futureoffhsas - bmj

and reaccreditation in the future.9 The authority willneed to involve local consultants and general practi-tioners from outside the district in audit and reaccredi-tation.

PRIMARY CARE PROVIDER UNIT

This unit or trust will be formed from the providerarms of the current community unit and family healthservices authority. The unit will contract for com-munity services with the purchasing authority orgeneral practice executive committee team or withindividual practices or the private sector. Some com-petition for the provision of primary care and commu-nity services will therefore be introduced.

PRIMARY HEALTH CARE TEAMS

General practitioners and primary health care teamswill negotiate a contract with the purchaser andprovide services under the contract. Not all practiceswill want to contract for an expanded range of servicesand local circumstances will also affect contractingdecisions. The purchaser may contract with theprimary care provider unit instead of primary careteams. Primary care teams will manage their ownbudget for staff, prescribing, general medical services,etc, and be accountable to the purchaser for theirperformance.The model envisages that a regional management

tier will have an important role in strategy develop-ment, monitoring, and accountability.'0

Consequences ofthe modelThe model will give general practitioners the

enhanced influence, powers, and responsibilities offundholders without the administrative burden. Theywill have a flexible local contract focusing on theneeds of their patients. Doctors elected to the generalpractice executive committee will have additionalpurchasing responsibilities.

Flexible contracting will increase accountability tomanagement and make management sensitive tothe needs of patients. Integration of primary andsecondary care is central to an internal market driven

by primary care and should encourage a needs ledrather than a service dominated approach.Under our model contracting may cause difficulties

with dispensing, deputising, partnership agreements,profitability, and investment in premises. Arbitrationwill be needed to prevent exploitation by the pur-chasing authority. The national contract has had manysuccesses and there is a danger these could bethreatened by fragmentation.The model requires that general practitioners and

managers develop new skills particularly in contracting.The evidence that contracting is an efficient mecha-nism in the NHS is still limited. General practitionerswill be concemed that purchasing pressures willdisturb the doctor-patient relationship, and doctors'perception of their role as the patient's friend and ally.

ConclusionsOur model is one possible means of enhancing the

benefits of the NHS reforms while minimising some ofthe problems of fragmentation. The model gives a clearrole to general practitioners, reduces their administra-tive burden, and will stimulate the development ofprimary care services. A strong contracting frameworkwill be coordinated right across the NHS, balancingthe increased responsibilities and power of generalpractitioners and their accountability for the outcomeof the care they provide.

1 Tudor Hart J. The inverse care law. Lancer 1971;i:405-12.2 Department of Health. Caringfor people. London: HMSO, 1989. (Cmnd 849.)3 O'Dowd TC, Wilson AD. The future of general practice: set menus and

clinical freedom. BMJ 199 1;303:450-2.4 Taylor D. Developing primary care: opportunities for the 1990s. London: King's

Fund Institute, 1991.5 Glennerster H, Matsagnis M, Owen P. A foothold for fundholding. London:

King's Fund Institute, 1992.6 Foster A. FHSAs: today's and tomnorrow's priorities. London: Department of

Health, NHSME, 1991.7 Bosanquet N. The future of general practice: family doctors and payment

systems: the local option. BMJ 1991;303:233-4.8 Roland M. The future of general practice: fundholding and cash limits in

primary care: blight or blessing. BMJ 1991;303:171-2.9 Irvine D. Managing for quality in general practice. London: King's Fund

Institute, 1990.10 North East Thames Regional Health Authority. Primary health care in the

90s-a strategic statement. London: North East Thames Regional HealthAuthority, 1991.

(Accepted ) December 1992)

The Future ofFHSAs

FHSAs and prescribing

Rhona Panton

This is thefifth andfinal articlein a series ofarticles on thefuture offamily health servicesauthorities

Department ofPharmacyPolicy and Practice, KeeleUniversity,Keele ST5 5BGRhona Panton, head ofdepartment

Series editor:Dr Andrew Harris

BMJ 1993;306:310-4

Prescribing by general practitioners cost the NHS £2-3billion in 1991-the biggest single cost after staffing-and the drug bill is now rising at 11% a year. Familyhealth services authorities and their professionaladvisers are charged with the challenging task of"improving the quality and cost effectiveness of pres-cribing," but any consideration of prescribing costsrequires an understanding of how they are affected byfactors outside the family health services authority'scontrol. These include price regulation by the govem-ment; differential pricing between hospitals and thecommunity; the use of generic and branded products;and the prescription charge, which conceals from thegeneral public the true cost of medicines.

Containing costsIn most developed countries the pharmaceutical

industry is an important part of the economy and its

products contribute directly to health gain. Govern-ments, which are purchasers, are faced with thedilemma of safeguarding the benefits while containingthe price of drugs. The ability to develop new drugs isnow greater than most countries' ability to pay forthem without rationing or screening systems-forexample, France controls individual prices and Ger-many has initiated a reference system which pays abasic price for all drugs in the same category.2 In GreatBritain the government's control system is the pres-cription pricing regulation scheme, a voluntary agree-ment between the industry and the government thatagrees profitability on NHS business. A measure of thescheme's effectiveness is that the United Kingdom hasthe fifth highest drug prices in Europe (about where weshould expect to be).' The industry recognises thepressures to contain costs and knows that it mustconcentrate on developing clearly better products,work towards European standardisation of prices, and

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FHSAs have an important rolein improving the standards ofprescribing and dispensing

accept the generic market in return for an extendedpatent period.4

Hospitals are given large discounts on drugs toencourage consultants to use and endorse them. Suchdiscounts can mean the price is many times lower forthe branded drug than for the generic drug andconsultants may be unaware of the price in thecommunity. The good business outcome of this policyfor the pharmaceutical industry is evident in a recentsurvey in which four out of five general practitionersclaimed to follow the hospital prescription on patientdischarge.' Drugs are expensive in primary care, notnormally because of the unit cost, but because manypatients take them for many years. Thus hospitalrecommendations, based on discounted prices, canresult in high cost commitments for primary care.

Generic substitution is common in hospitals, butonly two out of five prescriptions are written genericallyin primary care.6 The percentage of generic prescribingcould be increased if legislation allowed the prescriberto "tick the box" for the generic equivalent or, as inNorth America, the pharmacist could, with propersafeguards, offer the generic drug as an option. Anincentive in the United Kingdom could be to reducethe prescription charge by, say, 50p if the patientselected the generic option.Most European countries have a copayment system

for medicines, but in the United Kingdom patients areunaware of drug costs and only 22% pay prescriptioncharges. Ways of informing them would be to put theprice on the pharmacist's label and make financial needthe only basis for exemption from prescription charges:more patients would pay the charges (which could havean annual ceiling) but the unit payment could bereduced.

Improving prescribingNone the less real improvements could be made in

prescribing, and fundholders have shown savings.Drugs are a science based industry's problem solvingapproach to health care and should be seen in thatcontext. Prescribing is one possible treatment option;others include counselling, educating patients on selflimiting illnesses, and changes in lifestyle to improvehealth. Better definition of expected health gain,treatment goals, and outcome measures for drug

treatment would reduce unnecessary prescribing; pro-vide safer treatment; and ensure that drugs are usedappropriately. Family health services authorities havea key role in helping general practitioners to achievethese outcomes.

All family health services authorities are fundedequally to purchase professional advice on prescribing,but evaluation of the success of medical advisers hasbeen impeded by a variety of changes that have affectedprescribing. These include specialist drugs, such aserythropoietin and growth hormone, being movedfrom hospital to primary care, mostly because hospitalsare cash limited and primary care budgets are not.Health promotion clinics are diagnosing and treatingdisease-sometimes with drugs. Finally, doctors plan-ning to become fundholders may not have workedassiduously to control prescribing in the knowledgethat their budgets will be based on historical costs. Theoutcome of these changes is that the drug bill is risingfaster than it has for some years and above the rate ofinflation.Three models of good practice have emerged. In the

first, medical advisers with a reasonable workload havedeveloped good relationships with practices and arenow well placed to advise on prescribing. In thesecond, medical advisers have acted as diagnosticiansto determine the needs and concerns of each practiceand to identify those where prescribing is an issue;pharmaceutical advisers then visit and offer help. Inthe third, medical advisers have developed a manage-ment role in the family health services authority,addressed wider health strategy, and planned practicedevelopment; pharmaceutical advisers have led in allaspects of prescribing, involving the medical adviseronly when the issue is whether to prescribe rather thanwhat to prescribe. The NHS Management Executivehas now created a prescribing team, one of whose firstactions has been to require that prescribing is a priorityfor medical advisers. This has required some familyhealth services authorities to reconsider wider roles, tofocus medical advice on prescribing, and to agreetargeted savings.

Prescribing analysis and cost data are a computerrecord of all general practitioner prescribing andprovide an excellent research base to investigatechanges in prescribing, trends, and the health gain andcost implications. As data are available on individualdrugs and the doctor ordering them, professionaladvisers can use them to inform their visits to apparenthigh and low cost prescribers and to make recom-mendations for change. Key ways in which they haveworked to lower costs are in reducing the prescribingrate (which is often high in poorer areas); increasinggeneric prescribing by informing people of the savings,addressing concerns, and, in the west midlands, offer-ing laboratory analysis if patients believe there to be adifference in symptom control; and providing draftformularies and guidance on their management.

"Underprescribers" may be simply prudent pres-cribers but may also not be informed on the latestthinking on the benefits of drug treatment. They canbe helped to improve the quality of their prescribing bydrug treatment protocols, formularies including newerdrugs, and targeted drug information.

Prescribing at the interfaceProfessional advisers can help general practitioners

to determine their requirements for prescribing at theprimary and secondary care interface and ensure thatpurchasers include these criteria in contracts. Theserequirements include the development, jointly withhospital consultants, of drug treatment protocols forconsistency of clinical management, specific policies-for example, on the use of antibiotics-and shared care

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protocols for new drugs they are asked to prescribe.Professional advisers who are members of drug andtherapeutic committees can ensure that primary careconcems are heard and addressed and that they areinformed of any changes in hospital prescribing thataffect them. A development of this will be to agreeappropriate drug treatment when patients are in hos-pital to ensure we do not recreate the difference in drugpolicies shown between United States acute care andveterans hospitals.

Problems in prescribing at the interface present astrong case for commissioning agencies that wouldconsider drug purchasing across both care sectors.Meanwhile professional advisers, both directly andthrough their managers, address changes that affectprescribing in primary care with regional healthauthorities, purchasers, and providers; among thesechanges will be better information systems betweensecondary and primary care so that patients beingdischarged into the community have their medicinesavailable and that "at risk" patients are identified:pharmaceutical services must follow the patient.

Evaluation of the cost effectiveness of drug treat-ment is in its infancy, and health economics can informthe debate. General practitioners need such informationin a more relevant form, related to current patientneeds and gains. Family health services authorityadvisers are well placed to develop this research area, toevaluate drug use, and to facilitate local work bygeneral practitioners on targeted areas.

Prescribing in general practiceAll non-fundholding practices have indicative pres-

cribing amounts set and monitored by professionaladvisers. The amounts are primarily derived fromhistorical practice data, with new weightings for ageand sex and a formula that includes an "uplift factor."The system to date has lost credibility among generalpractitioners since the uplift factors proved inaccurateand the predicted outtums erratic. The latest develop-ment is that each region has a prescribing budget for allprescribers, which will require development in ameaningful way with prescribing norms.

Practice specific work includes analysis of prescrib-ing and visits to understand the reasons for apparentover- and under-prescribing. Prescribing analysis andcost data offer valuable insights into practice indicatorsof prescribing that are worthy of further investigation(box).

Regional drug information centres inform profes-sional advisers on new drugs and their likely costimplications. They also provide unbiased informationon how new products compare with the range, give costcomparison charts, and draft shared care protocols fordevelopment and agreement with consultants andgeneral practitioners.

Practice visits have resulted in identifying trainingneeds, the need for (and writing of) policies to improvethe quality of prescribing, and the development ofdrug use analysis, including all of the cost implications.

Will budgets be cash limited?Fundholders already have cash limited budgets. In

the west midlands 26 fundholders made a combinedsaving of over /JIm on their drug bill: the ability toretain the savings for practice development seems tohave provided a strong incentive. Early assessmentsindicate that fundholding has been a success in enablingpractices to manage their budgets and develop patientservices in the way it chooses. If confirmed, theseoutcomes are likely to make fundholding the normprovided that the Treasury continues to allow healthministers this method of resource management. Since

Some indicators ofprescribing in apractice* How actively is a disease-for example, asthma-being treated?* How do practices with specific expertise-forexample, teaching practices and those where doctorshave hospital sessions-compare with others?* How do fundholders and non-fundholding generalpractitioners differ?* How do consultation and prescribing rates relate tomeasures of deprivation and practice population com-pared with similar practices?* What are the priority training areas and how canthey be met?* Which doctors are most or least likely to use newproducts?* Which outdated drugs are still used?* In which therapeutic areas would a protocol help?* How effective is the intervention of family healthservices authority professional advisers measured byreanalysis of prescribing analysis and cost data?

the general election the move to fundholding has beendramatic and the suggestion that cash limiting willapply to all practitioners will fuel this trend. It is, ofcourse, too early to judge whether fundholding hasimproved the quality of prescribing, and research onthis is urgently needed.More practices might consider a prescribing contract

alone if they were allowed to retain a percentage of thesavings. These could be monitored against referralrates if each family health services authority had aminimum contract dataset (all of the necessary contractdata) for all patients. Another management systemcould be to calculate the modest savings achievable bypractices or locally based groups of practices and to paythis sum to those who achieve the target. Finally,treatment protocols could each be delivered as an itemof service a logical step from payment for healthpromotion clinics which diagnose disease. All wouldhave to allow agreed improved prescribing costs to beadded. Local incentive schemes are the most likely wayof getting general practitioners to change prescribinghabits by ensuring that they see the benefits retained inlocal health care. Until then, talk of cash limitedbudgets will only add to general practitioners' sense ofbeing required to make too many changes too quickly.

Will expensive specialist prescribing require healthrationing?

Health economists regularly forecast rationing ofexpensive drugs: an easy target since their costs-andthe patients receiving them-are readily identifiable."Shared care" high cost drugs are, however, a verysmall part of the primary care drug bill-less than 1%in the west midlands in 1991. All high cost drugs arealready rationed in hospitals through drug and thera-peutics committees and clinical pharmacy services.Best practice screening before a drug is used includes:

* Appraisal of current prescribing practice and identi-fication of the likely benefits, and of the risk in notintroducing the product* An estimate of the cost to the hospital and identi-fication, if appropriate, of authorised prescribers* A review period and reassessment of the benefits.7

Such screening ensures appropriate use of expensivemedicines and is a model of the way in which any NHSdevelopment should be evaluated before being imple-mented. Purchasers will seek such systems fromproviders when setting contracts. Family health ser-vices authority professional advisers will be keen to see

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that the system is not bypassed by hospital consultantswho, having had a request to use a product turneddown, ask general practitioners to initiate the prescrip-tion.When consultants ask general practitioners to share

the care that is, to prescribe specialist products-they accept an obligation to inform: shared careprotocols should explain the rationale of treatment,cost, side effects, and the aspects of care for which thehospital consultant will remain responsible. Manyshared care products are high cost. Fundholders, if notreimbursed for their use, may insist that drugs beincluded in the hospital price. This will result in a twotier system, where patients will be treated (by non-

fundholders) or not. The logical way forward is forpurchasers to agree the number of patients they willpay for and for the region to ensure that this provisionis adequate. The cost will then follow the patient.Further rationing of high cost drugs should be resisteduntil the costs of other developments are equally wellknown, debated among peer groups, and evaluated inuse.

Of more urgent concern is the uncontrolled way inwhich new drugs, formulations, and presentations (notof individual high cost but likely to be used for largenumbers of patients) are introduced, without assess-

ment of health gain or cost, into primary care prescrib-ing by consultants' recommendations, patient pressure,general practitioners' individual decisions. Such assess-

ments should be nationally obtained from researchunits and available to all prescribers. Consultants andgeneral practitioners need clearer explanations that a

resource can be used only once, and higher expenditureon prescribing in primary care means loss of develop-ment money for the NHS. General practitioners needassurance that control of expenditure will result in thesavings being retained in local health care. Incentiveschemes (previously described) with agreed localbenefits, such as the provision of more health visitors,are most likely to reassure general practitioners on thispoint. The development of purchasers must include a

requirement that providers examine the appropriate-ness of all prescribing (including the price differentialof products in secondary and primary care) and thatdischarge and outpatient recommendations are for a

therapeutic group, rather than specific products. Whileprofessional advisers can, and do, work towards "onceonly" savings such as changes in the prescribing ofgeneric drugs, the real control needed is the introduc-tion ofnew products only after assessment of the healthgain and financial consequences.

On the other hand, a harder look should be taken atthe range of prescribable products of doubtful value,such as, peripheral and central vasodilators, coughmixtures, baby creams, mild analgesics, and shampoos,and the value of others for example, vaccination forforeign travel' should be reassessed. The productsalone cost many millions, to which the cost ofprofessionals' time should be added. General practi-tioners can be supported in refusing requests for theseproducts in two ways: by the extension of the limitedlist (planned for June 1993) and by a structured patienteducation campaign to inform patients that the doctorcannot prescribe all medicines and that some illnessesare self limiting.

Prescribing and dispensing standardsProfessional audit, established in medical practice

and proposed for pharmacists,9 is invaluable for pres-cribing analysis and offers the opportunity to settreatment goals, measure success in achieving them,and re-evaluate the process. Practice indicators fromprescribing analysis and cost data can illumine auditand highlight discussion areas (box).

Further research is needed to understand the reasons

why doctors prescribe as they do, and the culturalneeds of the society in which the doctor works,including issues of deprivation and doctor and patientexpectation, must be addressed before any judgment ofexcessive prescribing is made." The legal mechanismfor determining that judgment comprises a committeeof three doctors, appointed by the family healthservices authority (with specific criteria for their selec-tion). A judgment of excessive prescribing can result inan amount being deducted from the doctor's remunera-tion." This procedure is seen by most family healthservices authorities as a last resort, after practicesdeemed to be prescribing inappropriately have beenoffered information and help to lower their prescribingrates and costs. Some practitioners, especially single-handed ones, may benefit from training initiatives fordoctors to reduce "sympathetic prescribing" underpressure from patients.

Pharmacists' dispensing standards are tested by thefamily health services authority and by the RoyalPharmaceutical Society of Great Britain, whosemandatory code of ethics includes standards of practicefor dispensing. Disciplinary action is taken against any

pharmacist who fails to comply and the royal society'sinspectors, in their role as enforcers of both theMedicines Act and the profession's code of standards,visit community pharmacists regularly. Collaborationbetween the royal society and family health servicesauthorities would be a sensible way forward in improv-ing dispensing standards.

Future roles for community pharmacistsCommunity pharmacy, an underused resource, will

change with the NHS reforms and become betterintegrated into the prescribing process to ensure

optimum pharmaceutical care. In hospitals pharmacistsalready advise prescribers, through drug informationand clinical pharmacy services, and encourage costeffectiveness and patient safety in drug usage. Inprimary care prescribers rightly expect a safe andaccurate dispensing service, but they have lost theregular advisory service and are most often given druginformation by drug company representatives.Occasional visits from medical and pharmaceuticaladvisers need to be supplemented by a readily availableand local source of advice and information. One optionwould be for the family health services authority toemploy community pharmacists on a sessional basis tovisit local practices.'2 The authority's professionaladvisers could target an area of concern, brief com-

munity pharmacists on the issues, and use theirpractice visits to inform general practitioners. Suchtraining could be funded by the postgraduate trainingallowance.More effective use could be made of the pharmacy's

patient medication records-for example, to analyse a

practice's prescribing patterns and make recommenda-tions for change. Patients whose ability to take

BMJ VOLUME 306 30 JANUARY 1993

Some indicators useful for audit ofprescribing in general practice* Treatment consensus among partners and consis-tency of prescribing* High cost areas where drug information can helpwith comparative costs* The need for a repeat prescribing system; a list ofdrugs preferred by the practice and practice policies-for example, on prescribing antibiotics and benzodia-zepines* Comparison of practice prescribing with the familyhealth services authority average

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medicines is a critical issue could be encouraged to usethe same community pharmacy on each occasion. Thepharmacist could be informed of the risk and would bewell placed to help the prescribers achieve theirtherapeutic objectives (for example, by offering com-pliance aids, visiting the home, or checking usage ofthe product) and to inform them of any problems.

Medicines do not come without risks, and patientsare harmed by them through no fault of the drug or theprescriber. Pharmacists should lead in actively en-couraging patients to report side effects, or lack oftreatment success, and either resolve the problem orinform the prescriber.Fundholding strengthens the case for pharmacists

working in health centres.'3 In addition to dispensing,community pharmacists could offer the same range ofservices as their hospital counterparts: they couldscreen and recommend new products to prescribers,analyse prescribing pattems, and ensure safe andappropriate drug therapy since they would have accessto patients' notes.

Family health services authorities and consumerswill, however, wish to ensure the viability of localpharmacies, with their convenience of access, thesavings pharmacists make to the NHS by respondingto common ailments, and new services such as needleexchange programmes for drug misusers. Their futurewould best be secured by implementing the repeat dis-pensing system, recommended in a recent Departmentof Health report,9 and developing a contract that paysfor services other than dispensing-for example, healthpromotion-where the pharmacist can offer oppor-tunistic advice without the need for identification orreferral.A reduction in the number of single handed phar-

macies is likely, as is the development of specialistpharmaceutical services (such as parenteral nutrition)previously available only in hospitals. Joint treatmentprotocols should be extended to the community phar-macy wherever possible so that local practices knowwhat the pharmacist will sell. Such protocols will beessential with the extension of the limited list-indeed,fundholders may find reimbursing pharmacists, work-ing to a protocol, cheaper than-writing prescriptions.

ConclusionThe quality of prescribing can be improved by the

activities of family health services authority profes-sional advisers. Some outcomes, such as reducingunnecessary prescribing, will result in savings whichcould be maximised if family health services authoritieswere empowered either to make fundholding the normor to offer incentives to all general practitioners.Certain quality developments will have little or no costsaving effect but will improve patient safety-forexample, the preferential use, wherever possible, ofwell tried drugs with a long safety record. Others, suchas the use ofnewer drugs when these are appropriate tothe patient's needs, will cost more.The future roles of medical and pharmaceutical

advisers are unclear. Purchasers will need more adviceon prescribing; in a contract setting this will includethe definition of health gain from drugs, secondary careagreement of joint treatment protocols, systems toensure appropriate prescribing at the primary careand secondary care interface, and definition of the

Summary* Drug costs are rising worldwide and price controlsare set by governments* The United Kingdom has a unique database ofprescribing from which practice indicators and auditof prescribing can be derived* FHSAs are funded to provide professional adviceto prescribers* Most fundholders have achieved savings on theirdrug bills; other incentive schemes are needed* Research is needed to measure prescribing out-comes and health gain before new drugs and formula-tions are used* There are prescribing interface issues betweenprimary and secondary care which may best beresolved by the development of purchasers* Community pharmacists have a developing role toplay in improving prescribing

standards and range of pharmaceutical services. Theseprofessional advisers will need statistical and analyticalskills as well as expertise in drug therapy. The familyhealth services authority's role of advising generalpractitioners, both on improving their prescribing andon how to ensure value for money, will remain andthey will be required to show the effectiveness oftheir interventions. A golden opportunity and theenthusiasm of professional advisers would be lostif cost reduction was required to dominate withoutfull analysis of the health gain to be achieved fromimproved (and sometimes costlier) drug treatment.Increasi-ng links between family health services authori-ties and postgraduate education and academic units areimportant and enable commissioning input to trainingand research agendas.Drugs will continue to have a key role in preventing

and treating disease and in ameliorating symptoms.These health gains keep people independent,employed, and out of hospital, but their cost effective-ness will need to be continually evaluated alongsideother options.

1 Department of Health. Improving prescribing-working for patients. London:DoH, 1990.

2 National Consumer Council. Pharmaceuticals-a consumer prescription.London: NCC, 1991.

3 Remit Consultants. Impediments to parallel trade in pharmaceuticals within theEuropean Community. London: HMSO, 1992. (Final report prepared forDG IV of the Commission of the European Communities.)

4 Kessler A. International solutions needed for drug marketings. Chemist anaDruggist 1992;236:605.

5 School of Management, University of Manchester Institute of Science andTechnology. Deternmining the drug informiation needs of general practitioners.Liverpool: Medicines Resource Centre, 1992.

6 Department of Health. Statistical bulletin on general pharmaceutical services,England and Wales. Government Statistical Service 1980-1991. London:DoH, 1992.

7 Baker John A Lant, Ariel F, Sutters A. Seventeen years' experience of avoluntarily based drug rationalisation programme in hospital. BMJ 1988;297:465-9.

8 Typhoid vaccination. Weighing the options [Editorial]. Lancet 1992;340:341-2.

9 Royal Pharmaceutical Society of Great Britain. Pharmaceutical care: the futurefor community pharmacy. Report of the joint working party on the future role oJthe community pharmaceutical services. London: RPSGB, 1992.

10 Bradley C. Uncomfortable prescribing decisions: a critical incident study.BMJ 1992;304:294-6.

11 NHS Management Executive. Excessive prescribing by GPs; referral to aprofessional committee. London: NHSME, 1992. (EL(92)90.)

12 Newton-Syms FAO, Dawson PH, Calvert RT, Cook J, Feeley M, Booth TG.The influence of a pharmacist on general practitioner prescribing. Pharma-ceuticalJournal 1988;294:R2.

13 Parr C. Equal partnerships in primary health care teams. College of PharmacyPractice Annual Lecture. PharmaceuticalJournal 1992;248:616.

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