Introduction

This study, carried out in Scotland, is relevant to commissioners and general practitioners, as it demonstrates why there are variations in prescribing practice, and how these can be managed. The authors have noticed that there is “significant variation in the quality of prescribing” and they have carried out an ethnographic study into why that is and how it can be changed. This study is based on three Scottish general practices, and they were recruited based on all nine of Audit Scotland’s prescribing quality indicators, so that examples of high and low prescribing quality are represented. The evidence studied included “394 hours of participant observation, nine semi-structured interviews and a review of 46 practice documents.”

Types of prescribing decisions

The evidence drawn from this research showed that there are two types of prescribing decisions being made:

• Macro prescribing – these are strategic, evidence-based decisions, based on the overall picture, not just one patient, but the average patient, with one particular condition, requiring one drug. Clinical governance is part of this decision process. However, they do not take the individual patient requirements into consideration.
• Micro prescribing – these decisions, on the other hand, do consider patient preferences and co-morbidities, and rely on clinical expertise, rather than research evidence.

The definition for evidence based practice is the “integration of best research evidence with clinical expertise and patient values,” so ideally a combination of macro and micro prescribing methods.

Results

The researchers found that the practices with high quality prescribing indicators implemented both macro and micro methods in their decision-making activities. They used their own clinical expertise combined with the best research available and the values of the patients. The practice with poor quality prescribing indicators only based their prescribing decisions on the individual which, while it may seem the right decision for the patient, without the evidence, one cannot be sure.

It is difficult, because when you are with the patient, you want to do the best for them, but they are part of a population, and by making prescribing decisions based on the population as a whole and combining it with the evidence, the expertise and the values, a better prescribing decision could be made.

Commentary

This paper is very interesting because it helps decision-makers understand how prescription decisions are made, and suggests ways in which these decisions can be made more effectively to reduce variation. The study was carried out on three Scottish GP surgeries, and there was a small paragraph for each which described the ethos of each practice. These are useful because they remind us that the organisations are people-driven, and it gives us an idea of what the priorities are for the staff and the organisations.

As commissioners in England, you should see whether you can relate to these practices, and decide if macro and/or micro decision-making is taking place in GP surgeries in your areas of responsibility. If you can see similarities between England and Scotland, then it might be useful for you to think about how you can support the improvement of prescribing decisions, both macro and micro, so that there are fewer variations in practice.

Link

An ethnographic exploration of influences on prescribing in general practice: why is there variation in prescribing practices? (PDF)
A Grant, F Sullivan, J Dowell
Implementation Science, 2013, 8:72

Supporting material

Prescribing in general practice in Scotland (PDF)
Audit Scotland
January 2013

Evidence-based medicine (abstract only)
DL Sackett
Seminars in Perinatology, 2997, 21(1):3-5