For many years now, there has (in the UK) been a near-universal imposition of 28-day prescribing.
There is, quite simply, no rational basis for this policy in relation to long term medicines on repeat.
There is incoherency where we are told that we can only have a 28-day supply of a medicine even if it has been prescribed to be taken as needed.
There are the potentially severe consequences of running out of many medicines. For example, steroids, insulin, thyroid hormone.
Short prescribing, with the intention that we only apply for a repeat in the last few days, puts people at risk from supply issues, from other difficulties in getting their prescription issued (even as basic as distribution problems or just feeling ill).
For those who do not live near the GP surgery or pharmacy, there can be transport and time costs, sometimes considerable. This multiplies if the pharmacies do not have the product on their shelves, ready to dispense.
The major beneficiaries of 28-day prescribing of medicines which are prescribed long term seem to be to pharmacies. The specific claim that pharmacies are pushing for 7-day prescribing of MCA (multi-Compartment Aids) to recover costs rather supports that view.
We need pharmacies, pharmacies have to be viable, but effectively making work for them so they can increase their income seems entirely wrong-headed.
This imposes extra work on GPs and other prescribers. While this is always an issue, it is of particular relevance when there is a health emergency of any sort.
That if we are unlucky enough for the next repeat to fall at Christmas/New Year we clash with an already busy time where we are requested not to contact our GPs, if possible.
Those who impose and enforce 28-day policies are ignoring advice and research which questions its existence.
This includes the MHRA report on levothyroxine, published in 2013, where the CHM advised prescribing on a three-month basis. And more recent articles published by the British Journal of General Practice and the paper that used as a reference, the BMA, Pulse, and others.
I have included extracts from each below.
Prescription intervals
Doctors should provide prescriptions for intervals that they feel are clinically appropriate. This should take into account:
• possible reactions
• the stability of the treatment
• patient compliance
• necessary monitoring.
Sometimes a doctor may give six or even twelve months supply on one prescription as this is cost-effective and convenient for patients.
We have also received requests for GPs to consider shorter duration prescribing (28-day prescriptions).
Prescribing intervals can place significant workload on doctors and surgery staff, and should be in line with patients’ medical needs. Pharmacy requests to issue a seven-day prescription should be discouraged.
The request for seven-day repeat prescriptions to defray the pharmacist’s costs for the filling of MCAs has become an increasing pressure for GPs. Our advice is to resist such demands unless there is a clinical reason for restricting supply to seven days.
• Consistency of size, shape and colour of the medication could be more effective than using MCAs (can be confusing for patients).
• There are some storage problems involved in using MCAs, such as possible deterioration of drugs after being taken out of the packet.
• There are alternative ways to support patients taking medication, such as medicine advice charts, which allow the drugs to be retained in their packaging with advice sheets
The GPC supports the PSNC in that both pharmacists and dispensing doctors issuing MCAs should be properly reimbursed for the services they provide to patients.
bma.org.uk/advice-and-suppo...
28-day prescription lengths for people with long-term conditions should be reconsidered, say health research team
March 13, 2018
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 new studies published in Applied Health Economics and Health Policy and the British Journal of General Practice today. The 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.
Longer prescription lengths do seem to be associated with patients taking their medicines more regularly.” – Dr Ed Wilson, Senior Research Associate in Health Economics
In related work already 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 the 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 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 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 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 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.”
References
‘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. Applied Health Economics and Health Policy. 13 March 2018
‘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. British Journal of General Practice. 13 March 2018
phpc.cam.ac.uk/pcu/28-day-p...
Why it’s time to re-think guidance on 28-day prescriptions
13 March 2018
Health researcher Josephine Exley says there is mounting evidence that cutting ‘waste’ associated with long-term scripts may be a false economy
In England, the NHS spends over £9 billion each year on prescription medicines dispensed through hospitals and GPs, which is equivalent to 7% of its total budget.
Long-term treatments with medication often play a fundamental role in the clinical management of patients with stable long-term non-communicable conditions, such as diabetes, asthma and hypertension. In many cases, patients are provided with so-called ‘repeat’ prescriptions that are usually issued without the need for further consultations with the GP.
Guidance issued by the Department of Health recommends prescription lengths balance patient needs and good medical practice, while also considering NHS resources. To try to control the costs of unused or partially used medications – estimated to cost around £400m a year – local commissioning groups have encouraged GPs to shorten prescription length, typically to 28 days.
However, our study commissioned by the National Institute for Health Research shows that increasing the length of prescriptions for people with long-term conditions could result in substantial savings for the NHS.
Despite the link between longer prescription lengths and increased waste, the study found that switching to longer prescriptions could result in cost savings, as the biggest impact on cost was the time administrating repeat prescriptions. Identifying patients with particular long-term conditions and characteristics that could benefit from longer prescriptions would be a good start toward realising these savings.
A good example is antidepressant prescriptions. Ninety five per cent of these prescriptions are less than 60 days, but a previous study showed longer-term prescriptions could potentially save as much as £305 million. This means that providing longer prescriptions for just one long-term medical condition would negate a large proportion of the costs of ‘wastage’.
The latest study also suggests that longer prescriptions could be associated with improved medication adherence. Therefore, there could be clinical benefits to increasing the length of repeat prescriptions for patients with chronic conditions. This could result in further long-term cost savings due to reductions in the use of health services by patients.
Another factor that could impact the cost savings are the personal costs incurred by patients through the shorter prescription lengths. The current evidence does not include the time and travel costs of patients that have to travel to hospitals, pharmacies or GPs to pick up their prescriptions. If these personal costs were considered then there is likely to be further savings associated with issuing longer prescription lengths.
Furthermore, 28-day prescription lengths have been described as disempowering and a hassle that can cause anxiety for patients when they are running low, particularly when their ability to travel is constrained.
We still need to do more research on these potential associations, but the evidence available suggests that the policy on 28-day prescriptions does at least require a re-think. The argument that it saves on ‘waste’ has been shown to be questionable, with the costs associated with dispensing fees and prescriber time outweighing wastage costs.
The current evidence base does not support policies and guidance promoting shorter prescription lengths over longer prescription lengths. If anything, the significant cost savings to the NHS warrants a look at whether more patients with long-term conditions should be issued longer prescriptions.
Josephine Exley is a Centre for Evaluation fellow at the London School of Hygiene & Tropical Medicine and a former senior analyst at RAND Europe
pulsetoday.co.uk/clinical/c...
Long-Term Costs and Health Consequences of Issuing Shorter Duration Prescriptions for Patients with Chronic Health Conditions in the English NHS
• Adam Martin,
• Rupert Payne &
• Edward CF Wilson
Applied Health Economics and Health Policy volume 16, pages317–330(2018)Cite this article
Abstract
Background
The National Health Service (NHS) in England spends over £9 billion on prescription medicines dispensed in primary care, of which over two-thirds is accounted for by repeat prescriptions. Recently, GPs in England have been urged to limit the duration of repeat prescriptions, where clinically appropriate, to 28 days to reduce wastage and hence contain costs. However, shorter prescriptions will increase transaction costs and thus may not be cost saving. Furthermore, there is evidence to suggest that shorter prescriptions are associated with lower adherence, which would be expected to lead to lower clinical benefit. The objective of this study is to estimate the cost-effectiveness of 3-month versus 28-day repeat prescriptions from the perspective of the NHS.
Methods
We adapted three previously developed UK policy-relevant models, incorporating transaction (dispensing fees, prescriber time) and drug wastage costs associated with 3-month and 28-day prescriptions in three case studies: antihypertensive medications for prevention of cardiovascular events; drugs to improve glycaemic control in patients with type 2 diabetes; and treatments for depression.
Results
In all cases, 3-month prescriptions were associated with lower costs and higher QALYs than 28-day prescriptions. This is driven by assumptions that higher adherence leads to improved disease control, lower costs and improved QALYs.
Conclusion
Longer repeat prescriptions may be cost-effective compared with shorter ones. However, the quality of the evidence base on which this modelling is based is poor. Any policy rollout should be within the context of a trial such as a stepped-wedge cluster design.
link.springer.com/article/1...
Impact of issuing longer- versus shorter-duration prescriptions: a systematic review
Sarah King, Céline Miani, Josephine Exley, Jody Larkin, Anne Kirtley and Rupert A Payne
British Journal of General Practice 2018; 68 (669): e286-e292. DOI: doi.org/10.3399/bjgp18X695501
Abstract
Background Long-term conditions place a substantial burden on primary care services, with drug therapy being a core aspect of clinical management. However, the ideal frequency for issuing repeat prescriptions for these medications is unknown.
Aim To examine the impact of longer-duration (2–4 months) versus shorter-duration (28-day) prescriptions.
Design and setting Systematic review of primary care studies.
Method Scientific and grey literature databases were searched from inception until 21 October 2015. Eligible studies were randomised controlled trials and observational studies that examined longer prescriptions (2–4 months) compared with shorter prescriptions (28 days) in patients with stable, chronic conditions being treated in primary care. Outcomes of interest were: health outcomes, adverse events, medication adherence, medication wastage, professional administration time, pharmacists’ time and/or costs, patient experience, and patient out-of-pocket costs.
Results From a search total of 24 876 records across all databases, 13 studies were eligible for review. Evidence of moderate quality from nine studies suggested that longer prescriptions are associated with increased medication adherence. Evidence from six studies suggested that longer prescriptions may increase medication waste, but results were not always statistically significant and were of very low quality. No eligible studies were identified that measured any of the other outcomes of interest, including health outcomes and adverse events.
Conclusion There is insufficient evidence relating to the overall impact of differing prescription lengths on clinical and health service outcomes, although studies do suggest medication adherence may improve with longer prescriptions. UK recommendations to provide shorter prescriptions are not substantiated by the current evidence base.
The MHRA report on levothyroxine recommends three-month prescribing. When I asked for that (as a new patient at a new surgery) the doctor very much implied that the pharmacists wouldn't like it - she gave me two months.
Levothyroxine Tablet Products: A Review of Clinical & Quality
Considerations
07 January 2013
9. Levothyroxine should be prescribed and dispensed in quantities covering three months supply, where appropriate, in order to address issues of continuity of supply and also to improve convenience to patients.
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