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, tinyurl.com/safesedation), 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” (tinyurl.com/gmcprescribing), 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 http://www.ombudsman.org.uk/make-a-complaint/feedback-about-us 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