Lessons on the failure of the Better Care Better Value prescribing indicator for renin-angiotensin system drugs in treating hypertension: a qualitative study from general practitioners' perspectives

The problem

To improve the prescribing efficiency, in April 2009, the NHS issued a Better Care Better Value (BCBV) prescribing indicator for angiotensin converting enzyme inhibitors (ACEIs) and angiotensin receptor (ARBs), expressed as the proportion of items written for ACEIs as a percentage of the total items of ACEIs/ARBs, with a proposed target of 80%. Research has indicated that the policy failed in achieving this target, and the actual national figure was 70.1% in June 2014. However, the reasons underpinning the policy failure are not completely studied. Therefore, this study aimed to identify the potential reasons behind the policy failure.

The approach

In-depth semi-structured interview was conducted on general practitioners (GPs) as they are primarily involved in the policy uptake and adoption. A sample of 44, 29, and 22 GP practices in Nottinghamshire, Derbyshire, and Leicestershire, respectively, were randomly selected based on practice sizes. Practice manager and senior GPs of the selected practices were approached to invite GPs in their practices to participate in the study. The interviews used a pre-designed interview schedule to explore GPs' experience in prescribing ACEIs/ARBs, and views on the policy implementation and barriers for the policy uptake for approximately 30 minutes. Interviews were audio-recorded, transcribed verbatim, and analysed using a thematic approach. Ethical approvals were obtained from the NHS R&D departments in the three areas.

Findings

Overall, 16 GPs were interviewed, with a mean age of 43.3 years (SD=7.4), and most were male (n=13), partner GP (n=9), from Nottinghamshire (n=9). In accordance with NICE guidelines, most participants reported that ACEIs were prescribed as first line treatment and ARBs were reserved for patients who could not tolerate ACEIs. Four factors emerged from the interviews as possible barriers for lack of policy uptake, including lack of awareness, negative attitudes to the policy, lack of financial incentives and loss of cost differential between ACEIs and ARBs following patent loss of some ARBs. Most GPs never heard of the policy, which they attributed to bad policy dissemination and advertisement. There is a lack of agreement with the policy's aims, GPs regarded the policy to reduce their prescribing autonomy, doubting its authors' credibility, and being cost-oriented and non-sustainable. Most importantly, the final barrier centred on reported reluctance to switching established ARBs users due to concerns around the switch reducing patient adherence. Given the asymptomatic nature of hypertension, which makes patients hardly interested in antihypertensive medications, and GPs' conceding to patients' pressure to not change their medication for non-medical reasons.

Consequences

Understanding the barriers for this policy failure is important not only to assist in developing strategies to increase the future effectiveness of the BCBV policy but also provides lessons on how to maximise the uptake of other policies

Credits

• Amanj Baker
• Li-Chia Chen
• Rachel Elliott