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

Research published in the British Journal of General Practice says 28-day prescriptions for people with long-term conditions lack robust evidence and should be reconsidered

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 today (March 13). 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 £9bn. 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.”

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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.

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