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Independents' Day

Pulse Campaign MP/GP visits

case history

You are running through the mail and discover a handwritten note to start Mrs Jones on a drug you have never heard of. There is no other information except to say a letter will follow soon. You know Mrs Jones has complex medical problems and this is a drug that is used in renal failure, but feel you don't have the necessary information or experience to initiate this therapy. You decide not to prescribe and you contact her renal physician. In the meantime Mrs Jones discovers that you have not prescribed this and jumps to the conclusion that you are not prescribing because it is expensive. She writes to her MP who faxes you a letter ordering you to prescribe it ­ or else!

Dr Alex Williams

'I don't respond to veiled threats'

The issue at the centre of this dilemma is vicarious responsibility. If you put your name on the prescription you are responsible for the effects of the drug and, more importantly, any potential side-effects and litigation that may arise in the future.

My first thought is to ignore the threats from the MP (which I can deal with later) and to try to gather some more information.

I would try to speak directly to the renal physician and get some more information about the new drug. They should take responsibility for prescribing unless there is a shared-care guideline that has been written and you are happy to agree to its terms.

The truth of the matter may be that the hospital's prescribing budget is being overspent and this is a ploy to deflect the costs into primary care.

It may be prudent to ring the prescribing department of the PCT and speak to the head and ascertain if this is a high-cost drug and covered by the top slice of the overall prescribing budget, or if it would be taken from the practice prescribing budget.

I would then contact the patient by phone to arrange a meeting either at their home or in the surgery. I would ask the practice manager to be in attendance to corroborate what was said. I would try to defuse any difficulties with a warm welcome and a cup of tea, then explain the difficulties of prescribing new and high-cost drugs to the patient.

I would be quite open and frank about our prescribing budget and make the point that savings were always used to improve the practice in some way ­ and not providing direct profit for the partners.

I would want to discuss all the difficulties with the partners, perhaps at a partnership meeting, and maybe formulate a response to the MP at a partnership level. I would be keen to make the point that I did not respond to veiled threats and would consider taking this up with the parliamentary ombudsman (if there is such a beast).

Dr Tonia Myers

'Go on offensive'

This is one of those no-win situations when you can shoot yourself in the foot by trying to practise 'good medicine'. This time my generally sound rule of thumb ­ never to sign a prescription for a drug I have never heard of ­ has backfired.

My basic error was not to contact Mrs Jones at the outset to explain my dilemma. I need to redress this from a position of strength. My first step is to contact the PCT prescribing adviser to see what the stance is on this 'expensive' new drug. They usually agree as long as I am 'comfortable' in prescribing and there is a shared care protocol.

I will then phone Mrs Jones and go on the offensive, by expressing my surprise that she has written to her MP rather than contacting me to discuss the prescription.

I will then launch into an explanation about the legal responsibility of the prescriber, and say I am unable to prescribe a drug unless I fully understood the potential side-effects and monitoring requirements.

My philosophy is that specialist drugs are best prescribed by the consultant advocating the therapy, and that the hospital is actually 'cost-dumping' into general practice. I will explain that while I have a duty to prescribe cost-effectively, my drug budget does not affect my personal income.

I will assure her of my ongoing good intentions regarding her care, but suggest she asks the consultant to issue the prescriptions. If he can't, I will prescribe, as long as he sends me a written shared-care protocol, which should have accompanied the initial request.

Dr Zoe Rogers

'I'd check out drug'

This is an all too familiar scenario. It is important to respond promptly to Mrs Jones while being extremely careful not to breach patient confidentiality to her MP.

Even acknowledging she is my patient could constitute a breach in some circumstances. I would send the MP a brief acknowledgement explaining that patient confidentiality prevents me from commenting further. I would send a copy of this and the MP's original letter to Mrs Jones.

I would meet, or if this were not possible, speak with Mrs Jones at the earliest opportunity to explain my decision. Before I meet her I would aim to speak with the renal physician and also the pharmacist or prescribing adviser at the PCT.

This drug may be redlisted or have ring-fenced prescribing money to cover its cost. If it is redlisted, then any criticism of a decision not to prescribe it can be deflected to the PCT, and in any event it will mean that the hospital needs to prescribe it.

If there is ring-fenced money for it, I can explain this to Mrs Jones to emphasise that the cost of the drug has not influenced my decision. If the drug is not redlisted, I will still need to talk to the hospital consultant to make sure it is safe for Mrs Jones to take given her complex medical problems.

Only if I feel confident that the drug is safe and I have sufficient information to prescribe it would I do so. I would agree with the renal physician any specific monitoring that is required and whether the hospital or the practice will do this.

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