Wednesday 27 January 2016

Premedication by GPs - complaint to PHSO

By email.
27 January 2016

Dear Dame Mellor,

We, as a group of GPs, would like to bring to your attention our concern over a growing trend of requests for the prescribing by GPs of sedative medication for reasons such as investigative scans, dental treatment and on one recent occasion, for which we believe your office was involved, as pre-operative medication. Due to the potential risks involved sedation requires close monitoring and should therefore be the responsibility of the professional who is carrying out the procedure/investigation and able to ensure that proper precautions are taken (Academy of Medical Royal Colleges 2013, Safe Sedation Practice for Medical Procedures,, over which a remote prescriber such as a GP has no control.

The case in which we believe your office was involved is concerning to us all. We seek clarification of your role in this case and reasoning for the advice that was given to the patient involved.  The case details are as follows:

A patient was due to undergo a cataract operation about which they were extremely anxious and was instructed by the ophthalmologist involved to obtain a prescription for diazepam from the GP, to be taken on the morning of the planned procedure.  The GPs whom the patient requested this from declined to prescribe on safety grounds for reasons stated above. These reasons were explained clearly to the patient. The ophthalmologist was informed both verbally and with a letter.

The patient, dissatisfied at the GPs’ decision, allegedly contacted your office directly and was informed that it was the GPs’ responsibility to prescribe the sedative medication.  So far as we know, your colleagues made no attempt to gather information from the GPs involved and no written confirmation of the advice given by the Ombudsman has ever been received by the GP practice.

In an era of ever-increasing workload in the NHS it is of course important for colleagues to work collaboratively. However, this must be done appropriately, with prior  agreement, and with patient safety at the heart of the process. Taking responsibility for sedation during a procedure, which anyone who prescribes a pre-operative sedative drug accepts, is not part of a general practitioner’s areas of duty or competence.

The guidance from the Academy of Medical Royal Colleges (cited above) emphasises the importance of responsible sedation. We therefore find it most worrying that staff in your office might have given the impression that a GP should be expected to provide such a prescription without any attempt to gather details about the case.

We would like to draw your attention to the “Shared care” chapter of the General Medical Council’s 2013 guidance “Good practice in prescribing and managing medicines and devices” (, particularly paragraphs 35-39:

Prescribing guidance: Shared care
35. Decisions about who should take responsibility for continuing care or treatment after initial diagnosis or assessment should be based on the patient’s best interests, rather than on your convenience or the cost of the medicine and associated monitoring or follow-up.
36. Shared care requires the agreement of all parties, including the patient. Effective communication and continuing liaison between all parties to a shared care agreement are essential.

Prescribing at the recommendation of a professional colleague
37. If you prescribe at the recommendation of another doctor, nurse or other healthcare professional, you must satisfy yourself that the prescription is needed, appropriate for the patient and within the limits of your competence.
38. If you delegate assessment of a patient’s suitability for a medicine, you must be satisfied that the person to whom you delegate has the qualifications, experience, knowledge and skills to make the assessment. You must give them enough information about the patient to carry out the assessment required. You must also make sure that they follow the guidance in paragraphs 21 – 29 on Consent.
39. In both cases, you will be responsible for any prescription you sign.

This guidance would appear to preclude the prescribing of pre-operative or sedating medication for investigations by most General Practitioners, as they will not be familiar with the appropriate dosage for sedation nor in a position to monitor the patient for adverse effects, but as signatory to the prescription would be liable for any effects or adverse consequences of the drug.

We believe these important safety principles should be enshrined in policy at every level to protect patients’ safety and allow health professionals to continue to practice safe medicine. No doctor, whether based in general practice or hospital, should ever be coerced into prescribing any drug they do not feel they have sufficient knowledge of or competence to prescribe. We trust we can rely on you and your office to support these important safety principles.

We have put this letter in the public domain and would be happy to do the same for your reply.

Yours sincerely,

Two of the GPs of the patient in question (anonymised in the interests of patient confidentiality),
+John Cosgrove, GP, Birmingham,
John Hughes , GP, Manchester,
+Fran Ferner, GP, Cardiff,
+Emma Nash, GP, Portsmouth,
Tom Caldwell, GP, Worcester,
Hanne Hoff, GP, Farnham.

Reply received 2 February 2016:

Dear Dr Cosgrove
Thank you for your email to Dame Julie Mellor on 27 January 2016. I work in Dame Julie’s Corporate Casework Team and I have been asked to respond on her behalf.
I have read your email and can see that you have anonymised this information in the interests of patient confidentiality. Unfortunately, without the specific details of the case such as the name of the complainant/doctors and/or GP Practice we are unable to respond to the concerns you raise.
I should add that if the doctors involved have any concerns about our decision making they are entitled to ask us to reconsider the case. We can then take a view as to whether our decision was sound. Details of our review process can be found on our website at and this process is open to organisations in our jurisdiction as well as complainants.
I am sorry that we are unable to respond to your concerns at this time but if you would like us to consider the specific case then please ask the doctor(s) concerned to contact me.
Yours sincerely
Nicki SmithExecutive Assistant (Corporate Casework Team)Parliamentary and Health Service Ombudsman

My response 2 February 2016:

Dear Ms Smith,

Thank you for your response. Please note that we were not looking for feedback on this specific case. Could you please confirm Dame Mellor's agreement with the principles we have described?

Yours sincerely,
John Cosgrove.

Latest reply received 15 February 2016:

Dear Dr Cosgrove

Thank you for your email in which you ask us to confirm that Dame Julie agrees with the safety principles you relay in your first email. Whilst we recognise you are seeking an answer to the broad application of the safety principles we are unable to do so because our role is to provide final decisions on individual cases.  As I said in my previous email, we can consider any concerns that the doctors involved may have in our decision making. It remains open to the doctors involved to make a complaint to us about our decision making.

Yours sincerely

Nicki Smith
Executive Assistant
Parliamentary and Health Service Ombudsman

Thursday 21 January 2016

Why schools should not say "Get A Note From Your Doctor"

According to the Mail on Sunday, a growing number of schools are now demanding that parents of children unfit to participate in PE lessons consult GPs for letters.

"Bundesarchiv B 145 Bild-F010151-0007, Salzgitter-Lebenstedt, Volksschule" by Bundesarchiv, B 145 Bild-F010151-0007 / Steiner, Egon / CC-BY-SA 3.0. Licensed under CC BY-SA 3.0 de via Wikimedia Commons.

GPs are contracted to treat those who.are unwell or believe themselves to be unwell. In reality, most people know well that most illnesses are self-limiting and do not require medical treatment. If everyone consulted a GP about every self-limiting illness, we would be swamped. (Clearly, establishing that an illness is self-limiting can only be done confidently with hindsight; until then, judgement and risk-taking is required, whether that be of the patient or parent or of a healthcare professional).

With the growing workload in general practice and finite resources, it is imperative that we move towards less professional healthcare involvement (and/ore acceptance of risk by patients/parents/teachers/employers) in the treatment of self-limiting illnesses.

Writing notes for school is not an activity that GPs are contractually obliged to undertake. As such, they would be entitled to charge parents for such work if no other body is willing to fund it. This has the potential to discriminate against those least able to pay, also likely to be those most likely to be unwell. The blame for such discrimination would consequently lie squarely with those setting this policy, not with GPs.

Of course, it is not all about money. A very real danger here is that this policy will encourage more parents to bring their children to see their GP for self-limiting illnesses or perhaps even non-medical problems. The cost of this will be that the unwell will have to compete with this new group of patients for access to healthcare.

I also question whether I as a GP would be best-placed to make an assessment of whether a child is fit to exercise. If a parent says they are not, I would be inclined to believe them. If this happens frequently and they do not have a chronic medical condition (and would therefore be likely to provide evidence such as repeat prescriptions, obvious disability or hospital appointment letters), I might gently challenge that view. There is no reason why a teacher or school nurse could not do the same.

If a school nurse had concerns about a child's health (or perhaps that they might be missing too much PE), I would be very happy to speak to them as one healthcare professional to another.

If trust between parents and teachers has been lost, it is not the responsibility of GPs.

If anyone thinks general practice might be able to help with a particular problem, they should reach agreement with GPC before issuing advice to a population. This was one of the recommendations (3.3) contained within the Further Blueprint for Primary Care I co-wrote with Dr Hussein Gandhi (+Dr Gandalf ) in June 2015.

This is the full version of a response of mine quoted in an article in +Pulse Today.