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Blanket 28-day prescribing policies 'cost more than they save'

Policies promoting 28-day prescribing by GPs are likely to be a false economy as they cost at least as much as they are projected to save, pharmacy researchers have suggested.

Their study said the Department of Health-endorsed policy to promote shorter prescribing durations costs at least an additional £150m a year due to increased dispensing fees from pharmacies.

It found the policy had been effective in prompting a ‘generalised change in prescribing behaviour’, with GPs prescribing five fewer doses per prescription compared with a decade ago.

But the analysis led by Professor David Taylor, professor of pharmaceutical and public health policy at University College London School of pharmacy, concluded the policies had been applied too ‘rigidly’ in some areas, and said GPs should be allowed to use their discretion in determining prescription duration.

Published in the journal Primary Care Research and Development this month, the study looked at trends in prescribing data from 1998-2009 in England for 11 medicines, including simvastatin, aspirin and ramipril.

The medicines represented a fifth of all prescription items supplied and apart from amoxicillin, which was included as an acute comparator, all the medicines showed a significant drop in doses per prescription. This drop in prescription length meant an extra 35 million items were dispensed during 2009 compared with 1998.

The researchers calculated this would equate to an additional £150m a year in dispensing fees and, when taking into account other costs such as patient/GP time, loss of disease control and so on, the benefits were unlikely to outweigh the expense.

They cited a University of York analysis showing that in England policies to reduce the cost of unused medicines in the NHS were likely to only generate savings of up to £150m at best.

‘A cost of £150m, the available evidence suggests, is considerably in excess of any possible savings that a blanket rather than selective use of 28-day prescribing periods is likely to generate,’ the researchers concluded.

Dr Bill Beeby, chair of the GPC clinical and prescribing subcommittee and a GP in Middlesbrough, said the study showed rigid 28-day policies were based on flawed figures.

He said: ‘The problem is most people do take their medicines and so it is inconvenient, insulting and demotivating to have to get their medicines every 28 days.’

Dr Peter Swinyard, chair of the Family Doctor Association, told Pulse that GPs should be allowed to decide prescribing lengths on a case-by-case basis ‘depending on the drug and on the patient’.

He said: ‘There are some areas of the country where PCTs have been extremely heavy handed with practices and have performance-managed them to make sure they only prescribe in 28-day cycles.’

But Dr Agnelo Fernades, assistant clinical chair at Croydon CCG, said guidelines for practices in his area had helped to dramatically reduce the quantity of drugs wasted.

He said: ‘In south-west London alone, three metric tonnes of wasted drugs were returned last year from patients who didn’t take them.

‘Yes, 28-day prescribing creates extra work for GPs because they have to generate the prescriptions, but you have to balance the inconvenience with the fact that patients will be more compliant in taking their medication. I think 28-day prescribing is the right thing to do.’

Changes in average number of doses per prescription
Source: Prim Health Care Res Dev 2012, online 3 October
Drug19992009
Ramipril 5mg5439
Amlodipine 5mg4337
Atenolol 50mg4639
Simvastatin 10mg4336
Levothyroxine 50µg7443

Readers' comments (16)

  • patient pays for each item. 28 days simvstatin cose just only £1.00. it seems reasonable to give it for three month. i did not know there is policy of 28 days. i only restrict this to antidepressant sedatives antipsychotics and nsaid's and some rather expensive items

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  • if patient pays for prescription then it would benefit them to have a private prescription as they would pay less. This is accepatable if the GP doesnt charge them for the prescription. It would also lower the spend on NHS drugs

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  • the pharmacy fees come out of the global sum, so not sure how the extra cost is viewed as an extra cost.

    extra work for gps? then use repeat dispensing prescribing, especially under eps2.

    think this research needs further investigation

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  • 28 day prescribing is a nonsense and needs to be left to the discretion of the GP. People with long term conditions like hypothyroidism waste so much money and patients time as they wade through numerous plastic bottles of pills because they have to collect their prescription every 28days. It would make greater sense to give them a longer prescription duration and save on the plastic bottles, paper and ink, waste of chemists time as they repeatedly make out the same prescription and patients fuels as they keep driving to these places to collect their prescriptions -give longer prescription duration and help our environment!

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  • Reduce the weight of the drugs

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  • Hmm, how many people above has actually worked in GP practice as a partner?

    Repeat script is a huge problem in primary care - I often have more than one receptionist doing the scripts and I spend about an hour/day looking at the questions raised. Even purely for re-printing some of the monthly scripts, it takes time.

    On the other hand, there are savings to be had for reducing the waste, especially for expensive medications. I would happily give 3 months of simvastatin, but will limit pregabalin to one month at a time - I think this is sensible and assume what this research is getting at.

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  • Bob Hodges

    New research has also just shown that bears shit in woods.

    'Blanket' anything is a bad idea and wastes time/money.

    Individual discretion of the GP on a case by case basis is the way forward, but the powers that be don't like that because it shows that GPs can't actually be replaced by a cheaper alternative.

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  • I give stable patients a 6m batch of prescriptions in monthly intervals. That way, the pharmacy still gets paid a reasonable upkeep, the patient is checked by the community pharmacist at the time of dispensing, and I only have to sign the prescription twice a year.

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  • Dispensing fees come from pharmacy global sum and are a fixed amount so if there are more of them their value is proportionately reduced. The study does not recognise this. If you want to reduce workload in the practice AND avoid waste through long prescribing intervals embrace EPS2 and repeat dispensing. Why does 28 day prescribing lead to loss of disease control?

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  • I have been saying this for years. Not only is it the extra dispensing costs, but the hours of extra work for the receptionists, not to mention the extra prescriptions for us to check and sign.
    My PCT (Surrey) really bullied me about this and I was ashamed to keep asking really stable sensible patients to keep forking out the money and effort to come in every month for things like HRT and Thyroxine etc.
    Now I've retired and I have to put up with the same nonsense. I have such a palaver to get my drugs. My surgery is five miles away (I live in the country) and every month I have to take in the damned script request, I can't email it or phone it. I then have to go back for the drugs. It's ludicrous and really expensive.

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