Understanding the gap between prescribing guidelines and behaviour: a qualitative study in UK general practice

Problem

Despite increasing expenditure on medicines and widespread availability of evidence-based guidelines to inform medicines’ rational use, considerable variation exists in guideline uptake and application by clinicians. The range of health professionals prescribing in general practice may contribute to this variation. Recent NHS policy supports pharmacists’ inclusion in general practice teams; pharmacists’ professional skills are viewed by some as suited to fostering an evidence-based approach to prescribing.There is a need to identify the key determinants of current prescribing behaviour before developing strategies which reduce variation and promote evidence-based prescribing.

Approach

To investigate influences on prescribing in general practice and specifically to explore:• Determinants of prescribing behaviour from prescribers’ perspectives• Use/influence of National Institute of Health and Care Excellence (NICE) and other guidelines on prescribing • Role/potential of general practice-based pharmacists (PBPs) to promote evidence-based prescribingSemi-structured qualitative telephone interviews and focus groups were conducted with two samples: (i) general practice-based prescribers: General Practitioners (GPs), nurses and PBPs (ii) key informants: individuals working in NHS roles, with responsibility for influencing and monitoring general practice prescribing. A target sample matrix was developed to reflect a range of prescribers from various professional backgrounds and diverse general practice characteristics, and key informants working in assorted local, regional and national roles. Recruitment was through local and regional contacts and snowball sampling. Interviews and focus groups were audio-recorded and transcribed verbatim. Thematic data analysis identified themes about the influences on prescribing and PBPs' roles. Data saturation was considered to be achieved when the sample matrix was complete and no new themes were identified.

Findings

Data collection took place between November 2018 and April 2019. Interviews were completed with 17 prescribers (GPs (n=6), pharmacists (n=6), nurses (n=5)) and six key informants. One focus group was conducted with five key informants. Both samples stated that guidelines fundamentally influence prescribing, but identified competing influences including the prescriber’s professional background, socio-economic profiles of patient populations and attitudes of individual patients. Media portrayals of medicines and public opinion were also identified. Prescribers identified practice-level influences, e.g. attitudes towards shared learning, and key informants emphasised the impact of NHS organisational policies and the availability of services. Key informants also highlighted underlying problems (e.g. polypharmacy) and ‘medicines optimisation’ principles (e.g. safe prescribing) developed to address these issues. Both samples identified PBPs’ specific medicines expertise and highlighted variation in PBPs’ roles and access to support. Prescribers’ views were mixed about the extent to which PBPs’ may influence prescribing in the future.

Consequences

Prescribing in general practice is influenced by multiple and competing factors. Development of successful strategies must first identify and then focus on influencing factors that are amenable to modification and take account of the range of professionals with prescribing responsibilities in general practice.