Ambiguous lockdown regulations for level 4 cause confusion and dismay!!
In view of the current Extension of the deadlinesCOVID-19 pandemic the HPCSA has implemented the following initiatives:
- Extension of the deadlines for renewal and payment of annual fees to 1 July 2020. Important also; is that the period of validity of the existing HPCSA practicing certificates will apply until 30 June 2020.
- Amendment to the Telemedicine Guidelines of 3 April 2020 to apply during the COVID-19 pandemic.
Under the national state of disaster, it appears that the National Command Council are ruling the country, and that the Constitution could be running, at best, a close second.
Unfortunately the drafting of certain regulations accompanying the lock down from level 5 to level 4 are ambiguous especially as far as the medical services which can be offered by our general practitioners in concerned as well as other medical practitioners.
Furthermore the need for travel permits is still unnecessarily complex.
Worst of all, over the past weekend new regulations on the supply of chronic medication emerged without discussion or input from the profession. It is now possible for patients on chronic medication to obtain Medication from their pharmacist or courier pharmacy for a period of 12 months before being checked or examined by the general practitioner in charge of the case.
The implications for primary healthcare have possibly not been realised and are extremely grave under this new regulation. It has been actively opposed by the IPA foundation of South Africa as well as by CPC Qualicare care.
The redacted article on this (see page 3) by Dr Steven van der Merwe of Simonstown, will give you more insight into why we have reacted as vehemently as we did. Please read it thoroughly.
Stay safe and stay well.
Tony Behrman and the Qualicare team
Chronic prescriptions: Validity extended to 12 months!!
By Dr Steven van der Merwe of Simonstown
Despite all the efforts of university to try and make me a responsible doctor and despite the experience gained from working in government and private sector (locally and internationally); following Evidence-Based Medical protocols and continuously updating my knowledge through reading, CPD etc, I fall into despair as to the manner in which the care of our patients is continuously tampered with and our attempts are “managed”
Repeat prescriptions validity extension
Health (NDoH) on recommendation of the South African Health Products Regulatory Authority (SAHPRA) have published a notice to extend the period of validity of a prescription for all Schedule 2, Schedule 3, and Schedule 4 substances. An exemption from the requirements of Section 22A(6)(f) of the Medicines and Related Substances Act (Act 101 of 1965) was published today.
This means that if a patient had a valid repeat prescription for Schedule 2, 3 and/or 4 medicines that was dated on or after 30 October 2019 the patient does not need to obtain a new repeat prescription for the following 6 months as the prescription is now valid for 12 months from the date of issue.
For prescriptions issued from today and up to 30 October 2020 the prescription is also valid for 12 months and not 6 months.
The exemption itself is valid for 18 months.
A copy of the Gazette No. 43260 of 30 April 2020 can be accessed
Essentially what this means is that: Patients do not require a script every 6 months, and thereby implying that patients do not require a valid re-evaluation consultation for any chronic illness .
Chronic conditions requiring monthly medication and 6 monthly checkups:
Countless world class, peer-reviewed articles describe the unequivocal need for follow-ups in conditions such as Hypertension; Diabetes; Chronic Heart Failure; Asthma; Ischaemic heart disease; Chronic Obstructive Airway Disease; Thyroid conditions; oncology-related follow-up; geriatric care to name but a few. For those who don’t understand there are vital checks performed when a doctor is dealing with these conditions, that could (by neglecting them) have dire consequences.
To name a few:
- clinical examinations of the retina in a hypertensive and diabetic patient;
- assessing kidneys functions;
- Adjusting a dosage for increasing age or disease severity;
- checking for insidious side-effects that the patient might have been completely unaware of unless examined.
- Other issues often discovered at these follow-up 6 monthly consultations include the increased need for B2 stimulant inhalers,
- Detection of an incidental breast lump,
- Early dementia/alcoholism
Numerous systems can go wrong in the human body in 6 months – let alone a year or more!
International guidelines for good clinical practice applies including the SAMDSA; JNC8; Allergy and Asthma; AHA. It is these guidelines which the legal professional as well as the HPCSA will use when assessing the expected conduct of the “reasonable practitioner,” and against which you will be judged.
The articles below may be consulted as they emphasise where a regular 6 monthly consultation adds value to the care of the patient with a chronic medical condition.Hypertension and kidney disease: a deadly connection.
- Curr Hypertens Rep. 2008 Feb;10(1):39-45.Barri YM1.
- P T. 2015 Mar; 40(3): 185–190. Keith T. Veltri, PharmD and Carly Mason, PharmD, BCPS
- Curr Opin Cardiol. 2015 Jul;30(4):383-90. doi: 10.1097/HCO.0000000000000189. Chrysant SG1.
- Valeska Ormazabal, et al Angiotensin-Converting Enzyme Inhibitor-Induced Cough
- CHEST: Vasc Health Risk Manag 2011; 7: 591–596. Peter V. Dicpinigaitis, et al
- Dirk Devroey1,2 and Viviane Van Casteren
- Can Fam Physician. 2014 March; 60(3): 225.Tareef Al-Aama, MB BS FRCPC
- J Allergy Clin Immunol Pract. 2018 Mar - Apr;6(2):536-544.e1. doi: 10.1016/j.jaip.2017.06.039. Epub 2017 Aug 26.Sullivan PW1 et al
- Findings From the American Heart Association Go Red for Women Strategically Focused Research Network.Journal of the American Heart Association. 2018;7:e008590.Brooke Aggarwal et al
Scheduled medication implicated
Schedule 2, 3 and 4 medication are all potently lethal i.e. anti-hypertensives; insulin and other anti-diabetic agents; anti-epileptics; cardiac rhythm controlling medication. What’s more, with the new regime of annual repeat prescriptions, these will mostly now be delivered – without any intervention by courier or local pharmacies. This article is not aimed at my pharmacist colleagues in my community. We get along very well and have an excellent professional relationship.
COVID-19 in question?
If the ill-conceived idea was COVID-19 related, then I can assure anyone, that my surgery is far safer in this respect than any other exposure at shopping centres; pharmacies, grandchildren visiting and walking without a mask and failure to use surgical gloves and sanitisers.
Others that should not be forgotten are, subtle cognitive decline (only observed by knowing your patient through regular reviewing); patients stopping medication without consultation and patients taking “natural” remedies or OTC medication that they do not always declare.
What about that “while I am here doc….” situations?
So many times during a 6 monthly follow-up, I am asked to check a lump or lesion and it turns out to be early manifestation of cancer and the patient can be spared from a shortened life span.
These are but a few of the reasons why a regular follow-up with the GP is so important.
My practice’s position regarding the Departmental recommendation as shown above is:
- Follow-ups are part of good care and patient management. Whomsoever thought up this pathetic scheme is falling into to the same trap as some of my ill-informed patients i.e. “ but all I need is a script” - with a script comes many responsibilities etc. and every time a doctor puts pen to paper he/she could potentially be causing severe interaction; complications and death.
- My practice will not allow for our patient’s care to be compromised in this way. I instruct that no pharmacist handle our original scripts falling into this category abovementioned.
- Should this new protocol be followed and leads to a patient’s ill health or complications, I will lay the blame fully at the hands of the dispensing pharmacist and we know where the medico-legal fraternity will look for answers.
- If a patient of mine does not want to follow my international EBM protocols and wishes to be managed in this proposed way, then they are welcome to find another practitioner that will adhere to the gazetted manner. If they have bona fide financial problems or have had to drop their medical aid etc. I would be more than happy to make a plan for them or assist them in becoming part of the False Bay Hospital outpatient department if required.
I have known many of my patients for more than 20 years now. I will NEVER compromise my care of them.
General Practice is in the forefront of medicine and not to be messed with. We should be allowed to do the job that we have been called to and in the way that we have been taught at some of the best second-to-none universities in the world. We continuously keep up to date with the latest information and thus our knowledge is credible.
It is clear to me that the person or persons, who took this decision are either un-educated in medical care or (even with training) have very little insight into what patient care necessitates and demands.
Dr Steven van der MerweMBChB (Stell); B. Nutrition (Stell); Cert Oncol (Newcastle - UK)
M.Mus cum laude (NMMU); Spec Cert Comp (Berklee – USA)
Suite 1 Harbour Bay Medical Centre
Dido Valley Road
Simon's Town, 7975