A lot of decision making I am asked to undertake involves an element of risk management. Whether it's risks of leaving mentally unwell folk in their own home or whether it's around timing of discharge planning (when folks aren't cured but are things "good enough" to go home?), or of course prescribing. Stopping or initiating medication has clinical consequences, and thus risks.
My team has, I believe, a healthy attitude of positive risk taking. External agencies, partner organisations, patient and carer groups and our own Trust Board agree, so hopefully my belief is reasonable.
There are scenarios when I'm twitchy and would see risks as unacceptable. Almost always, since these are discussed as a team with the patient/carers, concensus can be reached and a sensible management plan generated. With prescribing it's a little different since I do that in discussion with the team but prescribe independently. We do have nonmedical prescribers but they're not independent prescribers and I don't envisage a day when nonmedical prescribers will initiate or change medication without discussion with a Consultant Psychiatrist. Currently our clinical governance framework requires this and it's firmly entrenched in our Medicines Management structure, so although nonmedical prescribers support, review, titrate and advise, the initiation or withdrawl of medication always always involves a Consultant Psychiatrist. Almost always it's the Consultant Psychiatrist doing it, since nonmedical prescribing is a tiny proportion of our prescribing.
Prescribing practice is singularly unique in my corner in that the risks (unlike other risks) are almost wholly carried by the Consultant Psychiatrist. It's therefore of interest to me how my colleagues and I prescribe (and an area that's audited and reviewed).
One theme that's arisen has been of varied prescribing of anti-dementia drugs.
I prescribe widely almost wholly irrespective of severity of the dementia (i.e. whether it's mild, moderate or severe I'm keen to prescribe if the medication's of benefit) which is outside the NICE guidelines (technology apprasial TA 111) which directs us to prescribe just for moderate severity dementia. I feel uncomfortable waiting for someone to deteriorate before prescribing, so prescribe for mild dementia. One colleague does not, sticking pretty closely to NICE guidelines. It's hard to say they're doing the wrong thing, it's easier to say I'm doing the wrong thing. Either way, there's a difference in clinical care, depending which of us you see, which is determined by where you live.
So I prescribe a lot of anti-dementia medication. At the other end of the spectrum is a colleague who prescribes far less anti-dementia medication than I do. A potential risk of the medication is to slow the heart rate down (bradycardia). At some point the heart rate is normal and all's fine. At some point it's so slow it's hugely abnormal and you're unconscious. There's a range in between where it's not perfectly normal but it's having no clinical consequences, through to sometimes causing problems, to having ongoing minor problems, to being more serious. This gives a grey area then, at what stage should a doctor no longer offer medication because the possible risk of possibly getting bradycardia may possibly make the heart rate slower and possibly cause serious problems? Some doctors prescribe readily with a pulse rate of 60, some won't prescribe. Either way, again there's a difference in clinical care, depending which doctor you see, which is determined by where you live.
The drugs also ramp up risks of conduction abnormalities within the heart, a lot of elderly folk have ECGs that aren't perfect and aren't totally normal, which of these folk are excluded from having medication? Again, it's up to the doctor to decide what seems too risky, with different clinicians having different views of this.
Postcode prescribing. I really can't see a way around this.