GPs are doling out so many drugs that Copperfield can’t remember their names. How about a QOF for prescribing nothing at all?
One of the nicer things patients say to me, typically when I’m checking the BNF to see whether my proposed up-dosing of their antidepressant has strayed from therapeutic to homicidal, is: ‘I don’t know how you remember all those drugs, doctor.’ And one of the less nice things I say in reply is: ‘I don’t, dumbass, that’s why I’m looking it up.’
The punters have a point, though. There’s a cornucopia of drugs in our pharmacopoeia: We have a pharmacocornucopia. Except we haven’t. We’ve got an unholy therapeutic mess.
And it’s of our own making. As the BNF has expanded, our ability to prescribe rationally has shrivelled. We dish out medication like it’s a proxy measure of how much we care.
As ever, to enjoy the crassest examples, look no further than your nearest pile of discharge letters. A baby burps in hospital. Result? A long-term prescription for ranitidine and domperidone. A 28-stone behemoth slips in the bath and fractures some ribs? That’s a ‘low-impact fracture’, apparently (in which case, so is the result of standing in front of a train), necessitating alendronate and calcium/vitamin D, forever. An elderly patient on no treatment whatsoever is admitted with pneumonia? She’s discharged on 13 separate medications and is therefore more confused than when she was hypoxic.
But it’s not only hospital doctors who are at the cutting edge of incompetence.
We GPs are just as guilty. I’ve just been summarising the notes of a recently registered child. Her previous consultations go like this: ‘Conjunctivitis. Rx chloramphenicol drops, amoxicillin, paracetamol, chlorphenamine.’ That’s not a prescription, that’s pharmacological child abuse.
Before I get too self-righteous, though, I should confess the following. Today, I caught myself signing prescriptions for 90-year-old nursing-home residents on statins, ACE inhibitors and ß-blockers, for diabetics on more drugs daily than I hope to take in a lifetime and for a depressive whose need for SSRIs and quetiapine revolves entirely round who’s saying what to whom on Twatbook.
Enough. We’re all guilty. This is iatrogenocide. And it’s got to stop.
So I propose a very different pharmacological future. One in which we get QOF points for every patient without a repeat prescription slip. One where prescribing incentive schemes incentivise the opposite – so that for every patient leaving the surgery empty handed, we get a Hob Nob. And one where prescription management centres exist to scrutinise and reject the lengthiest FP10s, and beat the guilty party with sticks.
In fact, let’s have a complete pharmaceutical amnesty. Stop most drugs now, forever. Sure, the pharma industry might wither, and a small but hardcore cohort of GPs might actually have to start paying for their lunchtime sandwiches.
But every revolution has its casualties. I’m not a complete nihilist, though. I’d allow aspirin, paracetamol, steroids, a handful of antibiotics, a couple of antihypertensives and, for special occasions, a statin. Imagine the time and money saved, the enormous amount of good done and the minimal harm.
Don’t know how I remember all those drugs? Simple.
‘Sick Notes’ by Dr Tony Copperfield is out now, available from Monday Books.
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