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Opinion: “Restrictions and confounding factors that limit our freedom of choice are usually financial”

If every decision I make and procedure I do holds the power to kill or cure my patient, and ruin me if it goes wrong, I feel I should have a right to make those decisions on my own terms

10 April 2018, at 10:42am

Clinical freedom is highly valued. For many vets it is seen as a right. It is the yin to the yang of the responsibility we have as vets to our patients, and to the daily risk we carry in doing something wrong and getting sued or struck off. If every decision I make and procedure I do holds the power to kill or cure my patient, and ruin me if it goes wrong, I feel I should have a right to make those decisions on my own terms. It is therefore no surprise that when something interferes with that freedom, vets, and I imagine other clinicians, feel deeply aggrieved.

In a recent round of interviewing vets for a job, a recurrent dissatisfaction cited by those working for corporates was a feeling that there was a restriction in drug availability. They felt they had been working in very tight clinical and billing regimes that could limit treatment options. The overall effect of working to financial targets on a limited regime of treatment options is proving to be quite demoralising.

Restrictions and confounding factors that limit our freedom of choice are usually financial. They can come from a variety of sources, including from the owner’s budget and from insurers. The worst of this is when insurers rule out treatment options, like stem cell therapy for arthritis, or an arbitrarily constructed list of non-covered conditions, simply to keep premiums low. It is deeply frustrating to have treatment options narrowed by an accountant in an insurers office. It is not ideal for the poor patient either.

To put this in context, I asked a local GP friend of mine to give us an idea of what clinical freedom is like for doctors. To keep it concise we focused on prescribing drugs in a GP surgery. They responded:

“GPs have the freedom to prescribe whatever they choose, believe it or not. One of the many roles of a GP however is as an NHS resource allocator, which has become ever more sharply focused in recent decades, such that a strong culture of cost-effective prescribing has developed. Until a few years ago, we were actively incentivised to prescribe more than 95 percent generic versus branded drugs, but now generic prescribing is the default position, unless a branded drug in the same class is more cost effective.

“Twenty-two local GP practices in North Devon are actively compared with each other by Clinical Commissioning Group pharmacist advisers across the board and we feel uncomfortable to be at the wrong end of a bar chart suggesting our practice is squandering NHS resources compared with our more efficient local colleagues. Conversely, we are proud to be shown to be not just comparatively cost-effective prescribers, but also safe and NICE compliant, though the latter is harder to prove without detailed audits.

“As individual prescribers using desktop software, we are automatically reminded which of the 900 or so drugs are in our county formulary, and how much they cost per prescription. If we choose a medication which is less cost effective, we are reminded with a pop-up using Scriptswitch software. Although we are strongly encouraged to prescribe within local formulary boundaries (our last compliance I believe was around 98 percent) and this again has been a comparative indicator, there are many reasons why we go “off formulary”. These can include patient intolerance, patient selection (though this is a tiny proportion), secondary care initiation of drugs and dispensing preferences, if you are lucky enough to be a dispensing practice (though still subject to local comparative scrutiny). 

“Hospital consultants are increasingly accepting of GPs changing a chosen drug to its more cost effective equivalent, and we will sometimes challenge a suggested prescription if its indication is not licensed, as it is ultimately the prescriber’s (ie the GP’s) responsibility if a serious adverse event occurs.

“Many GP practices have in-house pharmacists now and we have recently taken on one to share with three other practices. She is able to prescribe, as are our nurse prescribers.

“I could write a lot more, but how about a pint some time? Ask me about: repeat prescribing, bulk changes, audits and searches in response to safety alerts, controlled drugs, doctor’s bags (what, no drugs?!), private prescriptions, out of hours drug stock...” 

As usual, please email me with any comments or feedback on garethcross@hotmail.com. How free are you in your work? Perhaps you believe that some restriction or guidance is a good thing – let me know. 

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