Waiting times for paediatric mental health services are longer than ever. Dr Emma Davies, Medicolegal Consultant at Medical Protection, looks at the potential impact on primary care.
The recent figures from NHS Digital make sobering news. Last year saw a 39% rise in referrals for NHS mental health treatment for under 18-year-olds; the total was over one million compared to 839,570 in 2021. Put another way, about one in six children are suffering from a mixture of feeling suicidal, self-harm, serious depression, psychosis, anxiety and eating disorders. Last year 7,719 children were admitted for eating disorders alone (up from 4,232 in 2019).
Added to this are those waiting for neurodevelopmental assessments; often the support, treatment or specialist input needed is delayed until a diagnosis has been formalised. Meanwhile a child’s education, home life and development can suffer at a key time in their lives.
The waiting times for referral to CAMHS can vary widely depending on location and, in the meantime, families will often require support and advice. It is helpful to know about the resources available to children and their families such as:
It is not surprising that some parents will choose to see private specialists, who may offer a diagnosis and advice on the treatment required with the expectation that the child’s GP will action the treatment plan. We have had a number of requests for advice relating to this, especially when a child is recommended medications that are unfamiliar to GPs or are being used “off license”. Questions often asked are:
If problems arise relating to the treatment where does the responsibility lie?
The GMC guidance on prescribing starts off by stating: “You are responsible for the prescriptions that you sign. You must only prescribe drugs when you have adequate knowledge of your patient’s health and you must be satisfied that the drugs serve your patient’s need.” There are provisions in the guidance (paragraphs 76-78) for prescribing at the recommendation of a colleague which state:
“If you prescribe based on the recommendation of another doctor, nurse or other healthcare professional, you must be satisfied that the prescription is needed, appropriate for the patient and within the limits of your competence.
“If you delegate the assessment of a patient’s suitability for a medicine, you must be satisfied that the person you delegate to has the qualifications, experience, knowledge and skills to make the assessment. You must give them enough information about the patient to carry out the assessment. You must also make sure that they follow our guidance on ‘Decision making and consent’ in paragraphs 42 to 47.
“In both cases (paragraphs 76 – 77), you will be responsible for any prescription you sign.”
Therefore, both the specialist and the GP would be jointly responsible for the prescribing. The guidance goes on to cover shared care prescribing as follows:
“If you share responsibility for a patient’s care with a colleague, you must be competent to exercise your share of clinical responsibility. You should:
- keep yourself informed about the medicines that are prescribed for the patient
- be able to recognise serious and frequently occurring adverse side effects
- make sure appropriate clinical monitoring arrangements are in place and that the patient and healthcare professionals involved understand them
- keep up to date with relevant guidance on the use of the medicines and on the management of the patient’s condition.
“In proposing a shared care arrangement, specialists may advise the patient’s GP which medicine to prescribe. If you are recommending a new or rarely prescribed medicine, you should specify the dosage and means of administration, and agree a protocol for treatment. You should explain the use of unlicensed medicines and departures from authoritative guidance or recommended treatments. You should also provide both the GP and the patient with sufficient information to permit the safe management of the patient’s condition.
“If you are uncertain about your competence to take responsibility for the patient’s continuing care, you should ask for further information or advice from the clinician who is sharing care responsibilities or from another experienced colleague. If you are still not satisfied, you should explain this to the other clinician and to the patient, and make appropriate arrangements for their continuing care.”
Can I refuse to prescribe if I am not familiar with the medication recommended?
Good Medical Practice starts with: “Good doctors make the care of their patients their first concern: they are competent, keep their knowledge and skills up to date, establish and maintain good relationships with patients and colleagues, are honest and trustworthy, and act with integrity and within the law.”
Prior to refusing to prescribe a medication, you would need to consider what is in the best interests of the patient and to weigh up the risks of not prescribing versus prescribing. If you have concerns around the medication not being appropriate you should seek clarification from the specialist and could also consider seeking a second opinion.