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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)

  • The death of professionalism and the rise of bureaucratic nonsense. Is it any wonder GPs are leaving, given they have to put up with this sort of trivial rubbish, which means they have to balance getting told off by the medicines management wonks with doing the best for the patient and possibly fending off a complaint? Honestly, getting prissy over a paracetamol prescription for a child? Is this for real?

    P.S. Paul Roblin, sock it to 'em!

    Conflict of interest: I left UK GP in 2012 after 21 years in the NHS and I am now in Australia, where you can actually practice decent medicine and people value your skills and expertise.

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  • I donot think paracetamol will cause bankruptcy tp the practice
    personally i donot believe in formularies rather than i practice tailor made therapies after establishing the physiological dysfunction i am going to treat

    some times it is a long winded process so i only dispense 50 mls and the parents get the message and usually donot ask me to prescribe paracetamol-
    personally i will not loose my sleep over such menial matters and i also donot believe in earning the incentive pennies

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