It has long been recognised that general practitioners (GPs) make a variety of judgements about their patients and that these judgements, as with other non-clinical factors, can influence their behaviour.¹ Gender, ethnicity and social class are three important non-clinical influences which affect clinical decision-making and, potentially, prescribing.² It was postulated that the patient's ability to pay for medicines is an integral part of a GP's judgement about a patient, which may affect their clinical decision-making behaviour.

The aim of this study was to explore how costs incurred by the patient for pharmaceuticals affected general practitioners' prescribing decisions. Costs incurred by the patient for pharmaceuticals included costs from both prescription and OTC medicines.

Five focus groups were conducted with general practitioners from three Health Authorities between August and December 1998. From the 856 general practitioners initially contacted, 51 GPs attended. There were between 10 and 11 GPs in each of the five focus groups. Topics discussed were general influences on prescribing, the relative importance of cost to the patient for pharmaceuticals and strategies to make drugs cheaper for patients.

Given the nature of the discussion, cost to the patient was most commonly addressed in relation to the patient's exemption status from the prescription charge. However, patients were also discussed as to whether they were perceived to be responsible in how they managed both their health and finances. Other themes included how demanding the patient was for medical care or a particular medication and how genuinely deserving they were of free medical care. These themes were used to develop five categories of patients: the Demanding Payers, the Demanding Non-Payers, the Self-Regulators, the Borderline Patients and the Genuine Poor. These categories of patients will be discussed in greater detail.

The categorisations of patients made by GPs had reached a considerable level of sophistication and were not simply a function of the patient's social class. They were a central theme affecting GPs' decision-making with regard to prescribing. The study reinforces the importance of considering the context in which decision-making occurs and how non-clinical factors influence the outcome of the doctor- patient consultation.

References

1. Eisenberg JM. Sociologic influences on decision-making by clinicians. Ann Int Med 1979;90:957-64.
2. Clark JA, Potter DA, McKinlay JB. Bringing social structure back into clinical decision-making. Soc Sci Med 1991; 32: 853-866.