Welcome to Confidence to Thrive, the podcast helping growing practitioners and healthcare entrepreneurs navigate the challenges and risks of regulation while building brands that matter. Every episode, we tackle a different issue facing healthcare practitioners or entrepreneurs, or we interview a guest who is working on the leading edge of private healthcare, building something that matters in their sector or profession.

My name is Jody Raynsford, and on today's episode, I'll be discussing with Christopher Cloke Browne, director at Owlicity, the challenges of prescribing across borders as a GMC (General Medical Council) registered medical practitioner.

The nationality of a patient and their location when the consultation is made make the situation more complex from a legal and regulatory perspective, and that's what we'll be discussing in this call. So let's get into it.

Hi, Chris.

CHRISTOPHER CLOKE BROWNE: Hi, Jody.

JODY: Okay. So we are talking about cross-border prescribing. Why is this a particular issue in functional medicine, and what is the core challenge that arises from it?

CHRISTOPHER CLOKE BROWNE: Yeah, it's really— I think COVID started it, and pre-COVID, but COVID really accelerated the move to delivering healthcare remotely, so teleconsultations. And functional medicine in particular is particularly adept at teleconsultations. And a lot of that comes down to the fact that they gather a lot of information about the patient. They have a patient take-home form which is about 40 pages long that goes through all your conditions and so on. They do a lot of functional testing, so they have the test results and they're really working off that and not poking and prodding the patient, as in traditional medicine. So a lot of functional medicine is delivered as telemedicine.

As soon as you're doing that and looking for the best client bases, you quite often quickly get into an international community and not just an international community, but a sort of internationally mobile community. So even if it is a patient from your country, they might well spend quite long periods abroad but want to keep their treatment up. So you will find that most functional medicine is delivered as a remote service.

JODY: And so what are the challenges in terms of understanding firstly around the location of both the business prescribing and of the patient. Where is the prescribing legally being done?

CHRISTOPHER CLOKE BROWNE: Yeah, so this is the thing, and we've been asked to look at this by a few of our functional medicine clients now. So they've got to a point where they are being asked to prescribe, or have got to a point where they possibly need to prescribe for their patients who are abroad. And that's a mixture of their UK-based patients who just happen to be abroad, and foreign patients who are abroad. So I've been starting to look into this issue in quite a lot of detail. I think the sort of first thing that strikes you is that we will need to differentiate between diagnosis, treatment and prescribing for the patient, and the fulfilment of a prescription. So those are different things, which we'll get into. But I think the thing to really keep top of mind is that most jurisdictions, and most of the jurisdictions that we have looked at, because there's a lot of functional medicine patients in those jurisdictions, seem to define medical care as taking place in the country where the patient is.

So even if I'm a UK doctor sitting in the UK, I'm GMC registered, so I think that's all fine. But if I'm actually delivering telemedicine to a patient in, let's pick Italy, because that's one that I've looked at most recently, Italian law says that as far as Italy's concerned, that consultation is taking place in Italy. And that does make a certain amount of sense because should there be negative consequences from the consultation on the patient, then it's Italy's hospitals that will be dealing with it, and the costs and so on, and hassle and everything will fall to Italy. So they have said, "Yeah, as far as we're concerned, that consultation happens in Italy."

JODY: And is the law in various places explicit about this, or has this emerged as either case law or supplementary regulation as a result of particular cases coming up or particular situations?

CHRISTOPHER CLOKE BROWNE: I think it's fairly explicit in Italy and then the UAE (United Arab Emirates) are the two I've looked at most recently. UAE, particularly Dubai being another big centre of functional medicine. Both explicitly say that with telemedicine that the consultation happens in the country. They don't explicitly say anything about whether you need to be a Dubai registered doctor to deliver telemedicine.

Yeah, it's interesting. It's almost gone halfway. So both Italy and Dubai now have a concept of telemedicine, and this is another important step. So both countries have now defined telemedicine as a medical service in that country. So in order to deliver a medical service in both of those countries, you have to be a locally registered doctor in both of those countries. But they don't explicitly anywhere exclude a doctor who's registered in another country from delivering those services, but you don't meet the correct criteria for their laws. So one would say be careful. It looks— you can't absolutely say it's illegal, but it wouldn't read well.

JODY: And is there widespread awareness of this? So anyone that is coming to practise functional medicine in the first place— clearly thinks that there's opportunity. It's so normal now to have international clients, to have people in different countries. You might be calling someone, you might even not know that they're in a different country as well. And so is there widespread awareness of this being a particular issue among newer healthcare practitioners and healthcare practitioners who are expanding their service on a more global basis? Or is this something where there needs to be more education on this?

CHRISTOPHER CLOKE BROWNE: Yeah, I think definitely there needs to be more education on it. I think our feeling is it's something that practitioners don't know for sure, and they're definitely feeling uneasy about it, because we're getting a lot of questions now. I think we're just getting to the stage where these functional medicine practices have grown and developed and taken on clients all over the world. And that's fine when it's the initial stages and you're just going through the health forms, the 40-page form as I mentioned, and possibly even getting a few blood tests. You have somebody locally take the blood, send it off to a lab, you get the results back, you can look at the results, discuss the results. But you're getting to the stage now where the practitioner is probably getting a good understanding of the patient, and now it's time to actually do something with the patient.

JODY: Yeah.

CHRISTOPHER CLOKE BROWNE: And all of a sudden that's really starting to tip you into this medical domain. And people are uneasy and they're rightly uneasy.

JODY: So you've got two aspects that are working together. You've got the fact that you are operating in an area where online consultations and potentially prescribing those has become more ubiquitous, and it's sometimes not even clear as part of that consultation where someone is or where they are. Things that you have to verify beforehand, presumably before you do any kind of consultation or diagnosis. And also along with the shift in what it is that you are potentially prescribing— more advanced supplements— as functional medicine becomes more advanced and we get into more advanced biochemistry, so you've got those dual challenges to face.

CHRISTOPHER CLOKE BROWNE: Absolutely, yes, yeah. And just as a general sort of thought and comment— if you are effectively prescribing in a foreign country, there's first the issue: are you doing so with the right permissions, the right regulations, qualifications, and so on to prescribe in that country? And secondly, the medications that are legal and the doses and all the rest are likely to be different as well, so you have to check the legality of what you're prescribing. It's— again, you're not prescribing under UK regulation, you're prescribing under Italian regulation, or Abu Dhabi regulation or whatever it is. So the medication, the legality of the medications is also different.

JODY: And dosage as well, and recommended dosage.

CHRISTOPHER CLOKE BROWNE: Yes, absolutely. It's the whole lot can be different. Now interestingly, there are so many shades of this, Jody, and we're starting to— We've put together about half of an advice document, but we're going into a lot more detail in the advice document because as we dig further, everything's nuanced. I think the sort of next thing to consider and one of the questions we get— So say a UK patient comes to see you.

JODY: Yeah.

CHRISTOPHER CLOKE BROWNE: And you give them a prescription here in the UK. So they've— and this could be telemedicine or they could physically come and see you. Let's say they physically came to see you in the UK, and you give them a prescription. They then go to Spain for six months, and they have your prescription.

JODY: Yeah.

CHRISTOPHER CLOKE BROWNE: Can they fulfil that prescription? And the answer to that one is actually easier, because that's fine. You've consulted them in the UK, it's UK law, you're a prescriber in the UK, so you're all fine. So there are a set of criteria that say as long as the local pharmacy can identify who the patient is, who you are, quite often what your qualifications are, there's a whole bunch of details that go on the prescription. Yeah, and it's legal to prescribe in the UK or in that country, then the local pharmacy can fulfil that prescription. But yeah, if we're getting into the layers of nuances, interestingly, if we go to Ireland, so Republic of Ireland— Yeah, I think the UK doctor's qualification— don't hold me to this, because I need to check it, but I think from memory, the UK doctor's qualifications are recognised. Yeah. So they can prescribe, it's just that Ireland won't accept telemedicine prescriptions.

JODY: Oh, okay. Oh, it is nuanced then.

CHRISTOPHER CLOKE BROWNE: Yeah, so really—

JODY: Absolutely. Okay. So you're going to have to travel. You're going to have to get your doctors to come to you if you're in Ireland.

CHRISTOPHER CLOKE BROWNE: Yeah, or yeah, or go to Ireland or whatever it is. But the point is, I think where we're getting to is that you are going to have a fairly detailed understanding country by country.

JODY: Yeah.

CHRISTOPHER CLOKE BROWNE: You might actually, if you've got larger client bases and really want to service them, you might need to either have a local doctor or get some of your doctors qualified.

JODY: Yeah.

CHRISTOPHER CLOKE BROWNE: The thing that's coming across my mind, coming from financial services business and I— And again, it was— the unfortunate thing is the whole Brexit thing. So you had medical services under freedom of services and recognition of qualifications and all the rest within the EU.

JODY: Yeah.

CHRISTOPHER CLOKE BROWNE: So when the UK was within the EU, everything was open to you. As a UK registered doctor, everything in the EU is open to you.

JODY: Yeah.

CHRISTOPHER CLOKE BROWNE: And that's still true within the EU. So much like me as a financial services firm continuing to do business in Europe, I now have a little foothold in Europe, and that opens up Europe to me.

JODY: Yeah.

CHRISTOPHER CLOKE BROWNE: You might actually want to set up a little foothold in Europe and get some of your doctors licensed in Europe. Yeah, and then that would open up all of the European countries to you, I think. Again, that's all the details we're going through for the final version of the document, but that looks as if it certainly works in financial services.

JODY: So if we think about specific situations where issues can arise, so obviously a UK GMC registered medical practitioner prescribing either in person or over a teleconsultation in the UK, absolutely fine. If that person has that prescription, takes it abroad and uses it, that's absolutely fine. What about the situation where they say go abroad and then, with a lot of medication you need another consultation after, say, six months. We were talking about ADHD medicine earlier. Yeah, a consultation after six months to assess everything and then again, the prescription's signed off. So the initial prescription in the UK. You're abroad, you're having a teleconsultation with your doctor. I think so that changes it.

CHRISTOPHER CLOKE BROWNE: They will have to do that according to whatever the law or regulations of the country you're in.

JODY: Yeah.

CHRISTOPHER CLOKE BROWNE: Of the country you're in. So strictly speaking, they shouldn't be having that consultation, or most likely, because it seems that most countries want to define that as the delivery of healthcare services and would want you to be a licensed practitioner in the country.

JODY: Yeah.

CHRISTOPHER CLOKE BROWNE: Again, all of these things get a little bit more awkward and a little bit more difficult. So if it's one of your UK patients who just happens to be abroad—

JODY: Yeah.

CHRISTOPHER CLOKE BROWNE: Should you or shouldn't you? I think very much, if you're going for absolute letter of the law, then it says no. The GMC themselves have various criteria. And I think one of the most important criteria, which plays well to functional medicine, is that you have a good understanding of that patient and their medical history and medical needs.

JODY: Yeah.

CHRISTOPHER CLOKE BROWNE: And because functional medicine is so much based on all this assessment and analysis of the patient, and they have these huge forms and blood tests and so on, that they can very much claim that they have a unique understanding of the patient.

JODY: Yeah.

CHRISTOPHER CLOKE BROWNE: I think that piece plays well. But you always have the problem of— if the law says to deliver medical services, and telemedicine is a medical service, then telemedicine to somebody in that country, unless you're licensed, you shouldn't be doing it.

JODY: Yeah, yeah. And so the nationality of the patient is largely irrelevant.

CHRISTOPHER CLOKE BROWNE: Largely irrelevant— it's the locations that really matter. Yeah. And as I say, I think that comes down to a very sensible concept that just says, look, we're the ones picking up the pieces here, so we'll say what's right and what's wrong.

JODY: In practical terms, then what should medical practices be doing firstly to ensure that they are staying on the right side of the legal and regulatory practices that are being suggested, but also protect themselves against the consequences of getting this wrong?

CHRISTOPHER CLOKE BROWNE: Yeah, so yeah, at the very extreme, I think you need to worry about exactly where your patients are in terms of telemedicine consultation. I guess the one thing that's just popped into my head and I haven't even looked at is what happens to— actually if they're on a cruise ship, then I guess it depends on the flag of the ship.

JODY: I can imagine you getting a call and they're saying like, "Where are you?" Go, "In the middle of the ocean." Can you just go and check the flag of the ship so we can specifically verify the territory?"

CHRISTOPHER CLOKE BROWNE: And then that's going to be a flag of convenience, like Panama or whatever it is. So off you go. So absolutely, strictly speaking, and then you would need to worry— and this is always a big question in functional medicine— is, are the services you're delivering actually healthcare services? So a lot of functional medicine practitioners will say that they are delivering health advice or health coaching, and a lot of it would look like that, at least in the early stages. But again, if you are a sophisticated functional medicine practice and you are starting to design programs and protocols that are targeted around specific diseases— as with the whole sort of question of GMC registration in the first place— that gets harder and harder to justify. And we haven't looked into where that sort of borderline between just sort of health coaching and health advice and medicine lie in any country other than the UK. But I wouldn't be surprised if it's in similar places. If, to the extent you need to be GMC registered for what you're doing with your patients in the UK, then you probably need to be locally registered for your patients outside the UK.

JODY: So what's the most practical way of doing this as a practice? Is it to say that if we do teleconsultations, we will only do consultations if you are in these particular countries, because you've already researched the fact that there is an equivalence in terms of GMC regulation? And what would be the practical way to deal with that?

CHRISTOPHER CLOKE BROWNE: Yeah, I think that might well be the case— looking to get registered. The good news side is— and particularly Europe, we were all one and everybody was happy, and so I think that's— that should be fairly straightforward. And again, to me perhaps the most straightforward way is just to go and register in one country and do it from there. I'm just trying to think about the big sort of centres of patients, so trying to narrow the search down to what matters. I think the other big centre would be the Middle East.

JODY: Yeah.

CHRISTOPHER CLOKE BROWNE: Now interestingly, the Middle East still very much favours UK medicine.

JODY: Yeah.

CHRISTOPHER CLOKE BROWNE: So I think as a UK registered doctor, it's probably relatively easy to get registered in a lot of the Middle Eastern countries. Yeah, a good friend of mine who worked for me is now out in Abu Dhabi. And he was telling me that interestingly, the wealthy Arabs in probably across the UAE— they don't trust their local doctors. They don't think they're particularly well-trained, even though they probably are.

JODY: Does anyone trust their local doctors? It's—

CHRISTOPHER CLOKE BROWNE: Yeah, yeah, they think that British doctors are the best in the world.

JODY: Oh, okay.

CHRISTOPHER CLOKE BROWNE: So they all troop off to Harley Street, which—

JODY: Yeah.

CHRISTOPHER CLOKE BROWNE: Is a big question in itself. And even the British doctors who go to the UAE, they don't trust them, because they think if they were any good, they would have stayed in the UK. So yeah, so there seems to be at least great admiration in the Middle East for UK medicine, so I think that's a useful thing. And from the very little bit I've done, I think it's potentially not that hard. Again, not that hard. And then the time, effort, and expense of keeping registrations is a whole new thing.

JODY: And in terms of the consequences of getting this wrong, what happens both from a legal perspective and from an insurance perspective? I take it then that if the medicine is being seen as done in the country in which the patient's in, then there will be any action taken by the local equivalent of the GMC? How would that work? What is the consequence?

CHRISTOPHER CLOKE BROWNE: Yeah, so this is something you can probably draw some comfort from— in that if you're not present there, and one of our sort of checks is, by no presence, we mean that you don't have an address and that you don't have assets there, because those assets can get seized. Yeah, courts can find against you, and assets can get seized. Then it's harder for anything to be done about it. Clearly, all of the medical regulators have a path to go and say, "By the way, Dr. Smith was providing treatments unlicensed in my country, and we were unhappy about it." So and I would imagine the GMC would probably take that quite seriously. I think you're always exposed to that route.

JODY: Yeah, so that's what the question was about really— was whether there is that level of communication between bodies within territories as well when these issues happen.

CHRISTOPHER CLOKE BROWNE: Yeah, no, I think the regulators quite often— I think it's even worse than that. There's sometimes a sort of certain one-upmanship with the regulators. So you can imagine a sort of Dubai regulator trying to prove that— he's felt looked down upon by the UK GMC for years and now saying, "Your house isn't in order. All your doctors are practicing in my jurisdiction unlicensed."

JODY: And then from an insurance perspective, what is the issue in terms of invalidating their insurance if they are operating outside of territories?

CHRISTOPHER CLOKE BROWNE: Yeah, the first thing to do is to check your insurance allows it. And again, when you look through the GMC guidances, "Do you have valid insurance?" is about the second line in everything. So that's something that we've looked at. And we can certainly insure doctors for doing this activity. Again, where it becomes more awkward is if they are deemed to be unlicensed, then unlicensed activity would almost automatically— Oh, yeah, you can imagine insurers getting very upset about that. Technically, you can't insure illegal activity. So if it's illegal, which it would be if it's unlicensed or unregulated, then it can't be insured. So we can certainly provide insurance for people who are doing it right, but doing it wrong, the insurance just becomes invalidated.

JODY: Okay. So there's quite a lot that someone will have to go through in order to figure out whether they are on the right side. And I suppose with the line about having the right insurance, it's quite a broad term, and I imagine that there's quite a bit of ignorance as to what their insurance does actually cover, as we've discussed multiple times on this podcast, as to whether it—

CHRISTOPHER CLOKE BROWNE: Yeah, I think people are relatively wise to the fact that they need to check that. And again, from the work that I've been doing, some of the medical defence organisations now specifically put out and say, "We don't cover telemedicine into foreign jurisdictions." Much more explicit. So I think that's relatively clear, but again, whether your insurance covers it is a different question.

JODY: Okay. So that should be— So if you are currently or considering teleconsultations, first thing to do is to check with your insurer to make sure that firstly you are covered. And—

CHRISTOPHER CLOKE BROWNE: Yeah.

JODY: Presumably you would then give advice as to which territories you are in, and then it would go from there.

CHRISTOPHER CLOKE BROWNE: Yeah, I think we're, as I say, we're halfway through putting out some fairly detailed advice and trying to really unpack all these different levels of where is the person. And as we discussed, you have to differentiate between the diagnosis and treatment, which can include the writing of a prescription, and the fulfilment of a prescription to get the full story. So it's really then trying to trace all that through. So in its most complex form, you have a teleconsultation with somebody who is abroad, and you conclude that they need a prescription, and you provide them with a prescription. I think that's got all the sort of components to it. And at its simplest form is you have a face-to-face consultation with somebody in the UK, and that's all been going on for years and hasn't happened. You can then go to teleconsultations in the UK. You can then go to the idea of consultations in the UK where the person takes his prescription abroad. And I guess almost related to that is the person taking the medication abroad. But I don't— I think that's probably less of your problem because, as long as you prescribed it in the knowledge that it was for consumption in the UK. We all take our medications on holiday with us.

JODY: Yeah, absolutely. We're going to be talking about prescribing in a separate podcast episode as well, and the additional challenges around that in functional medicine and supplementation and doing that as a GMC registered practitioner. But for now, I think that's a good place to wrap up the conversation around that. And as you said, there's going to be more that comes out of this as you complete your research around this and start advising clients on it as well. And so I look forward to having a further discussion on that later down the line. Thank you very much, Chris.

CHRISTOPHER CLOKE BROWNE: Thanks, Jody.

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This podcast was brought to you by Owlicity Insurance Advisors, who support your business ambitions. Owlicity advises practitioners, owners, and entrepreneurs of healthcare practises on mitigating risks so your business can thrive. Learn more about how Owlicity can support you by finding the link in the show notes or visiting owlicity.co.uk