Today’s report by the General Medical Council about prescribing errors makes salutary reading. If I have one criticism about it, it is that, as far as I can see, the research they commissioned focused on the views of GPs and their immediate colleagues, less so if at all on the patient perspective.
Are we hearing only one side of the story? I suspect so.
Does that matter? Absolutely.
The facts that emerged from the comprehensive research with doctors as well as the analysis of prescribing data may speak for themselves. But appropriate diagnosis of the issues raised, and proposals for improving practice, require a more holistic approach. The more immediate issue for the medical profession on days like this is that they have no patient commentary to put alongside their own views, to demonstrate a convergence of agendas. And if not a convergence, why not?
Reading the extracts from the GP interviews I confess that, while some made my blood boil, others did not. In fact, I felt some empathy. There is clearly a sense of real struggle if not bafflement on the part of our medical colleagues in knowing how to deal with some patients. Of running out of ideas. A tension that has it’s roots perhaps in embedded notions among GPs about their role and the role of the person who walks through the door. The whole language of ‘compliance’ or ‘adherence’ is revealing in itself.
It is good that the Royal College of General Practitioners (RCGP) and others have been smart off the blocks in saying that they will review their training of members in light of the report. Likewise, the GMC makes a lot of sensible recommendations that focus on the GP, their team, and how processes can be better supported and improved. Both are doing what they should, given the findings. Yet, I just wonder whether our onus on GPs and their systems as the beginning and end of the solution is misplaced.
For at the heart of the matter seems to be something deeper about the relationship between doctors and their patients, and also between patients and their medicines. My own relationship with, and attitudes and behaviour when it comes to, taking medicines are complex to say the least. I know it is the same for others. We must therefore look beyond the GP and their surgery for more durable solutions to the failures in practice highlighted by the GMC.
And then I remembered this report – ’N=1: Why people matter in medicines’ – which I have covered before on my blog and whose recommendations I have cut and pasted below. The overlaps with the GMC’s report are evident, the divergence as clear as day. Ahead of its time then? Ahead of its time now? It feels that way.
Recommendations for more effective engagement
The pharmaceutical industry, medicines regulators, commissioners and prescribers need to capture and appreciate what patients say about medicines more thoroughly and comprehensively, and to understand the stories that people tell about medicines: how they use them; the benefits they experience; and the adverse reactions that can arise, so that we can make the most of this area of healthcare.
Start the process with a collection of patient terms and descriptors, collected throughout the medicines system: in clinical trials; regulatory decisions; technical appraisals; the consulting room; the pharmacy, in order to help health professionals work with patients to get the most from a medicine they have decided to take.
Create new opportunities to capture and react to patients’ views and experiences about medicines. The current opportunity to report suspected adverse drug reactions through the Yellow Card Scheme needs greater use and a higher profile. We need to explore other options to report – for example developing a patient formulary and using initiatives like healthtalkonline.
The Expert Patients Programme should explore how it could further develop expert medicine users to provide support and advice to people about their medicines.
To build further on existing achievements, more sustained effort needs to go into the quality and design of medicine information leaflets, addressing a range of needs, and using a range of formats and approaches – including exploiting opportunities offered by new communication tools.
Recommendations for service improvement
GP consortia in collaboration with local networks of pharmacists, nurses and other healthcare professionals should introduce a proactive system of aftercare to allow patients to be contacted in the first few weeks after starting a new medicine. Some people may need longer-term support. We welcome the planned introduction of the Department of Health’s ‘new medicines service’ which may be an opportunity to improve the management of medicines use.
Every GP practice in the country should have access to a local pharmacist adviser, to whom they can refer patients with medication problems, and who can be used as a source of advice for both patients and GPs on medication related issues.
Patients should control access to their care record and, if they wish, allow pharmacists and other healthcare professionals to access and input into their electronic NHS patient record.
There should be a better use of information technology in general practices to assist the public in requesting and obtaining prescriptions.
Recommendations for improving research for the benefit of the public
Reporting guidelines on patient and public involvement in medicines research should be developed to: improve standards of reporting of patient and public involvement (PPI); strengthen the evidence base for PPI in medicines research; and encourage its inclusion in research design and conduct. These guidelines should be primarily aimed at scientists writing up their research for publication or involved in peer review, and at academic journals.
Health departments across the UK should collaborate and fund initiatives to improve public awareness and understanding of the importance and role of research in delivering quality care. We would like to see public involvement in health research extended to include their involvement in the development of new medicines.
The new National Institute for Health Research (NIHR) School for Public Health Research and NIHR Policy Research Unit on Behaviour and Health to be established as part of the government’s white paper proposals on public health should investigate public health-orientated approaches to the use of medicines, alongside conventional applications of pharmaceutical technologies.
Regulatory approaches should also support consideration of the population benefits of medicines use. The outcomes of regulatory decisions should be evaluated in terms of population health benefit, together with an evaluation of the acceptability of such an approach to the public.