Exclusive Practices in some areas of England are being ‘bullied’ into issuing antivirals to all residents of care homes as a precautionary measure, leading to GPs being called out to deal with side effects from patients who had not had flu symptoms in the first place.
Care homes demanded practices urgently issue bulk Tamiflu prescriptions, to be given to asymptomatic residents as a precautionary measure following flu outbreaks, on the request of Public Health England local leaders.
One local leader said practices felt they were ‘bullied’ into prescribing, and were unable to properly test for renal functions, check medical records or even ask the patients’ consent.
The GPC told Pulse the problem had arisen in both England and Wales and that the BMA had major concerns both about the clinical justification for the move and the impact on workload, and it has called for urgent meetings with PHE on the matter.
In one area, the instruction led to residents – most of whom were well and fully vaccinated – getting Tamiflu without their consent or undergoing necessary tests, with some suffering side effects that meant they needed follow-up visits from the GP.
The Department of Health (DH) gave GPs the go-ahead to prescribe antivirals at the end of last year, as circulating levels of flu started to increase, following a letter from Public Health England (PHE) director of health protection Dr Paul Cosford.
The PHE guidance also includes recommendations for ‘post-exposure prophylaxis’ with Tamiflu in people considered at risk of complications, who have not been effectively protected by vaccination, in line with 2008 NICE guidelines.
However, GP leaders said they had received complaints from GPs that practices had received faxes – often after 6.00 pm or during busy surgery hours when no staff were available – to request urgent prescriptions for large numbers of residents, in some cases before the DH authorisation to prescribe antivirals had been given, and without prior information about the plans around prophylaxis.
In some cases practices were simply instructed to fax through prescriptions, while in others they were asked to first contact the care home in order to identify the patients – both symptomatic and any asymptomatic contacts – and calculate the recommended doses of the drug, based on their most recent renal test results.
Dr Paul Roblin, chief executive at Berkshire, Buckinghamshire and Oxfordshire LMC, said many cases in his area had happened before the DH had given GPs the green light to prescribe antivirals, and that some GPs had been ‘bullied’ into providing the prescriptions without checking patients’ records, or ensuring patients were able to give consent to treatment.
Dr Roblin said: ‘I’ve had a number of complaints from practices saying they were phoned up – often at a time when they had little capacity – and instructed to prescribe Tamiflu to a whole host of patients in care homes, which you can’t just do.
‘These were people who were well, it was being prescribed in a preventative fashion to patients just because there had been cases [of flu] in the home. You can’t just give it to a patient without explaining the benefits, and many of them are cognitively impaired.’
‘But practices felt bullied into it. One refused completely, but several complied, causing a lot of hassle to their existing surgeries. And then some ended up doing it badly because they just signed the prescriptions – you are meant to tailor the dose depending on kidney function, which they didn’t do because they didn’t have time to do it.’
As a result, Dr Roblin said, one very elderly woman was given Tamiflu despite her care plan stating she should not have treatment other than symptom relief, while in one care home five of 43 residents given Tamiflu had fallen ill the next day with diarrhoea and needed extra GP visits the next day.
Dr Roblin said PHE should take responsibility for prescribing Tamiflu to asymptomatic patients who have been vaccinated if this had been decided.
Dr Roblin said: ‘My view is that PHE should prescribe the medication, since they have investigated what is happening in the home and reached a prescribing conclusion according to their own guidelines.’
GPC negotiator Dr Dean Marshall confirmed to Pulse several areas had raised the issue and that the GPC was concerned about PHE shifting responsibility for prescribing antivirals in this way onto GPs.
Dr Marshall said: ‘I’ve had a few other people reporting it as well, so this is becoming a bigger issue. We have put in a call to have a discussion with PHE and will be feeding back our concerns.
He added: ‘It doesn’t seem to be co-ordinated very well, with different processes in one area from another. We’ve had reports of out-of-hours organisations getting involved in it as well – this is about treating people are not ill, who have had the flu jab, and this is being dumped on out-of-hours who I imagine are already pretty busy at the moment.
‘It’s another example of bits of the NHS just dumping work on GPs, not working together with us to plan work, never mind the concerns about the clinical appropriateness of giving the drug.’
PHE were contacted for a statement but did not get back to Pulse in time for publication.
It comes as official figures found that the incidence of flu this week was the highest for three years.