Responsibilites of an After Hours Provider

by Dr Jonathan Brown

13SICK is a provider of After Hours care and is an Approved Medical Deputising Service (AMDS). We exist to look after patients when they can’t see their regular GP or to provide urgent episodic care when necessary. The AMDS has a set of guidelines that govern how we should operate and quotes below are taken from these guidelines.

Summary

1. 13SICK provides episodic care: 13SICK provides after-hours care on behalf of regular GPs, limited to urgent issues when usual GP care is unavailable.
2. Chronic Disease: Management of chronic conditions (e.g. diabetes, hypertension, mental health plans, repeat prescriptions) must be referred back to the patient’s regular GP. Weight management is a chronic condition
3. Scripts: A single script (up to 1 month) may be issued on a case-by-case basis, but not for ongoing or convenience-based requests.
4. S4 / S8 medications: S4/S8 medications (e.g. opioids, benzodiazepines) must not be prescribed routinely. Real-time prescription monitoring must be used.
5. Medications like Ozempic, Wegovy, and Duromine relate to chronic issues (see item 2)
6. Centrelink / Private Reports: Forms for Centrelink, fitness to drive, insurance, or employment are not appropriate for after-hours services.

Scope of an After Hours Service (an AMDS)

13SICK looks after almost 4000 GP clinics across Australia. Practices direct patients to us when they are closed. The AMDS guidelines state that,

AMDS providers ensure continuity of care for patients who cannot be treated by their regular GP or GP Practice during the after-hours period. These services are provided on behalf of their regular GP or GP Practice.

AMDS providers may also provide urgent episodic care for patients who are not referred by a regular GP or GP practice.

AMDS Service Providers are expected to provide urgent after-hours services for patients on behalf of their regular doctors. Accordingly, it is not appropriate that deputising doctors employed by AMDS Service Providers provide services to patients who present with symptoms or circumstances that can be addressed by their regular general practitioner.

What is deemed outside of our scope as an After Hours service?

We have to adhere to the AMDS guidelines as an After Hours service and the AMDS gives guidance on what is deemed to be outside of our scope:

The following are examples of the types of consultation requests the department deems to be the sole responsibility of a patient’s regular general practitioner. These requests are deemed to fall outside of the deputising activity that may be performed by a doctor enrolled on the AMDS Program:

1. Health promotion activity that requires ongoing care
Deputising doctors are encouraged to provide brief interventions regarding smoking, alcohol, or recreational drug use, but would refer to the patient’s regular general practitioner for medication and management of smoking cessation or opiate withdrawal.

2. Management of chronic disease
Examples that would be considered inappropriate include:

• Routine referrals to other health professionals, or pathology and imaging tests
• Blood pressure or blood glucose monitoring
• Discussion of test results
• Repeat prescriptions
• Medication reviews
• General practitioner management plans
• Chronic disease management plans
• Mental health care plans
• Specialist referrals

3. Certification
Examples considered inappropriate include:

• Medical reports including but not restricted to:
  – pre-employment medical reports
  – insurance medical reports
  – Services Australia – Centrelink medical reports and certificates
• Fitness to drive assessment
• Taxi subsidy forms

Important: We exist to look after patients until they can see their regular GP again. There are cases where patients have an urgent need for a script and this needs to be addressed on a case-by-case basis

Can an After Hours Doctor provide one-off prescriptions?

If we look at the scope of practice guideline above, an After Hours service is not meant to supply repeat medications for chronic disease. We can, however, provide up to one months’ supply of medication as a one-off script and this must be made on a case-by-case basis. The AMDS guidelines say,

Participants on the AMDS Program are prohibited from issuing multiple repeats for prescribed medications. A single prescription can be issued for up to a month’s supply. To obtain further repeat prescriptions patients must see their regular general practitioner or practice. This requirement is to encourage continuity in prescribing recognition of the increase in multimorbidity and polypharmacy.

Participants on the AMDS Program are not prohibited from prescribing medicines to a patient who has not been referred for a deputised attendance by their regular general practitioner. Participants on the AMDS Program will remain eligible to prescribe medicines to un-referred patients if they identify a genuine clinical need to issue a prescription.

If a patient presents to 13SICK subsequently asking for repeat prescriptions they need to be asked to go back to see their regular GP.

What about ‘repeat prescriptions’?

The AMDS Guidelines limit the ability of deputising doctors to prescribe multiple repeat medicines as a routine practice and confirm that AMDS Program participants should not be issuing repeat prescriptions as a matter of patient convenience and must identify a genuine clinical need.

What does the AMDS say about patients ‘running out of a prescribed medicine’

The AMDS understands that there are cases where patients need a one-off script for a medication. The guidelines say,

The AMDS Guidelines consider that a patient “running out of a prescribed medicine” is a recognised challenge in general practice and offer scope for an AMDS Program participant to prescribe as a means of preventing significant harm to a patient who has not been referred by their regular general practitioner.

13SICK stance on S4 / S8 Medications

As Doctors we have to be mindful of medications that have potential to cause harm. We are not the patient’s regular GP and do not have their full medical history. The AMDS guidelines are clear that an After Hours provider is not to manage chronic disease and problems such as chronic pain and chronic sleep issues should not be managed by us.

Important: There are cases where patients have an urgent need for a script that has run out and this needs to be addressed on a case-by-case basis. If a Doctor deems that the patient needs a one off script for an S4 or S8 item they should consult the real-time prescribing system in the patient’s state. In some states it is mandatory for the Doctor to check realtime prescribing software.

Opioids are the most common cause of fatal accidental overdoses in Australia. Benzodiazepines, such as diazepam and temazepam, are the second most common cause of accidental overdoses resulting in death.

The list below shows medications that are monitored on SafeScript Victoria and these are medications that should not be prescribed routinely prescribed:

Type of prescription	Examples
Strong opioid painkillers	Buprenorphine, Codeine, Fentanyl, Hydromorphone, Methadone, Morphine, Oxycodone, Pethidine, Tapentadol.
Strong medicines for anxiety or sleeping tablets (benzodiazepines)	Alprazolam, Flunitrazepam, Bromazepam, Clobazam, Clonazepam, Diazepam, Lorazepam, Midazolam, Nitrazepam, Oxazepam, Temazepam.
Other strong sleeping tablets	Zolpidem, Zopiclone.
Stimulants for ADHD or narcolespsy	Dexamphetamine, Lisdexamfetamine, Methylphenidate.
Other high-risk medicines	Esketamine, Ketamine, Quetiapine, Pregabalin, Gabapentin, Tramadol.

Other medications prone to misuse: Baclofen

Weight loss medication

Weight loss is a chronic problem that should be managed by the GP. As such weight loss medications (Ozempic, Wegovy, Duromine) should not be supplied by our service. Ozempic is a PBS item for managing diabetes. As an After Hours service we have no way to validate that a patient takes Ozempic for diabetes so it is not to be issued on the PBS.