In these modern days of unrestricted and affordable travel it is becoming increasingly common for non-UK residents to present in pharmacy seeking treatment. This is particularly true for citizens of EU member states, but also for travellers to the UK from outside of the EU. This poses a number of questions; how do these patients obtain treatment if they fall ill? Can their prescriptions be dispensed? Can you supply medicines in an emergency? This CPD article will look at the issues to consider and provide guidance on the legality of supply and best practices to follow.

Requests for treatment from a non-UK resident

It is imperative that requests for treatment from visitors from abroad are dealt with appropriately and within the law. It is also true that you have a duty of care to a patient no matter which country they hail from. Patients have a basic right to be dealt with fairly and promptly.

The most obvious difficulties that may arise would be communication problems due to language barriers or country-specific differences in products and licensing.

Where language barriers are an issue steps should be taken to overcome them and to determine the patien's needs. Although communication might be difficult, referring the patient onwards just passes the problem to another healthcare professional and is likely to leave the patient with a further delay in treatment. Modern technology may help with communication problems; there are now various translation 'apps' available or Google™ could be used. Additionally, it is possible that a member of the pharmacy team has some grasp of the relevant language - it is always worth asking.

Requests for specific medicines can be handled using the Martindale to determine UK equivalents. Numark Information Services regularly take queries on UK equivalents of foreign products. There is not always a direct equivalent in every case but there will usually be a clinically appropriate alternative.

Requests for simple OTC treatments or responding to the symptoms of minor ailments should be handled in accordance with your usual medicine protocols.

Dispensing a foreign prescription

Rather than a request for an OTC medicine you may get presented by a prescription issued in a foreign country. An alternative scenario is where a UK resident has travelled abroad for private treatment and presents a foreign prescription for dispensing.

Can you legally dispense a prescription issued in a foreign country?

Prescriptions issued in countries outside of the EEA cannot legally be dispensed.

You can legally dispense a prescription that has been issued by a doctor, dentist, prescribing pharmacist* or prescribing nurse* (*where they exist) registered in a European Economic Area (EEA) country or in Switzerland. This does not apply to a prescription written by any other healthcare professional e.g. a physiotherapist or optometrist.

If the prescription is in a foreign language there are other points to consider. You will have to use your professional judgement to decide if you can understand the language well enough to safely dispense the prescription. If there is any doubt as to the precise intentions of the prescriber you should consider whether it is wise to dispense.

Pharmacists should take steps to confirm the registration status of the EEA prescriber. This can be done via the relevant regulatory body for that country or via their embassy in the UK. The GMC website has contact details for EEA authorities.

If you decide not to dispense you should take steps to ensure the patient can obtain appropriate treatment. Identify the medication if possible and refer the patient to a UK prescriber.

Requests for Prescription Only Medicines (without a prescription)

There are often country-specific differences in medicines legislation - what might be available over-the-counter in one country could be a prescription only medicine in the UK. In these cases you will have to make a decision on whether to refer to a prescriber or whether you can issue an emergency supply. The usual regulations on emergency supplies apply, so where it is practicable to obtain a prescription the patient should be referred onwards. Perhaps an introductory phone-call or referral letter can be made providing the GP with the information that has already been gathered.

Patients from abroad can register as temporary residents with a local GP, although any prescription issued is likely to be privately funded. European countries do have reciprocal arrangements with the UK with regards funding of healthcare whilst abroad; the European Health Insurance Card allows EU residents to receive free or reduced cost healthcare - usually with respect to hospital treatment. Note this is not a valid exemption from UK prescription charges. Some countries outside of the EEA also have reciprocal healthcare arrangements with the UK, for example Australia and New Zealand. Eligibility should be determined on a case by case basis.

Current emergency supply legislation permits the supply of POMs to patients registered with a prescriber within a country in the EEA or in Switzerland, provided the usual emergency supply criteria are met (see below). In this context a prescriber refers to a doctor, dentist, prescribing pharmacist* or prescribing nurse* (*where they exist).

There is no provision in law to make a supply to a patient registered with a doctor outside the EEA. Does this mean you cannot make a supply to a patient visiting from, say, Australia? Or America?

From a purely ethical standpoint, what is the difference between a patient from Europe and a patient from America? Should an American visitor be denied treatment where a European visitor can be accommodated?

Ethically, the patient must be your primary concern, regardless of country of origin. Where there is a clear need for an emergency supply, could you justify withholding treatment? Consider the clinical consequences of not supplying drugs such as warfarin, digoxin or salbutamol (as examples).

In all cases, your professional judgement should be informed by the following:

The pharmacist would need to use their professional judgement over the time interval from when the medicine was last prescribed and the emergency request made.

The pharmacist should confirm the dose that the patient needs to take.

The legislation prevents emergency supplies of Schedule 1, 2 and 3 controlled drugs. The legislation also prevents emergency supplies of medicines without a UK Marketing Authorisation.

An emergency supply can be made for a maximum of 5 days treatment of a controlled drug (i.e. schedule 4 or 5 drugs) or up to 30 days of a POM. Note that emergency supplies are not permitted for P or GSL medicines.

Emergency supplies must be labelled "Emergency Supply" in addition to standard labelling requirements.

A record of the supply must be made in the prescription register including the reason it was considered an emergency and why a prescription could not be obtained.

Further Information

Prescriptions from EEA countries:
Medicines, Ethics and Practice; Edition 40 July 2016, pages 43-44; Royal Pharmaceutical Society

Emergency supplies:
Medicines, Ethics and Practice; Edition 40 July 2016, pages 50-52; Royal Pharmaceutical Society

European Health Insurance Cards:
http://www.nhs.uk/NHSEngland/Healthcareabroad/EHIC/Pages/about-the-ehic.aspx