Academics urge rethink on 28-day prescriptions for people with long-term conditions

The widely adopted
practice of issuing 28-day rather than longer duration prescriptions for people
with long-term conditions lacks a robust evidence base and should be
reconsidered, according to a study published in the British Journal of General
Practice on 13 March. Related research shows that considerable savings
could be made by the NHS switching to longer prescriptions.

Over a billion NHS
prescription items are issued each year by pharmacists in the community, at a
cost of over £9 billion. Many of these medications are used for the management
of long-term health conditions, such as diabetes or heart disease.
Prescriptions for these medications are issued through the ‘repeat prescribing’
system. This allows patients to request a further supply of medicines without
needing to make another appointment with their doctor. Local guidance by
clinical commissioning groups in many parts of the country encourages GPs to
issue shorter supplies of these repeat medications, partly to reduce wastage.
Prescriptions are typically 28 days in length, but this policy has been
questioned.

The study, led by
RAND Europe in Cambridge and funded by the National Institute for Health
Research, examined previously published studies that looked at this issue,
dating back as far as 1993. The researchers found nine studies that suggested
that longer duration prescriptions are associated with patients being more
likely to take their medications (better so-called adherence). They also found
six studies that suggested that shorter prescriptions might be associated with
less wastage, although these studies were considered to be very low quality.

In related work
published in BMJ Open, the researchers undertook an analysis of 11 years of UK
GP prescribing data. This found that any savings due to reduced waste resulting
from issuing shorter prescriptions were more than offset by greater costs due
to the additional work required by GPs and pharmacists. Longer prescriptions
could save GPs’ time, which could in turn be used to increase time spent with
patients. Savings to the NHS from lengthening all prescriptions for statin
drugs alone (one of the most commonly prescribed medications) were estimated at
£62 million per year.

And in a further
economic modelling study, published today in Applied Health Economics and
Health Policy, the researchers have shown that if longer prescriptions result
in better medication adherence, this could lead to improved health outcomes
and, as a result, further reduced costs for the health service.

Dr Rupert
Payne, from the University of Bristol’s Centre for Academic Primary Care
and one of the study’s authors said:

“This has been a contentious issue for
many years. Our research shows that the current recommendations to issue
shorter prescriptions have been based on a lack of sound scientific evidence.
There is the potential for longer prescriptions to lead to important benefits,
by improving patients’ adherence and thus the effectiveness of the drugs,
lessening workload for health care professionals, and reducing inconvenience
and costs to patients.”

However, Dr Payne
also cautions that lengthening prescriptions could have undesirable
consequences for pharmacists.

“Community pharmacies receive a fee for every
prescription they dispense. So simply switching every repeat prescription item
from, for example, one month to three months, could result in a large reduction
in pharmacy income. Therefore, although the NHS may save money, it could lead
to a loss of pharmacy services. Changes to policy around the length of repeat
prescriptions should also consider how pharmacies are reimbursed.”

Dr Ed Wilson,
health economist at the University of Cambridge’s Primary Care Unit and
co-author said:

“Our results show that in many cases, longer prescription
lengths could indeed both reduce administration costs and improve health
outcomes. This is because longer prescription lengths do seem to be
associated with patients taking their medicines more regularly. However,
the evidence base is not perfect so any national change in policy for repeat
prescriptions should be phased and needs evaluating fully to make sure we do
see the benefits we expect.”

Dr Sarah
King, Research Fellow at RAND Europe and lead author of the study, said:

“Currently, the UK Department of Health and Social Care advises that the
frequency of repeat prescriptions should balance patient convenience with
clinical appropriateness, cost-effectiveness and patient safety but does not
specify a recommended period. Given our study results, CCGs and local NHS may
wish to reconsider current recommendations for 28-day prescription lengths for
patients with stable chronic conditions.”

Papers

‘The
impact of issuing longer versus shorter duration prescriptions – a systematic
review’ by Sarah King, Celine Miani, Josephine Exley, Jody Larkin, Anne
Kirtley, and Rupert A. Payne. Published in the British Journal of General
Practice. 13 March 2018.

‘Long-term
costs and health consequences of issuing shorter duration prescriptions for
patients with chronic health conditions in the English NHS’ by Adam Martin,
Rupert A. Payne and Edward C.F. Wilson. Published in Applied Health Economics and Health Policy. 13 March 2018.

‘Retrospective,
multicohort analysis of the Clinical Practice Research Datalink (CPRD) to
determine differences in the cost of medication wastage, dispensing fees and
prescriber time of issuing wither short (less than 60 days) or long (less than
or equal to 60 days) prescription on lengths in primary care for common,
chronic conditions in the UK’ by Brett Doble, Rupert A. Payne, Amelia Harshfield
and Edward C.F. Wilson. Published in BMJ Open. 5 December 2017.

‘Clinical
effectiveness and cost-effectiveness of issuing longer versus shorter duration
(3-month vs. 28-day) prescriptions in patients with chronic conditions:
systematic review and economic modelling’ by Céline Miani, Adam Martin,
Josephine Exley, Brett Doble, Edward C.F. Wilson, Rupert A. Payne, Anthony
Avery, Catherine Meads, Anne Kirtley, Molly Morgan Jones, and Sarah King.
Published in National Institute for Health Research Journals Library. December
2017.