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Should GPs initiate outpatient prescribing?



The Government is right to propose this, argues Dr Peter Weaving. However, Dr Ahmed Nana says the latest prescribing initiative is poorly thought through and could put GPs at medico-legal risk.

A recent letter from our local haematologist stated: ‘Clearly this patient would benefit from eltrombopag.’ It not only sent me straight to Google – it also perfectly illustrates why we in North Cumbria decided to take over outpatient prescribing.

Any patient needing medication as the result of an outpatient appointment is now given a hand-written note for their GP of the suggested prescription. Hospital pharmacy will dispense any urgently needed treatment, but this is rare, and any red-light drug is subject to local protocols.

There’s no-one better than GPs to follow or adapt a consultant’s recommendation, which is why the Department of Health is right to propose this.

We know our patients, have access to their medical record and we know about local guidelines and formularies. We know expensive pickapril offers no real advantage over its fellow ACE inhibitors and that elitostatin is only indicated when 80mg standardostatin has failed to deliver. We also understand isomerisation is an anagram of patient prolongation.

Never doubt that consultants are the target of advertising as much as – if not more than – us. One consultant, if turned, can influence an awful lot of GPs.

And we know the cost of a drug because we see it every time we write a prescription.

Of course, some of my fellow GPs were worried there would be a tidal wave of patients hot-footing it from outpatients demanding to get their new prescription. But in fact, it didn’t take long for everyone to realise that the normal clinic letter arrived soon enough anyway.

The system is simple, safe, effective and efficient and our prescribing bill is the lowest in the North-West. What’s saved

can be spent elsewhere – to support pharmacists working in surgeries, for example. The over-riding principle is that it is we who know our patients best and we who are best placed to initiate prescribing.

Dr Peter Weaving is a GP in Brampton, Cumbria and commissioning locality lead for NHS Cumbria

One of the 50 ‘efficiency’ prescribing tips in the new QIPP initiative is to shift outpatient prescribing – and its costs – from secondary to primary care.

But GP time has clearly not been budgeted for and it’s obvious the Department of Health sees general practice as a fixed-cost dumping ground. At the very least, this is going to mean more face-to-face time at reception. But also, the current state of communication between primary and secondary care makes the policy unworkable. Outpatient letters take between four to 12 weeks to arrive at my practice, making it impossible to know what to prescribe when I have an irate patient in front of me.

Some secondary care colleagues write a small note with the name of the drug that is to be prescribed, but little information on the indication. This is unacceptable, particularly as prescribing is often off-licence.

Would we be happy initiating hospital drugs such as leflunomide or isotretinoin?

I don’t feel I have the expertise and should a problem arise I doubt the medical defence bodies would be very understanding.

And why should patients have to make a further visit to get medication anyway? What about the patient with three fits a week, who is told he needs to see his GP to get his medication?

What about cost? Is the payment by results tariff going to be unbundled to remove the prescribing element and a slice of payments transferred to the primary care prescribing budget?

In my opinion, a better option is for the consultant to write an FP10 with enough to last until the letter is received by the GP.

The patient can then go to their community pharmacy, avoiding the long queues and problems with stock availability, which seem to be an increasing problem at hospital pharmacies.

Dr Ahmed Nana is a GP in Leicester

Yes No Prescribing