Worlds apart? An exploration of prescribing and medicine-taking decisions by patients, GPs and local policy makers

Current healthcare policy in the UK has been shaped by two major forces; increasing accountability to evidence-based standards and increasing patient involvement. Shared decision-making brings the patient into prescribing decisions, and guidelines introduce a third decision-maker, the policy maker, into the doctor-patient consultation. This study explored the decision-making processes used by patients and GPs in comparison to local policy makers.MethodQualitative interviews with 8 GPs, 14 patients and 2 PCT Prescribing Advisers, followed by quantitative questionnaires completed by 305 GPs and 533 patients.ResultsPatients made individual medicine-taking decisions based on experience, personal financial and human cost, trust and the relational aspects of their interactions with doctors over time. In contrast local implementation of prescribing guidelines was based on consideration of financial costs, efficacy and risks, based on objective clinical evidence at a population level. GPs adopted a mid-position between these two polar views.Guidelines are written from a different perspective to the worldview of patients, and they tend to downplay the criteria most important to patients. This has the potential to have a harmful effect on patients' medicine-taking and adherence. Paradoxically, enforcing the use of guidelines could inhibit the achievement of guideline targets.