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Is it ethical to pay GPs not to prescribe problem drugs?

Proposals to limit antibiotic and antipsychotic prescribing spark ethical and practical concerns

By Nigel Praities

Proposals to limit antibiotic and antipsychotic prescribing spark ethical and practical concerns

The NICE revamp of the QOF was never going to be plain sailing, and six months in the institute is already in ethically choppy waters.

In seeking to recast the framework in its own image, NICE is forging ahead with plans for a wide range of new indicators – no less than 39 ideas were unveiled by Pulse last week.

Plans to incentivise GPs for encouraging patients to eat vegetables and fish raised some eyebrows.

But it was the proposals to pay GPs not according to the care they provide but for the treatments they manage to avoid prescribing that really got people talking.

Indicators to reduce antibiotic prescribing for self-limiting respiratory tract infections and use of antipsychotics in patients with dementia are the first of a new breed, and have sparked concerns over the ethical implications and how they will affect the doctor-patient relationship.

Looming over it all is the fear of gigantic Daily Mail headlines castigating GPs for raking in cash for not doing something they weren't supposed to do anyway.

So what will the press make of the proposed indicators?

Professor David Price, a GP in Norwich and professor of primary care respiratory medicine at the University of Aberdeen, says he is in favour of promoting good practice but claims placing these indicators in the QOF is a step too far.

‘It will build up distrust,' he says. ‘The relationship is not clear-cut. Is the doctor doing this for my own good or because he has been told to do it?

‘I get worried when the QOF becomes the only way of achieving change in practice, whereas there is an element that we should just be good doctors,' he says.

The indicators are due to go through a robust piloting process before they are introduced into the QOF.

A consensus panel at the National Primary Care Research and Development Centre has already said the antipsychotic use indicator needs further work.

Dr Colin Hunter, a GP in Aberdeen and chair of the QOF Advisory Committee at NICE which drew up the proposals, says the plans are under review and he will be reconsidering the indicators after the centre reports back in November.

‘We felt the indicators for antibiotics and antipsychotics would not quite work and have sent them back to be looked at again and they have not gone into piloting yet.

‘The [proposed set of indicators] are in early development and the vast majority will not come before negotiators before June 2010,' he says.

But the proposals may fuel BMA misgivings over the clash between NICE's role as a rationing body and the role of the QOF in driving up standards in primary care – dismissed by the Government in a consultation earlier this year.

Professor Martin Roland, professor of health services research at the University of Cambridge and one of the architects of the QOF, shares some of these concerns, although he is supportive of gradual evolution of the framework.

‘There are many aspects of care that are important, but supported by professional consensus rather than by randomised controlled trials, and it will be important for NICE to take a broad view on what constitutes evidence.

‘A good indicator is one which reflects good practice – judged by evidence or professional consensus – and can be measured without intruding inappropriately into the interaction between doctor and patient,' he says.

So against those criteria, how do the two most controversial proposed indicators – for reductions in use of antipsychotics in patients with dementia, and antibiotics in respiratory tract infections – measure up?

The prescription of antipsychotics has become a political hot potato, with increasing evidence they can cause harm to patients with dementia.

An estimated 60% of care home residents take the drugs, despite a study published earlier this year showing a serious increase in mortality risk.

It showed 46% of patients prescribed antipsychotics survived more than two years, compared with 71% in the placebo group.

Rising concern has seen the Department of Health promise a crackdown on use of antipsychotics, with a review into their use due for publication this year.

A report on the implementation of the National Dementia Strategy published in July promised to encourage the use of alternatives to antipsychotic medication.

In anticipation of this, a number of PCTs have already introduced an audit of use of antipsychotics in care homes this financial year.

NHS Northamptonshire has commissioned a full antipsychotics audit in 2009/10, with three pharmacists charged with reviewing the prescribing practice in care homes in their area and reducing use of antipsychotics.

But the NICE proposals go further.

Professor Clive Ballard, professor of dementia research at King's College London, says he supports QOF indicators in this area, but only with increased investment in alternative treatment approaches.

‘There are situations where the risk of symptoms of distress are very severe, but this is only about 10-20% of the people currently being prescribed antipsychotics.

‘Incentivising not prescribing is good, because it should hopefully cut down use of the drugs in these situations,' he says.

NICE currently recommends that patients do not receive antipsychotics for more than six to 12 weeks, but the proposals for the QOF would only allow GPs to prescribe antipsychotics if they agreed to a regular checks and clearly explained the risks of treatment to the patient and the carer.

Dr Peter Smith, a GP in Weston-Super-Mare, North Somerset says the proposals undermine his clinical judgement and are not practical.

‘It is not reasonable to ascribe a percentage to the use of these substances in these cases. Each case is considered on its merits.

‘This all seems to be part of a general trend to deny GPs freedom to act in our patients' best interests and it dates from the time of Harold Shipman, who broke the bond of trust in our profession,' he says.

Dr Smith also disputes that discussions over the risks of antipsychotics with carers will lead to a reduction in the use of the drugs.

‘They recognise acute agitation and confusion is very frightening and use of these medications is entirely justifiable,' he says.

Antibiotics

GPs already face a crackdown on their use of antibiotics from the new Care Quality Commission and under NICE's plans could find their pay tied to reducing use of the drugs.

NHS managers are already introducing schemes to pay GPs for using antibiotics less. A Pulse investigation earlier this year showed half of PCTs had incentive schemes to cut GP antibiotic prescribing rates, with 40% of them set up in the past year.

These schemes have been successful. An incentive scheme run by NHS South West Essex saw big reductions in use of certain antibiotics in 2008/09, with a 16% reduction in use of cephalosporins and a 20% reduction of quinolones.

GPs say the message about rational prescribing is getting through to doctors and patients, but are unconvinced by the idea of QOF indicators.

Dr Gary Calver, secretary of Kent LMC, says an antibiotics incentive scheme in his area has been successful, but including indicators in the QOF could undo the good work.

‘It could be wrongly perceived by the public as being paid not to prescribe antibiotics. It may be counterproductive.'

The proposed indicators for the QOF would restrict antibiotic use for self-limiting respiratory tract infections – such as otitis media, bronchitis and acute cough – to patients who were severely ill, the elderly or those with risk factors for complications.

Professor David Price, says this approach is potentially dangerous for patients with lower respiratory tract infections.

‘It could be a danger if you push it too hard. It is not always possible to know who those patients are and we don't have reliable tools to identify them,' he says

Professor Price's own research shows dramatic benefits for early antibiotic use in at-risk patients with a LRTI. In findings published in April this year, his study showed the morality risk in these patients was cut by over half when prescribed antibiotics early.

What is NICE proposing?

Antibiotics

- No antibiotic or delayed antiobitic prescribing strategy in patients with acute conditions, such as otitis media, tonsillitis, rhinosinusitis, cough or bronchitis
- Patients to be given information about the ‘usual natural history' of the illnesses
- Patients to be offered advice about the need for antibiotics, when to use a delayed prescription and when to re-consult
- Immediate antibiotic prescription in certain patients, including who are systemically very unwell, have signs or symptoms of more serious and in certain older patients and children

Antipsychotics

- Not prescribing antipsychotic drugs in patients with Alzheimer's disease, vascular dementia or mixed dementias with mild-to-moderate non-cognitive symptoms
- Treatment with an antipsychotic drug offered under certain conditions, including a discussion with the person with dementia and/or carers about the possible benefits and risks of treatment and regular assessment of changes in cognition and changes in target symptoms.
- Treatment should be time limited and regularly reviewed (every 3 months or according to clinical need)

FAQs

Who has proposed the new indicators?

The Primary Care QOF Framework Indicator Advisory Committee at NICE – comprising GPs, academics and other experts – have selected areas from the institute's guidelines that are being developed as indicators. Criteria were relevance to primary care, feasibility, clinical effectiveness, effect on outcomes and by how much they will reduce health inequalities.

What happens next?

They are being developed as workable indicators by academics at the National Primary Care Research and Development Centre. They will assess the evidence and how practical they are for implementation and present a report to the advisory committee later in the year.

How will they be piloted?

Suitable indicators will be taken forward for piloting by the NPCRDC in 30 GP practices across the UK. If successful, NICE will consult on the developed indicators with stakeholders (patients and professional groups) and recommend them to negotiators from the GPC and NHS Employers.

When could they be included in QOF?

The indicators are not due for piloting until next year, so they are likely to be fully developed until QOF 2011/12.

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