1. Preamble

1.1 A wide range of health care systems are represented in the European Union of General Practitioners (UEMO), and the role of the general practitioner is different in each. The UEMO believes that each health care system has developed to meet the needs of an individual country, and should respect its unique national identity. The UEMO recognises that on many issues, including the issue of prescribing drugs in general practice, experience of different health care systems will be reflected in a wide variety of opinions and differing viewpoints, but it believes that there are many areas of common concern on which a universal UEMO policy can be based. This statement focuses on these areas and provides a position statement on which the national member organisations, the UEMO and the medical profession in Europe can base their lobbying activities.

2. Introduction

2.1 In every country, general practitioners take the leading role in prescribing drugs to their patients. They have a unique relationship with their patients and an understanding of their patients' needs. When governments want to cut prescribing costs, the GP is usually the first target and, in some cases, this can lead to a significant deterioration in the doctor-patient relationship. Therefore, the profession needs to take a strong stance, speaking on behalf of their patients, but also looking at the problem realistically, and taking a range of factors into consideration.

3. Responsibility: the role of the general practitioner

3.1 The UEMO believes that it is the responsibility of the doctor to prescribe the most appropriate treatment for his or her patient. This must be based on evidence and effectiveness, rather than cost. In order to do this, GPs must have access to information on the latest developments in prescribing and treatments, so that they are able to make the correct choice for their patients. Although electronic means of communication have improved the ease with which information is available, further resources and support are needed.
3.2 Education is a key requirement. The UEMO believes that prescribing issues must be included in undergraduate and postgraduate medical education, so that GPs of the future are prepared for the challenges which lie ahead.

The UEMO:

• supports the role of the GP as the leading advocate for his or her patient, and in most cases, the main prescriber during the patient's lifetime.
• believes that as the GP has access to ongoing support, education and information, he or she is the most appropriate person, in the community setting, to decide on the best treatment for his or her patients

4. Reality: the role of the patient

4.1 Patients are increasingly independent, being better informed and more aware of the choices available to them.
4.2 Many patients regularly use the internet to obtain information, and in some cases, to use online pharmacies and to buy prescription-only drugs. There is currently no quality control mechanism for internet sites and the medical profession is extremely concerned that patients are vulnerable to receiving incorrect advice, and have access to drugs and treatments which may be unsuitable, or even dangerous. On line medical advice cannot take the place of a GP who knows his or her patient and can monitor developments and provide follow up treatment.
4.3 In many countries, the principles of patient self-medication are deeply entrenched. Patient self-medication can have many advantages, but also involves potential risks. This can be further compounded by the growth of direct-to-consumer advertising. It is vital that GPs are aware of the drugs which the patient is taking, and patients therefore have a responsibility to keep their GP informed of any over-the-counter treatments which they may be using.

The UEMO:

• calls for a mechanism to monitor medical sites on the internet to be established as a matter of priority
• supports greater patient independence, provided that the patient has access to reliable and accurate guidance and informs the GP of any additional drugs or treatments which he or she is taking
• views with concern the move to direct-to-consumer advertising and insists, on behalf of patients, that European regulators ensure such advertising extols patients to consult with their physician before commencing or changing their medication

5. Reality: the role of the pharmacist

5.1 Pharmacists in many countries are assuming the traditional role of the GP as the first point of patient contact. The UEMO strongly believes that the position of the GP must not be diminished. Patient care is first and foremost the responsibility of the GP. There are, however, good examples of positive co-operation between GPs and pharmacists in some countries. The UEMO believes that these examples of good practice can be a useful guide for other countries facing similar situations. Where possible, pharmacists and GPs should work together in the best interest of patient care, but diagnosis and prescribing are medical responsibilities.

The UEMO:

• believes that the GP must retain overall responsibility for patient care
• believes that the separate roles of the GP and the pharmacist should be clearly defined, but that closer co-operation could be usefully developed

6. Restrictions: the role of the government

6.1 Budgetary restrictions have already been placed on GPs in several countries. In others, they are imminent or threatened. Governments frequently place the responsibility for cutting the cost of drug prescription directly on GPs, and there have been cases where governments have linked compliance with prescribing budgets to the income of individual doctors.
6.2 The UEMO believes that budgetary restrictions can jeopardise patient care. They can obstruct the clinical freedom of the general practitioner to prescribe the best and most effective treatment available. 6.3 The UEMO opposes prescribing restrictions on the basis of cost. However, the UEMO recognises that the pricing policies of drug companies, combined with public demand for high profile treatments, means that governments will never be able to provide an entirely unlimited prescribing budget. Difficulties in providing the best treatment available with limited resources are therefore inevitable.
6.4 GPs will therefore need to achieve a balance between cost effectiveness and their own clinical freedom to prescribe the best treatment for their patient. In order to do this, GPs need their governments to provide positive support rather than punitive measures, and to provide clear, unequivocal guidance. The UEMO believes that when making decisions on setting prescribing budget limits, maintaining the quality of patient care must be a priority, and the best way to ensure this is to involve the medical profession at all stages. Budgets should therefore only be imposed if they have been discussed and agreed with the medical profession.

The UEMO:

• recognises that any country's drug budget is unlikely to be unlimited, but opposes prescribing restrictions on the basis of cost alone
• believes that any national budgetary restrictions on prescribing must be developed in consultation with the medical profession
• opposes any direct link between prescribing budgets and sanctions on individual GP incomes
• will not support any restrictions which harm the quality of patient care calls for improved guidance on prescribing issues to be provided to all GPs