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While GPs have the clinical freedom to prescribe treatments or medication according to the patient's best interests, the finite resources in the NHS can impose restrictions, says Dr Nicholas Norwell

The Medical Defence Union is occasionally asked for advice by GPs who have to balance resources against the clinical needs of their patients. These GPs want to know what action they should take if limited resources mean they are unable to treat effectively.

Examples are a local hospital restricting referrals and a PCT restricting prescribing of a particular drug or treatment. Such situations can present dilemmas for doctors whose ethical duty is to make the care of their patients their first concern.

In Good Medical Practice the GMC states: 'If you have good reason to think your ability to treat patients safely is seriously compromis-ed by inadequate premises, equipment, or other resources, you should put the matter right if that is possible. In all other cases you should draw the matter to the attention of your trust or other employing or contracting body. You should record your concerns and the steps taken to try to resolve them.'

GPs who are also managers may have to make decisions for a whole practice, or, if on a PCT board, for a group of practices, about the allocation of resources. And as GPs take on more responsibility for commissioning health services, they are also having to make more decisions that balance clinical effectiveness against cost-effectiveness.

The GMC has specific guidance for doctors who act as managers in its newly revised booklet Management for Doctors.

It recognises that effectively managing resources can present dilemmas for doctor managers, and states that the extent to which a doctor manager will be held accountable will inevitably depend on 'the circumstances: your position, the resources available to you and the nature of the problem'.

In paragraphs 21-23 of the booklet it states: 'Management involves making judgments about competing demands on available resources. At times you may not have the resources to provide the best treatment or care that all your patients need.

'At such times your decisions should be based on sound research information on efficiency and efficacy, and in line with your duties to protect life and health, to respect patients' autonomy and to treat justly.

'You should take into account the priorities set by government and the NHS or your employing or funding body. You should discuss the issues within the health care team, with senior management and, when appropriate, with patients.'

For GPs serving on PCT boards, the GMC advises: 'You are accountable to the GMC for your own conduct and for any medical advice you give. If you are concerned that a board decision would put patients or the health of the wider community at risk of serious harm, you must ask for your objections to be recorded formally, and you should consider taking further action.

'If you have good grounds to believe that patients or the health of the wider community might be at risk of serious harm, and you have done all you can to resolve the problem by raising your concerns within the organisation in which you work, you may consider making them public, provided that patient confidentiality is not breached.

'You should consult a defence body or professional association before taking a decision of this kind.'

Recently members have raised concerns about resources when asking the MDU about referral management centres, which some PCTs have set up to monitor and process referrals. Referrals might be sent to a specialist (who might be a nurse specialist) other than the one the referring GP chose, or may be referred back to the referring GP. GPs feared the referral letter might be lost in the process or referring to the centre might breach patient confidentiality.

The MDU has advised doctors that, in line with GMC advice, they must tell patients that their referral letter will go via a referral management centre.

It is also advisable to have a system in place to track referrals to ensure they do not get lost in the system. For urgent referrals, GPs may decide to follow them up themselves if they have heard nothing within a certain period.

Case history

A patient with multiple sclerosis asked her GP to prescribe a drug she had discovered on the internet, which had apparently shown good results in trials in America. The GP had not heard of the drug before and noted that it was expensive and unlicensed in the UK.

It appeared the GP could prescribe the drug on a named-patient basis, obtaining supplies from the manufacturers. He sought advice on his liabilty if he prescribed it.

The MDU advised that the GP could, in principle, prescribe the drug if he obtained informed consent and if he reassured himself that there was a responsible body of medical opinion which would support his prescription. However, the fact that he had never heard of the drug before made a prescription unwise.

The MDU suggested the GP seek advice and guidance from the PCT prescribing lead. The GP did so and was advised that the PCT would not support a prescription for this drug, partly because of its expense, partly because it was unlicensed and partly because there was not a responsible body of opinion in Britain supporting its use.

The PCT prescribing lead, through his contacts, found also the drug had some serious side-effects which were not apparent from the data the patient had found on the internet. The GP was able to advise the patient in an authoritative way that the drug was not appropriate for her.

The case mentioned is fictitious, but based on cases from the MDU's files. Doctors with specific concerns are advised to contact their medical defence organisation for advice.

Nicholas Norwell is a medicolegal adviser with the MDU

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