Friday, 27 June 2008

GP Prescribing

5 years ago I had a disagreement with a local GP. Usually I'm pretty easy going and can tolerate the numerous foibles and idiosyncrasies that Consultant and GP colleagues may possess. 5 years ago a GP didn't want to prescribe galantamine for a patient with dementia. The patient had been on it for ages, was gaining benefit, was stable with no side effects and had moderate dementia . . . our shared care protocol (largely written by the APC) directs that the GP should then, ". . . reply to the request for shared care as soon as practicable," and add the drug to the patient's list of repeat prescriptions. This GP didn't want any truck with this shared care malarky, and as independant practitioners it's quite within their gift for them to do what so ever they wish. But with that latitude comes some responsibility. I wrote back to the GP conveying my disappointment that she sought to act outwith the district-wide agreed protocol but, if she had good clinical grounds to do so, she was perfectly at liberty to allow the galantamine to be stopped and explain to her patient why she was doing so. I'm normally hugely reasonable and go to inordinate lengths to support GPs but when I'm messed about I'm very Consultoid. Fortunate it only happens once every 5 years or so, then.

Sadly, it's happened again.

The problem is that a GP isn't wanting to prescribe any medication for any of her patients with dementia. This puts us all in a difficult position. The general public now perceive antipsychotics as dangerous and bad and speak of the, "urgent message" to GPs, "warning them of the danger." Tim Kendall (who really, really should know better) has said that GPs need reporting to the General Medical Council for such prescribing and saying clearly, "I think the doctors should be disciplined."
The Americans have said antipsychotics shouldn't be used in dementia care.
Our MHRA have said 2 antipsychotics should not be used in dementia care.

The GP is uneasy about prescribing. I'm happy to accept responsibility in the decision, initiation, titration and review of such prescribing. But at some point I need to discharge patients or I'll end up with squillions of patients and won't be able to be effective in addressing clinical need promptly. Other GPs are happy that if I get the patient sorted and stable and ask them to then prescribe, that's fine. Common sense gets a look in, hurrah.

After doing the work and getting things sorted then asking the GP to pick up the ongoing care, I guess I could just discharge the patient back to the GP to do with as they so wish, if having consulted a Consultant for an opinion they don't want to accept or action such an opinion.

What makes this a slightly thornier issue is that I was at a meeting with Anna Walker this week who's the Chief Executive of the Healthcare Commission. They're the body who regulate health, so are a pretty scary crowd. Her agenda for the near future now includes review and improving and rationalising prescribing in Primary Care.

Tempestuous times ahead, eh?


Jobbing Doctor said...

Dear Shrink,

Once again a helpful and toughtful post. We are in deed sailing into choppy waters, and the issue is very much one of a curtailing of professional autonomy in the guise of regulation.

These issues will recur thanks to (and I'm sorry to have to say this) arrogant idiots like Tim Walker - who demonstrates his authoritarian ignorance with every comment. GPs will be bullied into changing prescribing, and will not want to take the risk of prescribing anti-psychotics; you and I know that patients will suffer as a result (although some might improve).

I am very exercised about this whole issue - it has been handled disgracefully - and those doing it ought to be ashamed of themselves.

On a positive note, both Ann Close and David Haslam are on the Healthcare Commission. They are good people who will represent the best of pragmatic practice. I've met them.

cellar_door said...

Good post, thanks! We have had similar problems on my current placement (elderly assessment day unit). One of our patients was doing well on antidepressants, until she had a fall (she apparently tripped on something). The GP immediately took her off the meds (without informing her consultant, or even the day unit) at which point she relapsed and ended up being admitted to an inpatient unit. We have a lot of problems with patients who go into general hospital getting taken of psych meds too, and then wondering why their patient is now psychotic and shouting at 3am...

Made by Mandy said...


I can't help wondering why the GP doesn't want to prescribe dementia medication to their patients?

Is this some NICE (well maybe not so NICE)guiidline they are following or some directive from the PCT or just personal view? Obviously, it needs discretion when trying to find out but to make a cover all decision like that, well, there must be some underlying reason. Or is it financial? Do these drugs take a large chunk out of their budget? Not that that should be reason to stop prescribing something that works for patients but it happens, and sometimes it happens too much!

davmal said...

The Healthcare Commission scary? I've been involved with a complaint relating to the death of a mentally ill patient, and no one in the NHS trust seemed at all scared. Now it's time to find out whether the Commission is scared of the Ombudsman, but I think that's pretty unlikely too.

By the way in this case the GP and also a specialist in another field did try to interfere with psychiatric prescribing, but they did not succeed.

Anonymous said...