Mindful of the gap: A process for delivering better medical prescribing?

The causes of drug-related morbidity and mortality are complex, occurring at all stages of the drug use process (Table I) and can be typically categorised as those resulting from inappropriate prescribing, administration (by both health care practitioner and patient) or monitoring. Consequently, the solution to address these problems must draw on expertise that embraces clinical pharmacology and clinical pharmaceutics, an understanding of patients’ views and expectations, as well as effective systems to ensure appropriate monitoring and safe drug use. The problem of poor prescribing is not new and periodically dominates media headlines. A recent editorial by Aronson, Henderson, Webb, and Rawlins (2006) highlighted concerns, widely shared by health care professionals, educators and students, about aspects of junior doctors’ training that relate to the prescribing and use of medicines. As junior doctors undertake most hospital-based prescribing it is of no surprise that prescribing by doctors, and the appropriateness of their training, remains the focus of discussion around this issue. Poor prescribing is thought to be the result of many factors, although the evidence supporting the different claims made is variable (Audit Commission, 2001; Maxwell, Walley, & Ferner, 2002; Barber, Rawlins, & Dean Franklin, 2003). The most common speculation is that there is a problem in the quality of both undergraduate and postgraduate prescribing-related training offered to juniors. However, it should be appreciated that the process of prescribing is becoming more difficult with more potent drugs available, an ageing population, and the frequent need for polypharmacy. A number of solutions have been proffered to help improve prescribing, with better training for medical students being the most common. Others suggest that a system should be established in which pharmacists support prescribers in a more formalised way, while many recognise that the use of decision support software must play a role in any future approach. The increasing emphasis placed by the National Health Service on competency-based training is exerting pressure to increase individual accountability for the actions they take and to embed the process for maintaining standards. But who should be responsible for the prescribing component of this? And what is the ideal system? To expect medical students to grasp, in five years, both knowledge and skills to prescribe and use the range of available medicines appropriately is perhaps unrealistic. Maxwell and Walley (2003), on behalf of the British Pharmacological Society (Clinical Section Committee), have set out the key elements of a safe and effective prescribing curriculum that they expect to be achieved at the point of qualification. This is, in our view, more aspirational than deliverable.