If a primary care organisation urges a change in prescribing, should patient choice be taken into account?
Our primary care organisation (PCO) is having a purge of PPI prescribing and, following an audit of our use of these drugs, we have been changing patients requiring maintenance treatment from the market leader to a less expensive agent. We write to patients explaining the change when repeat prescriptions are issued. However one of my patients is refusing to co-operate. He admits that he has not tried the new drug, but feels that because his existing treatment has suited him for eight years it is unreasonable for us to stop it for financial motives. Because he is on the drug for symptomatic treatment of GORD, with no endoscopic abnormality, I feel inclined to tell him that he either accepts the change or goes without treatment. Can I do this?
A GP'S VIEW
Dr Peter Ilves, GP in South West London
There are four main issues here: the patient, the NHS finances, the pharmaceutical industry, and the evidence ensuring that any change is clinically safe.
Be very careful that you do not challenge the ethical code by which we must practice medicine - that is to treat patients in the best way we know how.
The GMC makes a statement in its code and guidance that we should consider the wider cost implications of treatments, but this is lower in its hierarchy than the clinical need of the individual patient.
Offering the choice between new treatment or no treatment is not clinically sound. If the patient requires symptomatic treatment then that fact is immutable; for the good of the patient the treatment should continue.
This might be an opportunity to establish whether the patient needs no treatment; in this case he should have no treatment, new or old. He might simply need an antacid.
There are strict evidence-based protocols for involving the pharmaceutical industry in delivery of changes, which must follow the ABPI rules. Be honest with the patient; explore the clinical need for his current therapy and give him the options openly and fairly. Involve him in the decision-making process and be clear that this is a financial initiative.
Compliance with and success of treatment depend on trust and information.
If the patient trusts you and is informed then you will both make the right decision.
We should all be aware that practice-based commissioning is, in part, a clever way of carrying out processes like this.
A PATIENT'S VIEW
Trevor Seemann, member of the Patient Partnership Group
It appears that the less expensive alternative medication is, in normal circumstances, equal in effect to the more expensive drug which this patient has been prescribed for what would appear to be an inordinately long period.
Eight years on a PPI is a long time and the patient's reluctance to accept change does not alone justify maintaining the status quo.
We all know that the NHS's resources are finite and that it is essential that prescribing economies are made wherever possible. This is in the interest of all patients because none of us wish to witness a bankrupt health service. In a free and fair society, the choice of the individual has to be tempered by the impact it has on the masses.
Patients do have rights and are entitled to expect an element of choice.
However there is no indication that this patient is in a life-threatening situation or would adversely suffer from a change of medication.
The patient needs to be convinced to accept the new drug regimen voluntarily.
As he is obviously intent on not changing I am inclined to agree with your proposal that he either accepts change or goes without treatment.
Patient choice does not mean that we have a right to the most expensive treatment available from an NHS that has financial limitations. Sometimes, clinical choices take precedence over financial concerns, especially in cases where experimental or revolutionary procedures or medication are concerned.
This, however, is not such a case. Hard as it may be for your patient to accept, he does not warrant exceptional treatment.
A MEDICO-LEGAL OPINION
Dr Richard Dempster, medico-legal adviser, Medical Protection Society
The GMC's guidance in good medical practice makes it clear that a doctor's first duty is the care of the patient. In fulfilling these duties it is important to respect a patient's right to be fully involved in decisions about their treatment.
You might want to discuss the patient's concerns further to find out why he is reluctant to change medication. Providing all available information about the new drug might help to reassure him. You might also want to explore other alternatives.
Although all doctors must appreciate that they need to be responsible with public funds, it would be quite wrong for you to discontinue or alter previously effective treatment purely for economic reasons.
I am sure that most PCOs accept that there will always be patients who disagree with proposed changes to their treatment, and situations when insisting on change is not appropriate. In these cases, PCOs should recognise that the correct course might be for the patient to continue with their tried-and-tested medication.
If you are still unsure about the correct course of action, you should liaise directly with your medical director, citing the GMC guidance, and seek assistance from your medical protection organisation if required.