General practice threatens to withhold repeat prescriptions until patients have flu vaccineBMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j4682 (Published 10 October 2017) Cite this as: BMJ 2017;359:j4682
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Re: General practice threatens to withhold repeat prescriptions until patients have flu vaccine - An opportunity to air a data quality issue
Whilst we can’t condone any unfair pressure on patients to have their influenza vaccine at the surgery (1), there is a downside of pharmacist vaccination which this article provides the opportunity to air. The issue is that of data integrity following pharmacist administered vaccination.
The communication from pharmacist to GP after they administer a flu jab is suboptimal. It is often a paper sheet which just states that the immunisation has occurred and does not provide either the vaccine manufacturer or batch number details. The paper communication does not provide any recommendation about the importance of coding the key data into practice computerised medical record (CMR) systems – in contrast to many other communications, even the police, give recommended codes to use around the issue of firearm licences.
The limitations of the current approach are:
• The information, if sent on paper, might just get scanned into the patients records (not coded) and will not be visible when it comes to conducting searches for who is immunised
• There are no recommended codes to ensure consistency of coding
• Missing data about vaccination can affect our ability to monitor vaccine effectiveness. The established method requires us to know accurately whether a patient with flu has or has not been exposed to vaccination (2).
• The lack of information about manufacturer or batch number makes monitoring of adverse events (currently recommended by the European Medicines Agency) more challenging (3); and reduces the chance of being able to link any severe adverse event to brand or batch.
• Whist some pharmacies use a bespoke software that provides a record for the patients General Practice – it does this as a .pdf (Adobe’s Portable Document format). It would be much better if it transferred coded information, in the way for example that blood test results are transferred into general practice CMR systems.
In a health system where patients increasingly enjoy the benefits of electronic prescribing, and much other data are shared electronically, a better way of passing more complete information about pharmacist vaccination back to GP records should be found.
Simon de Lusignan
Professor of Primary Care and Clinical Informatics, University of Surrey
Medical Director Royal College of General Practitioners (RCGP), Research and Surveillance Centre,
Euston Square, London, UK
Medical Director RCGP Clinical Innovation and Research Centre
Chair of Clinical Innovation and Research RCGP
(1) BMJ 2017;359:j4682
(2) de Lusignan S, Correa A, Smith GE, Yonova I, Pebody R, Ferreira F, Elliot AJ, Fleming D. RCGP Research and Surveillance Centre: 50 years' surveillance of influenza, infections, and respiratory conditions. Br J Gen Pract. 2017 Oct;67(663):440-441. doi: 10.3399/bjgp17X692645.
(3) de Lusignan S, Dos Santos G, Correa A, Haguinet F, Yonova I, Lair F, Byford R, Ferreira F, Stuttard K, Chan T. Post-authorisation passive enhanced safety surveillance of seasonal influenza vaccines: protocol of a pilot study in England. BMJ Open. 2017 May 17;7(5):e015469. doi: 10.1136/bmjopen-2016-015469.
Competing interests: Simon de Lusignan as part of his University role is the Medical Director of the RCGP Research and Surveillance Centre - its public health role includes surveillance for influenza and supporting estimates of vaccine effectiveness. Simon is also a member of a number of European vaccine research consortia has a grant from GSK to pilot a system to monitor European Medicines Agency Vaccine side effects; (all of these are through the University of Surrey). These activities are frustrated through an inability to get complete brand-specific vaccination data. Matt Hoghton has no competing interests. Imran Rafi has no conflicts of interest.
JK Anand's commentary is spot on and makes the case for health care reforms that have long been been avoided. Paternalism, the selfish greed of many medical practitioners, the profit-seeking interests of the pharmaceutical and medical device industry, and the compliant expedience of politicians explain why these reforms have not been adopted.
Paternalism--"the doctor knows best"--is always a moral hazard for physicians and is a clear and present danger for patients in every encounter with a physician.
Payment of fees for service invites fraud and abuse. How could it be otherwise in a system that operates largely on the ill-founded assumption that physicians are committed to their patient's best interests, including the patient's and society's ability to pay?
So-called "quality" is an ill-defined and elusive concept in the practice of medicine, as the BMJ editor recently editorialized when pointing out the unrelieved uncertainty of medicine (1).
And, yes, paying doctors on a fee-for-service basis to report harmful side-effects of the medicines they prescribe would leverage the perverse incentives of the fee-for service system to produce a tad more of enlightened practice of medicine.
1. Godlee, F. Unrelieved uncertainty. BMJ 2017;358:j4347.
Competing interests: No competing interests
Assuming the headline is correct, the GPs concerned were acting unlawfully. They did not seek informed consent. They just demanded that jabs be accepted.
Here is a suggestion. Please give ALL general practitioners a respectable per capita yearly allowance and abolish fee per immunisation, per IUCD, per condom prescription, per every other procedure. Bin the Quality Outcome nonsense.
Here is a challenge. Pay a doctor (hospital or private or NHS GP) a fee for notifying every side-effect of any drug, including imm and vacc products.
I have a hunch that we will see medicine practised with greater conscientiousness.
Competing interests: No competing interests