guide for prescribers, provides prescribing guidance for health professionals working in primary care settings.

The information has been collated from various resources, including those produced by health boards and trusts, the General Medical Council (GMC), and Welsh Government.

This Guidelines summary does not include recommendations on prescribing for oneself or family, malaria chemoprophylaxis prescribing in general practice, implications for patients of being prescribed controlled drugs, medical tourism, or vaccines for occupational health purposes. For recommendations in these areas, refer to the full guideline. 

Throughout this summary, reference has been made to GPs; however, the comments should equally apply to non-medical prescribers who have responsibility for prescribing in the relevant areas.

Reflecting on your Learnings

Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.

Clinical Responsibility

• Legal responsibility for prescribing lies with the prescriber who signs the prescription. However, it should be noted that the British Medical Association (BMA) advises that: ‘Independent prescribers are professionally responsible for their own actions. However, where a nurse prescribes as part of their nursing duties, the employer may also be held responsible’
• It is important that prescribers prescribe drugs or treatment, including repeat prescriptions, only when they have adequate knowledge of the patient’s health, and are satisfied that the drugs or treatment serve the patient’s needs
• Non-medical independent prescribers (nurse, pharmacist, optometrist, physiotherapist, chiropodist, podiatrist, therapeutic radiographer, paramedic) may prescribe for any medical condition within their area of competence
• Nurse independent prescribers and pharmacist independent prescribers in Wales can prescribe a controlled drug within their clinical competence on the same basis as other medical practitioners and dentists
• Optometrists, therapeutic radiographers, and paramedic independent prescribers cannot currently prescribe controlled drugs
• Physiotherapist and chiropodist/podiatrist independent prescribers can currently prescribe a limited list of controlled drugs
• The prescribing rights of different professions have changed, and continue to change over time. For up-to-date advice, refer to the Pharmaceutical Services Negotiating Committee website
• All prescribers are encouraged to report suspected adverse drug reactions using the Yellow Card reporting scheme. The GMC states that you must report serious suspected adverse reactions to all medicines and all reactions to products marked with a black triangle in the British National Formulary (BNF) and elsewhere using the Yellow Card scheme
• At the interface between hospitals and GPs, prescribing responsibility will continue to be based on clinical responsibility
• Systems should be in place to ensure such responsibility can be accepted, with health boards and local statutory organisations representing various health professionals (for example, local medical committees) working together to identify deficiencies in local arrangements and providing mutually acceptable solutions.

Patients on Repeat Prescriptions Who Do Not Consent to, or Fail to Attend for Monitoring or Medication Review

• Initial discussions using a shared decision approach when the repeat medication is started, outlining the risks involved and the importance of follow up, is recommended
• When considering a patient who does not attend for monitoring, it is important to be aware of the GMC guidance:
  • 'you are responsible for the prescriptions you sign and your decisions and actions when you supply and administer medicines and devices or authorise or instruct others to do so. You must be prepared to explain and justify your decisions and actions when prescribing, administering, and managing medicines'
  • 'you are responsible for any prescription you sign, including repeat prescriptions for medicines initiated by colleagues, so you must make sure that any repeat prescription you sign is safe and appropriate. You should consider the benefits of prescribing with repeats^[A] to reduce the need for repeat prescribing'
  • 'whether you prescribe with repeats or on a one-off basis, you must make sure that suitable arrangements are in place for monitoring, follow up, and review, taking account of the patients’ needs and any risks arising from the medicines' 
• The practice should have a repeat prescription review policy that is followed. This should include guidance on setting appropriate review intervals and how to identify when reviews are due
• For patients overdue a review, contact should be made with the patient requesting their attendance for review and an explanatory note attached to the patient’s notes so other members of the practice team will be alerted. Communication may be made via standard letter or other method approved by the practice. If that fails and depending upon the risks involved, further approaches to the patient should be made
• The GMC states: ‘The prescriber needs to take into account the patients’ needs and any risks arising from the medicines’. The prescriber should therefore contact the patient to understand their concerns and difficulties (for example, travel, work issue), assess the patient’s capacity, and try to address any issues raised
• If these measures fail, the prescriber needs to decide if continuing prescribing poses more harm to the patient than not prescribing
• The prescriber should contact the patient outlining the risks of continued prescribing in absence of follow up and either issue shorter prescriptions that the patient will be forced to collect or, depending on the risks, discontinue the medicine if they fail to attend within a given time limit
• In the event of a patient who does not attend for medication review, a team approach is recommended, involving the primary healthcare team
• Community pharmacists may be able to improve patients’ understanding of the need for clinical review of their medicines when carrying out a medication use review or at the point of dispensing. 

Prescribing of Valproate in Females of Childbearing Age 

• Valproate should not be used in females of childbearing potential unless other treatments are ineffective or not tolerated. If a suitable alternative is not available, valproate can be used in females of childbearing potential provided the patient is enrolled and fulfils the conditions of the Pregnancy Prevention Programme
• Guidance document on valproate use in women and girls of childbearing years (bit.ly/3Ke4XCx) gives further information on the prescribing of valproate to female patients who have not agreed to the Pregnancy Prevention Programme through completion of an annual risk acknowledgement form
• Patients should be reviewed annually and have a completed risk acknowledgement form before receiving ongoing supplies.

Patient Requests for Medicines of Limited Benefit

• Prescribers may be faced with patients requesting a treatment that the prescriber considers would not be of overall benefit to them. In such cases, the GMC advises, 'If, after discussion, the doctor still considers that the treatment would not be of overall benefit to the patient, they do not have to provide the treatment. But they should explain their reasons to the patient, and explain any other options that are available, including the option to seek a second opinion.'

Private Referral

Patients Who Request to Be Referred Privately

• Such patients are expected to pay the full cost of any treatment they receive in relation to the care provided privately; consultation fees, diagnostic tests, drugs prescribed, or treatment provided by a clinician in the course of a private consultation should be at the patient’s expense
• Patients should be informed of this expectation prior to referral. 

Top-up Payments

• Top-up payments, where the patient typically pays to receive a medicine (for example, a cancer drug which has not had NICE or All Wales Medicines Strategy Group [AWMSG] approval) but then returns to NHS care, may be seen as different to private care, where the patient pays for all ongoing treatment. There is no legal barrier to top-up payments for medicines not routinely funded for use in Wales
• The Medicines Funding in the NHS report recommends that patients opting for top-up treatment should not lose their entitlement to NHS treatment. However, health boards have the power to charge for associated monitoring and care (excluding unpredictable events)
• There are also recommendations relating to procedural issues that should be considered when top-up treatment packages are introduced.

Private Prescriptions

Following a Private Consultation

• A private consultant (that is, the person providing the private opinion, which may be a physician, dentist, or other healthcare consultant) may see a patient privately in order to give an opinion to an NHS GP regarding diagnosis or further management. Alternatively, the consultant may treat a private patient for whom they will continue to have clinical responsibility and will personally determine the ongoing treatment for that particular condition. Until the consultant discharges the patient, this remains an episode of care. In this case, the consultant should prescribe privately for their private patient, and a GP may refuse to prescribe on the NHS in such a situation, as they do not have the clinical responsibility for managing that particular condition
• Once the private episode of care is completed, a GP may consider providing an ongoing NHS prescription if required
• Following completion of the episode of care, if the medicine is not on the health board formulary it would not be expected for the GP to provide an ongoing supply on an NHS prescription. Practitioners providing private treatment should keep this in mind when selecting treatment options. It is advisable that GPs inform patients of this possibility before referral and mention it in any referral letters
• The GP must continue to provide NHS treatment and prescriptions for other conditions for which they retain clinical responsibility. Exceptions to this (that is, continuing to provide NHS treatment where they retain clinical responsibility) would be where:
  • prescribing a medication would be outside the competence of the prescriber, for example specialised medicines not suitable for prescribing in primary care, in which case the prescriber must make arrangements for appropriate care
  • where the prescriber considers that the treatment would not be of overall benefit to the patient, in which case the prescriber must explain this to the patient and include the option to seek a second opinion
  • where the medication is generally not provided within the NHS (for example, a drug listed under Part XVIIIA of the NHS Drug Tariff)
• The GMC advises that it is good medical practice to ‘contribute to the safe transfer of patients between healthcare providers’, ‘share all relevant information with colleagues involved in your patient’s care’, and ‘when you do not provide your patients’ care yourself … be satisfied that the person providing care has the appropriate qualifications, skills, and experience to provide safe care for the patient’
• If the consultant considers that an emergency NHS prescription is required, it is important that they contact the GP to share this information and to gain the agreement of the GP
• Patients should be informed that unless it is an emergency prescription requests would be subject to the usual delay for routine prescription requests as specified by the practice
• For a specific condition, where a private consultant recommends a medication that is more expensive without good evidence that it is more effective than that recommended by the NHS, health board prescribing advice should be followed by the GP. This advice should be explained to the patient, who will retain the option of obtaining a private prescription from the consultant.

For NHS Patients 

• A GP may issue a private prescription for any item in circumstances where the medicine is not available on the NHS. These circumstances are where:
  • the item is listed in Schedule 1 of the NHS (General Medical Services Contracts) (Prescription of Drugs Etc.) (Wales) Regulations 2004 as amended (the so-called ‘blacklist’). This list of products may also be found in Part XVIIIA of the NHS Drug Tariff
  • the item is listed in Schedule 2 of the NHS (General Medical Services Contracts) (Prescription of Drugs Etc.) (Wales) Regulations 2004 as amended (the so-called ‘selected list scheme’) and where its use is for persons or purposes other than those specified in the Schedule
  • the product is a travel vaccine, not included in current public health policy, for example, tuberculosis, Japanese encephalitis vaccine, rabies vaccine, yellow fever vaccine (if at a yellow fever vaccination centre)
  • the product is being prescribed in connection with travel and is for an anticipated condition (for example, antibiotics for travellers’ diarrhoea or acetazolamide)
  • the product is being prescribed for malaria chemoprophylaxis.

For a Branded Product 

• Where NHS policy recommends that a generic medicine is used and a patient requests the branded equivalent, a private prescription cannot be issued if the patient is being treated within the NHS, unless the product cannot be prescribed on the NHS as specified above in the 'blacklist'
• While issuing an NHS prescription for patients who request a branded equivalent is not prohibited, practices should be aware that as a guiding principle, it is appropriate to prescribe the most cost-effective medication for a patient
• Consistent prescribing of excessive amounts of high-cost products where no clinical justification exists could be considered an example of inappropriate or excessive prescribing. 

Prescribing of Medicines for an Unlicensed Use 

• The GMC defines ‘unlicensed medicines’ as medicines used outside the terms of their UK licence (marketing authorisation) (sometimes referred to as ‘off-label’ use) or which have no license (marketing authorisation) for use in the UK. However, there may be different considerations when prescribing off-label or unlicensed medicines
• For non-medical independent prescribers, the distinction between these is particularly significant, as certain prescribing restrictions apply to medicines for which there is no UK marketing authorisation (unlicensed medicines)
• Pharmacist and nurse independent prescribers are able to prescribe unlicensed medicines subject to good clinical practice
• Physiotherapist, chiropodist/podiatrist, optometrist, therapeutic radiographer, and paramedic independent prescribers are only able to prescribe off-label medicines, and not those without UK marketing authorisation 
• The prescribing rights of different professions have changed, and continue to change over time. For up-to-date advice please refer to the Pharmaceutical Services Negotiating Committee website
• Although prescribing unlicensed medicines is not recommended, the GMC states that: ‘you may prescribe unlicensed medicines where, on the basis of an assessment of the individual patient, you conclude, for medical reasons, that it is necessary to do so to meet the specific needs of the patient’.

Information for Patients

• Give patients (or their parents or carers) sufficient information about the medicines you propose to prescribe to allow them to make an informed decision
• Some medicines are routinely used outside the terms of their licence, for example in treating children. In emergencies or where there is no realistic alternative treatment and such information is likely to cause distress, it may not be practical or necessary to draw attention to the licence. In other cases, where prescribing unlicensed medicines is supported by authoritative clinical guidance, it may be sufficient to describe in general terms why the medicine is not licensed for the proposed use or patient population. You must always answer questions from patients (or their parents or carers) about medicines fully and honestly
• If you intend to prescribe unlicensed medicines where that is not routine or if there are suitably licensed alternatives available, you should explain this to the patient, and your reasons for doing so
• Be careful about using medical devices for purposes for which they were not intended.

Prescribing Outside National Guidance

• A negative recommendation will not impact on the clinical freedom of the prescriber. However, a positive recommendation by AWMSG, subsequently endorsed by Welsh Government, places an obligation on health boards to fund accordingly
• AWMSG advice is interim to NICE guidance, should this be subsequently published
• A prescriber must ensure the decision to prescribe a medication is made with consideration of patient equity and must be responsible, appropriate, and in line with current prescribing practice for NHS Wales patients in accordance with AWMSG, NICE, and local formulary advice
• While issuing a WP10 in circumstances that fall outside of the national/local recommendations is not prohibited, practices should be aware that this could be considered an example of inappropriate or excessive prescribing
• Medicines associated with a statement of advice in relation to the AWMSG appraisal process ‘cannot be endorsed for use’ and therefore should not be prescribed routinely within NHS Wales
• Healthcare professionals should make clinical decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer and informed by the summary of product characteristics of any medicine they are considering
• National and local guidance will often clarify what prescribers should do for identified individuals, for example, who to immunise against influenza. Prescribers may make a decision, on a case-by-case basis, to prescribe outside any national guidance or programme if there is a compelling clinical reason to do so. If the case is made to immunise outside of the national programme, this is a General Medical Services (GMC) service. GPs should not offer their registered patients a private service.

Prescribing Duration

• People that are stabilised on their medicines and are suitable for longer prescribing intervals can be considered for repeat dispensing (28-day prescriptions for 6–12 months)
• The BMA notes that: ‘Prescribing intervals should be in line with the medically appropriate needs of the patient, taking into account the need to safeguard NHS resources, patient convenience, and the dangers of excess drugs in the home’
• A 28-day repeat prescribing interval has been broadly recommended to synchronise medication repeat prescriptions and reduce errors when medicines are stopped or changed. However, discretion should be used for individual patients or medicines, where a different duration may be appropriate, and which may include patients with stable chronic conditions being treated in primary care. This should be coupled with a rigorous and effective medication review process
• For controlled drugs listed in schedules 2, 3, and 4 of the Misuse of Drugs Regulations it is strongly recommended that prescriptions do not exceed 30 days.

Prescribing of Borderline Foods and Dietary Products

• Prescribing of borderline foods and dietary products should comply with the recommendations of the Advisory Committee on Borderline Substances. Prescribers should satisfy themselves that the products can be safely prescribed, that patients are adequately monitored and that, where necessary, expert hospital supervision is available
• A complete list of products can be found in the BNF or Part XV of the NHS Drug Tariff
• Most of the conditions for which they can be prescribed fall into the following categories:
  • dysphagia
  • gastrectomy
  • inflammatory bowel disease
  • liver disease
  • malabsorption states
  • malnutrition (disease-related)
  • metabolic disorders
  • renal failure
  • specific skin disorders
• There are several areas where prescriptions for dietary products do not comply with the above recommendations, and the responsibility lies with individual GPs who may use their judgement to make exceptions to the above recommendations. This may occur following recommendations from a dietician, or for a medical condition requiring nutritional support for a defined period of time
• GPs are strongly advised against prescribing dietary products for patients (including in nursing or residential homes) outside the uses listed in this section, and using them as an alternative to liquidising/purchasing appropriate food.

Complementary Medicine and Alternative Therapies

• Public Health Wales’ publication, Complementary therapies and alternative medicines, states: ‘Complementary medicines/alternative therapies are generally NOT used by the NHS. They are occasionally used as a treatment as part of a mainstream service care plan (for example, as part of an integrated multidisciplinary approach to symptom control by a hospital based pain management team) and as such will be used as part of an existing contract. On existing available evidence the LHB [local health board] will not support referral outside of the NHS for these services. Prior approval is required on a case-by-case basis for any requests outside the above criteria. The request for referral would need to be supported by evidence of the clinical effectiveness of the treatment and be to appropriately trained and qualified practitioners with recognised qualifications’
• Physiotherapists can decide to use certain alternative therapies as part of their NHS treatment plan if they consider it appropriate.

For further information on herbal medicine and homeopathy, refer to the full guideline.

Common Ailments

• The GMC advises that prescribers ‘should prescribe medicines only if you have adequate knowledge of the patient’s health and you are satisfied that they serve the patient’s needs’
• Declining patient requests from the outset may deter patients from making similar future demands (for example, requests for simple analgesia or for antibiotics for viral infections)
• The Community Pharmacy Common Ailments Service provides NHS treatment and advice to patients for a number of common ailments, using the Common Ailments Formulary, and is available to any patient registered with a Welsh GP. 

Fertility and Erectile Dysfunction Treatments 

Fertility Treatment

• It is not expected that GPs will prescribe treatments for specialist fertility centres.

For information on interface prescribing and private prescriptions, see the Clinical responsibility and Private referral sections. 

For more information on the Specialist Fertility Service policy in Wales, please refer to the full guideline.

Medicines for the Treatment of Erectile Dysfunction

The information in this section relates to the prescribing of medicines for the treatment of erectile dysfunction in Wales. For more information, please refer to the full guideline.

• Alprostadil, sildenafil, tadalafil, or vardenafil can be prescribed for the treatment of erectile dysfunction (ED) on NHS prescription in the following circumstances:
  • a man who is suffering from any of the following:
    • diabetes^[B]
    • multiple sclerosis
    • Parkinson’s disease
    • poliomyelitis
    • prostate cancer
    • severe pelvic injury
    • single-gene neurological disease
    • spina bifida
    • spinal cord injury
  • a man who is receiving treatment for renal failure by dialysis
  • a man who has had the following surgery:
    • prostatectomy
    • radical pelvic surgery
    • renal failure treated by transplant
  • a man who has been diagnosed as suffering severe distress resulting from ED where the assessment has been made by a specialist service or GP under arrangements made with a health board to provide such assessments
• Prescriptions must be endorsed ‘SLS’ (generic sildenafil should continue to be endorsed SLS in Wales)
• For patients who have been assessed as suffering from severe distress as a result of ED, guidance is amended to remove the restriction of specialist service supply, enabling GPs to prescribe the medication for this indication
• The assessment of severe distress resulting from ED may be undertaken by GPs or specialist teams. All health boards should have clearly defined commissioning arrangements for this assessment. A commissioned, specialist-led service will support equality of access to therapy and minimise conflict in the doctor-patient relationship
• Once-daily preparations should only be considered in patients who anticipate frequent use of single-dose preparations (that is, at least twice-weekly). This should be based on the clinician’s judgement (and in accordance with local formulary advice).

For information on criteria for assessing severe distress, frequency of ED treatment, and use in management of other clinical conditions, refer to the full guideline.

Visitors

Visitors from Overseas

• Overseas visitors who are entitled to NHS treatment in primary care include, but are not limited to:
  • patients who require emergency or immediately required treatment, which the treating doctor deems cannot reasonably be delayed until the patient returns home (this includes oxygen therapy and renal dialysis)
  • a person intending to be resident in this country for 6 months or more (subject to paying an Immigration Health Surcharge where applicable, and registration with a practise is necessary)
  • patients from within the European Union member countries holding an S1 or S2 form for specific treatment of a particular condition (and prescriptions for this condition only)
  • patients may be assigned to a contractor whose list is open by the health board
  • refugees (those whose applications to reside in this country have been approved), asylum seekers (those who have submitted an application and are awaiting a decision), and failed asylum seekers (those who have been refused leave to remain in the UK, but are yet to return to their home country)
• This list contains the most common categories, but prescribers should check an individual’s situation before providing or declining NHS care as special conditions may apply
• Where appropriate, patients should be encouraged to register—permanently or as temporary residents—with a general practice to receive NHS care.

Temporary Patients

• In line with the terms of The National Health Service (General Medical Services Contracts) (Wales) Regulations 2004:
  • any person requiring emergency necessary treatment can receive this from any GP for up to 14 days if they have been in the practice area for a period of less than 24 hours
  • patients intending to reside in an area for more than 24 hours but fewer than 3 months should register as a temporary patient
  • patients intending to reside in an area for more than 3 months should register with a GP at their new address as soon as possible
  • visitors are not encouraged to register as temporary patients simply to facilitate an ongoing supply of a repeat prescription. In an emergency, visitors can access the Emergency Medicines Supply service from a community pharmacy via the Choose Pharmacy platform. Alternatively, their own GP may be able to provide a prescription directly to a community pharmacy for dispensing
  • advice relating to repeat prescribing for temporary residents during the COVID-19 pandemic can be found at gov.wales/getting-medicines-during-coronavirus-pandemic#section-43563.

Travel Abroad

• The NHS ceases to have responsibility for people when they leave the UK
• For patients intending to be away from the UK for a period of at least 3 months, the health board can remove them from the contractor’s list of patients
• Following Brexit, healthcare provisions akin to those provided by EHIC will continue. If an EHIC is still in date, it will remain valid for travel to an EU country. If an EHIC has expired, a new UK Global Health Insurance Card (GHIC) should be applied for
• Patients should be advised that neither the EHIC nor the new GHIC is a replacement for travel insurance, and that they should have both in place prior to travel
• Patients are advised to check specific details on the UK Government website.

Medication

• Medication required for a pre-existing condition should be provided in sufficient quantity to cover the journey and to allow the patient to obtain medical attention abroad. If the patient is returning within the timescale of a normal prescription (usually 1 and no more than 3 months) then this should be issued, providing it is clinically appropriate
• Patients carrying certain prescribed medication for their own personal use may require a doctor’s letter or a personal licence. This will depend on the duration of travel, the type of medicine (for example, codeine, Sativex), and the country of travel
• Patients who require over-the-counter (OTC) medicines should check that the medicine is available OTC in the country of destination
• For longer visits abroad (for example, more than 3 months), the patient should be advised to register with a local doctor in the destination country for continuing medication; this may need to be paid for by the patient. It is wise for the patient to check with the manufacturer that medicines required are available in the country being visited
• GPs are not required to provide prescriptions for medication that is requested solely in anticipation of the onset of an ailment whilst outside the UK, but for which treatment is not required at the time of prescribing (for example, travel sickness, diarrhoea). Patients should be advised to purchase these items in the UK prior to travel; advice is available from community pharmacists if required
• A private prescription may be provided for any prescription-only medicines (POMs) if deemed appropriate and necessary, such as ciprofloxacin for traveller’s diarrhoea (for use outside Asia). Patients should be advised about the appropriate use of self-medication and when they would need to seek medical attention abroad. 

Immunisation for Travel Abroad

• Immunisations that are reimbursable under the GMS contract must be provided free of charge to registered patients who require them. These travel vaccines include:
  • hepatitis A
  • combined hepatitis A and B
  • typhoid
  • combined hepatitis A and typhoid—first dose (second dose is with hepatitis A alone)
  • tetanus, diphtheria, and polio as given in the combined Td/IPV vaccines
  • cholera
  • paratyphoid
  • smallpox
• A number of other travel-related vaccines, including hepatitis B and Meningococcal A, C, W135, and Y vaccine, are not remunerated by the NHS as part of additional services, although the vaccine costs may be reimbursable. The regulations do not impose any circumstances or conditions as to when these immunisations should be given on the NHS or as a private service. Charging for these is at the discretion of each general practice
• In the case of hepatitis B vaccination, which is also available as a combination product, the practice may charge any patient a private fee for hepatitis B for travel, as long as it is not combined with hepatitis A, which must be given on the NHS
• The following travel immunisations are not generally prescribed as part of an NHS service nor are they remunerated by the NHS if given for pre-exposure to travel:
  • Japanese encephalitis
  • meningitis vaccines
  • rabies
  • tuberculosis
  • tick-borne encephalitis
  • yellow fever
• Practices may charge for both the prescription and the administration of these vaccine at their discretion
• No charge should be made to any NHS patient of the practice for providing advice. 

Malaria Chemoprophylaxis

• There is no NHS regulation that prevents a GP prescribing drugs for the prevention of malaria at NHS expense. However, Welsh Office guidance in 1995 encourages GPs to prescribe privately
• A GP may provide medicines for malaria chemoprophylaxis via a private service and charge the patient for prescription and/or the supply of medication (pharmacy [‘P’] medicines and POMs)
• Patients can purchase ‘P’ medicines for malaria chemoprophylaxis directly from the community pharmacy
• Local community pharmacists also have access to up-to-date advice regarding appropriate prophylactic regimes and can advise travellers accordingly.

For information on duration of chemoprophylaxis treatment, exceptions, and additional advice on how to prevent suffering from malaria, please refer to the full guideline.

Footnotes

[A] Under the repeat dispensing system, the prescriber produces a master ‘repeatable’ prescription on a standard FP10 (WP10 in Wales) prescription form for the patient’s repeat medicines. This is annotated to distinguish it from a standard prescription form and also gives details of how many instalments the prescription contains

[B] The Association of British Clinical Diabetologists and the Primary Care Diabetes Society provide advice relating to the read coding of diabetes in remission

Sections Not Included in this Summary

This Guidelines summary does not include recommendations on prescribing for oneself or family, malaria chemoprophylaxis prescribing in general practice, implications for patients of being prescribed controlled drugs, medical tourism, or vaccines for occupational health purposes. For recommendations in these areas, refer to the full guideline.