Commissioning presents GPs with a series of ethical dilemmas. The GMC must take the lead, says Dr Krishna Korlipara.
The NHS reforms mark a fundamental shift in the delegation of responsibility to GPs, who – until now – have mainly been providers of primary care. As they take on their new role as commissioners, purchasing secondary care and community services, they face the challenge of achieving substantial savings to reduce the financial deficit that many will inherit.
In February, the GMC launched the first major review of its Good Medical Practice guidance for five years, and it is also consulting on its supplementary Management for Doctors guidance.
It is imperative that the GMC takes this opportunity to review and update its ethical guidance, to make it easier for GPs to understand their duties and obligations under commissioning. The updated guidance needs to examine various scenarios in the new world of GP consortia and gives a clear direction on how GPs should conduct themselves when faced with conflicting pressures from other clinicians and managers acting on the Government’s behalf.
As GPs are placed at the heart of the NHS reforms and take key decisions about commissioning healthcare, questions will inevitably be raised about the potential for conflict of interest.
On the one hand, they have to provide the best possible care for their patients – but at the same time, they will have to make hard decisions about purchasing care cost-effectively.
Conflicts may arise when GP commissioners are put under pressure to save money by reducing prescribing costs and hospital referrals to help their consortia stay within budget.
GPs even risk being accused of profiting from patients’ illnesses as they make difficult prescribing decisions for patients with cancer, Alzheimer’s disease or other costly conditions.
It is not unreasonable to expect doctors to prescribe drugs responsibly and cost-effectively to their patients at all times. Indeed they should be able to justify to their peers, and the GMC if necessary, that they have always acted ethically and in patients’ best interests.
They should certainly resist any temptation to reduce prescribing costs by denying patients appropriate drugs necessary to treat their condition.
Where there is a choice of drugs that are all equally effective, a GP would be expected to prescribe the drug that is most cost-effective. But if the prescribing GP faces pressure from the managers or clinicians leading the consortium to stop prescribing drugs that are necessary and appropriate for their patient’s condition, they should explain the professional duty placed upon them by the GMC’s ethical guidance – to provide the best care and treatment their patients need based upon the evidence of clinical effectiveness for the drug.
If the matter is still not resolved, the GP should make a note of the conversation in the patient’s records and write to the GMC complaining about undue pressure being brought to bear by a fellow doctor in the consortium.
If similar pressure is brought upon a GP to reduce hospital referral rates, they should first examine their own referral patterns and take action to reduce unnecessary referrals. But they should resist any pressure to reduce appropriate referrals that they feel are in their patients’ best interests.
They should declare a potential conflict of interest in any forum where such a conflict may arise, to the patients themselves, to carers and to their fellow professionals. This must be appropriately recorded in the patient’s notes – for the GP’s own protection in the event of a complaint later – to demonstrate that he or she has acted ethically at all times.
Above all, GPs should remember to make the health and wellbeing of patients their first priority in accordance with the GMC ethical guidelines – and those guidelines must be updated to reflect the challenges of GPs’ new role.
Dr Krishna Korlipara is chair of the Bolton GP Collaborative Consortium and was a member of the GMC Council from 1984 to 2008.
Dr Krishna Korlipara