One of my partners has a particular interest and expertise in a specific clinical area. I suspect he is receiving generous inducements from pharmaceutical companies and lavish trips abroad to speak at conferences. I am concerned that this is affecting his prescribing, which seems, in this area, to be profligate and at odds with local and practice guidelines. What should I do?
Dr Elliott Singer: Determine the cause of the increased prescribing
There are two issues here that need separating. Firstly, does having expert knowledge in an area affect how we manage cases? Secondly, do close relationships between clinicians and the pharmaceutical industry affect prescribing?
GMC good medical practice states that we must work within the limits of our competence. A clinician with specialist knowledge in a particular area is likely to manage the problem beyond the point where most GPs would have referred. The management may include prescribing different drugs or different combinations of drugs. It could be for this reason that the partner is prescribing more and going beyond the limitations of any local or practice guideline.
The effect of the pharmaceutical industry on clinicians’ prescribing habits is more of a dilemma. In the UK, pharmaceutical companies cannot directly advertise to patients, so rely on representatives building up relationships with clinicians in local areas to encourage them to prescribe a particular version of whatever class of drug. Sponsoring clinicians to attend conferences is a step on from this approach. In fact just by seeing a drug rep, a clinician is more likely to prescribe a particular drug.
You therefore need to determine whether or not the increased prescribing is because your partner is managing more complex cases and reducing referrals to secondary care or just prescribing more of a particular drug. Developing a practice protocol so that the partner will see the other GPs’ patients suffering with illness in this area rather than referring to secondary care will be beneficial for both patients and the practice. Agreeing the practice formulary will be part of this protocol and should state the order in which the drugs will be prescribed and justify any deviation from local guidelines.
Dr Elliott Singer is a Medical Director for Londonwide LMCs and a GP in Chingford, North London
Dr Edward Farnan: Do an audit of practice prescribing
While it may benefit the practice to have a partner who has this level of expertise as he can ensure the practice is up to date with the latest developments, the partner should not allow his association with the pharmaceutical company to influence his prescribing, or any other part of his clinical practice.
GMC guidance says that doctors must prescribe drugs or treatment which serve the patient’s needs, and any treatment must be based on the best available evidence. Doctors must not allow any interests they have to affect or be seen to affect the way that they prescribe for or treat patients. In addition, all doctors must make good use of the resources available.
An audit of the practice’s prescribing, broken down by partner, will reveal whether or not your partner’s prescribing is at odds with guidelines or the prescribing habits of his colleagues. If there is no discrepancy, then your concerns may not be well-founded. If there is a discrepancy, then you may wish to discuss this with him. He may be able to explain this by virtue of his expertise. For example, is he seeing patients with more complex conditions in this area, for whom the treatments recommended in the guidelines have been unsuccessful? If there is no justification for his prescribing, then as a practice you may wish to put in place a plan for amending his prescribing habits taking into consideration local guidelines and the GMC’s guidance above.
Dr Edward Farnan is a medicolegal advisor at the MDU and a former GP
Dr Matt Piccaver: A gentle reminder may be necessary
We must all be seen to be immune from commercial influence in terms of prescribing decisions, even if this is difficult – most of what I prescribe is medication, with lifestyle advice probably a close second.
We have an ethical and moral duty to our patients to ensure that what we do is in their best interests. This includes prescribing decisions. Your colleague could be seen to be infringing the GMC’s guidance recommending doctors to remove themselves from decision making processes where there may be a conflict of interest.
In terms of local prescribing habits, being an outlier practice might result in further scrutiny at CCG level. We are all in part custodians of a rapidly shrinking NHS pot of money, and thus have a responsibility to maximise clinical and cost effectiveness in terms of treatment choice.
A polite word, or gentle reminder might be required. How you might go about that may depend upon your relationship with the partner in question, as well as your style of interpersonal communication. They might see nothing wrong with what they are doing. An informal chat might be the opening gambit, escalating to a discussion in a partnership meeting. What you do eventually depends on how ‘nuclear’ you want the situation to go. If your partner can be shown to be going against GMC requirements, consistently, and without being open or honest in their dealings, then this might need to be escalated. A simple review of prescribing metrics might be sufficient to confirm or allay fears regarding influence over prescribing matters.
Personally I favour a pragmatic approach. A gentle chat, perhaps a review of prescribing data (if nothing useful for appraisal), and if all seems in order, you may have to let the matter drop.
Dr Matt Piccaver is a GP in Glemsford, Suffolk.
Conflict of Interest note: Dr Piccaver’s practice is a part dispensing practice and he is director of a pharmacy. He has written content for education companies targeting the pharmaceutical industry.