Towards rational prescribing

One tenth of the NHS's budget (pounds sterling 3.6 billion in England and Wales in 1992-3) goes on drugs prescribed by general practitioners. This drug bill grew by 14% last year, making it a target for Treasury efforts to find politically acceptable ways of limiting NHS spending. Despite recent headlines of “GPs' wasteful drug habits” British general practitioners prescribe fewer drugs than their counterparts in many developed countries and are usually described as “conservative prescribers.”1 But, according to the Audit Commission's recent report A Prescription for Improvement: Towards More Rational Prescribing in General Practice, they should become even more conservative.^2,3

Based on studies of 10 family health services authorities and interviews with 54 practices, the report details examples of “best practice.” The authors insist that what they want is rational prescribing - that is, prescribing that takes account of efficiency, safety, appropriateness, and economy - not cheaper prescribing. In some cases, rational prescribing could even increase the drug bill - for example, if all general practitioners prescribed half as many inhaled steroids as they do bronchodilators then drug costs would rise by pounds sterling 75m. But deaths would fall, and the total cost to the NHS of patients with asthma would fall because of fewer hospital admissions.4

The report claims that substantial savings would result from less overprescribing (which would save pounds sterling 275m), the prescribing of fewer drugs of limited clinical value (pounds sterling 45m), and more generic alternatives (pounds sterling 50m). Given the variations in prescribing, many general practitioners would agree that there was appreciable room for improvement.

The reasons given by the report for the increase in the total cost of drugs prescribed by general practitioners include more elderly patients; the shifting of work into the community; the impact of new drugs, such as cholesterol lowering agents; health promotion; increased demands by patients; the pharmaceutical industry's “hard sell” tactics; and the shifting of costs from hospitals. General practitioners' spending on expensive specialist drugs rose by one fifth between 1991-2 and 1992-3. The report also cites evidence that unemployment leads to more consultations and higher prescription rates.5

From the general practitioners' perspective, the sticking point is time. Longer consultations, allowing explanation and reassurance, could reduce the “quick fix” of a prescription to end some consultations. Rethinking prescribing, reviewing individual patients, using the potential of computer systems, and changing patients' expectations all take time. Yet where is this extra time to come from? The interim results of the national workload survey show that consultation times are falling while workload has increased by nearly 10% in three years.6 The report's solution - more delegation to practice nurses, counsellors, and others - won't work. We know from the workload survey that the average general practitioner's 65 hour week increases with the number of staff employed.

The Association of the British Pharmaceutical Industry suggests in Cheap Prescribing: Can We Afford It? that British general practitioners already prescribe fewer innovative medicines than their counterparts abroad.7 They may therefore miss the benefits that new drugs can have in reducing the costs of treatment and investigation and in preventing illness.

Encouraging doctors to prescribe cheaper medicines may not always be truly cost effective. Examples include the failure of British doctors to use modern treatments for hypertension; we still favour β blockers and diuretics. Other European doctors prescribe newer angiotensin converting enzyme inhibitors - although they cost more, the association and some doctors in Britain believe that they are more effective. The association suggests that treating the estimated six million adults with raised blood pressure not currently receiving drugs would cost pounds sterling 280m- 380m. However, the return would be pounds sterling 800m savings in hospital treatments of cardiovascular disease.

The Association of the British Pharmaceutical Industry is also concerned that because a drug's therapeutic effects may not have been fully explored on release they may never be exposed if the medicine is underused. Although general practitioners respect the association's responsibility to protect a valued, successful, and research based industry, their future preoccupations are likely to be wider than the industry's, particularly if they see the budget for hospital services being reduced as a result of “overspends” on prescribing.

Predicting how much support general practitioners will give to the various initiatives to contain prescribing is difficult. They viewed the recent rise in prescription charges as illogical and unfair and favoured a review of the whole system. On the other hand, they have been reassured that the advisory committee on extensions to the limited list has secured professional advice and has taken a reasonable time over its deliberations. The use of indicative amounts to contain the costs of prescribing has been controversial and probably counterproductive, having little credibility because of the methods of calculation.

General practitioners' fears that fixed prescribing budgets will be imposed have sometimes resulted in a protective reluctance to reduce prescribing lest a low starting point for such a real budget results. Many see the new prescribing targets (introduced next month) as a step towards fixed budgets, which could threaten general practitioners' clinical freedom and their ability to meet all of their patients' needs. If general practitioners had to prescribe within fixed budgets, the resulting furore would probably channel their energy away from rational prescribing.

For general practitioners to follow the Audit Commission's recommendations they will need reassurance that their savings are not going to be negated by the pharmaceutical industry increasing its prices under the Pharmaceutical Price Regulation Scheme. General practitioners are likely to support local purchasers working to resolve problems at the interface between general practice prescribing and hospital prescribing. Local therapeutic committees with representatives from purchasers and providers could help to devise acceptable prescribing policies, local formularies, and a common approach to the introduction of new drugs. General practitioners might also support more use of over the counter preparations: many patients who expect these on prescription could afford to buy them.

General practitioners might well support greater generic substitution because the arguments used against it - mainly the possible poor quality and safety of generic drugs - are no longer valid (regulation by the Medicines Control Agency secures the effectiveness of generic preparations). The Greenfield committee originally proposed generic substitution a decade ago. It recommended that doctors indicate a preference for a proprietary preparation by ticking a box on the prescription form.

Most general practitioners realise that, in an underfunded NHS, prescribing has to bear its share of financial constraints. So although they will want to see their patients continue to benefit from appropriate, cost effective treatments, they will undoubtedly want to address the Audit Commission's proposals constructively. The scope for achieving the savings in prescribing envisaged by the commission's report will ultimately depend on an equally constructive approach from the Department of Health to general practitioners' ever increasing workload.