Variations in general practice prescribing: a multilevel model approach to determine the impact of practice characteristics, including fundholding and training status

Monthly prescribing behaviour is assessed over a 3‐year period, 1 April 1992 to 31 March 1995. Total monthly number of items prescribed and overall net ingredient cost are analysed for 263 general practices, serving the 1 million residents of Birmingham, UK. Patients aged over 65 years play an important role in elevated prescribing activity. Practice composition varies considerably between training and non‐training practices, and between fundholding and non‐fundholding practices. Accounting for these differences, fundholders expend less and prescribe fewer items than their non‐fundholding counterparts. This is observed against a steady increase in prescribing activity over the study period. There are, however, marked downward shifts in both the number of items prescribed and overall monthly expenditure occurring with every new wave of fundholding. The magnitude of these changes raises doubts about the efficacy of the transition to fundholding and the impact of such large changes upon patient care.