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Noel Wardle: Is more knowledge a dangerous thing?

Will each pharmacist have a “duty” to access the SCR before providing treat, asks lawyer Noel Wardle

The news from NHS England that the summary care record (SCR) will be available to all NHS community pharmacies in England, with implementation expected to begin in autumn 2015, has been largely welcomed by the profession.

The SCR will provide pharmacists with access to key information about patients, such as medication history and allergies. The ability to provide greater clinical input into their patients’ care - both during informal discussions with patients at the counter and during more focused, clinical discussions such as medicines use reviews - is seen as a step forward for community pharmacy’s role.

However, behind this good news story, some have voiced concerns about the potential liabilities that may arise from access to the SCR and the increased workload on community pharmacists if they have a “duty” to consult the SCR when providing pharmaceutical services to patients. Are these concerns justified and, if so, what should community pharmacists do to prepare for the arrival of SCR access?

 

Do you have to consult the SCR?

The question on most pharmacists’ minds will be whether and how often they need to consult the SCR – at the time of each patient contact or only sometimes, and how will they decide when is appropriate?

As is often the case, there is no black or white answer. In the exercise of his or her profession, pharmacists are judged by the standards of their peers and are expected to perform their tasks with reasonable care and skill.

If a patient suffers injury as the result of the pharmacist’s actions, they may bring a claim for damages against the pharmacist. The court would have to consider firstly whether the actions of the pharmacist fell below “the standard of the ordinary skilled man” and, if so, whether those negligent actions caused the patient to suffer injury.

In the case of Horton v Evans, the court considered a pharmacist’s obligation to consult records.

For many years Mrs Horton had taken one 0.5mg tablet of dexamethasone a day. On one occasion the prescriber provided a prescription for 28 x 4mg tablets and had omitted to specify the dosage. Mrs Horton took the prescription to Lloydspharmacy, where the PMR system showed that the same branch had dispensed 0.5mg dexamethasone to her on seven previous occasions. The pharmacist noticed that the strength of the tablets was greater than in the past and looked up the medication in the BNF, where he found that 4mg was within the usual therapeutic range for a daily dose. Consequently, he did not question the prescription with the prescriber.

The patient then moved to the US and continued to take dexamethasone 4mg tablets (having been prescribed 4mg by a US doctor relying on the medication label from the Lloydspharmacy supply). She developed the symptoms of Cushing's syndrome and brought a claim for damages against both the prescriber and Lloydspharmacy.

In the Horton case, the court held that the pharmacist was – at least in part – responsible for Mrs Horton’s injuries. The pharmacist had access to the PMR, knew that the dose had increased significantly and failed to check this increase with the prescriber.

The facts in Horton can be distinguished from circumstances where a patient goes into a branch that they have not used before and would therefore not know the patient’s prescribing history. In those circumstances, the pharmacist may well not have had the requisite knowledge of previous supplies – or the dramatic increase in strength – and may reasonably have relied on dosage guidance in the BNF.

However, if all pharmacists have access to the SCR, then all pharmacists will at least be able to access the patient’s prescribing history, even if the patient has not been into that branch before. Should the facts of Horton be repeated and Mrs Horton were to go into a pharmacy she had not used before – but that had access to the SCR – would the court expect the pharmacist to check the SCR and for the SCR to alert the pharmacist to the increase in dose?

 

Use your judgement

The General Pharmaceutical Council’s standards of conduct, ethics and performance require pharmacists to “get all the information you require to assess a person’s needs in order to give the appropriate treatment and care”.

That cannot mean that each pharmacist will have a “duty” to access the SCR before providing treatment and care to every patient: this should not be the standard of care expected of the ordinary skilled pharmacist. In practical terms, it would be impossible for pharmacists to check the SCR before every patient interaction.

It will be a matter for the pharmacist’s professional judgement to assess whether they require access to the SCR in order to give each patient the appropriate treatment and care. The pharmacist will be expected to consider – in relation to each supply or provision of service to a patient – whether access to the SCR is necessary to assess the patient’s needs, and the pharmacist may be required to justify a decision not to access the SCR in any given case.

When the pharmacist has not consulted the SCR, and this has caused injury to a patient, the court would have to assess whether the pharmacist’s actions were reasonable in the particular circumstances of the case.

The difficulty for pharmacists, of course, is that the court will have the benefit of hindsight when making this assessment: it will know what the SCR says. Unless the pharmacist has consulted the SCR, then its contents will be unknown to the pharmacist. However, it will be a rare case where a failure to consult the SCR causes a patient to suffer harm.

Community pharmacy has rightly welcomed increased access to patients’ medical history. Pharmacists know their patients best, and have sufficient knowledge and experience to make clinical judgements regarding access to the SCR. Pharmacists will no doubt provide guidance and training to their staff.

Pharmacists will quickly get used to the additional step in the dispensing process: “Do I need to consult the SCR?”. Once that becomes a routine part of the pharmacist’s – and the pharmacy’s – practice, everyone should see the benefits.

 

Noel Wardle is a partner at Charles Russell Speechlys LLP

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