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Benefits vs harm

Hard-wired GP

Luke Koupparis

Tuesday, 15 May 2018

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pills_AdobeStock_120891918_v2.jpgMedication plays a huge part in the management of many conditions that we see as clinicians. There are many more pharmacological treatments available for treatment than there were in the cupboards of doctors in the past. We are also seeing larger numbers of patients on multiple different types of medication, treating a myriad of co-morbid conditions.

In primary care, our clinical systems constantly flash up warnings at us on interactions, allergies, contra-indications, renal function, ongoing monitoring when new drugs are added or prescribed. There are also many more associated practitioners like clinical pharmacists working within primary care looking at stopping medications where they are not needed or at safety issues for those taking particular types of high-risk drugs.

So, I was interested to read about a new system to help the NHS monitor, learn from and prevent medications errors that has been launched by the Department of Health and Social Care. On the face of it, seems like a useful tool that would help improve patient safety and reduce mistakes in prescribing. However, it also plans to link prescription medication with an admission to hospital and the starting area will be GI bleeding.

It is likely that we can predict the headlines already. "GPs prescribing too many non-steroidal anti-inflammatory drugs resulting in patients being admitted to hospital with intestinal bleeding.

However, can we class this as a medication error that can be prevented or an unintended risk of taking the medication?

I am regularly presented with patients who rely on anti-inflammatory drugs to manage their pain of arthritis and despite my warnings of the risks they continue to take it (even buying over the counter if not prescribed). Many doctors will endeavour to prescribe PPI cover to reduce the risk of developing a GI bleed in patients who are taking NSAIDs. But there are risks with this. Many will have seen the recent US data that suggested a higher risk of death with taking PPIs.

So where does this vicious cycle end?

We prescribe to alleviate symptoms using drugs that work very well in many cases, but as with anything in life, there is no free lunch and we are faced with the unintended consequence of the initial treatment causing a side effect and having to prescribe further drugs to prevent this.

Many will say that we should not be prescribing drugs, such as NSAIDs, long term to patients who are at greatest risk of developing side effects. However, this group may not see the consequence of this action. We will then be faced with patients being left in constant pain and more immobile causing a reduction in quality of life and ongoing misery. Moving to other therapeutic classes is likely to present us with equal challenges and risks with groups suggesting they are also being overused.

There is also the other side of the story that causes concern here. Namely that doctors are not prescribing drugs fast enough. Take sepsis for example, where GPs have been criticised for not being aware enough about the early signs to treat effectively and quickly. However, we are also told that at least 1 in 5 prescriptions for antibiotics may be inappropriate and GPs are told to reduce prescribing levels to 10% in the next two years.

So, which group is the right one and the one we should listen to? How do we prevent ourselves getting caught up in the middle of different bodies, all wanting to pull us in different prescribing directions?

As with anything in medicine, the answer is that we need to consider each scenario in the context that it presents. It is certainly not black and white, as the Daily Mail headlines may suggest.

I completely agree that it is important to have a robust system that picks up human prescribing errors that have a negative impact on patients. We should learn from these mistakes and ensure we have a reflective culture to prevent recurrence.

However, I fear that this new tool will merely serve to generate tabloid paper headlines on how GP prescribing is contributing to hospital admissions and, no doubt, following on from that how this is contributing to hospitals being overrun. In my view, it will simply result in views being polarised into opposing sides, neither completely correct.

A tool that links prescribing to hospital admissions really doesn’t tell the whole story and cannot disentangle the complex job that all doctors perform treading a tightrope of treatment benefits vs iatrogenic harm. Perhaps it will serve to reinforce the vital role of the GP in looking at the patient in front of them in a holistic way, and not merely as a risk of admission statistic. Let’s hope so.

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Luke Koupparis

Luke is a general practitioner in the Bristol area with interests in men's health, child health, minor surgery, online education and medical information technology. He is the IT lead for Bristol clinical commissioning group. He also works as the medical editor to OnMedica helping to deliver high quality, peer reviewed information to the wider medical community. In his spare time he is a keen road cyclist.
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