Chris Lancelot: GPs are being forced into unethical dilemmas

A recent news item revealed that NHS Bedfordshire is attempting to use Annex 8 to surcharge all practices which don't hit a 74 per cent target for simvastatin prescribing (GP, 5 November).

The GP Record, by Fran Orford

The original purpose of Annex 8 was to enable PCTs to deal with any GP who prescribes recklessly, such as the dispensing doctor who selects the most expensive alternatives, purely to increase his profits. It was never intended for other scenarios. As Dr Bill Beeby (chairman of the GPC prescribing subcommittee) says, Annex 8 should be reserved 'for the most recalcitrant of people, in the most extreme situations'.

Despite this, NHS Bedfordshire has decreed that any practice failing to hit its 74 per cent target will have the cost difference sequestrated under Annex 8.

Now I could just about agree to the use of Annex 8 against GPs who unthinkingly prescribe the more expensive statins. But the PCT isn't doing this. Instead, it will penalise every doctor who doesn't hit its arbitrary target, however carefully that GP may have considered the options, and whatever their individual patients' needs - because the PCT has decreed that there will be no exception reporting.

It is argued that atorvastatin has both a better effect on the lipid profile and fewer side-effects than simvastatin. GPs do not appreciate their professional opinion being subverted and coerced by the PCT, especially where the science is itself in flux. To make matters worse, colleagues in Bedfordshire tell me that a local hospital now discharges MI patients on high dose atorvastatin, recommending it be continued for two years. So what does the conscientious GP do - ignore consultant advice?

The more assiduously GPs follow consultant recommendations, and the more they spot simvastatin side-effects, the more they risk being surcharged. They can't even give atorvastatin by private prescription to their NHS patients: that is illegal.

This puts many GPs in a no-win situation: either do what they believe professionally is wrong for the patient or be fined by their PCT. And what about patient choice here?

In my opinion, NHS Bedfordshire's decision is an abuse of the regulations, a blunderbuss approach to a complex problem, unethical, unprofessional and dictatorial. Other than that, it's a great idea.

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