Prescribing consultations, safe and negotiated

Types of prescribing case

• Requests. The patient wants a specific medicine: antibiotics, a benzodiazepine, a stronger painkiller, a drug started privately. The question is whether it is safe and appropriate, and what else would help.
• Negotiation. You recommend something the patient is unsure about, such as a statin, an anticoagulant or insulin, or they want to stop something you think helps.
• Reviews and polypharmacy. An older person on many medicines, side effects that may be caused by treatment, or a repeat that needs rethinking.
• Errors and safety. A prescribing error, an early request or a medicine that needs monitoring.

How the RCGP domains apply

These summaries are ours. The domain names are the RCGP's; read its own descriptors on the marking and results page and in the SCA consultation toolkit. See how the SCA is marked for the grades and pass mark.

A practical structure for a request

1. Hear the request in full. What do they want, what for, and why now?
2. Understand the problem. Take the history the request depends on. The right treatment may be different from the one requested.
3. Explore expectations. “What are you hoping the tablets will do?” This often shows the real need.
4. Share your view honestly. Say what you think and why, in plain words. Mention benefits, risks and alternatives.
5. Negotiate a plan. Look for common ground: a different medicine, a short course with review, self-care, or a delayed prescription where appropriate.
6. Safety-net and review. What to watch for, when to come back, and when the plan will be reviewed.

Polypharmacy and medicine reviews

In a review case, start with the person, not the list. Ask what each medicine is for as they understand it, which ones they actually take, and what side effects bother them. Look for medicines that may be causing falls, confusion or constipation, and for ones no longer needed. Agree changes one or two at a time, explain what to look out for, and plan review. Involve carers and the community pharmacist where that helps.

Common pitfalls

• Saying yes to avoid conflict. An inappropriate prescription is a clinical management failure, however good the rapport.
• Saying no without exploring. A refusal with no alternative leaves the need unmet and the patient likely to look elsewhere.
• Lecturing about risks. Tailor benefits and risks to what matters to this patient.
• Ignoring the medicines list. Interactions, kidney function and frailty often decide the answer.
• No review date. Every change needs a plan for checking it worked.

Natural phrases

• “What are you hoping this will help with?”
• “What’s worked for you before, and what hasn’t?”
• “I’m not comfortable prescribing that, and I want to explain why.”
• “What I can offer instead is…”
• “Which of these tablets do you actually take, and are any of them a nuisance?”
• “Let’s change one thing at a time so we can tell what’s helping.”

See also the shared decision phrase bank.

Practice prescribing cases

These cases centre on a medicine: a request, a negotiation, a review or a safety problem.

• "My old doctor always gave me a few diazepam" · Telephone
• "I just need a few diazepam for the flight — my old GP always gave them" · Telephone
• "I’ve just moved here and my methadone runs out today — I need a script now" · Telephone
• The sleeping tablet repeat · Video
• "I always get antibiotics for my throat — just give me a course so I can get back to work" · Video
• "It’s my fourth water infection this year — just give me antibiotics again" · Telephone
• "I just need the steroids and antibiotics I usually get — don’t start on about the smoking" · Video
• "I just need another blue inhaler — I get through them, but they sort me out" · Video
• "I’ve been on these omeprazole for years — I just want a repeat, not a lecture" · Video
• "I’ve run out of my methotrexate early — can you just print me another script today?" · Video
• “My ADHD clinic has sent you a letter — can you take over my prescription?” · Telephone
• "I’m one of the nurses here — could you just quickly prescribe me some antibiotics/sleeping tablets without making a big fuss or recording it? I’d rather it stayed private" · Telephone
• “My daughter says I rattle when I walk — and I keep ending up on the floor” · Video
• "Since the new tablets I’m confused, constipated and can’t wee properly" · Video
• "My readings are only a bit up — do I really need to be on pills for the rest of my life at 58?" · Video
• "Every doctor just tells me to eat less and move more — I’ve heard about the jab, can I have it?" · Video

Each case page shows the candidate brief you would read in the 3-minute window. The learning points sit behind a spoiler, so read the brief, practise, then look. The full case, with the role-player script and examiner checkpoints, is in The Hot Seat.

How to practise

Read a case brief, set a 12-minute timer and run it with a partner, the AI patient or out loud on your own. The Hot Seat holds the full case bank with a scorecard for each case. The Consultation Conversation Lab drills the Relating to others skills (cues, ideas and concerns, shared plans), and Worked Example Consultations show what a passing consultation sounds like from start to finish. Then put a few of these cases into your next mock exam.

Frequently asked questions

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