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Independents' Day

What should I do if my colleague isn't following our prescribing policy?

Our practice has a policy to not prescribe paracetamol routinely to children. However, a mother of a child I am treating said she’d been given a prescription for it a few months previously by a salaried GP in the practice. How should I respond, and how should I bring the issue up with the GP in question?

Dr Jessica Garner: Explain the practice’s policy to the patient

According to GMC guidance, a treatment should be prescribed only if a GP is satisfied that it will serve the patient’s need and if it’s in line with best available evidence.

NICE guidance suggests using antipyretics in children only if they are distressed by fever, and that unnecessary use in self-limiting viral infections should be avoided.
The practice policy therefore seems appropriate, so explain it clearly to the mother, providing written and verbal information on how best to deal with self-limiting viral infections.

GPs have to tread the line between working autonomously while operating within local and national frameworks. If this is an isolated incident where the salaried doctor has not supported a practice policy, deal with the matter in an informal way, via a quick email or over a coffee.

But when practice policies are repeatedly ignored, more formal action may need to be taken. Discuss the matter one to one with the salaried doctor. There may be reasons why they are failing to uphold practice policies, such as stress or excessive workload.

If this fails to resolve the situation, consider discussing it at a practice meeting. Encourage the GP to take more responsibility for adhering to practice policies, while creating steps as a practice to make following the policies easier. These could include computer ‘pop-ups’ for prescribing or an extra session clarifying policies for staff who are unsure.

Dr Jessica Garner is a GP in Worcestershire


Dr Emma Richards: Chat informally with your GP colleague

It is only fair to treat all patients the same. However, some GPs prescribe this sort of medication in cases of true economic necessity or other special situations. Check that this is not one of those cases before explaining the practice policy to the patient and why this may not have been adhered to previously, taking care not to undermine your colleague. Let them know if the local pharmacy runs a ‘pharmacy first’ or ‘minor ailments scheme’, where they could get paracetamol free.

Next, ask your colleague why they made the decision. Maybe they were unaware of the practice policy, or mitigating circumstances prompted them to prescribe. Alternatively, they may have made an independent decision because they have strong views about this policy. Chat informally with them about this, before suggesting it as a learning point and topic for discussion at the next practice meeting.

Consider doing an audit or monitoring prescriptions. Variation in prescribing between local practices is likely to cause confusion and frustration for patients so this request is likely to arise again. Therefore, it might be worth bringing this up with the LMC or the CCG prescribing committee.

Dr Emma Richards is an honorary clinical research fellow at Imperial College, London and a GP registrar in Surbiton, south-west London


Dr Waris Ahmad: Check you can defend the policy

Check you are implementing the policy in a way that doesn’t leave the practice vulnerable to complaint. After all, this might be the reason why the salaried GP ignored it. And although 2007 guidance on fever in children advises antipyretic agents should not be used with the sole aim of reducing temperature, they should be used in children appearing distressed and continued as long as distress lasts. This might explain the GP’s decision.

This policy may be valid clinically, but as a blanket policy it suggests, contrary to the NICE guidelines, that there is no place for antipyretic use in children with fever. This is very difficult to defend if challenged and the practice should seek advice from their CCG or health board medicines management team to get views from other clinicians and to risk-share if this were to happen.

Practice policies should be evidence based after discussions with all clinicians. Each GP should feel comfortable, their clinical autonomy should not be affected and they should not feel restricted. Discuss the reasons behind this failure to implement policy at clinical meetings, making sure the salaried GP explains why they departed from policy.

Dr Waris Ahmad is medicines management and elective care lead on NHS Birmingham South and Central CCG

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Readers' comments (12)

  • I suggest if the DoH wanted to save millions on OTC available drugs it would of made something called an advert or poster after EastEnders or Big Brother. Millions would receive the message within 15 seconds. It hasn't. Doctors are as individual and unique as patients. Avoid slipping into the mediocrity of protocol mania.

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  • Really ?
    Are there not much more important issues to debate than this?

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  • Strictly speaking the GP contract obliges a GP to prescribe any medication he/she believes is clinically necessary on an FP(10) and nothing else.
    See schedule 6, part 3, para 39 (1) of the GMS regulations
    There are undoubtedly situations where paracetamol can be clinically desirable so although we all advise OTC medication purchases, when we do so we are in breach of the regulations. Similarly the practice prescribing policy is also in breach of the regulations so I don't think they should be too critical of the "aberrant" GP

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  • I agree with Paul Roblin

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  • The poor GP who prescribed it probably got harrassed by the mom for paracetamol, like anyone else.

    Its so easy to have ivory tower glasses on life but try working in a deprived inner city practice, refusing calpol.

    You might as well make water flow uphill

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  • Medicine by protocol - a dumbed down approach. Treat each case on its individual merits and stop dumbing down medicine.

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  • Yes I agree about not routinely prescribing paracetamol for kids for every cough and cold I and would welcome more support in this from other doctors but any attempt to curb another doctor's autonomy to make decisions he or she sees fit is abhorent. Hving chats or any formal measure to try to change another doctors prescribing is not right unless they are putting patients at risk. I thought we wanted to maintain out independent contractor status for this reason not so we can bully saleried GPs in to towing the line.

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  • Paul Robin is absolutely right.

    Unless you can prove a child does not get distressed by fever when their parents are telling you it causes distress, it will put you in a vulnerable position to defend your practice.

    Do you really want to be subjected to fitness to practice hearing, court appearance, or in your local clinical director's hot seat over paracetamol? Call me chicken but I don't.

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  • Trust your colleagues decision and give him leeway if he feels this is clinically justified. Policies are ramifications - they stop you from thinking independently and restrict your development.
    We often succumb to pressure from peers who in turn are goaded by policy makers. Does anybody remember the early 80s where beta blockers were not considered the in thing to prescribe after MIs. Try explaining that to a physician today and watch the response. Trends go and come but good sense must prevail at all times.

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  • Prescribing policy is wrong , and needs to change..

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