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Why should there be carrots? - Withering's Wisdom - March 2015

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Why should there be carrots? - Withering's Wisdom - March 2015

According to the Daily Mail of February 18, GPs are to get yet another bonus ‘for doing their job’. It’s extraordinary, isn’t it? GPs must be the only group of workers in the country who can expect to get paid twice for doing what they’re already paid to do. I’m talking about antibiotics, if you hadn’t guessed. The Mail headline says that GPs can get bonuses if they prescribe fewer antibiotics and the article goes on to say that the suggestion has come from none other than NICE.

Really? I checked the NICE website. I found a draft guideline, for consultation, on ‘Antimicrobial stewardship’. It recommends setting up local antimicrobial stewardship teams to monitor antibiotic use, with peer review of GP prescribing – but no mention of any bungs – sorry, financial incentives. GP magazine also reports the NICE connection, though in less strident terms.

Its headline says that NICE has ‘suggested’ that GPs ‘could’ be incentivised to reduce antibiotic prescribing through the Quality and Outcomes Framework (QOF). However, even this is not accurate. The story actually comes from a comment made by the NICE director for clinical practice, Professor Mark Baker. That is a long way from being carved in the tablets of stone of NICE guidance; the official line is that NICE has no current plans to add antibiotic prescribing incentives to the QOF (the current QOF consultation document makes no mention of antibiotics).

However, this antibiotic ‘bung’ story is one that refuses to go away. Back in 2009, the Daily Telegraph reported that about half of all primary care trusts were running incentive schemes that paid GPs to reduce antibiotic prescribing. One paragraph reveals the addled thinking behind these schemes: “They [the PCTs] argue that it is necessary to pay GPs, who now earn an average of more than £100,000 annually, as explaining to patients why they should not receive an antibiotic can take a lot longer than simply writing a prescription.” It beggars belief, doesn’t it?

 

Giving GPs a financial incentive not to prescribe
interferes with clinical decision-making

 Incentivising GPs – or, indeed, any other health professionals – in this way, is wrong on so many levels. The first objection is obvious: GPs are already very highly paid; it’s ridiculous to have to pay them extra for what they should already be doing. From a psychological standpoint, it’s rewarding bad behaviour, something every parent knows not to do. The second is less obvious. Giving GPs a financial incentive not to prescribe interferes with clinical decision-making. What if an antibiotic is actually necessary – will the monetary conflict of interest mean that an inappropriate decision is made to defer prescribing or not prescribe at all, putting the patient at risk? It also affects the doctor-patient relationship.

A patient could be forgiven for asking: “How much do you get for not giving me an antibiotic?” That explanation would take a whole lot longer than simply writing a prescription! And then there is the fact that the NHS is desperately short of money. In what parallel universe would it make sense to give a bung to already very well-paid people to do something they’re already paid to do, knowing that doing this means less money for other services? And then the biggest reason of all – it doesn’t work anyway!

Back in 2009, half of all PCTs were already providing financial incentives to reduce antibiotic prescribing, yet, since then, despite all the well-publicised concerns about the development of antibiotic resistance, the number of prescriptions for antibiotics has increased, not decreased. If, as seems to be the consensus, GPs are responsible, we need a system that has more sticks and fewer carrots.

Where antibiotic prescribing is considered to be poor, the proposed antimicrobial stewardship teams should be given powers to insist that GPs undergo a training programme, and if that still doesn’t work, to name, shame and fine them. Up to now we have had too many carrots and not enough sticks: it’s time to give the sticks a go.

Pen name of a practising independent community pharmacist. Withering’s views are not necessarily those of ICP

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