Drugs are the mainstay of medical treatment, yet there are few reports on what constitutes “good prescribing.” What is more, the existing guidance tends to imply that right answers exist, rather than recognising the complex trade offs that have to be made between conflicting aims. This paper proposes four aims that a prescriber should try to achieve, both on first prescribing a drug and on subsequently monitoring it. They are: to maximise effectiveness, minimise risks, minimise costs, and respect the patient's choices. This model of good prescribing brings together the traditional balancing of risks and benefits with the need to reduce costs and the right of the patient to make choices in treatment. The four aims are shown as a diagram plotting their commonest conflicts, which may be used as an aid to discussion and decision making.

In 1992 Britain spent pounds sterling3.3bn on drugs and associated services, yet surprisingly little has been published on what constitutes good prescribing. The most common definition is from a far sighted paper by Parish in 1973—that it should be “appropriate, safe, effective and economic.”1 However, drugs, the NHS, and society have moved on since then, and my own experiences have led me to question whether this definition is still appropriate.

The stimulus came when I was chief pharmacist in a hospital and a doctor asked whether I would supply sleeping tablets that were on the NHS blacklist for a dying man. The patient had no family and had come into hospital to receive care in his last few days of life. He had been using the sleeping tablets for more than 10 years, buying them on private prescriptions because he thought they were better than any NHS alternatives. The question was considered against the definition of Parish. According to these criteria, temazepam …