I work with good GPs. I have a good relationship with them. Since joining this Trust, no GP has ever referred a problem as urgent and not had it attended to within 24 hours. No urgent emergency has has to wait more than 4 hours. We're audited on this every month, so I know we're a responsive service, which GPs appreciate.
Because of this relationship we've developed, there's been a healthy dose of common sense between Primary and Secondary Care.
Say a drug dose changes and a patient needs an ECG doing in a couple weeks but it's a way to trawl to the hospital, most GPs have no issue with the ECG being done in their surgery by their Practice Nurse. It's eating up a bit of their Practice Nurse time, it's generating no income for them, they have to mail the ECG to me, the ECG can be done in the hospital, but to smooth out things for their patients they offer this choice.
I take on and manage and follow up patients who are outwith our operational policy, but if I didn't do this they'd cause chaos and difficulties for the GP.
To date it's worked well, we blur boundaries, support one another and take policies/protocols with a pinch (well, more huge great handfuls) of salt and simply crack on and do what's best.
I like this.
Recently, one group of practices has appointed a new pharmacist. She's keen. She's determined to bring prescribing costs down. She's never met me. She has written to me, prolifically. A few things concern her. Well, that's disingenuous, I assume they don't concern her since she's a pharmacist with the salient information to hand so will know that the prescribing is rational and appropriate. What concerns her is the cost. Through this, she's notionally concerned that :
Some patients with dementia are on lorazepam. They were battering people and were unmanageable. Now they're on 2mg of lorazepam regularly with some prn and are cured. They're in care homes with regular nurse follow up to ensure that the care homes use the minimum dose and complete diraies/use behavioural programmes rather than focus on medication. But although none of them are on more than 4mg of lorazepam, the British National Formulary (BNF) states a dose of lorazepam of 4mg in adults, 2mg in the elderly. These folks can sometimes have more than 2mg.
Of course, it's titrated to clinical need, there are no treatment emergent adverse events and it's working. So we use medication at the minimum effective dose, but that minimum is sometimes above 2mg. It's better than using lots of drugs at low (less effective/ineffective) dose. Our Royal College and voluntary groups advocate this.
She's asking that I undertake prescribing for all these patients, removing all such prescribing from the GPs. More than asking, she's saying that she's not willing for the GPs to prescribe these.
I'm sorely tempted to write back and suggest if she wants to change their drug regimen, go ahead and good luck.
A number of patients are on antipsychotic medication because of their dementia, causing memory loss and changes in thought so they're less adept at reality testing and become muddled. Antipsychotics can help smooth out chaotic thoughts so they can grasp the right train of thought more successfully more of the time. Also it can help with distress, helping folk feel less distraught. In some dementias people have delusions. They lose things, through poor memory, then try and understand why and reason it's been stolen, then look around over time and are mildly disoriented which fits with intruders, then develop abberant ideation as cognition deteriorates so can become deluded, with paranoid delusions. Antipsychotics can help these. Some will hallucinate. Antipsychotics can help these, too.
The BNF does not list licenced indications of Behavioural and Psychological Symptoms of Dementia for any drugs. Dementia care, with medication, is almost all outside the listed Summary of Product Characteristics (SPC) that all drugs have. The trials needed to get this evidence base, to change their SPC, aren't easy. They're not cost effctive and they're ethically fraught. Almost all prescribing in old age psychiatry is "off label" and outwith what the SPC says. A pharmacist will know this because the BNF has few modern drugs that we use that are developed with trials in older adults.
No means no!
I have no desire to take on routine prescribing responsibility for every patient with dementia. I have no computer for repeat prescriptions, all my prescribing is thoughtful and individual. If it is routine my GPs kindly undertake it.
What to do, what to do :
- thank her for her point of view and ignore the issue?
- decline to accept all these patient and let her GPs face her harrassment?
- decline to accept and advise her to discuss changes with her GPs?
- decline to accept and suggest that the drug plans are sound and that she change them at her peril?
It's folk like this that afford me an unhealthy glimpse in to how folk like Dr Rant can become so, erm, effusively colourful, in their frustrations with what's in essence unhelpful meddling.