Views & Reviews
No Holds Barred
Margaret McCartney: Don’t be bullied into prescribing Tamiflu
BMJ 2015; 350 doi: http://dx.doi.org/10.1136/bmj.h417 (Published 22 January 2015) Cite this as: BMJ 2015;350:h417- Margaret McCartney, general practitioner, Glasgow
I
have recurrent thoughts about times when doctors felt adamant about the
benefit of interventions—putting babies to sleep on their front, for
example, or giving steroids to people with head injury, or
bloodletting—that turned out to be lethal.
Now we have
guidelines, hundreds of them. Good guidelines would distil evidence
cautiously, making clear what we know and where the gaps are. They would
say how many people would get what benefit from a treatment, while
identifying the cost in terms of harm. But guidelines are not always
applicable to our patients,1 and they are meant to guide practice; rarely should they dictate it.
The
medical director and the centre director for the Thames Valley area of
NHS England have recently written to GPs about the prophylactic use of
oseltamivir (Tamiflu) for flu in nursing homes. They wrote, “It is
concerning that doctors may be deterred from prescribing antivirals and
this could be putting lives at risk.”
They noted
“differing interpretations of the evidence base” but added that the
Medical Defence Union has identified an “expectation on the part of the
public and the legal profession that NICE [National Institute for Health
and Care Excellence] guidance and PHE [Public Health England] advice
would be followed.” They also said “it is expected” that GPs “would make
a decision to prescribe based on the needs of their patient and the
evidence of best practice and guidance from national bodies such as NICE
and PHE,” adding, “There is also an expectation defined in the GMC’s
[General Medical Council] Good Medical Practice that a doctor will respond to an organisation advising on public health.”
This
reads as a veiled threat: if GPs decide not to prescribe oseltamivir
for all patients in a nursing home, lawyers and the GMC could dust down
their robes and eviscerate the doctor for not following orders. In a no
blame, patient centred NHS, things might be different.
Why
might doctors hesitate with their prescription pads? It could be
because 33 people have to be treated prophylactically to prevent one
case of flu.2
One in 20 will vomit, and one in 100 will have neuropsychiatric side
effects. Or maybe it’s because NICE didn’t include a negative trial in
its calculations.3 And PHE cites serial relative risks, but it remains unclear whether the data apply to multimorbid people in nursing homes.4
All
of this leaves us with a drug of uncertain, probably marginal
benefit—and difficult choices. The architects of mass public health
interventions still don’t grasp that populations are made up of
individual patients. Each person offered antivirals needs not just an
assessment of dose but also a discussion of risk and harm. Without extra
resources what work would PHE suggest that primary care staff stop
doing to fit this in?
Doctors must question what they are
told to do, speak up, and point out flaws in arguments when asked to
prescribe drugs of questionable benefit. Prescribing because of fear is
toxic to patient care and safety.
Notes
Cite this as: BMJ 2015;350:h417
Footnotes
- Competing interests: I have read and understood the BMJ policy on declaration of interests and declare the following interests: I’m an NHS GP partner, with income partly dependent on Quality and Outcomes Framework points. I’m a part time undergraduate tutor at the University of Glasgow. I’ve written two books and earn from broadcast and written freelance journalism. I’m an unpaid patron of Healthwatch. I make a monthly donation to Keep Our NHS Public. I’m a member of Medact. I’m occasionally paid for time, travel, and accommodation to give talks or have locum fees paid to allow me to give talks but never for any drug or public relations company. I was elected to the national council of the Royal College of General Practitioners in 2013 and am chair of its standing group on overdiagnosis. I have invested a small amount of money in a social enterprise, Who Made Your Pants?
- thebmj.com Blog: The BMJ Today: Should I prescribe anti-virals to prevent flu for nursing home patients? (http://blogs.bmj.com/bmj/2015/01/21/the-bmj-today-should-i-prescribe-anti-virals-to-prevent-flu-for-nursing-home-patients/)
- The BMJ’s readers can buy Margaret’s new book, Living with Dying, for £7.99 (RRP £11.99) including UK delivery from www.pinterandmartin.com with checkout code BMJ799.
- Provenance and peer review: Commissioned; not externally peer reviewed.
