The doctor, the patient and the prescribing adviser
Like many experienced GPs, I trained under the apprenticeship model – or ‘see one, do one, teach one’ – which seems quaint today in the age of competencies and evidence. The aim of my teachers was to get me practising safely, competently and above all independently.
Dr Pat Aitchesen's article was judged 'highly commended' in our clinical writing competition.
Like many experienced GPs, I trained under the apprenticeship model – or ‘see one, do one, teach one' – which seems quaint today in the age of competencies and evidence. The aim of my teachers was to get me practising safely, competently and above all independently.
These days, it seems that independent practice is under attack from all directions. We are urged to sit together as a clinical team to discuss problems, significant events, prescribing, referrals and admissions week after week, mainly with the aim of reducing some aspects of our work in order to cut expenditure. Prescribing is a particular focus, since this is one area a GP can control. The question is: who is really in charge?
I have been trained to sit with a patient and work out together what we will do next with their problem. The patient has come to tell me of his annoyance about a letter telling him he must switch medication. Clinically, there is little to choose between the two medications apart from cost, which shifts from year to year. But other considerations now influence my decision on drug therapy.
The prescribing adviser wants me to prescribe statin A this year. This patient is happy on statin B, which we switched him to some years ago as it was more cost-effective then. The prescribing lead partner wants me to persuade him to switch, which will allow us to stay green on the prescribing incentive scheme and protect our income.
The commissioning group and locality want to control drug budgets. A growing group of others have found their way into the room. More needless activity is added to the increasing workload.
We no longer expect complete clinical freedom, but we must keep the core values of general practice while we adapt and move forward. I work in a partnership of doctors with differing skills and attributes. We stay up to date and are fully aware of the financial implications of our decisions. We all value the opportunity to have discussions about clinical problems when we need them, and none of us is afraid to admit ignorance or that we are unsure how to proceed.
Despite all this, it now seems that a GP cannot make the decision to prescribe, treat or refer without clearing it with colleagues in the practice, the locality or the PCT.
This second-guessing of my actions amounts to an attack on my professional judgment. The act of prescribing is being reduced from a clinical decision formed after considering the complexities of an individual case to a purely cost-driven exercise that takes little account of the bigger picture.
Prescribing incentive schemes, started with the laudable intention of getting maximum value for limited resources, are being used to direct and limit clinical behaviour on flimsy evidence enforced by financial penalties. Our new local scheme has metrics so wide and vague in some areas that it is possible to achieve near maximum points on QOF clinical indicators but still not achieve a green status on arbitrary financial targets.
My job is to deal with a person who comes to consult with me as a professional. A consultation does not occur in isolation from the wider environment, but always contains four key elements. The essence of general practice is these four Ps; a patient, a physician, a problem and a plan. If we allow others to impose their own agendas on this and move to treatment by committee, neither patients nor doctors will ultimately benefit.
Dr Pat Aitchesen is a GP in Northampton