Recently I got a call from a colleague, complaining about a prescription, from an online prescribing service. It was for a relatively large quantity of benzodiazepines. Neither the patient nor the service were known to the pharmacist. They wanted to discuss if they were justified in refusing to dispense. The whole situation made the pharmacist uneasy and wanting to vent. As we talked, I realised that my pharmacy had received a similar prescription, but for much smaller quantities. A few discreet phone calls uncovered that prescriptions for the identical patient and medicines had been sent to all the pharmacies in our local town. The only differences were the prescribing doctors. This was a new one on all of us, although you would feel that it was predictable. Moreover, it gives a specific context to a general problem. Pharmacists are more frequently facing serious concerns about the positions that they are being put in, particularly resulting from online prescribing services. It is as if the responsibility for prescription suitability has moved from the prescriber to the pharmacist. We all understand the obligations we have to our patients, but always worked on the basis that it was a shared responsibility. Aside from the purely ethical, you have to ask where is the patient’s best interests served? Who, if anyone, is in charge? Convenience shouldn’t trump patient and societal safety.  

It is hard not to think of the Klondike rush when we see the profusion of online GP services that seem to expand daily.  While COVID was a catalyst, the rapid expansion reflects the age old, tongue in cheek, witticism. Some professionals would have a much better job if they didn’t have to deal with clients. While this does a disservice to the vast majority of online doctors, the direction of travel is concerning. There is a more commercial focus on some of the online sites. Sick certs on demand. Beta agonists on demand.  Guided questionnaires, allowing for imaginative answers from the patient, facilitating directional prescribing. A recent prominent RTÉ TV show illustrated how easy it was to get GLP1 agonists prescribed and dispensed, all online within Ireland, without as much as a token attempt at verification of patient details — not that the credit card isn’t verified. Prescriptions arriving to pharmacists with requests to check blood pressure and BMI before dispensing are a particular peeve.   

In pharmacy, any website has to be registered with the PSI and has a logo to reflect this. It doesn’t appear that this is the situation for online prescription services. You would think that this is an area that the Medical Council would be exercising a certain amount of vigilance. Yet, if they are, it is hard to see the evidence. A search of their website shows that the last guidelines on provision of telemedicine services were issued were in 2020. These guidelines are good, but the last five years have moved much faster than anyone anticipated. The concept of an online prescription ordering service was barely a twinkle on the telehealth background. While prescribers are required to follow Medical Council guidelines on how to treat a patient, it is not clear if there is any quality assurance for the public. The risks are known. It is time they were addressed.     

On a related issue, it doesn’t feel long ago that I sat in on a teleconference where new prescribing rules were discussed for COVID. Part of that discussion was, if a patient had a prescription, and it was valid, then it was valid for their medical card. This is now a source of confusion. Way back, in the distant past, the green duplicate GMS form was clear. If it had a medical card number in the box, then it was valid for the purposes of claiming. This was in the era where patients tended to have a single GP, and it was a much less complicated time. Fast forward: We now have much larger practises with multiple doctors. Within these groups, some of these doctors do not have GMs contracts and others do. To date, it has been common for pharmacists to assign two separate doctors to a prescription. One being the prescribing GP and the other is the contracted doctor. This hasn’t been a problem. Now we are seeing a much more complex landscape. What if a patient goes to a practise that is not the one they are registered with? Sometimes GPs will refer patients to a colleague that has a deemed expertise in a particular area. There are the walk-in clinics. The public versus private hospital differentiation has disappeared. Medical card patients frequently get treated in, and arrive with, prescriptions from private hospitals. The question arises, if a patient has medical card eligibility, then should it matter where the prescription originates?