Over a billion NHS prescription medicines are issued by pharmacists in England every year – at a cost of over £9 billion. Many of these are prescribed by GPs to manage long-term health conditions, such as diabetes or cardiovascular disease.
The current “repeat prescription” system allows patients to request a further supply of medicines without the inconvenience of another doctor’s appointment.The UK Department of Health advises that the frequency of repeat prescriptions should “balance patient convenience with clinical appropriateness, cost-effectiveness and patient safety”.
However, it does not recommend a specific time period. As a result, local health service commissioners have developed their own guidance, with many encouraging GPs to issue short-term supplies of repeat medications, typically 28 days in length. This is supported by the UK’s Pharmaceutical Services Negotiating Committee.
One of the key reasons for issuing monthly supplies is the opportunity to reduce medication waste, which has been previously estimated to cost the NHS around £300m a year in England alone. If patients have fewer pills in their possession, it is harder to mislay or stockpile them.
It is also possible that fairly frequent contact with the doctor may aid the discovery of potential drug intolerance, and provide more chances for medication review.
But is this approach the right one? From the perspective of patients, shorter prescriptions also mean more opportunities to forget to reorder supplies, and often necessitate additional trips to the GP and pharmacy.
Time and effort spent dispensing pills in community pharmacies is also considerable, and arguably an inefficient use of pharmacists’ valuable skills. Shorter prescription time frames exacerbate this. The workload for GPs authorising further prescriptions can also be substantial.
Our recent research challenges the current practice of shorter repeat prescriptions. We identified evidence from nine reports suggesting that longer duration prescriptions are associated with better adherence by patients to their medications (in other words, patients are more likely to take their pills the way the doctor intended).
A single American study of statins, a drug commonly prescribed to patients with cardiovascular disease, even found improvements in lipid control with longer term prescriptions. (However, other studies examining health outcomes or patient experience were lacking.)
In analysing 11 years of UK GP prescribing data, we found that shorter prescriptions were indeed associated with reduced medication waste. But those savings were more than offset by greater costs due to the additional work required by GPs and pharmacists.
Consider, for example, the impact of switching statins – the most widely prescribed drugs in UK primary care – to longer durations of around three months. This has the potential to save over £500m per year in doctor and pharmacist time – precious GP time which could be ploughed back into a struggling health service, seeing patients rather than signing bits of paper.
One could argue that the growth of electronic repeat dispensing, where GPs can authorise multiple repeat prescriptions at a time, could help deal with this issue. But there is still the opportunity for over £60m in savings through reduced dispensing costs for these drugs alone.
An economic modelling exercise found longer term prescriptions to be more cost-effective than shorter ones, driven primarily through health gains due to better medication adherence.
Medications are a daily part of the lives of millions, and in many cases unavoidable. Yet the current recommendations that require patients to make monthly trips to pick up more pills are simply not justified by the 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.
A bitter pill?
News that issuing longer prescriptions is more cost effective is likely to be welcomed by most GPs. But pharmacists may be less enthusiastic.
Community pharmacies receive dispensing fees for each NHS prescription, so reducing the frequency could lead to a large reduction in income. The NHS may save money, but critical pharmacy services could suffer. Changes to national policy around the length of repeat prescriptions would therefore need to consider how pharmacies are reimbursed.
Simply increasing the dispensing fee will not be straightforward, as some drugs may be more suitable for switching to longer prescriptions than others. It may not be possible, either, to recommend a new, standardised, longer prescription length.
Further research is likely to show that the one-size-fits-all model of 28 day blanket prescription policy is unsustainable. Different conditions, drugs and patient profiles may require different prescription lengths.
There are undoubtedly limitations to the work we have carried out so far, and it is necessary to make assumptions about the degree to which improvements in adherence lead to health gains – although evidence suggests a clear link.
The only way to provide a definitive answer to this question is to conduct a clinical trial. This is a potentially significant challenge that would require strong support from practices and service commissioners. Given patients frequently report irritation in the process of ordering regular medications, a trial would also offer the opportunity to compare and contrast the “customer” experience.
Until then, we must accept that the evidence does not support the current 28 day prescribing policy. The NHS needs to reconsider its approach – both to reduce costs and improve patient care.