Clinical Indications: What Prescribers Need to Know

What does the GMC expect?

That you consider it. The sentence is in the section Keeping up to date and ensuring safe prescribing of Good practice in proposing, prescribing, providing and managing medicines and devices, and a footnote to the words “clinical indications” links to this website. See what the GMC guidance says for the full paragraph and its dates.

Dr Masters made the case in a 2013 letter to the BMJ on polypharmacy: “A simple solution to this problem is to add the clinical indication to the prescription instructions at the time of issue” (PubMed).

How long does it take?

Adding indications to existing repeat prescriptions takes time. At present, clinicians add the indication as free text to the directions on the electronic prescription. In EMIS, the free text is stored and offered from a pick list on future issues of prescriptions, for all patients. There is no separate indication field. At Highfield Surgery, the pilot practice (5,800 patients), indications were added as each repeat request came in, and it took one and a half years to reach 85% coverage; in one week of observation the practice produced 1,200 repeat items with indications attached (FAQ 3).

This site’s summary of a 2019 hospital study says pharmacists found indications practical on new prescriptions but “time consuming and difficult to apply to pre-existing medicines” (hospitals). Dr Masters’ 2013 letter suggests adding the indication “at the time of issue”.

Are there confidentiality issues?

Yes, for some conditions. FAQ 4 says that where an indication covers a sensitive issue, giving epilepsy and cancer as examples, patients should be asked whether they agree to it being placed on the prescription. Patients who prefer not can have “patient preference no indication” on their repeat prescription.

Because the pharmacist records the indication with the directions, packages left visible in shared accommodation could be seen by others, and FAQ 4 suggests advising patients to be more discreet with their medicines. It also suggests mentioning clinical indications in the practice leaflet.

At Highfield Surgery, in three years, two patients asked for their wording to be changed and two asked for no indication (FAQ 14).

Who is responsible for the wording?

The prescriber. FAQ 7 says the prescriber “should remain medicolegally responsible” for the indication phrases, and that Dr Masters recommends picking recommended phrases from lists, not adding standard phrases automatically. In a 2004 poll of 360 GPs on onmedica.net, 70% favoured adding indications automatically to all repeat prescriptions.

The Sample Directory suggests wording. It is an example, not a working directory, so check each phrase before you use it. At a 2005 focus group, an expert cardiac patient group discussed the phrases for heart medicines; the write-up concludes that such a group “may be helpful in the discussion of appropriate phrases”.

How do I get started?

1. Set simple targets: patients over 75, then over 65 (FAQ 9).
2. Move on to groups such as patients with diabetes or heart disease, or any patient on more than four items.
3. Take wording from the Sample Directory, checking each phrase, and keep to three or four words.
4. Add the indication as each repeat request comes in.
5. Tell your local pharmacies and care homes: it is courteous.
6. Agree sensitive indications with the patient first.
7. Audit how many repeat items leave the surgery without an indication. See GP practices.

Is there evidence that it helps?

Not for adherence, on Dr Masters’ own account. FAQ 6 (2006) says “at present there is no evidence that clinical indications assist with adherence”, and his single-practice statin study says “prospective studies with controls should be undertaken”. See the evidence and research.