Margaret McCartney: Prescribing incentives feel grubby because they are.

Last week it emerged that Oxfordshire Clinical Commissioning Group has suggested that GPs should review patients in nursing homes and “rationalise” prescribing. If enough drugs are stopped or switched to meet the threshold, the GPs keep half the cash saved. Cue righteous outrage from the national press. It feels grubby because it is. There’s little doubt that incentive programmes, particularly the Quality and Outcomes Framework in general practice, have led to reflex prescribing and overprescribing. Doctors must satisfy their paymasters’ suspicions in justifying why they haven’t prescribed, rather than why they have. Yet clear evidence shows that single disease guidelines for prescribing in multimorbidity aren’t fit for purpose. Financial incentives are rotten to the core. Money is used to make GPs prescribe, and then to make us not prescribe. This is, in essence, manipulation of the trusted relationships between doctors and patients by unseen puppeteers, who suppose that the desired outcomes will occur if just the right amount of pressure is correctly applied. Self employed contractors, many wobbling financially, are in a bind. Not doing the work means loss of income. But doing the work is anti-professional. No one could argue that we should prescribe expensive varieties of drugs when cheaper and generic is better, and no one should support wasting money on poorly evidenced products. And overtreatment is a harmful waste of resources. Professionalism means doing the right thing, not the cheapest or easiest thing.