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GPs 'threatened' by NHS bosses over refusal to prescribe flu antivirals

Health bosses have warned GPs they could face medical negligence claims and threatened them with referral to the GMC if they refuse to deliver preventive flu treatment to care home residents as part of their usual contractual work, Pulse has learned.

NHS England South chiefs have warned GPs they should get advice from their medical defence organisation before refusing any request because no enhanced service is in place, in case a patient or relative should take action.

It also emerged that GPC has raised concerns about public health officials have threatening GPs with referral to the GMC if they refuse to comply with the requests to administer bulk Tamiflu prescriptions.

This is despite GP leaders repeatedly advising Public Health England (PHE) and NHS England over the past two years that GPs are not contracted to provide preventative care during flu outbreaks under GMS/PMS essential services, after they found practices were being bullied into prescribing bulk prescriptions at very short notice and without time to carry out the necessary precautionary checks in their patients.

GPC recently wrote again to PHE calling for a halt to the requests until a seven-day, round-the-clock national or local service has been commissioned.

But these calls are still being ignored with GPs in some areas continuing to be served with demands to issue the prescriptions including during out-of-hours periods.

In one case an email from the Head of Primary Care NHS England South, seen by Pulse, advised: ‘Our understanding is that the GP is the responsible clinician for their patients. If they assess the patient and for clinical reasons do not administer antiviral medication they should record in the Patient Record.

‘If they refuse to assess the patient based on non-payment grounds they should also record their decision in case a patient or relative takes an action because the patient suffered as a consequence, when there may have been an element of prevention. GPs may wish to check their position with their Medical Defence Organisation.’

Dr Paul Roblin, chief executive at Berkshire, Buckinghamshire and Oxfordshire LMC, has been leading the campaign to insist public health and NHS managers put in place a proper contract in the same way as in cases of flu, invasive Group A Streptococcus or Hepatitis A or other infectious disease outbreaks.

Dr Roblin told Pulse the email was among ‘what I regard as threats, issued by NHS England, saying if you don’t heed PHE we advise you to contact your defence society’.

The GPC also confirmed to Pulse it has seen evidence of GPs being threatened with GMC referral, although it could not provide details because of concerns around confidentiality.

However, the letter from the GPC, addressed to PHE medical director Professor Paul Cosford, stated: ‘The BMA is continuing to hear of examples where GP practices are being told by local public health officers that they must prescribe oseltamivir to all residents in a care home following a person contracting influenza within that home, in some cases we’ve seen evidence of GPs being threatened with GMC referral if they do not comply.

‘It is unacceptable that these requests continue and that there is still no properly commissioned service to fulfil this work.’

Dr Andrew Green, GPC clinical and prescribing policy lead, told Pulse the GPC has arranged another meeting with NHS and public health chiefs to try to sort out the dispute.

In the meantime, Dr Green advised that ‘to avoid potential difficulties when faced with an acute situation, I would recommend that all practices write to their CCGs making it clear that this is not a service they are in a position to offer, due to the adverse impact that this may have on their care of other patients, and asking them what alternative seven-day commissioning arrangements they propose to arrange’.

PHE said in a statement: 'PHE’s medical director has been clear in correspondence it is for individual doctors to decide how best to apply the guidance and justify any substantial deviations from it when they treat their patients.

'PHE also makes an assessment of each outbreak through our local teams in discussion with GPs and other colleagues locally and advises accordingly. We have seen no specific example of GMC referral being suggested for inaction on antiviral use.

'Arrangements for the administration and commissioning of antivirals is an issue for the NHS and commissioners to resolve. PHE believes, along with many doctors, that we must treat patients first and deal with contractual issues separately.'

NHS England declined to comment but confirmed that it is due to hold a meeting with GPC to discuss the matter.

 

 

Readers' comments (21)

  • So refer to GMC all medics that do this bullying at PHE.
    Since this is predictable the arguement sort now deal with commisioning later holds no water.
    Not sure can sue for GPs failure ot act that actually isnt their role....PHE on the other hand can be.

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  • Surely if PHE have made the mistake of making these threats in writing then it should be a relatively easy legal case against them including counter GMC referrals with valid cause.

    Public threats are significant especially when there is a clear process for this ( PHE direct CCG to commission this work)

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  • Thank goodness i am retiring soon.

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  • Look at the backgrounds of these bosses -political stooges, bankers, sons of 'nobility - might help you to understand the arrogance and bullying nature.
    Until you liquidate NHSE, you will not get out of this decaying rut which NHS has become.

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  • This comment has been moderated

  • What does Tamiflu do? I thought that Science did an article on how little the benefit is ie pros vs cons. I know Science is not a medical publication, but seriously how effective is Tamiflu?

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  • I spent several hours reviewing the evidence, including the Cochrane review and NICE guidelines on antivirals for influenza. My conclusion was that the evidence was limited/lacking. Therefore I felt I could refuse on these grounds of risks outweighing benefits rather than get into any dispute about payments or workload.

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  • Surely the precedent is there. PHE prescribe for Meningococcal contacts so why not for flu contacts?

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  • This comment has been removed by the moderator

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  • Patients have chosen a government that does not value doctors and so we should all declare WAR on patients. Essentially this means telling them that seeing as you are not prepared to pay us or treat us properly we are now all going to go PRIVATE and you can take the consequences of your choice.

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  • Let's give them all Amoxil for pneumonia contacts as well!(this is tongue in cheek, and not intended to promote new NHSE ideology. They would only use their cronies new expensive antibiotics for this anyway.)

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  • general practice is cheap labour. every thing in included in that magical global sum including vacuum cleaning patients house as cleanliness will reduce risk of infection.

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  • I suggest cancel all your clinic appointments that day so you can issue all the tamiflu. Tell all the acute patients to go to A/E as you are on 'Purple Alert' from PHE.

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  • So what is the problem? Some ministerial suits think that GPs are denying effective treatment for serious illness? If so, ask those affected to book a routine appointment to discuss. What's that? Do you want an urgent appointment? No. Cos it's neither a serious problem nor there is an effective treatment.

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  • 6:13 has hit the nail on the head. Book all the patients in whom you need to do a virtual review on prior to prescribing tamiflu. Therefore reducing your capacity to see little Johnny with his sore throat of 9 minutes who then has to go to casualty. Then it'll be commissioned.

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  • Vinci Ho

    Time certainly flies.
    When I look back , this has been an unresolved issue since 2014 . PULSE had a nice summary of Cockrane' studies:
    Cochrane Review of Neurominidase Inhibitors - Summary



    What did the study look at?

    Randomised, placebo-controlled trials on adults and children with confirmed or suspected exposure to naturally occurring influenza

    Covered 107 clinical study reports from the European Medicines Agency, GlaxoSmithKline and Roche, plus comments by US Food and Drug Administration and Japanese drugs regulator.

    Total of 20 trials of oseltamivir (9,623 participants) and 26 trials of zanamivir (14,628 participants) included in formal analysis after initial judgement of design of the studies.



    What were the main findings?



    Duration of symptoms and hospitalisations/complications

    Oseltamivir reduced the time to first alleviation of symptoms from 7.0 to 6.8 days in adults, and by 29 hours in healthy children, but had no effect in children with asthma.

    Zanamivir reduced the time to first alleviation of symptoms from 6.6 to 6.0 days in adults, but had no effect in children.

    Oseltamivir had no significant effect on hospitalisations compared with placebo, with a risk difference of 0.15%. There were no zanamivir hospitalisation data.

    Neither drug had any impact on serious complications of influenza leading to study withdrawal, where tested.

    Oseltamivir cut self-reported, investigator-mediated, unverified pneumonia by 1.0% but had no effect in five trials that used a more detailed diagnostic form of pneumonia, while zanamivir had no effect on either self-reported or radiologically confirmed pneumonia.

    Zanamivir reduced bronchitis risk by 1.80% in adults, but oseltamivir had no effect on this. Neither drug reduced the risk of otitis media or sinusitis in children or adults.

    Side effects

    Oseltamivir increased nausea (by 3.7%; number needed to harm [NNTH] of 28) and vomiting (4.7%; NNTH of 22) in adults and vomiting (5.3%; NNTH of 19) in children, but cut risk of diarrhoea (2.3%) and cardiac events (0.68%) in adults.

    Oseltamivir also had dose-response effect on psychiatric events in two ‘pivotal’ trials.

    Flu prevention

    The risk of developing symptomatic influenza was reduced by 3% by oseltamivir (number needed to benefit [NNTB] of 33) and 2% by zanamivir (NNTB of 51) in individuals but there was no reduction in asymptomatic influenza with either drug.

    Side effects

    Oseltamivir increased psychiatric events (1.1%, NNTH of 94), headaches (3.2%, NNTH of 32), renal events (0.7%, NNTH of 150) and nausea (4.2%, NNTH of 25).

    The Cochrane Collaboration 2014; available online 10 April

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  • Vinci Ho

    The other issue is PHE being embroiled in substantial budget cut by the government. Expenses involved in these top to bottom directives , of course, are passed onto GPs.

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  • Just Your Average Joe

    'PHE also makes an assessment of each outbreak through our local teams in discussion with GPs and other colleagues locally and advises accordingly.

    The PHE director - I understand has a medical licence - and some of the team are meant to have some expertise in the area of flu prevention.

    I suggest these 'Supernumerary' health professionals (Some even drs) step out of their ivory towers and go to the multi bedded care homes - our local home where they tried to force the practice to prescribe had over 90 elderly and infirm patients - and go and spend the day or 2 it would take to assess these patients adequately.

    This would involve checking renal function and ensure the medication being forced onto these patients is adequately counselled with risk/benefits advised and recorded, best interest meetings set up for those unable to consent.

    Then a day or 2 to treat and support all those who suffer side effects as a result of the Tamiflu.

    Which GP has time in their day to do that as well as continue in their day job and see patients and be on call???

    Only Ivory tower/supernumerary staff at an institution like PHE has the time and resources to do public health preventative activity like this

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  • Just Your Average Joe

    PS - just for a laugh I asked our local pharmacy - they had 1 box in stock, and said it would take 2-3 days to source all the meds at earliest, then another day to label and dispense - loosing the window to give any benefit to the patients anyway.

    PHE could access the gazillions of doses they stock piled for the bird flu and hand them out from their stores saving resources.

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  • Just Your Average Joe

    PPS - just want the PHE director to answer - Who would be seeing all my regular patients while GPs step out for a few days to do this work????

    If someone came to harm as they were unable to access the GP would they be able to sue us and refer us to the GMC for dereliction of our core duties under the GP contract???

    Someone also explain what PHE actually do on a day to day basis to justify their existence, which prevents them from doing public health work in flu prevention????

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  • PHE they belong to the power-point , prawn sandwiches and POETS day brigade.Signposting and telling minion what to don while disappearing 'out of office'at approx 2 pm Friday afternoon.A bit like NHSE but not as much power.

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