Incentives not to adopt NHS low-value care prescribing guidelines in primary care

Abstract: NHS spending on prescribed medicines that could be purchased privately over the counter (OTC drugs) sums up to £569 million in 2016. To reduce these spending on low-value care, NHS England released guidelines on OTC prescribing in primary care in December 2017. However, these guidelines are not strictly enforced and many exceptions apply, which makes it questionable whether physicians fully adhere to the policy. We use this exogenous policy change in December 2017 in order to answer the following questions: (1) Do physicians adopt NHS low-value care prescribing guidelines in primary care? (2) Does adoption differ between dispensing doctors and their non-dispensing colleagues? (3) Does competition affect adoption? Comparing pre- and post-reform OTC prescribing in England with prescribing behavior in Wales, we identify guideline adoption and study heterogeneous treatment effects across different doctor types and competition intensity. We use monthly prescription data from all general practitioner practices in both, the NHS England and Wales, from April 2015 to June 2019. We show that (1) English physicians adopt NHS guidelines even without strict enforcement. However, overall, OTC prescribing decreases only moderately. (2) Self-dispensing doctors who have a greater financial disincentive to adopt the policy, adopt it less. The eduction in OTC items of dispensing doctors is significantly smaller compared to non-dispensing doctors. Results indicate that the rewarding system of a fixed item component might be the reason for a lower adoption. (3) If competition decreases, physicians follow the guidelines less. There is one potential demand-side reason for this negative competition effect. Since many patients in less densely populated areas are exempt from prescription charges and patient-physician relation is closer, doctors might be less willing to adopt the policy. Thus, physicians only moderately adopt this low-value care guideline. This holds in particular for dispensing doctors who have greater financial disincentives.