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Colleague is flouting practice policy on statins

Three GPs share their approach to a practice problem

Case history

You have noticed your salaried doctor is consistently prescribing statins at a lower threshold of coronary heart disease risk than either guidelines or practice policy recommends. He is also prescribing them to patients in their 80s and, in one case, to a 92-year-old.

When questioned he says his duty of care is to the patient in front of him and he believes the threshold for prescribing has been based on cost, not on the potential benefit to individual. In his opinion it's unethical to deny the drugs to patients who could benefit from them.

You point out his behaviour is likely to lead to a significant prescribing overspend and spoil the practice's chances of meeting prescribing incentives. This may hit patient care or the partners' pockets. Also, patients who consult other partners are starting to question the practice's inconsistency and asking why they have been denied statins.

You realise this may be a much wider issue than statin prescribing.

Dr Patricia Cahill

'When questioned about his prescribing he might have felt reprimanded and criticised'

It would be helpful to explore how this doctor really feels about this issue. When questioned about his prescribing he might have felt reprimanded and criticised. His response may have been defensive, trying to justify what he was doing. Was he aware of the guidelines? If not, he may have needed some sensitive support in addressing this.

It is also feasible that he has some resentment, such as about his pay, or a personal grievance relating to NHS rationing. Helping him to express himself fully could smooth negotiation.

The practice team members have a duty to patients to pursue best practice, based on the available evidence rather than on individuals' personal preference. This doctor may be doing his own thing in other areas, which could be putting patients at risk as well as making things awkward for his co-workers because of the inconsistencies being practised.

Evidence on how to treat older people with statins, especially those in their 90s, is sparse. I would allow him to explain why he believes it to be so beneficial to do so. He needs to feel heard and valued. If we listen to what he says we may actually broaden our criteria for prescribing statins.

It is likely he wasn't involved in drawing up this policy and so has no 'ownership'. This would be an opportunity to invite him to look through the practice protocols and discuss any other discrepancies between his views and those of the practice. Gaining his agreement to work to guidelines may solve the problem.

It may be appropriate to discuss economics, on how best to use available resources, the need of the practice to balance the books and earn income to survive. The partners could also honestly ask themselves whether they feel they are indeed too concerned about profit.

In the end, if he feels unable to abide by consensus opinion, and if he disagrees with the practice ethos, then it may be best for him to consider whether this post is the right one for him.

Patricia Cahill has been a GP for nine years and is currently a non-principal in Ipswich, Suffolk

Dr Simon Atkins

'It only takes one or two mavericks to end up with inconsistencies'

This sort of scenario is not uncommon in primary care these days. Most GPs will agree that they entered the profession to treat the 'patient in front of them', not someone who conforms to some statistic or other.

But health policy has moved away from being patient centred and is now more interested in figures and targets than in individuals.

The new contract has turned the art of medicine into medicine by numbers and many of us, like this salaried GP, are upset by its restrictive nature.

However, if as partners you have agreed a set of guidelines for

different aspects of practice, everybody working at the practice should adhere to them.

It only takes one or two mavericks and you end up with the sorts of inconsistency described, which confuses the patients.

But I would have to question this doctor's belief that people in their 80s and 90s would get any real benefit. Many people experience side-effects from them and they have to submit to the inconvenience of frequent blood tests to monitor cholesterol and LFTs. In my opinion, they would have to put up with a lot of hassle for very little – if any – benefit.

He obviously disagrees with the statins policy and we would therefore need to get together as a team to thrash things out.

This might involve inviting an expert along to discuss the pros and cons of treating people of different ages with these drugs. Hopefully this would help us reach a consensus.

If not, we may simply have to impose practice policy more heavy-handedly, which is unlikely to go down well and may cost us a valued colleague.

Simon Atkins is a partner in Bristol – he completed the VTS in 1999

Dr Patrick Clarke

'If we can't find a solution he may wish to look for another practice'

Prescribing differs widely from one GP to another. Our salaried doctor appears to have an unusually low threshold for prescribing. We will wish to discuss this to avoid overspending our prescribing budget.

Rationing in the NHS is something we all have to put up with, but the decisions he is making will affect not only the patients he is prescribing to, but also the practice as a whole.

I would organise a practice meeting to discuss prescribing in general. It would be important to discuss prescribing habits among all the doctors to share knowledge.

I would bring up the various coronary risk prediction charts to ensure all doctors are aware of when to prescribe. I would try to give everyone an opportunity to discuss their view, rather than singling out the salaried doctor.

It also appears the doctor doesn't feel part of the practice. I would ask my partners whether they had noticed any unusual behaviour from him. If this appears to be occurring in different areas, then there will be more justification to confront him.

I would want to discuss with the salaried doctor how he felt his relationship with the practice was going. It seems he doesn't feel an equal. The benefits we will be getting from reaching prescribing incentives won't be passed on to him.

It may be appropriate to include this doctor on the incentives scheme. I'd need to discuss this with the other partners because it will have financial implications.

It may be that there are too many differences between this doctor and the partnership. If we can't find a solution he may wish to look for another practice.

Patrick Clarke finished the VTS in 2002 and is now a partner in Burnham, Buckinghamshire

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