Hospital formularies restrict evidence based practice

Editor—I agree with Maxwell that evidence based prescribing is complex and requires clinical experience, common sense, and some knowledge of clinical pharmacology.¹ The drugs that I can prescribe are governed primarily by a strict hospital formulary and, in some cases, the primary care trust formulary. The formulary often has a limited number of drugs (often only one) that can be prescribed for each class, and the choice is often determined not by evidence but cost per tablet (and not even longer term cost effectiveness). This kind of restriction is often defended by policy-makers using the “class effect” argument. The hospital's necessity to slash the drug budget has led to some good drugs being excluded from the formulary, despite their use being supported by class A evidence and national clinical guidelines.

As clinicians, we are encouraged to practice evidence based medicine, and many of us spend hours every week familiarising ourselves with the latest research evidence in our specialties. What is the point of doing this without the power to prescribe the drug that we believe to be the best choice for our patients? Furthermore, why should pharmaceutical companies spend millions of pounds in supporting research and developing new and better drugs when the NHS urges drug formularies to include only those drugs which are the cheapest and not primarily those which are supported by good evidence? What will happen to clinical and prescribing autonomy as medical practice in the United Kingdom moves further towards being purely protocol driven?

If evidence based practice is to thrive or even survive in the NHS, I urge policy makers to reconsider the impact of their ever increasingly restrictive prescribing policy.