Things to consider:

1. What type of bag to use;
2. What to put in it - equipment, paperwork and drugs (and where to get them);
3. Prescription Forms;
4. How to Obtain Supplies;
5. Product Liability;
6. Controlled Drugs - the rules;
7. How to insure you bag.

What type of bag to use
The choices are really between a traditional Gladstone bag or modern equivalent, a brief case with sponge cut-outs or a tool box. I use the latter because it is huge, cheap and strong. It also makes me look more like a plumber than a doc which might be sensible doing visits in dodgy areas. It is also strong enough to act as a seat, particularly useful for not sitting in the old lady’s wet patch! Whatever you have, it should be lockable. A GP reported in the MDU’s booklet Cautionary Tales (1987) knows the penalty for not locking his bag. He was convicted for failing to keep drugs in a locked receptacle when his unlocked bag was stolen from the front seat of his car.

What to put in it - Equipment ^{Note 1}

• Stethoscope;
• Syphgmomanometer;
• Thermometer & Covers (use a digital one - I shattered a glass one on a visit, lacerated my thumb and bled all over the floor!);
• Peak Flow meter;
• Reflex hammer;
• Torch (+ blue filter);
• Tongue Depressors;
• Alcohol sterets;
• Ophthalmoscope;
• Fluorescein;
• Auriscope;
• Speculae; box for used ones and other grubby bits. How do you clean them? I use alcohol sterets;
• Gloves and lubricating jelly;
• Tape Measure;
• ECG ruler;
• Predicted Peak Flow Calculator;
• Obstetric Calculator;
• Urine bottles;
• Urine Dip sticks;
• Tourniquet;
• Sharps box - if you can fit it in - safer for everyone;
• Magnifying glass.

Panic kit for the car

• Oropharyngeal airways;
• Laerdal Pocketmask.

What to put in it - Paperwork

• List of telephone numbers;
• A small number of prescriptions;
• Medical Certificates;
• Headed Paper - practices or your own (without your home address);
• Envelopes;
• Private Prescriptions - a few;
• Spare male and female notes cards FP7/8;
• A map of the area - better in the car than in your bag;
• Dictating machine and tape - owning your own is quicker than looking for one and if you find it isn’t compatible with practice ones play the tape and record with theirs;
• Post it pads;
• Local pathology and x-ray forms.

What to put in it - Drugs
Drug stocks need watching because they go out of date. Carry out regular (6-monthly) checks (or programme your computer to remind you) to ensure that when you really need to use something from your bag, it has not expired. Drugs obtained in chemists’ own bottles may not automatically have the batch number or expiry date on - ensure they do! Batch numbers are needed to protect you if a patient alleges that the drug you dispensed caused them some harm. If a patient has a severe adverse drug reaction you are likely to need to know where that drug came from so the company can test other vials from the same batch and you may be able to turf some of the responsibility. You cannot divert responsibility if you don’t know who made it. Always record the lot number and expiry date of drugs you are dispensing yourself.

Most drugs should be kept at room temperature (4-25ºC) and many prefer the dark. Some drugs degrade quickly unless refrigerated. The ABPI Data Sheet Compendium lists the storage conditions under Pharmaceutical Precautions for each brand. Syntometrine is a difficult drug to store because it only lasts 2 months when stored above 8ºC. You may never need it but how will you feel facing a massive PPH miles from a midwife or hospital with only dud syntometrine? How many hours of your life will you spend checking your emergency drugs? The size of your stock really depends on how much visiting you do, particularly out of hours. When covering 100,000 patients overnight, you might easily get through several vials of diamorphine, frusemide and an anti-emetic. If you do Coop work be sure you have sufficient supplies or access to more in the middle of the night. Here are some suggested drugs to stock:

Oral ^{Note 1}

• An antacid;
• An H2 blocker;
• An NSAID;
• Analgesia - Soluble paracetamol;
• Another analgesic;
• Antibiotic - a penicillin;
• Antibiotic - not a penicillin;
• Anti-histamine;
• Aspirin;
• Buccal prochlorperazine;
• GTN spray (lasts longer than pills);
• Salbutamol inhaler;
• Steroid tablets (equivalent to total of at least 100mg Prednisolone);

Parenteral kit ^{Note 1}

• A butterfly for kids;
• A venflon for adults;
• Adrenaline;
• Antiemetic injection;
• Atropine;
• Chlorpromazine/Haloperidol;
• Diazemuls;
• Diazepam (rectal "Stesolid");
• Frusemide/Bumetanide;
• Glucagon;
• Glucose;
• Injection for Renal Colic (Pethidine 200mg or Diclofenac);
• Needles and Syringes;
• Opiate: Diamorphine/Morphine/Cyclimorph equivalent of at least 20 mg Morphine;
• Naloxone;
• Penicillin G 1200mg;
• Synto/Ergometrine;
• Water and saline for injections;
• Hydrocortisone.

Note 1: Compiled with the help of Adrian Midgley

Further information: Drugs and Therapeutics Bulletin 1995 Vol 33 No1 Pages 3-5 Drugs for the doctor’s bag.

Prescription Forms
These are valuable. Stolen ones cause a lot of hassle. Doctors are advised to read the recommendations printed in the front of the BNF for minimising the stealing and misuse of prescriptions. In particular, non-principals should note that when not in use pads should be kept in a locked drawer in surgeries and at home. It is easy to build up small numbers of prescriptions from a multitude of surgeries. Destroy the forms you no longer need rather than risk them being stolen. One locum whose car was stolen containing his bag and all the pads he’d accumulated from thirty local practices had a lot of explaining to do!

How to obtain supplies
Maintaining stocks of drugs is a professional inconvenience. The key is to keep one’s range of drugs as simple as possible and only to dispense the minimum needed, writing scripts for the remainder of the supply.

Drug reps often offer free starter packs which are occasionally useful. They tend to be the latest (and therefore not the cheapest) so prescribing a full course costs the NHS more than if you had a cheap standard generic in your bag. Opinion varies as to whether it is acceptable practice to switch to a different cheaper drug for the remainder of the course (provided on prescription). Try to get replacements from the practice that you were working for. Practices may have a cupboard of stock drugs but it can be a hassle to get drugs this way especially if you’re just doing a very short stint for them or if you don’t actually go to the practice premises (e.g. on co-op work).

The simplest way to buy an initial stock and then get replacements is to write a private prescription on headed paper and pay for the drugs yourself. Pharmacists are often reluctant to dispense small quantities of IV drugs as they have to buy them in quantity, but some will do so. It helps if you can get to know one or two. The pharmacist might give you a discount and advise on cheap options. Basic vials are not too expensive and you could share a pack of vials amongst other locums. You should claim them against tax as a necessary business expenses.

Some GPs write prescriptions for patients and then cash the script themselves. To use medication prescribed for a patient, even with their consent, could lead to an allegation of fraud by the NHS. It is therefore not recommended.

Product Liability
The Consumer Protection Act 1987 requires a producer to ensure that a product is up to standard and fit for the intended purpose. The supplier of a product has responsibility to identify the producer when damage is caused by a defect in the product. If this cannot be done then the liability rests with the supplier. GPs become suppliers when they dispense any product to a patient. To avoid liability it is essential to know the name of the supplier (pharmacist) or the manufacturer of the product. When dispensing drugs it is wise to record the manufacturer, the lot number and the expiry date of that drug. Producers can still avoid liability if they can show that the product was not stored in accordance with instructions e.g. in hot cars. So don’t do it!

Controlled Drugs (CDs) - the rules
The rules on CDs come from the Misuse of Drugs Act 1971 and the Misuse of Drugs Regulations. The latter were updated in 1985. The schedules of CDs are listed in the front of the BNF. The regulations govern the supply, possession, prescribing, storage, disposal and necessary record keeping for these drugs. Any doctor who contravenes them is committing an offence under the Act for which he may be prosecuted. Copies of the regulations are available from HMSO.
The following is a summary.

• Registered medical practitioners are allowed to possess and supply CDs (except Schedule 1 drugs) when acting in a professional capacity;
• Only doctors with a special licence are able to supply dipipanone, heroin or cocaine to anyone who is known to be or suspected to be dependent on any notifiable drug unless prescribed for organic disease or injury.

Obtaining supplies for emergency use

• Doctors are able to obtain supplies of CDs by signing a requisition which must state the recipient’s name, address, profession, total quantity and purpose of supply.

Record keeping

Registers must be kept recording all transactions for Schedule 2 (diamorphine, pethidine) drugs held by GPs. Registers must be set out as below. Many keep a running total of the amount in stock in addition to the required columns. The register should be bound, not loose leaf. Entries must be made in chronological order and on the day on which the drugs are obtained or supplied or on the next day. No entry can be cancelled or amended. Corrections can only be made by additional notes. Doctors must produce the register to authorised persons (eg Home Office inspectors) and the register must be kept for two years from the date on which the last entry is made.

Layout of Register of Schedule 2 Drugs

Entries to be made in case of obtaining drugs

Entries to be made in case of supply

An additional column can be used to record the running total of stock.

Destruction of CDs

GPs may not destroy any CDs in their possession except in the presence of an authorised person (police officers, Home Office Drugs Branch inspectors, Pharmaceutical Society of Great Britain inspectors or Regional Pharmaceutical or Medical Officers). A record must be kept of the date of destruction and the quantity destroyed. The authorised person must sign the record. This does not apply to drugs prescribed and dispensed to a patient but which become surplus to the patient’s needs. GPs and pharmacists are able to destroy such drugs.

Storage

All CDs must be kept in a locked receptacle which can only be opened by the doctor concerned or someone authorised by him to do so. A High Court judgement deemed that a locked car is not sufficient. Stocks must be kept to a minimum.

Further information
Banks and Waller: Drug Misuse: A Practical Handbook for GPs (Blackwell)

How to Insure your Bag
The important advice here is to think about this. Neither home contents or car cover will automatically cover a business item like this. Because it will take time, and cost £250 or more to replace a stolen one you should consider whether you are prepared to pay premiums specifically for this. BMA Services will quote for cover which includes medical equipment in home contents cover. They will also pay up to £25 ‘admin’ fee that your current insurer may charge for leaving them. Commercial cover is probably not worth it. One company quoted a minimum commercial premium of £200. Persistent searching may pay off but premiums need to be cheap to be worth it. On a similar topic one GP recently described in the GP press that he had a bottle of laxatives in his bag labelled morphine, just for the next thief. Not quite insurance but perhaps a small comfort for the hassle of the theft. Undoubtedly the thief will be able to sue him for the gut ache he endures due to the doctor’s ‘error’!