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Gold, incentives and meh

GPs could be forced to manage high-risk drugs with no extra funding

Exclusive NHS England is currently considering whether GPs should be expected to prescribe warfarin and methotrexate as part of their core work without the need for an enhanced service, Pulse has learned.

NHS Basildon and Brentwood CCG is in talks with NHS chiefs over whether it can oblige GPs to prescribe both high-risk drugs without resourcing them to monitor the drug properly through an enhanced service. If it is successful, this could open the door for other CCGs to take the same action.

It comes after the LMC intervened to warn practices that the CQC was treating GP practices ‘harshly’ for not monitoring warfarin safely.

As a result, several practices have – under GPC advice – served the CCG notice that they will no longer be prescribing warfarin.

The CCG has also recently removed the funding for monitoring methotrexate, with practices fearing a similar clampdown by the CQC.

And CCG leaders are taking advice from NHS England over whether it can continue to insist practices prescribe such high-risk medications as part of their core work.

The CCG withdrew funding for practices to pay for the monitoring of anticoagulation four years ago, and has refused to reinstate it. Commissioning leads have since claimed practices should still prescribe warfarin according to advice in the patient’s handheld record, with patients’ INRs monitored by the local hospital.

But practices in the region are being downrated by the CQC for being unable to monitor the INR.

South Essex LMC has issued advice to practices, saying: ‘CQC inspectors in the area are of the view that regardless of the patient being under such a service, GP practices must also be viewing and monitoring the INR. Practices in South West Essex do not have the facility to view INR results requested by the anticoagulation clinic. This stance by the CQC has led to practices being treated harshly during inspections.’

The LMC added: ‘In the circumstances, the LMC fully supports any practice that chooses to withdraw from providing any nationally or locally agreed enhanced service, and is firmly of the view that prescribing warfarin outside of safely agreed and properly resourced commissioning arrangements is not essential GMS.’

The GPC has backed the LMC’s position, stating its view that ‘if the service was previously covered by an enhanced service then it’s not part of essential services and commissioners should have an appropriate service commissioned, to which practices could then refer’.

But NHS Basildon and Brentwood CCG said in a statement: ‘The CCG is taking advice from NHS England as regards the responsibility for prescribing of warfarin and will await the outcome of this request before considering any required action.’

Dr James Hickling, deputy medical director for NHS England Midlands and East, told Pulse: ‘We recognise there is variation in how primary care services are commissioned, and we support local commissioners having discussions about how they can offer tailored solutions which best meet their patients’ needs.

‘NHS England is working with NHS Basildon and Brentwood CCG regarding the responsibility for prescribing some high-risk medications.’

Readers' comments (26)

  • And here they are again:

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  • GPC should never have allowed DMARDs and anticoagulation to be moved out to primary care.

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  • We are taking on more risk.We should be renumerated for taking this risk,otherwise this is abusive to primary care.THIS IS NOT PART OF THE CORE CONTRACT.Therefore it has to be negotiated accordingly.

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  • name and shame them

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  • Cobblers

    I have a problem with this scenario. How is it that any 'body' can INSIST that a doctor must prescribe a given drug at any time?

    Not possible.

    If a doctor has valid reasons then that is it. The GMC will take a dim view indeed of a doctor prescribing outside his or her comfort zone and causing harm.

    It is, perhaps, a reflection of the admindroids low perception of a GP as a "Gofer" who should be told what to do and when to do it.

    Perhaps a little expeditious Anglo-Saxon vernacular hurled in their general direction might concentrate minds.

    Or maybe have a quick look at all the so called 'shared care' schemes and refer the lot back to secondary care for them to take over.

    There is more power than you think in your hands. Ponder and act. The CCG will move.

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  • National Hopeless Service

    For those of you who want a salaried future in super-practices this is your future, one of being told what you will do regardless of the risks.

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  • This is already happening in various parts e.g. a antipsychotic monitoring increasingly being done in primary care.

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  • and DMARDs in rheumatology in my area where review times are now down to years and years behind schedule so we carry the extra responsibility for these drugs on our own without consultant advice or review

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  • we have a les for taking over Stable warfarin pts (with certain criteria for stable) .on one of the rare occasions we rejected an unstable highrisk transfer it caused major outrage and verbally aggressive phone calls from the hospital clinic end. Shorlty after, the pt died of an intracerebral bleed ,which did give us firm grounds for ensuring the 'Stable warfarin LEs ' didn't feature-creep into an 'accepting every warfarin -pt transfer from hospital as soon as they tried to handover'I now have to sort out an extremely frail patient who I can't believe the hospital put on warfarin at all,let alone discharged 2 days before a Bank hol weekend -they did phone us us on friday afternoon to let us know though.....doesn't incline me to consider this as core work !

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  • 1. move pts to NOACS asap if clinically allowed

    2. refer shared care pts back to sec care

    3. vote off CCG clinical leads

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  • Jo: absolutely right with NOACs. As a former CCG Medicines management GP Lead my advice is that it is important to understand the pressures CCGs are under, but the best way to do this is to get involved with the CCG and influence from within.
    As a CCG lead my mantra was always: extra work must be accompanied by extra resources.

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  • Vinci Ho

    The list can go longer .....

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  • JUST SAY NO. Say you do not have the resources/skills to do this and you do not feel clinical safe/appropriate to do it. There is no come back that they can make to that. You just need to stand up for yourselves.

    And call a vote of no confidence in the board of the CCG whilst you are at it.

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  • A vote of no confidence in your CCG board is an option but I would only do it if you're prepared to step into their shoes. If your CCG does not have the required number of board members it will be seen as failing. Fail on too many counts and you get an NHSE regime installed instead...
    The real problem here is that CCGs are trying to do everything with severely limited resources. This is not their fault - it is the fault of the government which we all have a chance to influence next week.
    Robin Jackson is right, influencing from within is a better option.

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  • AlanAlmond

    As has already been noted this is our salaried future and a prime example of exactly why this is being pushed so enthusiastically by those who are looking to control us.

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  • Should we not make our CCGs fail its better to deal with the organ grinder(NHSE)and not the monkey when dealling with bullies.

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  • Change everyone (more or less) to NOAC, problem solved, drug budget through the roof.

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  • MAKE gp's so poor that they leave the country. this will help the cause.

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  • She much for CCGs for being a membership organisation

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  • CCGs are a fire wall for NHSE to take the blame for cuts.It will be a membership organisation when blame is to be metered out,will do NHSE bidding on austerity otherwise.Get rid let NHSE take the blame.

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  • Some more morons from the old PCTs and establishment trying to cut deals and selling GP colleagues short. If only GPs had chosen to throw out the former establishment members it would have been a thorough cleanse. Unfortunately, you have medical directors from failed trusts move into CCG positions and the old guard who held the finances still eating away at the entrails of primary care; contract directors move to PCAs as heads so now they can embezzle to heart's delight with bankers turned nhse chiefs having champagne and celebrating the slow transformation to a private healthcare empire - waiting like that patient vulture till the life ebbs out of the system.
    Time to wake up ? Guess, it's too late !

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  • say no.
    say no
    say no ad infinitum!

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  • As above prescribe NOAC refer everything else to secondary care. Next

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  • @11.17
    Antipsychotics are not high risk at all.
    Lithium yes but antipsychotics no.

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  • Dear Hospital Doctor
    Please tell me how you measure the risks of antipsychotics?
    They should only be prescribed by GPs under joint care with psychiatrist, and only for psychotic disorders

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  • Home self-testing for prothrombin time (PT) and/or international normalized ratio (INR) provides comparable or better outcomes, including similar therapeutic INR levels, decreased thromboembolic events, all-cause mortality and major hemorrhage, when compared to testing in clinical settings.(J Okla State Med Assoc. 2016 Mar; 109(3): 99–100).

    I used to run an in-practice anticoagulation service and found it was very useful to patients. It was funded by CCG until funding removed, and then we could not afford the time.
    Personally, ( I have been home testing myself for some years), I find the process is both effective and time efficient.
    Home testing is to be encouraged. With proper funding, practice testing is an improvement in patient service. Why not fund this?

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