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Independents' Day

GPs 'bullied' into bulk prescribing flu medicine to whole care homes without necessary testing

Exclusive Practices in some areas of England are being ‘bullied’ into issuing antivirals to all residents of care homes as a precautionary measure, leading to GPs being called out to deal with side effects from patients who had not had flu symptoms in the first place.

Care homes demanded practices urgently issue bulk Tamiflu prescriptions, to be given to asymptomatic residents as a precautionary measure following flu outbreaks, on the request of Public Health England local leaders.

One local leader said practices felt they were ‘bullied’ into prescribing, and were unable to properly test for renal functions, check medical records or even ask the patients’ consent.

The GPC told Pulse the problem had arisen in both England and Wales and that the BMA had major concerns both about the clinical justification for the move and the impact on workload, and it has called for urgent meetings with PHE on the matter.

In one area, the instruction led to residents - most of whom were well and fully vaccinated - getting Tamiflu without their consent or undergoing necessary tests, with some suffering side effects that meant they needed follow-up visits from the GP.

The Department of Health (DH) gave GPs the go-ahead to prescribe antivirals at the end of last year, as circulating levels of flu started to increase, following a letter from Public Health England (PHE) director of health protection Dr Paul Cosford.

The PHE guidance also includes recommendations for ‘post-exposure prophylaxis’ with Tamiflu in people considered at risk of complications, who have not been effectively protected by vaccination, in line with 2008 NICE guidelines.

However, GP leaders said they had received complaints from GPs that practices had received faxes – often after 6.00 pm or during busy surgery hours when no staff were available – to request urgent prescriptions for large numbers of residents, in some cases before the DH authorisation to prescribe antivirals had been given, and without prior information about the plans around prophylaxis.

In some cases practices were simply instructed to fax through prescriptions, while in others they were asked to first contact the care home in order to identify the patients - both symptomatic and any asymptomatic contacts - and calculate the recommended doses of the drug, based on their most recent renal test results.

Dr Paul Roblin, chief executive at Berkshire, Buckinghamshire and Oxfordshire LMC, said many cases in his area had happened before the DH had given GPs the green light to prescribe antivirals, and that some GPs had been ‘bullied’ into providing the prescriptions without checking patients’ records, or ensuring patients were able to give consent to treatment.

Dr Roblin said: ‘I’ve had a number of complaints from practices saying they were phoned up – often at a time when they had little capacity - and instructed to prescribe Tamiflu to a whole host of patients in care homes, which you can’t just do.

‘These were people who were well, it was being prescribed in a preventative fashion to patients just because there had been cases [of flu] in the home. You can’t just give it to a patient without explaining the benefits, and many of them are cognitively impaired.’

‘But practices felt bullied into it. One refused completely, but several complied, causing a lot of hassle to their existing surgeries. And then some ended up doing it badly because they just signed the prescriptions – you are meant to tailor the dose depending on kidney function, which they didn’t do because they didn’t have time to do it.’

As a result, Dr Roblin said, one very elderly woman was given Tamiflu despite her care plan stating she should not have treatment other than symptom relief, while in one care home five of 43 residents given Tamiflu had fallen ill the next day with diarrhoea and needed extra GP visits the next day.

Dr Roblin said PHE should take responsibility for prescribing Tamiflu to asymptomatic patients who have been vaccinated if this had been decided.

Dr Roblin said: ‘My view is that PHE should prescribe the medication, since they have investigated what is happening in the home and reached a prescribing conclusion according to their own guidelines.’

GPC negotiator Dr Dean Marshall confirmed to Pulse several areas had raised the issue and that the GPC was concerned about PHE shifting responsibility for prescribing antivirals in this way onto GPs.  

Dr Marshall said: ‘I’ve had a few other people reporting it as well, so this is becoming a bigger issue. We have put in a call to have a discussion with PHE and will be feeding back our concerns.

He added: ‘It doesn’t seem to be co-ordinated very well, with different processes in one area from another. We’ve had reports of out-of-hours organisations getting involved in it as well – this is about treating people are not ill, who have had the flu jab, and this is being dumped on out-of-hours who I imagine are already pretty busy at the moment.

‘It’s another example of bits of the NHS just dumping work on GPs, not working together with us to plan work, never mind the concerns about the clinical appropriateness of giving the drug.’

PHE were contacted for a statement but did not get back to Pulse in time for publication.

It comes as official figures found that the incidence of flu this week was the highest for three years.

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Readers' comments (19)

  • This is a public health matter. GPs should not be asked to take part without extra funding - why do you think we get paid for flu jabs? It's not part of the contract.

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  • If a member of my family was prescribed tamiflu without INFOMED consent I would make a formal complaint.
    I would not prescribe it without discussion with the individual patient. Full stop.
    In my view signing a prescription without an assessment of risk and benefit and a discussion with the individual patient is negligent.

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  • Anything to do with embarrassingly large stockpiles of expiring medication?

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  • I blame The Daily Mail for most of the ills of the NHS. This "meddling menace" has caused untold damage to the NHS with its endless vicious attacks on NHS staff.
    The DAILY MAIL has "botched" the NHS through "megalomania and meddling"

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  • Vinci Ho

    Paranoia .
    Poor organisation and co-ordination .
    Using Tamiflu as prophylaxis and 'rescue pack'!
    What is evidence , PHE?

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  • Vinci Ho

    Dig this out again:
    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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  • v Ho

    nails it!

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  • If PHE advise patients require Tamiflu...then they should ask PH doctors to prescribe it. Just more dumping of non evidence based rubbish on an already over stretched service.

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  • Vinci Ho

    (1) Yes , it is a concern with incidence rising to a level higher in three years(2/100,000) but it is still single figure . Of course , we cannot be complacent as the the figure is rising per week. It is essential for PHE to watch closely on these figures
    (2) The government needs to run a proper campaign to raise the awareness of vaccination. Indeed, the uptakes of flu vaccination could have been better last few years . Primary prevention is far more important than secondary prevention in this case. But I wonder if these idiots actually understand that?
    (3) But then , what do I know? 'Better campaign for flu vaccination , seriously ? We have to focus on our campaign for general election , mate !!'

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  • As I've been the local Ebola lead, rather than the flu lead, for the past few weeks, I haven't reviewed the literature on this recently. As I understand it however:

    - Antivirals are not recommended as prophylaxis for patients who've been vaccinated - which is where all the hard work done vaccinating your care home residents will pay off!
    - Antivirals may be more effective at reducing viral shedding than at preventing illness. This is important in a care home situation, where part of the rationale is to reduce the attack rate.
    - Prophylactic use of antivirals may be more effective than therapeutic use (the therapeutic value falls of rapidly as the interval between onset of symptoms and initation of therapy increases).
    - Many care home residents will be particularly vulnerable; and the vaccine is less effective in older people.

    On balance, this is probably a lot more valuable than doing, say, NHS Health Checks.

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