sBMJ | Give us back our BNF

Give us back our BNF

Sam Leinster argues that the Department of Health's decision to stop providing for free a drug formulary to UK medical students sends out the wrong signals

Prescribing errors are one of the commonest adverse events in hospitals. A recent editorial in the BMJ suggested that this was the result of inadequate teaching of clinical pharmacology and prescribing at medical school, but prescription error is not limited to junior doctors.¹

There are a number of possible explanations for the problem, but the increasing complexity of modern therapeutics is partly to blame. New drugs and even new classes of drugs come into routine clinical use and are inevitably associated with new adverse events and drug interactions. It therefore seems important to encourage the habit of consulting appropriate reference material when writing all but the simplest and most commonplace of prescriptions to ensure that the correct doses are being given, that no predictable interactions will occur, and that no known contraindications have been overlooked. (Remember that even the most experienced pilots use a written list for their preflight checks.)

L P WOODS
See that book? You won't from January

In the United Kingdom, the British National Formulary (BNF) provides a useful practical guide to prescribing. Its value has been recognised in the past by the Department of Health, which has provided up to date copies for all clinical medical students in the hope that they will develop the habit of using it. Unfortunately, this does not seem to have encouraged use of the BNF by junior doctors. A small study of 1326 prescriptions by junior doctors found that they consulted the BNF in only 10% of cases.² They asked a more senior colleague for advice in 21% of cases, leaving 69% of cases in which they depended entirely on their memory for their prescribing. An electronic version on a personal digital assistant was no more effective. The BNF is also available online, but this evidence indicates it is unlikely to be consulted by most prescribers.

The Department of Health will no longer fund the provision of the BNF to medical students. Their previous policy sent out a clear message that they expect doctors to check their prescribing regularly. It could be argued that it does not matter that the BNF is no longer freely available because most prescriptions are written without reference to it. A considerable number of these prescriptions, however, contain errors, and all prescribers should be encouraged to use the BNF or a similar tool. Ceasing to provide the BNF sends negative signals about the department's view of the importance of checking prescriptions.

SIFTing the options

It has been suggested that medical schools in England and Wales should pay for the BNF out of the "service increment for teaching" (SIFT) allocation. This suggestion has a number of flaws. SIFT is paid to NHS organisations, not to medical schools, and it is given to ensure that teaching medical students does not have a negative effect on the delivery of service. It was first introduced because it was recognised that teaching hospitals cost more to run than other hospitals. As more hospitals have become involved in teaching, SIFT payments have spread beyond traditional teaching hospitals, but the purpose is still to mitigate the effect that teaching has on service delivery. The provision of BNFs to medical students does not seem to achieve this in any way.

SIFT is channelled to the NHS and foundation trusts through the strategic health authorities, which have seen their overall budgets for education and training drastically reduced this year as a result of the expected financial deficits in the NHS. Although SIFT has been relatively protected, the Council of the Heads of Medical Schools report cuts of 5-15%. Already difficult decisions have to be made, including the possibility in some medical schools of making teaching staff redundant, which threatens the quality of teaching delivered. Shifting responsibility for paying for the BNF from central Department of Health funds to SIFT will exacerbate the situation.

Ultimately, prescribing error will be reduced only when electronic prescribing with integrated drug information support systems is widely adopted.³ A reliable, effective, and affordable system for the whole NHS is still some way off. Until that day we have to depend on developing good habits in medical students that will continue to be displayed when they qualify and practise as junior doctors. Please can we have our books back?

Sam Leinster, dean, School of Medicine, Health Policy, and Practice, University of East Anglia, Norwich NR4 7TJ
Email: s.leinster@uea.ac.uk

Competing interests: None declared.

studentBMJ 2007;15:1-44 January ISSN 0966-6494

Aronson JK, Henderson G, Webb DJ, Rawlins MD. A prescription for better prescribing.
Patel A, Khan MS, Choong AMTZ, Habibi P. Prescribing habits of junior doctors: do digital pocket assistants (PDAs) encourage the use of a British National Formulary (BNF)? [Electronic response to Aronson JK et al. A prescription for better prescribing.] BMJ 2006. www.bmj.com/cgi/eletters/333/7566/459#141037
Bates DW, Leape LL, Cullen DJ, Laird N, Petersen LA, Teich JM, et al. Effect of computerized physician order entry and a team intervention on prevention of serious medication errors. JAMA 1998;280:1311-6.

Responses published this month

Articles	Responses
EDITORIALS Give us back our BNF	Rahul Potluri (January 15th, 2007) Read this response

EDITORIALS Give us back our BNF	Emily Rigby (January 17th, 2007) Read this response

	EDITORIALS Give us back our BNF Sam Leinster (January 2007)
	Rahul Potluri (January 15th, 2007) 4th Year Medical Student, University of Birmingham EMAIL
	It is quite pathetic that the funding for BNFs has been changed. If it is indeed the case that medical schools cannot offer BNFs to medical student for free, the standard of prescribing will go down even further. The latest BNF has been the most useful for myself as a medical student (even compared to reputed pharmacology textbooks) because of the regular review/updates and concise information about the use of medications according the NICE guidelines. This is definitely a backward step for medical education in the UK.

	EDITORIALS Give us back our BNF Sam Leinster (January 2007)
	Emily Rigby (January 17th, 2007) Chair, BMA Medical Students Committee: 4th year medical student BristolEMAIL
	The concerns of Leinster are ones that I have to echo. Education and training sources are being attacked from every direction as a soft target for recouping funding deficits elsewhere. With decreasing resources for medical students, the impact on patient safety cannot be expected to be anything other than disastrous. The British National Formulary (BNF) is an essential reference for those in practice, and it is essential that those in training develop their knowledge and skills before taking on clinical responsibility. A vital part of that education is knowing how and where to refer to for guidance; not only to ones superiors, but to the latest data and guidance of the BNF. With the Department of Health removing funding, will students have to pay to obtain their BNF? Studying medicine is inherently expensive and final year students now owe an average of £21,755, a figure which has been rising steadily for the last five years due to increasing demands on students funds. Studying medicine should not about how much money you are prepared to pay, but a commitment to improving patient outcomes. Good prescribing should be a skill nurtured from the start of training, a commitment that students and medical schools already make. Instead of adding a further challenge, the Department of Health should demonstrate their responsibilities in this area and give us our books back. BMA, - Survey of medical student finances 2005/06. http://www.bma.org.uk/ap.nsf/Content/Studentfinance0506?OpenDocument&Login