The National Institute for Clinical Excellence states that if its guidance on the use of proton pump inhibitors to treat dyspepsia was fully implemented it could reduce usage by at least 15 per cent, and therefore save the NHS in England and Wales£40m to£50m per year in drug costs.

The guidance suggests patients presenting with gastric symptoms can be pigeonholed into one diagnostic category or another.

Our qualitative interviews with 82 patients on repeat prescriptions for PPIs indicate the position is not so clear-cut, at least from a patient perspective.

Even if patients had received a diagnosis, they reported that it frequently changed in response to different medical consultations.

Patient diagnoses often differed from the recorded diagnoses that the GPs reproduced from the medical record. It seems that it is often hard to define and categorise the nature of the underlying pathology. In addition, as is well recognised, the severity of symptoms did not necessarily accord with the level of pathology.

Patients share with doctors and NHS managers a desire to take the minimum effective amount of medicine. Many of our respondents had experimented to find their own optimal dose of PPIs, often without their GP's knowledge. NICE has not acknowledged the potential for authorised patient self regulation.

Encouraging patients to participate in their own treatment management has advantages, not least potential cost-saving.

Long-term treatment with PPIs was currently the most effective in treating gastric symptoms. Yet younger patients in particular were concerned about the need to take these medicines palliatively for the foreseeable future while often not understanding the nature of their gastric problem.

On behalf of the patients we interviewed, we would like to ask:

Will the guidelines raise the threshold of PPI prescribing so that some patients may receive less than optimal treatment or effective symptomatic relief?

Is the lack of acknowledgement of the scope for patient self-regulation of PPIs a missed opportunity?

What can be done for younger patients who have no adequate explanation for the cause of their gastric condition, and who do not want to take PPIs - or any other medication - longterm, but find they cannot manage without them?

Janet Grime Kristian Pollock Concordance research fellows Department of medicines management Keele University