Background: Evidence-based medicine (EBM) has stimulated a proliferation of clinical guidelines and prescribing protocols which aim to increase quality and improve equity of healthcare through the standardisation of treatment and access to resources. The containment of rising prescribing costs is a major concern of European healthcare systems, which has led to a more overt rationing of resources. However, prescribing guidelines and cost-containment strategies reduce the capacity of health professionals to involve patients in discussion and choice of treatment and consequently work against the objectives of patient-centred medicine (PCM), which are a priority of current UK healthcare policy. Little is known about the impact of prescribing guidelines or cost-containment strategies on the practice of medicine in the primary care sector, their effect on relations between doctors and patients, and the ways in which laymen and professionals evaluate and respond to strategies for more 'rational' prescribing.
Aim: This paper considers the responses of general practitioners (GPs) in the UK to the conflicting commitments of meeting the clinical needs of individual patients and dealing with the situational constraints of the consultation, while also achieving a reduction in prescribing rates (and costs) of proton pump inhibitors (PPIs) in the treatment of gastric disorders.
Method: Qualitative interview-based research involving 26 GPs.
Results: Most doctors considered that they were making an effort to achieve a reduction in PPI prescribing, and none regarded his current prescribing of PPIs to be inappropriate. However, the raised prescribing thresholds for PPIs, which were a consequence of applying a cost-containment policy, conflicted with the GPs' stated commitment to provide the best and most appropriate treatment for individual patients. In addition, the aim to reduce PPI prescribing was often subverted by the situational constraints of the consultation, and doctors' desire to protect their relationship with patients.
Conclusion: An outcome of the conflicting pressures to which the doctors were subject in their efforts to meet clinical need while also reducing the cost of PPIs was the reinforcement of widespread assumptions and negative patient stereotypes relating to a 'mythology' of PPI prescribing. The prevalence of such stereotypes inhibits the reflexivity in medical practice, which is required for doctors to perceive and respond more constructively to patient perspectives of illness and treatment. Such typifications also function to justify the rationing of treatment on the basis of inappropriate judgements about the deservingness or moral worth of patients. The study illustrates the adverse impact on medical practice of GPs' responses to the competing pressures of meeting patient needs while complying with prescribing incentives and guidelines. It highlights the incompatibility of different policies relating to cost containment and patient-centred medicine and may help to explain the systematic inertia which appears to have hindered the development of genuinely patient-centred medicine over the last few decades.