Article Text

Original research
Multiplicity and complexity: a qualitative exploration of influences on prescribing in UK general practice
  1. Mary Carter1,
  2. Sarah Chapman1,
  3. Margaret C Watson2
  1. 1Department of Pharmacy & Pharmacology, University of Bath, Bath, UK
  2. 2Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
  1. Correspondence to Mary Carter; mdc50{at}


Objectives Despite widespread availability of evidence-based guidelines to inform rational use of medicines, considerable unwarranted variation exists in prescribing. A greater understanding of key determinants of contemporary prescribing in UK general practice could inform strategies to promote evidence-based prescribing. This study explored (1) current influences on prescribing in general practice and (2) the possibility that general practice-based pharmacists (PBPs) may contribute to greater engagement with evidence-based prescribing.

Design Semistructured, telephone interviews and a focus group were conducted, audio-recorded and transcribed verbatim. Thematic analysis was undertaken.

Participants General practice prescribers: general practitioners (GPs), PBPs, nurses.

Key informants: individuals within the National Health Service (NHS) with responsibility for influencing, monitoring and measuring general practice prescribing.

Setting General practices and NHS organisations in England.

Results Interviews with 17 prescribers (GPs (n=6), PBPs (n=6), nurses (n=5)) and 6 key informants, and one focus group with five key informants were undertaken between November 2018 and April 2019. Determinants operating at individual, practice and societal levels impacted prescribing and guideline use. Prescribers’ professional backgrounds, for example, nursing, pharmacy, patient populations and patient pressure were perceived as substantial influences, as well as media portrayal and public perceptions of medicines.

Prescribers identified practice-level determinants of prescribing, including practice culture and shared beliefs. Key informants tended to emphasise higher-level influences, including NHS policies, availability of support and advice from secondary care and generic challenges associated with medicines use, for example, multimorbidity.

Participants expressed mixed views about the potential of PBPs to promote evidence-based prescribing in general practice.

Conclusion Prescribing in UK general practice is influenced by multiple intersecting factors. Strategies to promote evidence-based prescribing should target modifiable influences at practice and individual levels. Customising strategies for medical and non-medical prescribers may maximise their effectiveness.

  • primary care
  • qualitative research
  • organisation of health services
  • protocols & guidelines

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  • Contributors MC, MCW and SC contributed to the design of the study. MC collected and analysed all the data. MC, MCW and SC contributed to the interpretation of the data for this manuscript. MC drafted the manuscript and MCW and SC critically revised and gave approval for the final version. All authors agree to be accountable for all aspects of the work.

  • Funding This work is supported by a PhD Studentship (reference 189447056) awarded to the lead author (MC) by the University of Bath.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval This study was approved by the Research Ethics Approval Committee for Health (ref. EP 17/18 233), University of Bath.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available upon reasonable request.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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