Your Views on NHS care.

[think about it]

Whilst it's not good to hear that your GP doesn't know what to do, at least he said this and told me he was going to get me some help.

 

To be fair, I can’t think of a better response, remember that your GP is just that – a General Practitioner – not a specialist, at least he recognised his own shortcomings and referred you to someone who may know how best to help. Far better that than politely ignoring your concerns or prescribing yet another medication and having you go away and try that.

 

I blame this on cost (practice managers watching the budget like hawks?)

 

When requesting medication for a problem, they will often fob you off with:-

 

''I can't prescribe you that'':-

 

a) ''It can be addictive'' (NHS speak for '' it's addictive and we're likely to spend so much time trying to get you back off it that it's not clinically indicated in your circumstances'')

b) ''It can cause cancer'' (NHS speak for ''it's carcinogenic and the risk far outweighs the benefit'')

c) '' Have you tried relaxation methods? (''in certain cases the psychosomatic symptoms are worse than the real ones, not any less genuine but the cure might not be in a bottle

 

D) It's not clinically indicated and no, Google doesn't always hold the answer in a manufacturer's website

 

Do I watch the budget like a hawk? Yes - Do I have any input on the GP's clinical decision making? No. The community pharmacy team may well seek to guide prescribing decisions and NICE and the health boards will tell the GP's what they can and can't prescribe. The PM takes no part in it besides writing the cheques to the pharmaceutical distributor.

 

You’re right, Vets may well be far more willing to write prescriptions to people who have to pay – the same way that prescription only medicines are advertised on TV in the USA. Your GP has a genuine interest in helping you and that help isn’t always in a bottle or blister pack, regardless of what wikipedia says.

 

We're subject to phenomenal amounts of guidance and constraint and regardless of what the Daily Mail says, we do actually care about our patients and do all we can to help.

 

What Sali says about misuse of repeat prescriptions is absolutely true - people order things they just don't use and it sits in a drawer until it goes out of date.

 

Two examples of this:

 

Steroid Inhalers, cost to the NHS - about £60 each (that's right, £60.00 per inhaler) and people order one a month and then leave them in a drawer gathering dust.

 

Viagra, up until last summer cost price £25 per pack - now just a couple of pounds for the generic Sildenafil Citrate (same stuff, different packet after the patent expired) we had a gentleman who ordered two packs per month - and why not, good luck to him... However, he passed away some years later and his family returned almost 40 packs to us, unopened. That's £1000 sat in a drawer just in case.

 

We can't re-use medication, for us to give out medication that we don't know if it's been tampered with, stored incorrectly, replaced with fakes etc would be an unacceptable risk and I certainly wouldn't be happy as a patient in my practice accepting second-hand drugs, would you?

 

We will however split bulk medication so whilst we'd never use one tablet from a blister pack, the dispensers may provide a 'part pack' of sealed medication for the same reasons mentioned above.

[think about it]

Sali, you’ve got some excellent questions there and some equally good points. So I don’t lose track I’ve broken your post up and I’ll do what I can to respond to each of the points in turn.

 

I wish a few more GPs - and many other professions - recognised their own shortcomings. My brushes with the medical profession through loved-ones have not been positive. More honesty and humility would be nice.

 

Whilst the community pharmacy team, NICE and health boards may tell a GP what he can prescribe, what influences a GP to choose one drug over another or any drug at all? You say you watch the budget like a hawk. Does this mean that prescriptions are restricted at the beginning of the financial year, only to be dished out like sweeties at the end in order to use up the budget and prevent the next year's budget being slashed? This is what happens to departmental budgets in private companies. Whilst it's not life or death when a company splurges on art work at the end of the year, it would be a little different in your business.

 

There is indeed an annual prescribing budget, it is generally based upon the previous years with an adjustment for any changes in list size.

 

In all honesty it’s a bit of a misnomer – the Dr’s prescribe what’s needed and the budget lands where it lands.

 

We do have targeted changes in prescribing from the health board – for example the one I used in a previous post to take people off a branded medication (Viagra) and onto a generic (Sildenafil). That said, the Dr’s can and do over-rule this if they feel that there is a clinical reason for doing so and this is taken account of. Another is the reduction in prescribing what are called luxury items of gluten free foods. No one says you can’t have the bread / pasta etc but if you want Jaffa Cakes then the NHS isn’t too keen on paying for them.

 

The prescribing budget is just one aspect of our funding and in all honesty is the one that I have the least control over – that doesn’t mean however that I simply ignore it. It tends to be an aspect that the use of generic drugs over branded has the greatest impact on or our excellent dispensary team who will negotiate deals with the distributors on commonly used items.

 

So yes, we do watch, we do ensure we’re getting best value but it’s watching and best value on what’s necessary and not exerting control over prescribing.

 

I’m not a Dr, I do however work with a few, am married to another and have a few with whom I’m good friends. So, my understanding of the choice of medication and prescribing by a Dr is a relatively well informed simplification:

 

The decision to prescribe is based upon the condition, the available research on how effective a drug might be (clinical indication) and which drugs are approved for use by the Health Board/NICE. There’s also a part of the decision that weighs up the risks associated with using that drug. Using something like Ibuprofen over a long time can leave you with an exceptionally sore stomach. So, a Dr takes into account the side effects and risks. They also weigh up what effect it’s likely to have alongside other treatment.

 

Generally, the stronger the medication the greater the risks and side effects are associated with it. There’s a balancing act there, do you first try the safest treatment that’s been shown to work in 80% of cases or do you plump straight for the industrial drain cleaner that will almost certainly kill the infection but might also kill the patient in the process? Okay that’s a bit dramatic but hopefully it illustrates the point.

 

Another point I often muse over is how much a doctor is influenced by reps from pharmaceutical companies. There is also the long-term problem of pharmaceutical companies not releasing ALL of their clinical trials data where it may not be conducive to business. NICE et al may be making judgements on what drugs can be prescribed on incomplete information. On top of this the NHS has a history of locking itself into contracts (but not just for drugs) for longer than the term of the patent, meaning they do not buy competitively and consequently waste huge amounts of money.

 

Medical reps used to be a big part of GP-Land, they’re not any more. There are now very strict rules on what they can and can’t do and even giving out branded pens and highlighters is against the rules, which is a shame because our stationery bill has shot up. The medications available are largely controlled by NICE and the Health Board so a rep is really barking up the wrong tree if they think that the GP is able to approve use of a drug. Equally, I have the pleasure of working with a few of the most cynical GP’s I’ve ever met and any sales ‘patter’ tends to fall on very deaf ears until some real academic research is produced. Such is the extent of the decline of the reps that we no longer see them here.

 

You’re right about the concerns over incomplete research information, it’s a far from ideal scenario. Equally as a contractor to the NHS I can only re-assure you that things are being tightened up on what feels like an hourly basis.

 

Having said that, I believe we all need a wake-up call. We take too much for granted because the NHS is free at the point of use and many people, for one reason or another, do not even contribute towards their prescriptions. It has made us careless. We need to remember it is OUR money and not to be wasted.

 

However, GPs too have a responsibility. I mentioned anti-biotics in an earlier post. Through unnecessary prescription and patients failing to finish the course, we can expect the emergence of a super-bug that no current anti-biotic (and I think there are no new ones in the pipe-line) will cure.

 

And the chap who was prescribed Viagra - what on earth was the GP thinking to allow this repeat prescription to go unchecked? Unless he told the GP he was working as a gigolo, (and I'm making an assumption on what condition it was used to treat) there were certainly grounds for a patient review.

 

Our chap with the stockpile was regularly reviewed an had re-assured our Dr’s that the meds were going to good use and as there are just 4 tablets per pack it’s not out of the ordinary to suggest that they weren’t being used every month.

You’re right, GP’s do have as much of a responsibility as the rest of us over the usage of anti-biotics and I agree entirely on the risk of a super-bug.

 

Here’s the challenge they face, for most people they get a cold/cough/sore-throat and visit their GP expecting to be prescribed anti-biotics. The GP refuses – the patient then goes to see another GP who, through either lack of judgement or not wanting to battle with the patient prescribes the requested anti-biotics.

 

The patient then stops seeing the better, stronger GP of the two in question and tells all of their friends and family that the new easy to win-over GP is ‘excellent’ and they then all start going to the new surgery.

 

Being a ‘Dr. No’ is challenging, so much pressure is placed on these better GP’s by the public and by less capable GP’s.

 

These people tend to be the same who then stop taking the medication as soon as they start to feel better, which would have happened even if they hadn’t been taking the meds. They put them in a drawer and as soon as they sneeze they start taking them again. All of the time the resistance to the medication increases until, eventually it’s rendered totally useless and we all die an agonising death from an untreatable infection.

 

The increase in litigation has something to do with this, there’s another post here where someone lost a very young friend to a most dreadful and aggressive cancer. However, in their description of what happened they explain that she presented to her GP with a sore throat and wasn’t given anti-biotics. It’s seen as a fault of the GP and of GP’s in general when they don’t prescribe something which, in retrospect wouldn’t have made any difference whatsoever. Such is the fear of litigation that this profession is one of a few that people have to pay out huge sums of money just to continue working in.

 

People decry doctors wages but I struggle to agree with them when seeing first hand the amount of pressure and expectation placed upon them, I can’t think of many other professions where someone has to pay £500 a year just to maintain their licence, almost £10,000 a year in liability insurance amongst many other registrations.

 

I don't think the Daily Mail or any other newspaper has made us believe that GP practices do not care for their patients. We just have higher expectations, are better informed and are less likely to be fobbed off. What's wrong with that?

 

Nothing is wrong with high expectations, we should have them, I know I do.

 

I think it’s down to being involved in your own care and showing an interest, I mentioned on another post how finding something on wikipedia doesn’t mean it’s right and I maintain that. But, by researching and discussing it with your Dr it means you’re both invested in your care and I’d advocate that we all do the same.

 

Sometimes Dr’s have to tell us things we don’t like to hear. Smoking will most likely kill you, so will being overweight, drinking too much, not eating the right things or exercising. It’s not the Dr’s fault if these things catch up with you – they don’t pour the drink, order the KFC or light the cigarette yet I see so many people who get offended when a Dr suggests a lifestyle change as a part of treating the many conditions that we see as a result of the modern lifestyle.

 

I think such reliance is placed upon the fact that modern medicine will fix all problems that we forget our own responsibilities in keeping ourselves healthy. Recently we’ve been sending people who need knee and hip replacements to an exercise programme if they’re obese. We’ve actually seen a decrease in the number of operations being required as people lose weight, build muscle and place less strain on their ailing joints and bones. They feel better as a result and if the op is still required then they’re physically fitter and better able to deal with the risks of major surgery. It’s win – win but people don’t like being told that they may well hold the best part of the cure to their own condition. Yes a new knee will help – but losing several stone, learning some healthy eating and exercise techniques and changing your lifestyle may well mean that you never need to be exposed to all of the risks associated with someone effectively cutting your leg in half and then filling the gap with titanium.