Increasingly, doctors recognise that they need guidance through the bountiful menu (thousands of medicines) so seductively served to them by the pharmaceutical industry. Principal sources of guidance
38 A professor of clinical pharmacology who has made special studies of prescribing and patient information writes: 'What should a prescriber record in the notes?'
Given the existing format of general practitioner notes and the limited time available for each consultation, it seems unlikely that detailed information will be recorded in the notes. A compromise is therefore inevitable. My suggestion is that doctors should make a point of recording the fact that they have warned patients about treatments which are potentially hazardous. Specific examples include the description of dietary precautions to be taken if a monoamine oxidase inhibitor has been prescribed and the issue of steroid treatment cards to patients given prednisolone. Similarly, it would be wise to record that a young woman given a retinoid for acne is taking adequate contraceptive precautions, or that a patient taking carbimazole for thyrotoxicosis had been warned to report to the surgery in the event of a severe sore throat.
'Despite all of these uncertainties, the good news is that patients who receive leaflets are more satisfied than those who do not. Satisfied patients are less likely to complain, and are therefore presumably less likely to take legal action against prescribers' (George C F1994 Prescribers' Journal 34: 7-11).
are the pharmaceutical industry ('prescribe my drug') and governments ('spend less'); also the developing (profit-making) managed care/insurance bodies ('spend less'); and the proliferating drug bulletins offering independent, and supposedly unbiased advice ('prescribe appropriately').
Even the pharmaceutical industry, in its more sober moments, recognises that their ideal world in which doctors, advised and informed by industry alone, were free to prescribe whatever they pleased,39 to whomsoever they pleased, for as long as they pleased with someone other than the patient paying, is an unrealisable dream of a 'never-never land'.
The industry knows that it has to learn to live with restrictions of some kinds and one of the means of restriction is the formulary, a list of formulations of medicines with varying amounts of added information. A formulary may list all nationally licensed medicines prescribable by health professionals, or list only preferred drugs.
It may be restricted to what a third party payer will reimburse, or to the range of formulations stocked in a hospital (and chosen by a local drugs and therapeutics committee, which all hospitals or groups of hospitals should have), or the range agreed by a partnership of general practitioners or primary care health centre.
All restricted formularies are heavily motivated to keep costs down without impairing appropriate prescribing (p. 15). They should make provision for prescribing outside their range in cases of special need with an 'escape clause'.
Thus restricted formularies are in effect guidelines for prescribing. There is a profusion of these from national sources, hospitals, group practices and specialty organisations (epilepsy, diabetes mellitus).
39 It is difficult for us now to appreciate the naive fervour and trust in doctors that allowed them almost unlimited rights to prescribe (in the early years of the UK National Health Service: founded in 1948). Beer was a prescription item in hospitals until, decades later, an audit revealed that only 1 in 10 bottles reached a patient. More recently (1992): 'There could be fewer Christmas puddings consumed this year. The puddings were recently struck off a bizarre list of items that doctors were able to prescribe for their patients. They were removed by Health Department officials without complaint from the medics, on the grounds they had "no therapeutic or clinical value".' (Lancet 1992 340: 1531).
'Essential' drugs. Economically disadvantaged countries may need help to construct formularies. Technical help has been forthcoming since 1977 from the World Health Organization (WHO) with its Model List of Essential Drugs, i.e. drugs (or representatives of classes of drugs) 'that satisfy the health care needs of the majority of the population; they should therefore be available at all times in adequate amounts and in the appropriate dosage forms'. Countries needing such advice can use the list as a basis for their own choices (WHO also publishes model prescribing information).40 The list is updated every few years and contains about 300 items. The current list is provided as Appendix 1 to this chapter.
The pharmaceutical industry dislikes the concept that some drugs may be classed as essential and therefore others, by implication, are deemed inessential. But the WHO programme has attracted much interest and approval (see WHO Technical Report Series: The use of essential drugs: current edition).
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