What influences prescribing in General Practice?
: an ethnographic exploration

  • Aileen Mairi Grant

    Student thesis: Doctoral ThesisDoctor of Philosophy


    Prescribing accounts for 11% of the total NHS budget. In the UK, there is an aging population who receive nearly half of all prescriptions, with the increasing age of the population, the prevalence of long-term conditions, cost and complexity of prescribing is likely to rise. Prescribing is influenced by numerous factors such as new drugs; aging populations; polypharmacy; and increased concern about adverse reactions. Although numerous initiatives are targeted at general practitioners to encourage application of research evidence the significant variation in prescribing quality and cost is difficult to explain. Previous studies have explored the influences of type of drug, focused clinical area, guidelines and the doctor/patient relationship. No study was found which has explored the details of the prescribing process using the ethnographic approach. This ethnographic study of three different general practices, involved participant observation, documentary review and semi-structured interviews. Analysis was an iterative process conducted in Atlas.ti by borrowing on grounded theory techniques and interpretative description. Practices were selected using prescribing quality indicators developed by Audit Scotland via PRISMS (Prescribing Information System for Scotland), which collects prescribing data for all practices in Scotland. Two practices which were ranked highly and one practice which was ranked low were observed. Practices made two different kinds of prescribing decision; macro and micro. Macro prescribing decisions are strategic, influenced by EBM and practice data, and consider the „average patient?. Micro prescribing decisions are made with an individual patient, considering their unique biology, context and perspectives. Practice pharmacists were instrumental in leading prescribing quality improvement in the larger practices and had an important role interpreting practice level data in light of the changing evidence. In the high ranking practices these changes were formulated into macro prescribing policy to rationalise and standardise their prescribing. The lower ranking practice suggested practices had to value collective decision-making and consistency in their prescribing behaviour to formulate a macro prescribing policy. Consistency in prescribing behaviour was facilitated by effective communication, which was important for shared values and practice identity. Practice identity influenced practice values, communication and organisation thus had a direct impact on their macro prescribing policy formulation and implementation. GPs used mindlines when making prescribing decisions at the micro prescribing level. GPs did not refer to explicit sources when seeking information but used personal prescribing formularies. These mindlines were iteratively developed from social networks with colleagues, secondary care and patient specific information from the practice pharmacist and from past experience. Through effective communication with colleagues these mindlines were shared.In conclusion, practices made two different kinds of prescribing decision; macro and micro. Both types of prescribing were dependent on effective communication channels, organisation, values and practice identity, illustrating the importance of communication for shared values, collective behaviour and prescribing decision-making.
    Date of Award2010
    Original languageEnglish
    SponsorsChief Scientist Office
    SupervisorJon Dowell (Supervisor), Frank Sullivan (Supervisor) & Jeremy Wyatt (Supervisor)


    • Ethnography
    • General Practice
    • Primary Care
    • Prescribing

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