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At the heart of general practice since 1960

We have been relegated to prescribing clerks for our hospital colleagues

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As we all know, general practice is sinking from a combination of poor workforce planning and ever-escalating workload, and yet the Government is keen to see a seismic shift of work from secondary care to primary care. NHS England has organised a series of workshops across the country helping GP surgeries to reduce their workload. The BMA has produced a document with handy template letters to try and redirect inappropriate work back to secondary care. This week I got really wound up by a cardiology nurse specialist asking me to refer a patient to a cardiologist at the same hospital. But that isn’t my biggest bugbear. My biggest frustration is: why don’t hospitals prescribe on FP10s?

Primary care has been using electronic interaction checking for over a decade. Why is secondary care allowed to continue being so dangerous?

Why should GPs face the bottomless pile of prescription requests from hospital clinics? These ‘non-urgent’ requests clearly state that the GP has up to seven days to provide the prescription, but of course patients (reasonably) want to start their new medication today. I assume this tradition is because GPs are more cost-effective prescribers than their secondary care colleagues, and the PCTs (may they rest in peace) didn’t trust secondary care clinicians to prescribe appropriately. Also, there may be a safety issue with hospital paper records being so unreliable that it’s simply not safe to prescribe any medication in case of dangerous interactions.

I am offended to be relegated to the status of a prescribing clerk for my hospital based colleagues. The solution to secondary care prescribing expensive drugs is to tackle secondary care prescribers, not outsource the task, unfunded, to GPs.

The solution to dangerous prescribing is to consign paper based prescription charts and medical records to the waste bin and instead have proper IT solutions which link to the local GP records. Primary care has been using electronic interaction checking for over a decade. Why is secondary care allowed to continue being so dangerous?

Last year, I tried to take this fight to the next stage. I contacted our CCG complaining about the single most irritating example of this: dexamethasone eye drops. As I’m sure most GPs know (from prescribing countless bottles), everyone who has cataract surgery needs dexamethasone eye drops for one month after. The hospital gives each patient one bottle. Now, if you use a pipette and have the steadiest of steady hands, one bottle may be enough. However, patients undergoing cataract surgery tend to have slightly shakey hands. One bottle doesn’t last.

So I wrote to the CCG and they asked me to audit how many times we have to prescribe dexamethasone eye drops to post-surgery patients. Within a week or two I had covered an A4 sheet with patients and I promptly shared my results with the CCG. The result? Nothing! The consultants stated one bottle is sufficient and so it is up to the GP surgeries to continue making up the shortfall.

In a practice with one patient having cataract surgery per week, this can create an hour’s extra workload per year (assuming it takes just over 60 seconds to generate a prescription). I’m quite tempted to redirect patients who run out to contact their consultant to get another prescription.

And I now know what I’m going to give my local hospital for Christmas next year: a guide on how to prescribe on an FP10.

Dr Phil Williams is a First5 GP in Lincoln, and former RCGP National Lead for the First5 initiative 

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Readers' comments (16)

  • Just tell them no.
    Write back a sh*tty-toned letter telling them that GMP requires them to prescribe, and that its in the reference costs for their tarriff.

    After about a month you start getting letters from consultants saying 'I've prescribed...', 'I've ordered bloods and given the patient a form and instructions...'

    Fight back. They shat on you because you don't resist. Busy hospital doctors will take the path of least resistance, like you. So resist for a short time, and your path will become less attractive.

    Flow dynamics dear boy.

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  • Is this really worth worrying about? I get one or two a day of these letters; each may take one minute to deal with.

    There are bigger challenges than this facing GP.

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  • To anon at 10:22
    This '1-2 minutes a day' is one department, one issue but contributes to the hour a day spent on prescription queries. That adds to the 1 1/2 hours a day reading through hospital letters, working out which ones secondary care have left some urgent outstanding investigation for GP to f/up (usually page 2, often risk of cancer etc if missed), contacting patients to tell them things primary care have told us but not them, re checking bloods etc.

    That's at least 2 1/2 hours a day, which contributes to me missing kids' bedtime and lead to me collapsing onto the sofa in an exhausted, angry, bling fatigue where I am too exhausted to think or converse with my wife.

    So yes, 1-2 minutes is important.

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  • typo 'blind fatigue' not 'bling fatigue' althoug I prefer the later...

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  • this has nothing to do with safe prescribing. it is the drug budget. prescribing budget was taken over from secondary care to primary care.
    even shared care protocol has no value as they don't initiate drugs. red drugs are also passed on to gp. unlicended drug are recommended for gp to prescribe.
    in one instance i was asked to prescribe a drug not in bnf and not available in uk.
    one consultant told me they have removed DP10 fron his table. it is MONEY and nothing to dO with safety. not faults of hospital doctors.
    I PROPOSE WE HAVE A SHARED PRESCRIBING BUDGET WITH SECONDARY CARE AND TAKE SHARED RESPONSIBILITY FOR INDICATIVE BUDGET

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  • Don't blame the hospital doctors, chaps, blame their managers. Some years ago my Trust decided that consultants would no longer be able to prescribe in outpatients except if it was absolutely necessary, and that we should tell our GP colleagues what to prescribe and let them do it. I resisted this bitterly, even seeking an opinion from the GMC, which said that if this was being done for financial reasons then it was not acceptable. I told our managers this, and asked them to rescind the order. They ignored me.

    Bear in mind that strictly if you do the prescribing then you may be the one held responsible if something goes wrong. Also if a hospital doctor prescribes on an FP10 it is considerably more expensive than prescribing through a hospital pharmacy - and you may find that a trade named drug is prescribed rather than a cheaper generic, because some generics are not as effective (usually down to the carrier substance). But look at it from the consultant's point of view - he is giving an expert opinion and is then not allowed to treat. Utter madness.

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  • As CCG GP Prescribing lead I won the battle on dexamethasone, and consequently the hospital issued sufficient bottles for the whole length of treatment. A small victory, but one straw off the camel's back.
    Prescription dumping is a fight your CCG must take up on your behalf (and indeed in its own interest since it affects its Drug Budget).If they won
    't help, you should collectively all give in to all those demands for pregabalin (in my smallish CCG it was costing us £600k p.a.!).That will soon bring them to your table.

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  • Azeem Majeed

    ROBIN JACKSON | Sessional/Locum GP03 Mar 2016 4:10pm

    Robin Jackson is correct. The CCG is the commissioner and they should set the service specification. In the example given in this article, if patients need more than one bottle of dexamethasone after cataract surgery, this should be made part of the service specification. Sadly, many CCGs seem unwilling to take on this challenge.

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  • i won many battles like prescribing riluzole for motor neurone disease, clomife for fertility , lots of red drugs, but once this is over they are back to square one and start doing same thing.
    one ED clinic who wanted to try muse for patient told patient to get script fron gp so they can try it on patient. i won that battle. i agree it is not hospital doctor's fault . it is manager who have poor prescribing budget and they must deliver.

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  • How about the issue of non prescribing nurse specialists running hospital clinics asking GPs to prescribe drugs they themselves aren't qualified to issue?

    Who's deemed to be responsible? It's happening more and more? It's an impossible situation. It's like 'do this please, a hospital consultant is possibly supervising me but if anything goes wrong - as the prescriber - you're responsible - cause I'm not legally able to prescribe this stuff myself- thanks'

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