Elsevier

Social Science & Medicine

Volume 60, Issue 6, March 2005, Pages 1335-1346
Social Science & Medicine

A qualitative study of GPs’ and PCO stakeholders’ views on the importance and influence of cost on prescribing

https://doi.org/10.1016/j.socscimed.2004.07.013Get rights and content

Abstract

With prescribing expenditure rising and evidence of prescribing costs variation, general practitioners (GPs) in the UK are under increasing pressure to contain spending. The introduction of cash-limited, unified budgets and increased monitoring of prescribing within Primary Care Organizations (PCO) are intended to increase efficiency and enhance GPs financial responsibility. Whilst GPs regularly receive data on the costs of their prescribing and also performance against a set prescribing budget, little is known about the extent to which GPs take cost into account in their prescribing decisions. This study undertook a qualitative exploration of the attitudes of various stakeholders on the relative importance and influence of cost on general practice prescribing. In order to explore a plurality of perspectives, data were obtained from focus groups and a series of individual semi-structured interviews with GPs and key PCO stakeholders.

The data suggest that although almost all GPs believed costs should be taken into account when prescribing, there was great variation in the extent to which this was applied and to how sensitive GPs were to costs. Cost was secondary to clinical effectiveness and safety, whilst individual patient need was emphasized above other forms of rationality or notions of opportunity costs. Conflict was apparent between a PCO policy of cost-containment and GPs’ resistance to cost-cutting. GPs largely applied simple cost-minimization while cost-consideration was undermined by contextual factors. Implications for research and policy are discussed.

Introduction

Expenditure on prescribing by general practitioners (GPs) in the UK rises annually, by 12% in 2002 (Department of Health (DoH), 2003). GPs are under increasing pressure to contain spending while at the same time to deliver improvements in the quality of their care by increasing the use of medicines such as lipid lowering agents (Cookson, McDaid, & Maynard, 2001). Drug utilization studies have consistently demonstrated significant variation among GPs in prescribing costs, only partly explained by health needs and socio-demography (Morton-Jones & Pringle, 1993; Audit Commission, 1994; Forster & Frost, 1991). Most doctors believe that the cost of a particular drug should be considered but only after efficiency and adverse effects, and that in many areas of prescribing, cost savings can be achieved without detriment to patient care (Denig & Haaijer-Ruskamp, 1995). GPs’ knowledge of drug costs, however, is weak (Walzak, Swindells, & Bhardwaj, 1994; Ryan, Yule, Bond, & Taylor, 1996) and whilst GPs believe that more cost information would enable them to lower prescribing costs (Silcock, Ryan, Bond, & Taylor, 1997), the relative importance of cost to other factors is unclear (Denig & Haaijer-Ruskamp, 1995).

Rising costs in primary care prescribing led to government attempts in the 1990s to encourage GPs to take responsibility for a finite budget for their prescribing and some other services in GP fundholding. Essentially, the introduction of fundholding encouraged GPs to consider the cost implications of their prescribing by giving individual practices the opportunity to directly control their own fixed cash budgets. A key financial incentive was incorporated whereby practices could invest any budget surplus for the benefit of practice patients. Fundholding practices contained prescribing costs more effectively than non-fundholders (Bradlow & Coulter, 1993; Wilson, Buchan, & Walley, 1995; Wilson, Hatcher, Barton, & Walley, 1996) largely through prescribing lower cost but similar medicines, for instance by generic prescribing (Rafferty, Wilson-Davis, & McGavock, 1997; Dowell, Snadden, & Dunbar, 1995), rather than by adopting more strategic approaches which might have led to prescribing fewer items (Harris & Scrivener, 1996). Although moderately successful in restraining prescribing costs, other problems and political considerations led to the ending of GP fundholding in 1998.

Changes to the structure of primary care in the UK and an end to the internal market system of the NHS was marked with the publication of the White Paper The New NHS, Modern, Dependable (NHS Executive, 1998). This established Primary Care Groups (PCGs) in April 1999. These covered all GP practices in a defined geographical area. An important element of the PCG constitution involved the management of local healthcare budgets within cash limits. As they take on increasing responsibility in managing their budgets and services, rather than being sub-committees of Health Authorities, PCGs were able to evolve into independent Primary Care Trusts (PCTs) from April 2000. The term Primary Care Organization (PCO) will be used here to encompass PCGs and PCTs. Cash-limited, unified budgets for prescribing and other services are now held by PCOs rather than GP practices, but attempts to constrain expenditure and increase accountability at the PCO-level continue. Any money saved on prescribing costs are now largely a collective benefit to all practices in the PCO, although there are still limited non-personal financial incentives for GPs to manage their prescribing (i.e. additional funding for their practice to use on projects to benefit their patients). Conversely, the penalties for over spending on drugs are only collective. Furthermore, incentives for cost constraint may be moderated by the new GP contract due to be implemented in all practices from April 2004, which has targets largely driven at quality improvement (DoH, 2004). These changes mean that earlier studies on how UK GPs know, use and view drug costs are probably of limited value (Walzak et al., 1994; Ryan et al., 1996; Silcock et al., 1997). Most of these studies relied on survey data and while this is useful in identifying variables associated with prescribing costs, qualitative research enables deeper insight into behaviour and attitudes that may explain how and why costs affect prescribing. This understanding is important for the development of strategies to promote cost-effective prescribing. The aim of the present study was to explore the attitudes of various PCO stakeholders on the relative importance and influence of cost on general practice prescribing. Although this examination has a particular significance around the new primary care structure in the UK, the pressures on GPs to curb budgetary demands are not unique to the UK, but exist across a range of healthcare systems, e.g. the European Union (Abel-Smith & Mossialos, 1994).

Section snippets

Method

A qualitative methodology was selected in order to capture a detailed description of stakeholders’ attitudes and experiences. The study used a mixed method of data collection combining focus groups and in-depth interviews. The advantage of focus groups is that participant interaction stimulates thinking and exchange of attitudes that may not be entirely revealed by responses to direct questions (Kitzinger, 1995). However, a disadvantage is that the group context may inhibit individual

Sample

Data collection was conducted with a total of 45 key stakeholders. In order to maximize sample variation, participants were selected by purposeful sampling to ensure a national spread of stakeholders considered to have detailed insight into the impact of cost on prescribing. These included health authority (HA) pharmaceutical advisers, PCO prescribing advisers, chief executives and medical directors, pharmacists employed by the PCO on a sessional basis to implement specific projects,

Data collection

Data collection was carried out between May and June 2001. The interviews and structure of the focus group discussions were developed from the findings of previous research on factors influencing prescribing (Prosser, Walley, & Almond, 2003) and supported by a literature review that included research articles related to issues of cost within medical practice. To develop these further and ensure a comprehensive range of issues had been included, two GPs, two PCO prescribing advisers and one HA

Analysis

All interviews and focus groups were audio taped and transcribed verbatim. Transcripts were checked for accuracy before analysis. Analysis followed a grounded analytical approach. This followed an iterative process whereby categories and concepts were identified, tagged and organized into major patterns and themes. Explanation was derived through moving back and forth between analysis and data, continually comparing one respondent's views with another's in order to confirm emergent accounts.

How cost-sensitive are general practitioners? (Box 1)

There were wide variations in the extent to which GPs considered cost. GPs’ approaches can be viewed along a spectrum from a reluctance to consider cost-based approaches (non-utilization) to the application of cost-consideration in practice (active utilization) (Box 1). A small minority of GPs (all non-PCO board members and from high spending practices) said they rarely considered the cost implications of prescribing. Two discrete reasons emerged for this: first, an unwillingness to take cost

Discussion

This study has explored GPs and PCO stakeholders approach to the limited resources available in local prescribing budgets. Some of our findings confirm and extend similar studies of this area (Avery & Heron, 1997), but offer insights into attitudes towards prescribing costs within a single, unified budget. In principle, cost-effective prescribing is a shared objective of most GPs and PCO stakeholders, although there were a few GPs for whom cost-consideration was immaterial. Most GPs accept the

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