Locums not represcribing neccesary medications. Negligence ?

[RogerHarris]

Getting prescriptions can be a real hassle sometimes. Especially if you are on daily medications to keep health. Here is some of the things that i have found throw a spanner in the works.

 

 

PRACTISE FACTORS

 

Practise holidays or training (training times unpredictable)

GP holidays or illness (Locum doesnt agree with doctors prescribing)

 

 

EXTERNAL FACTORS

 

own issues preventing getting to practise and/or chemist (numerous)

Prescribing problems at chemist

 

Some generic brands give side effects others dont, and the chemists switch brands constantly. So there has to be factored time in to go roaming round chemists.

==

 

MY GP is off for three weeks. I'm having another locum problem. Every time a locum replaces the GP they almost always have a problem with whatever he prescribes me. I go the practise to find refusals for presriptions i need to prevent illness and going into a sudden withdrawal. Losec and zopiclone. I thought the zopiclone would be an obvious one, but it seems it can extend to losec (omeprazole) as well.

 

It took ten days to have a suitable time to see the locum, and there is no represcription till he approves that, and even after all that, ive met locums who will happily let you slide into illness, because they dont agree or believe what the GP prescribed.

 

Previously i didnt have a job, so i could become sick or withdrawn, due to this hassle. Now a lot is at stake, as i'm self employed.

 

The no brainer is this. The locum steps in and says to himself, "this person asked for repeat of Psychiatric zopiclone and losec, thats 4 days early. No presciption" They Refused the entire prescription on the basis of one of the drugs being early (being early to allow time to tide over the repeating problems already mentioned, such as the current one, taking almost two weeks to resolve)

 

So what are they thinking (or not thinking). If they refuse a medication such as zopiclone, the patient can go into a state of withdrawal. IF they refuse the losec on the grounds it came in at the same time as the other prescription which was early, then the patient gets sick physically as well as being thrown into a withdrawal.

 

The patient has to be off work, and thrown into what is a chaos where anything can happen, till he can see the locum.

 

A withdrawal needs to be controlled as far as i am aware, so whats going on here ? I am sure someone could point out a way to deal in advance with this scenario. As you can see i already had to plan for too many scenarios already.

 

At the end of the day, there are a whole lot of things which can unpredictably cause a problem with getting a prescrption, so the practise of refusal, appears like negligence of some kind. I have been going through this for years. Others must have similiar problems.

 

The GP receptionist told me, that her husband found the omprazole generics, were inneffective, so like me he was requesting double dozed to get relief. The pharmacies and drug makers denied this for years. This is just one example, where it goes wrong. But its only at the stage where i can finally say to the doctor, look your receptionist had the same problem as me, that he finally listened. Previously i had tried explaining to him the drug companies keep their substrates for producing secret, (or sell them privately) which is one of many reasons why a lot of generics are poor imitations.

 

Taking these factors into account, the patient should be presribed by default, and asked at collection of that prescription to see the doctor or locum, at which point the reasons why they did not presribe will be discussed.

 

Without this rule as a safety net, it appears to there is some kind of negligence, constanly re-occuring.

[GlasweJen]

you should be able to make a same day emergency appointment to see the locum or just request that another doctor deals with you until your own doctor gets back.

[RogerHarris]

you should be able to make a same day emergency appointment to see the locum or just request that another doctor deals with you until your own doctor gets back.

 

Been through this. Regularly other doctors dont agree each others decisions, and resort to non prescribing by default. IT should be the reverse, they ought to prescibe by default, till the doctors sort it out amongst themselves which would hopefully include some kind of plan to deal with the ramifications of not prescribing.

 

For example if Doc A says to Doc B, this is bad practise, then a plan has to be put into place for dealing with taking away the medications. None of this happens. It appears like gross negligence.

 

EDIT. The plan also needs to take into account, when the patients life is able to accomodate with the stress of such a change. So really not only should there be no prescription refusal, but even if the doctors agree to not prescribe at some stage ahead, that needs to be done in agreement with the patient.

[poppynurse]

It may be that the doctor is not happy with you being on zopiclone long term as it's addictive and designed for short term use, you don't mention the dose you take but if it is only small the effects of withdrawal are not harmful. In the bad old days GPs used to prescribe sleeping pills long term until the problems of doing this became apparent but there are still some GPs who are behind the times, it may be that your locum is actually doing you a favour. However if you are on a high dose and have been using for a long time then gradual reduction is more appropriate. Unfortunately with any withdrawal of sleeping tablets there may be a rebound insomnia.

[RogerHarris]

It may be that the doctor is not happy with you being on zopiclone long term as it's addictive and designed for short term use, you don't mention the dose you take but if it is only small the effects of withdrawal are not harmful. In the bad old days GPs used to prescribe sleeping pills long term until the problems of doing this became apparent but there are still some GPs who are behind the times, it may be that your locum is actually doing you a favour. However if you are on a high dose and have been using for a long time then gradual reduction is more appropriate. Unfortunately with any withdrawal of sleeping tablets there may be a rebound insomnia.

 

This is really about refusal as a principle in itself. The locum also refused to represcribe losec, which i have had daily for 15 years and get ill as soon as its withdrawn. If they want to re-diagnose or find the root or another cure for the stomach problem, thats fine. That is not whats going on.

 

Regarding sleepers, how can a decision be made to suddenly throw a person into a complete drug withdrawal with no notice ? The withdrawal itself is a shock. which can drive a person crazy, never mind have it put upon you unexpectedly while trying to run a life.

 

I find this policy of refusal hard to reconcile at any level. They should prescribe and when you pick up that prescription, ask you to come and see the doctor. Not leave you stranded and landed with the re-emergence of illness.

 

To the person who made the point about emergency appointments, i cannot count the number of sick weekends i had where the prescription problems occured and no GP was available at weekends. It wasnt an emergency, but it sure messed up the weekend with a knock on effect through the next week, trying to recover.

 

Going to see the locum tommorow. I'll be recording his answers to these questions, to find out what their reasons are.

[RogerHarris]

Going to grill the locum tommorow, and ask him the following.

 

1. Did he check my medical history to establish why i need these prescriptions.

 

If locums answer yes, i'll ask him to tell me what that history told him to establish to what degree there is reasoning and depth of thinking. (my fear is that there isnt any, but id like to be pleasantly surprised)

 

2. Did he check my prescription record to establish if i had broken an overall prescription pattern, or did he just refer to the repeat prescription notes ? (the point being that these two are often not consistent in real time with each other)

 

3. When considering refusal of a prescription did he investigate the ramifications of non prescribing on patients health, such as withdrawal leading to illness ?

 

If yes, ill ask him what those ramifactions, to see what depth they went to.

 

 

The point is, if there is poor depth of thought when refusing, then the policy should be prescribe until, some effort can be brought to bear on the issue. Really what i'm trying to get a grip on, is if the refusal is linked to real health issues, and they were concerned about me as a patient, or has this policy come about to keep NHS budgets. If its the latter then how can i take these people seriously as doctors ?

[poppynurse]

This is really about refusal as a principle in itself. The locum also refused to represcribe losec, which i have had daily for 15 years and get ill as soon as its withdrawn. If they want to re-diagnose or find the root or another cure for the stomach problem, thats fine. That is not whats going on. I would suggest that if you have required omeprazole for 15 years that you ask the doctor what the underlying condition is and if there is any definitive treatment for it - things have moved on in 15 yrs. If you are ill as soon as it is withdrawn there could be a problem that is being masked, normally when folk miss a dose may just get a bit of indigestion. Also are you aware that you can now buy omeprazole direct from the pharmacy

 

Regarding sleepers, how can a decision be made to suddenly throw a person into a complete drug withdrawal with no notice ? The withdrawal itself is a shock. which can drive a person crazy, never mind have it put upon you unexpectedly while trying to run a life. I agree that the doctor should have agreed withdrawal with you but it something that a good doctor will always be thinking of, long term sleeping tablets are bad news.

 

I find this policy of refusal hard to reconcile at any level. They should prescribe and when you pick up that prescription, ask you to come and see the doctor. Not leave you stranded and landed with the re-emergence of illness. Fair point!

[ScarletPimpernel]

Getting prescriptions can be a real hassle sometimes. Especially if you are on daily medications to keep health. Here is some of the things that i have found throw a spanner in the works

 

 

PRACTISE FACTORS

 

Practise holidays or training (training times unpredictable)

GP holidays or illness (Locum doesnt agree with doctors prescribing)

 

That's clinical judgment, and is a matter for the doctor, since he is the accountable one.

 

EXTERNAL FACTORS

 

own issues preventing getting to practise and/or chemist (numerous).

 

Hardly the fault of the GP.

 

 

Prescribing problems at chemist

 

Some generic brands give side effects others dont, and the chemists switch brands constantly. So there has to be factored time in to go roaming round chemists.

 

I assume you mean dispensing problems; pharmacists don't prescribe. The whole point of using generic medications that they are all manufactured to the same standard. If a particular brand is causing problems, it could be a serious issue, and should be reported. There is a mechanism for doing this, through your GP - another reason for seeing him. It is possible for a doctor to prescribe branded medication in certain circumstances, but they are otherwise required to prescribe generically. In the alternative, you could ask the doctor to issue you with private prescriptions - you can then have the brand names you want, though you will have to pay the full price for them.

 

 

MY GP is off for three weeks. I'm having another locum problem. Every time a locum replaces the GP they almost always have a problem with whatever he prescribes me. I go the practise to find refusals for presriptions i need to prevent illness and going into a sudden withdrawal. Losec and zopiclone. I thought the zopiclone would be an obvious one, but it seems it can extend to losec (omeprazole) as well.

 

It took ten days to have a suitable time to see the locum, and there is no represcription till he approves that, and even after all that, ive met locums who will happily let you slide into illness, because they dont agree or believe what the GP prescribed.

 

You can address problems about appointments with the Senior Partner at the practice. They will have a procedure for this.

 

Previously i didnt have a job, so i could become sick or withdrawn, due to this hassle. Now a lot is at stake, as i'm self employed.

 

The no brainer is this. The locum steps in and says to himself, "this person asked for repeat of Psychiatric zopiclone and losec, thats 4 days early. No presciption" They Refused the entire prescription on the basis of one of the drugs being early (being early to allow time to tide over the repeating problems already mentioned, such as the current one, taking almost two weeks to resolve)

 

So what are they thinking (or not thinking). If they refuse a medication such as zopiclone, the patient can go into a state of withdrawal. IF they refuse the losec on the grounds it came in at the same time as the other prescription which was early, then the patient gets sick physically as well as being thrown into a withdrawal.

 

The patient has to be off work, and thrown into what is a chaos where anything can happen, till he can see the locum.

 

A withdrawal needs to be controlled as far as i am aware, so whats going on here ? I am sure someone could point out a way to deal in advance with this scenario. As you can see i already had to plan for too many scenarios already.

 

At the end of the day, there are a whole lot of things which can unpredictably cause a problem with getting a prescrption, so the practise of refusal, appears like negligence of some kind. I have been going through this for years. Others must have similiar problems.

 

These again are issues that you should resolve with the Senior Partner at the practice, or through the Patient Advice and Liaison Service at your PCT. It should be possible to come to a working agreement.

 

The GP receptionist told me, that her husband found the omprazole generics, were inneffective, so like me he was requesting double dozed to get relief.

 

The receptionist's recounting of her husband's opinion on medication is neither a valid clinical observation nor objective, and is probably inappropriate anyway.

 

The pharmacies and drug makers denied this for years. This is just one example, where it goes wrong. But its only at the stage where i can finally say to the doctor, look your receptionist had the same problem as me, that he finally listened. Previously i had tried explaining to him the drug companies keep their substrates for producing secret, (or sell them privately) which is one of many reasons why a lot of generics are poor imitations.

 

I'm afraid this is just tin-foil hat conspiracy theory. Unless, of course, you can point us towards some research.

 

Taking these factors into account, the patient should be presribed by default, and asked at collection of that prescription to see the doctor or locum, at which point the reasons why they did not presribe will be discussed.

 

Without this rule as a safety net, it appears to there is some kind of negligence, constanly re-occuring.

 

I disagree. I would not wish to see a doctor who is happy to continue issuing prescriptions without regularly reviewing the patient; that would be negligent.

 

It is an unfortunate fact that patients are not best placed or qualified to know what is clinically most appropriate for them; if they did we wouldn't need doctors! A medical practitioner cannot be considered negligent just because he doesn't do what the patient wants.

 

In summary, it's clear that there are some problems in this case, most of which centre around communication rather than clinical issues. None of them are insurmountable, in my view.

[RogerHarris]

That's clinical judgment, and is a matter for the doctor, since he is the accountable one.

 

 

 

Hardly the fault of the GP.

 

 

 

 

I assume you mean dispensing problems; pharmacists don't prescribe. The whole point of using generic medications that they are all manufactured to the same standard. If a particular brand is causing problems, it could be a serious issue, and should be reported. There is a mechanism for doing this, through your GP - another reason for seeing him. It is possible for a doctor to prescribe branded medication in certain circumstances, but they are otherwise required to prescribe generically. In the alternative, you could ask the doctor to issue you with private prescriptions - you can then have the brand names you want, though you will have to pay the full price for them.

 

I already tried asking to pay for the original. There is a double edged problem here. The generic companies and pharmacists both have a need for each other. They both increase each other profits through a process of trimming the product to its most efficient level. The generic companies in production, and the pharmacies in distribution. This process of efficiency operates on a feedback basis, with some companies having higher standards than others. You could compare that to any other competing market.

 

Like any vested interest system of this kind they are not able to admit to the customer there is a problem, when the customer is at the point of need. So the pharmacist will deny till he is blue in the face, that there is even an issue in this area. Right at the point of need, and when they have dealt with customer number 15 that month telling them the same thing. That looks like pharmacists telling porkies to me.

 

I noticed boots log customers complaints on generics and pass them to head office. They dont admit to the customer there is ever a problem, but over time, eventually will drop the really inneffective brands. They still dont publicly admit those brands were inneffective. So this system operates to increase its efficiency by submitting its customers to recieving less of what they need, while putting them through impersonal treatment, and denying they do so. Well is sure is a good way to ensure that people look after themselves. Who wants to get sick in this environment ?

 

The research paid for by the generic companies and carried out to prove the effectiveness of their own brands, is not a repetition of the research carried out on the original drug in regards to dose effectiveness. It can sets its own goalposts for that. The research priority is toxicity. It doesnt have to say 20mg of omeprazole works exactly like 20mg of losec. Yet for some reason its presumed that it does. Probably because the packaging implies it. Almost any drug addict could tell you the difference between brands of methadone by blindfold, and which works better. So obviously they are not the same.

 

This creates a problem when faced with the GP. The GP is told that the generics work as well as the originals, because their own trials said so. So what grounds has he to prescribe a patient asking for the original drug ? If you apply your own reasoning across the board, the patient does not know what is good for him, the GP does, and the patient is treated as annoying, until enough patients are telling him the same thing. SO once again. Here is an issue which takes time to resolve. While its being resolved, the patient needs the benefit of the doubt.

 

=====

 

I'm Sure glad you arent my GP. You played devils advocate with much of what i wrote, while conceding to none of it, while sounding like a detached robot. What you did was really stick to a few points you THINK you are sure of by authority. It kind of re-enforces what i just said about that kind of behaviour in the health system. Theres a film in the USA about this kind of business like behaviour in the health system called "sicko". Its point is that patients get shafted, while professionals get very wealthy, and overall the ratio of quality treatment to money is extremely low.

 

You know, a couple of decades ago in britain, we could get ill, close to death, relatives die, but we would never think about sueing the doctor, because back then our doctors were benevolent, in that they had a better affiliation with the people they treated. Things have changed. I've seen it happen slowly with my own GP. The move from budget premises to nice buildings, littred with brand adverts from the waiting card to every knick knack on the GP's desk. His behaviour is different. They are less confident in their own judgement, and this appears to put barriers between them and how they treat. My take on whats going on is facilitated by an inside view. My mother is a health professional in the NHS. She gets offered financial incentives, perks to endorse by means of her appointment to teach and train. She is given purpose and prestige by these private institutions, and she talks just like you sometimes.

 

Whats the result of all this ? Patients dont trust their health professionals judgement so much, if they think their thinking is over-controlled by money. There is something about all this which i thinks irks the soul of suffering people. A loss in bedside manner ? The patient in return will see their doctor as a piece in this game, and so the professionals in this becomes concerned with liability, the paitients will punish for consequence. In another couple of generations, the memory of the way things used to be will forgotten, and so it will not bother us so much anymore. The younger generation already dont know what i'm talking about. Benevolance ? Whats that ? The threat of sueing their health professionals is deemed a necessary evil.

[ScarletPimpernel]

Rest assured that I will never be your GP, not least because I am not a doctor!

 

You played devils advocate with much of what i wrote, while conceding to none of it, while sounding like a detached robot.

 

Alternatively, perhaps I tried to look at the situation dispassionately and objectively; I'm sorry if the answer is not what you wanted to hear, but that is a matter for you. It's just my opinion, of course; I'm in no position to influence anything at all.

 

I agree that there is a problem, but I think that it is largely one of communication rather than either negligence or some sort of conspiracy between doctors, pharmacists and drug manufacturers. I remain convinced that if you bring your concerns to the senior partner at the practice, or the PCT, some sort of working arrangement will result.

 

You don't appear to have taken prescribing guidelines into account, for example (national and local). Perhaps an explanation of these may assist you in determining how to proceed.

 

I note your interesting comment about generic drug testing, but surely a process already exists to report adverse reactions and ineffective drugs?

 

I agree with you that way in which parmaceuticals and other health products is sold in this country is deeply unsatisfactory and unsavoury.

[poppynurse]

How did you get on with your locum yesterday?

[RogerHarris]

How did you get on with your locum yesterday?

 

Surprisingly well. He had prescription records on a screen, explained what had gone wrong and modified the records to take into account the points i raised. It does appear like there was a lack of depth in thinking.

 

Luckily i had a fortnights spare prescription in advance, as thats how long this took to deal with.

 

when pressed on what the policy was on prescribing he said it was up to the gp. His policy at his own practise was to prescribe, and call in the patient when in doubt. As i thought it should be. He said other GPs or locums could be inflexible in this regard.

 

One good thing about this thread, is that it helped me to sort out relevant thoughts. When a person gets refusals at the point of medical need, it has a disorientating effect.

[mazzab]

Dear Roger

 

I am a GP and you raise some valid and interesting points. I think you need to sort out a long term plan with your own GP rather than a locum to sort out what you should be taking and what you shouldn't.

 

If you are convinced of the need for a particular brand of omeprazole then discuss a branded prescription with your GP, and get it on repeat. You could make the convincing points to him that you made in your above post (you might even suggest he reads this thread!)

 

I totally agree that someone with persistant symptoms for 15 years needs occasional investigation for helicobacter infection, ulcers etc every so often - this may be endoscopy or just blood or stool tests for helicobacter antigen.

 

As a GP I can thoroughly understand the reluctance of locum doctors to issue prescriptions for zopiclone - its a rubbish product with high addictive potential, rapid development of tolerance and frequently used as a drug of abuse.

 

I appreciate you have been using it for a long time and don't sleep without it - I would have warned you at the start that that would happen! I think you need to talk to your GP about why you need it regularly and possibly agree a withdrawal program.

 

If it was on formal repeat, or a plan was documented in your notes for formal withdrawal, your prescribing issues would be avoided. You need to sort out with you GP a specific dose aregimen nd repeat prescription to supply that dose and then stick to that dose rather than overusing - repeat prescriptions for 14 days worth of drugs issued every 10 days will make everyone suspicious - that's not getting it early every time but repeated overuse of a regular prescription - ie it should still be 14 days after the last one each time if you use them as prescribed even if you get it early - you will get it early 14 days after the last issue every time.

 

We know people take more, or sell them on, or stockpile for suicide attempts etc, etc. We have a duty to you the patient, but also to the community who fund the treatment, to ensure prescription drugs are not abused. I suspect there is a suspicion that this is what you are doing by the GPs in your practice. you need to have an open and frank discussion about this - but you may not get everything you want - that's compromise!

 

The NHS is there to look after the health of the whole community. It is not a free source of medicines just because you want them. I agree with comments regarding the role of doctors as gatekeepers to prescription drugs - just look at other countries with less regulation and you will see massive innapropriate use and abuse of meds like dihydrocodeine, benzodiazepines, antibiotics etc.

 

i think that you need a more holistic approach rather than just hoping a pil will make it all better. it rarely will!