Effective prescribing at practice level should be identified and rewarded

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Abstract
In the administrative corridors of the European Union there is no longer any talk of cows, sheep, or pigs but only of “grain consuming units” or GCUs. A similar level of bureaucratic jargon has come to surround what used to be known as patients in the British NHS, who, for the purposes of administering the funds that pay for their medication, are now known as “prescribing units” (PUs). Just as one cow consumes as much grain as three or four sheep and therefore counts as several GCUs, so a person over the age of 65, who is said to consume, on average, three times as many prescription items as someone aged under 65, is generally counted as three prescribing units.1 Attempts by statisticians and health economists to explain and refine the prescribing unit2–8 have generally been little read and poorly understood by those with most to gain or lose by the formulas produced. Yet the principle behind the jargon is simple, and the implications of an invalid model for capitation based drug budgets far reaching. General practitioners in England and Wales are expected to keep the total cost of their drug prescribing within specified limits (indicative prescribing budgets9) allocated by their district health authority (previously the family health services authority) and generally calculated on the basis of their previous year's performance plus a small allowance for inflation and real cost increases (the much criticised “historical allocation formula”). Although there is currently no binding sanction against general practitioners who exceed their indicative prescribing budgets, there is, buried within the small print of the latest NHS white paper, the news that, from 1999, primary care groups will have a unified budget for commissioning, prescribing, and practice administration—in other words, general practitioners' prescribing will be cash limited.10 …