Dilemma: A GP overprescribes benzodiazepines
A partner is prescribing far more opiates and benzodiazepines than other doctors. When challenged she says that it is because she looks after more patients with chronic pain and addictions than other doctors. You remain concerned. How should you proceed?
Develop a shared plan to change this with the doctor involved
The two possible explanations for this situation are a failure of clinical governance or deliberate prescribing for known misuse. Failure of clinical governance in this situation involves the doctor prescribing outside normal guidelines in terms of the indications for these drugs and quantities used. This situation may be compounded by a drift of patients from both within and outside the practice to this particular doctor because of her perceived ‘generosity’ with these drugs.
Prescribing knowingly for misuse might be for personal use, financial gain or in response to threats or pressure from a third party. To investigate this further, I would involve the pharmaceutical advisor, who would usually be able to provide names, dates and quantities of the drugs involved. These cases could then be reviewed and it is likely that a clearer picture would emerge.
If clinical governance appears to be the problem, a number of strategies can be employed. Drug and alcohol cases could be managed along shared care pathways and the doctor involved relieved of personal responsibility for these patients. If excessive prescribing has occurred in chronic painful or psychiatric conditions, involving the pain clinic and community mental health team may restore safe prescribing.
The key skill involved in this case is in maintaining good communication and trust and developing shared plans with the doctor involved, perhaps supported by regular reviews of prescribing and evidence of learning in this area of practice. If these measures could not be agreed to, or followed, or prescribing for misuse was suspected, formal processes might become necessary. Advice is available from the LMC, defence organisations, BMA and informally from the GMC.
Dr Richard Stokell is a GP in Birkenhead and associate director of the Mersey Deanery
State the facts and seek to address the problem as a practice team
In order to make any decision, you really need to be in possession of all of the facts. Frequently when a doctor whistleblows, it becomes apparent that they haven’t really talked to the doctor themselves. This is not good enough, doctors who might be in trouble need their colleagues to talk to them and that communication should be non judgmental and supportive.
There may be many factors which might make a difference. The doctor may indeed be seeing more patients with addiction and chronic pain. The doctor may have worked in a hospice, pain clinic or addiction centre and not only have more training and experience in this area but may be finding that all the patients with these problems are seeking him or her out.
It may be that the doctor is finding themself intimidated by these patients and would love to have the support of his/her colleagues in addressing this – if only that help were forthcoming. It may even be that the doctor is struggling with addictive problems of their own.
The facts could be underpinned by an audit but this should be done in an open fashion and with an open mind – after all it may be that the other partners are underprescribing these drugs.
With this sort of approach, to a problem which is owned by the practice as a whole, it is probable that the doctor will engage with the issue and (if the facts suggest a real problem) after reflection to engage with this as a learning need which could be addressed through the appraisal process.
If, the problem is not addressed in this way, then “whistle blowing” becomes an option. This should be done openly, with the doctor informed of what is going on. As this is a rare occurrence, advice should be sought, there are several possible sources – the LMC, the area medical director, the appraisal lead, a medical defence organisation being possibilities.
This is not an easy issue and the whistleblowing doctor needs resilience and determination – but it should never be done without sensitivity and compassion.
Dr Dennis Cox is a GP in St Ives, Cambridgeshire and RCGP national commissioning champion
Approach the responsible officer of your local area team if the matter can´t be resolved internally
In this case the doctor has already spoken to his or her colleague but remains concerned about patient safety. The next step should be to talk to a senior partner to discuss whether there is a problem and whether and how this could be managed within the practice. If dealing with the situation locally isn’t practical, or is tried without success, the doctor should raise her concern outside of the practice, for instance if in England with the responsible officer of the local area team of NHS England. If there is an immediate risk to patients then the doctor should also get in touch with the GMC.
Good medical practice is clear that doctors must take prompt action if they believe that a colleague could be putting patients safety at risk, including through their prescribing (see also our prescribing guidance).
But we know that raising concerns about a close colleague is difficult and to help doctors respond to concerns we have published guidance about where to go for support and advice and the steps to raising a concern in situations like this.
We have also produced an interactive decision-making tool to help doctors unsure about how to raise a concern and our website has more information about where to go for advice and support.
If a doctor is not sure how to proceed they can get further advice and support through our confidential helpline on 0161 923 6399.
Jane O’Brien is assistant director, education and standards at the GMC