Editorials

Safety, trust, and money are uncomfortable bedfellows

BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h5750 (Published 03 November 2015) Cite this as: BMJ 2015;351:h5750
  1. Stephen Chapman, professor of prescribing and head of medicines optimisation1,
  2. Therese Curtis, real patient volunteer2
  1. 1Centre for Medicines Optimisation, School of Pharmacy, Keele University, Staffordshire ST5 5BG, UK
  2. 2Newcastle under Lyme, Staffordshire, UK
  1. Correspondence to: S Chapman s.r.chapman{at}keele.ac.uk

Addressing safety should not need financial incentives

Safer prescribing has been an objective for physicians since Hippocrates. Yet medicines, although yielding massive net benefit at the population level, continue to cause harm to a considerable proportion of individual patients. Around 5% of hospital admissions could be associated with inappropriate prescribing.1 2

So what reduces errors? The PINCER trial3 compared simple feedback on prescribing errors with a pharmacist led intervention involving feedback, educational outreach, and dedicated support to GP practices. After six months’ follow-up, patients in the pharmacist led group were significantly less likely to have triggered indicators of unsafe prescribing such as receiving a β blocker if they had asthma or an ACE inhibitor or loop diuretic without appropriate monitoring. In a linked paper, Stocks and colleagues (doi:10.1136/bmj.h5501)4 took this one step further and extrapolated the indicators developed from the PRACTICE study5 to a representative sample of over 500 general practices using the Clinical Practice Research Database.

Within the composite indicators are some uncomfortable figures—in some practices, nearly 20% of patients taking aspirin or clopidogrel who had a history of ulcers were not prescribed gastroprotection. The figures for monitoring of medicines are equally unsettling—patients were taking high risk medicines such as warfarin or lithium without regular monitoring. Perhaps unsurprisingly, given the extent of polypharmacy, the prescribing errors are most prevalent in the elderly.

It seems unlikely that patients have declined monitoring or opted out of preventive co-prescribing after an informed discussion in such large numbers. It seems equally unlikely that such errors occur because of a lack of effort or intelligence on the part of the prescriber. So why does it happen? The usual suspects of time pressures, workloads, and patients lost in repeat prescribing of chronic medications while GPs battle with the immediate problems of the working day offer some explanation.

Since the early 1990s “big data” on the prescribing of medicines have attracted the attention of policy makers, budget holders, regulators, and academics as they strive to understand the complexity of primary care and produce benchmark indicators that can help target support to where it is needed most.6 The approach of Stocks and colleagues, using data on individual patients, seems sound.5 Where we part company with the authors is on what to do with the indicators.

Stocks and colleagues believe that the presence of practices with zero errors “sets expectations.”4 They also suggest that striving for such excellence could be encouraged by some form of financial incentive. Striving for excellence is something we would all readily sign up to, but it does sail dangerously close to the idea of league tables for prescribing safety. Financial incentives work if you subscribe to the “money talks, people mumble” school of thought. The tangle that the UK Quality and Outcomes Framework has become is surely leading policy makers to less simplistic thinking.7 Is pay for performance really a good basis for a productive relationship between patients and clinicians?

Our views, as an academic and a patient involved in undergraduate teaching, are in agreement. As patients we trust our doctors, and if, like in any other profession, heterogeneity exists and occasionally errors occur, we want to support them and in so doing reduce the possibility of such errors happening again. We don’t believe the only reason an individual or a practice will strive to do better is to earn money. We do believe that when problems are identified all health professions will pull together to make the necessary improvements.

Consultations involving multimorbidity and polypharmacy are inherently complex and require attention to the evidence but also to patients’ needs and preferences. Personalised medicine, biologics, and bio-similars are here to stay and are only going to increase in volume and add to complexity. Exquisite consultation skills and true clinical expertise are required; both seem unlikely to be deployed and developed as a result of financial incentives. A greater understanding of human decision making along with a renewed focus on consultation skills has the potential to support the move from “evidence based medicine” to “evidence informed decision making.”8 The indicators proposed by Stocks and colleagues have laid down one excellent platform against which an individual practice can judge success.

But doctors and patients need time to make good therapeutic decisions. Recent announcements by the Royal College of General Practitioners and the Royal Pharmaceutical Society9 have heralded an era in which clinical pharmacists routinely work with colleagues in primary care. Practice teams that include a clinical pharmacist to provide specialised knowledge on medicines could create that valuable time for patients. If the findings of Stocks and colleagues encourage such teams and help focus our efforts then safer prescribing and reduced variation should follow. If that happens, everybody benefits, most importantly, the patient.

Notes

Cite this as: BMJ 2015;351:h5750

Footnotes

  • Research, doi:10.1136/bmj.h5501
  • Competing interests: We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: SC received payment from Rosemont Pharmaceuticals for a lecture on medicines optimisation; he is a director of PDS, a university spinner company that produces decision support tools; he has unrestricted grants from Rosemont and Flynn Pharmaceuticals to develop medicines optimisation websites on insomnia and dysphagia and an educational grant from Boehringer Ingelheim as part of a joint working agreement with NICE to produce an implementation tool for NICE atrial fibrillation guidance.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References

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