Pharmaceutical and Medical Sales: GPs with the best prescription?: Three in 10 drugs are inappropriately prescribed, the Government says. Mark Barrowcliffe asks if we get a good deal from our family doctors

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IF YOU are a Roman Catholic you are more likely to leave your GP's surgery with a prescription than if you are a Protestant. According to a study by Dr John Griffin, of the Association of the British Pharmaceutical Industry, there is a clear correlation between the percentage of Catholics in a country and the amount it spends on drugs.

Catholics, apparently, are more willing to take the doctor's word at face value than their more truculent Protestant cousins. 'The most likely rationale is that in Catholic countries there is a greater acceptance of authority; the medical profession is seen in a more paternalistic role and this is accepted by the patient,' says Dr Griffin. So when the GP says 'you need tranquillisers, Mr Smith,' Catholics are less likely than Protestants to reply: 'Oh no I don't, send me to a stress clinic.'

These differences in attitudes are not just quaint idiosyncracies. They can take a large slice out of a country's gross domestic product. Italy and Portugal spend three times more of their GDP on drugs than countries like the Netherlands, Norway and Australia.

Italians, on average, get 11 prescriptions each a year from their doctors; Swedes get only four. In Britain we get six or seven each. This is a difference that can account for millions a year. Mind you, Protestants have no need to feel smug that they are preventing the doctor from fobbing them off with cough mixture just to get them out of the surgery. Their questioning, repressive natures mean they are more likely to challenge their doctors and go away with their ulcers - to which they are particularly susceptible - untreated.

So who is getting the best deal out of the doctor; should you feel pleased or cheated if your GP is a low prescriber? The Government tells us high prescribing is generally bad practice and doctors should strive to reduce their drugs bill. The evidence suggests that this is more than the Treasury trying to wheedle more cash for tax cuts.

Eighty per cent of visits to the doctor in the UK end with a prescription for drugs. But the Government says pharmacists have calculated that three in 10 drugs are inappropriately prescribed. And there are wide variations in GPs' prescribing habits. Some GPs prescribe five times more than others. Even after adjustments for the type of patients attending a practice - a GP in Worthing, with a lot of old people, is always going to prescribe more than his colleague practising in a new town - some GPs prescribe far more than others. The implication is that we are getting too many drugs and drugs we do not need.

One school of thought says that GPs should put patients on drugs only when there is no alternative.

Dr Stephen Head, a GP in Macclesfield and a prescribing monitor for Derbyshire Family Health Services Authority, says prescribing levels should come down. He says patients are sometimes not told that their illnesses can be treated in any other way than with drugs. A good example is mild high blood pressure.

'If I had that level (of blood pressure) I would want to try non-drug treatment first. How many patients are given the opportunity to explore other options?' He says patients who disagree with their GPs are just as likely to ask for drugs as reject them. They need re-educating to realise that no prescription is sometimes a good prescription.

'Patients know a lot more about certain drugs because of the mass media; we are dealing with direct consumer demand. I am not sure this is a good thing. But I am concerned that the tremendous upwards pressure on the drug bill does not result in an imbalance in the health service budget, so we end up taking money from other areas of the NHS to pay for more drugs.' Drugs account for around 10 per cent of the cost of the health service and their cost is rising at three to four times the rate of inflation.

Anecdotal evidence also suggests that the best GPs prescribe fewer drugs, perhaps because they are aware of other options for dealing with illness.

Certainly, one of the highest prescribers in Bradford was a 'Dr' Muhammed Saeed. He gained employment as a GP by the highly unusual method of forging a medical degree. One reason he was detected was that his prescribing levels were so much higher than any other GP in his area. But others point out that high prescribing can be the result of diligent groundwork, rooting out disease. Professor George Teeling Smith, director of the Office of Health Economics, found that practices classified by his study as 'moderately high prescribers' were offering the best care to certain groups of patients. They were treating a higher proportion of patients with diabetes and high blood pressure than their lower-prescribing colleagues. They also treated more of these patients than doctors classed as 'very high prescribers'. These doctors were the best at detecting diabetics and hypertensives.

There are other reasons why the low- prescribing GP may not always be the best. Since April 1991 doctors have been asked to conform to 'indicative prescribing amounts'. These are drug budgets that can be exceeded if the GP can show good reason. Other GPs, fund- holders, have been given more rigid drug budgets. If they save on their drug budgets they are allowed to plough the underspend back into building their surgeries or employing more staff.

Dr Chris Taggart, a Coventry GP, has no problem with the indicative amount, which he feels rightly asks GPs to consider the cost of the drugs they are prescribing. But he is uneasy about the effect of fund-holding, if only on patient confidence. 'There is a need to watch what you are prescribing but bringing it down to a question of money makes things stupid. If fund-holders save money on their drugs, maybe they can afford to redecorate their surgery, maybe they can put money into building work, which increases the value of their surgery. And how does the patient feel towards the end of the financial year, when the GP says he doesn't need any drugs? Can he have full confidence in that GP's decision?'

Jean Robinson, a patients rights campaigner, says patients have little to fear if the GP refuses to prescribe for them. She supports the Government's campaign to reduce the drug bill. She says it is more important to make sure that when the GP does prescribe he knows what he is doing. 'GPs' prescribing varies enormously. I think we have gone a bit beyond the stage where the GP would just hand out the drugs to get the patient out of the surgery but I am convinced there is a whole lot of unnecessary prescribing going on.

'The key is rational prescribing but the GPs do not know enough about it to do it properly. They are simply not informed as to the full side-effects of drugs. Look at antibiotics. A pharmacologist friend of mine says you should take those once or twice in your life but they are very commonly prescribed. Look at elderly people. They are often on a cocktail of drugs. Any geriatrician will tell you that when elderly people go into hospital ill they can often make them better by finding out what they are on and taking them off it. A great many GPs are unaware of the effects of mixing up various kinds of drugs.'

Mrs Robinson says the solution is for GPs to get better training in pharmacology and for patients to find out about the drugs they are being prescribed. 'If you go to your pharmacist and say, 'I'm on A and B, is there a difficulty?' they should know the answer. Also ask to see the drug data sheet. Then you can find out what the side-effects are.'

By questioning your GP you could be improving your own health and doing the country a service by cutting the drugs bill. Mrs Robinson, however, urges caution before you throw your pills through the window. Almost no drug is side-effect free. And sudden withdrawals from a course of drugs can be very harmful. Beware the example of the Christian Scientists who, despite abstinence from drink and cigarettes, have a significantly higher death rate than the secular population. The reason is simple: they refuse all medication.

(Photograph omitted)

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