Increasing the duration of repeat prescriptions may save NHS money and improve care
This research found that current guidance to issue 28-day repeat prescriptions is not based on good evidence, and that 3-month repeat prescriptions may be more cost-effective.
About the research
Over a billion NHS prescription items are issued in England each year by community pharmacists (e.g. on the high street or in GP surgeries), at a cost of over £9 billion.
Many of these prescriptions are for medications to manage long-term health conditions (e.g. diabetes, heart disease), and are issued through the ‘repeat prescribing’ system, allowing patients to request further supplies without an
additional doctor’s appointment.
Local guidance by many clinical commissioning groups encourages GPs to issue shorter supplies of these repeat medications, primarily to reduce wastage. Consequently, repeat prescriptions are typically 28 days in length.
However, this policy is disliked by many prescribers and patients, and the evidence base has been questioned. In a study commissioned by the NIHR Health Technology Assessment Programme, researchers looked into the clinical
and cost-effectiveness of longer versus shorter duration prescriptions for long-term medication, to see if there was evidence to support or change current guidance.
The study looked at several long-term conditions and included:
• A systematic review of relevant existing research
• A cost analysis of medication wastage using GP prescribing data from across England
• An economic decision model, to predict the costs and effects of differing levels of adherence to medication (i.e. how likely patients are to take their medications), depending on prescription duration.
•NHS England must recognise that policies encouraging shorter duration prescriptions to reduce costs are not supported by evidence; 3-month repeat prescriptions may result in greater savings than 28-day prescriptions, and may be more cost-effective over a patient’s lifetime.
• NHS England should consider developing national guidance to inform local decision making by practices, pharmacies and CCGs, recommending the use of longer prescriptions.
• Although longer prescriptions may on average be cost saving, any policy must be flexible; shorter prescriptions remain preferable in certain clinical situations.
• Increasing the use of the Electronic Prescription Service and repeat dispensing systems should be encouraged, but not as an alternative to considering increasing the recommended duration of long-term repeat prescriptions.
• Any policy change must include rethinking the funding model for community pharmacies, which currently receive a fee for every prescription dispensed. Decreasing the frequency of all repeat prescription items may substantially reduce pharmacy income, with potential consequent loss of key pharmacy services.
• The evidence and data underpinning the analyses that have been conducted make several important assumptions. Any policy rollout should be undertaken in the context of a robustly evaluated pilot or trial.
•Based on analysis of national GP data, savings ranged from £8.38 to £12.06 per prescription per 120 days if a single long prescription was issued instead of multiple short prescriptions.
• Nine previous studies suggested longer duration prescriptions are associated with better medication adherence.
• Assuming that adherence leads to improved disease management and better health outcomes, longer (3-month) duration prescriptions are associated with lower costs and are more cost-effective than shorter (28-day) prescriptions.
• Six previous studies suggested that shorter prescriptions might be associated with less medicine wastage, although these studies were considered to be of very low quality (e.g. risk of bias, small sample).
• However, our analysis of GP data found that waste-related savings from shorter prescriptions were more than offset by greater costs in GP and pharmacist workloads.
• It was not possible to account for use of the Electronic Prescribing System and “repeat dispensing”, which reduces demands on prescribers. Nevertheless, even if such systems were implemented, the costs of more frequent prescribing still outweigh any savings due to waste reduction (e.g. £104 million and £62 million per annum for antidepressants and statins respectively).
Policy Briefing 60: June 2018
‘The impact of issuing longer versus shorter duration prescriptions – a systematic review’ by S. King, C. Miani, J. Exley, J.Larkin, A. Kirtley, and R.A. Payne in British Journal of General Practice, March 2018 doi.org/10.3399/bjgp18X695501
‘Long-term costs and health consequences of issuing shorter duration prescriptions for patients with chronic health conditions in the English NHS’ by A. Martin, R.A. Payne and E.C.F. Wilson in Applied Health Economics and Health Policy, March 2018 doi.org/10.1007/s40258-018-0383-9
‘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 C. Miani, A. Martin, J.
Exley, B. Doble, E.C.F. Wilson, R.A. Payne, A. Avery, C. Meads, A. Kirtley, M.M. Jones, and S. King in National Institute for Health Research Journals Library, December 2017 doi.org/10.3310/hta21780
‘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 either short (<60 days) or long (>60 days) prescription on lengths in primary care for common, chronic conditions in the UK’ by B. Doble, R.A. Payne, A. Harshfield and E.C.F. Wilson in BMJ Open, December 2017 doi.org/10.1136/bmjopen-2017-019382
The study was led by RAND Europe. This is independent research supported by a grant from the National Institute for Health Research, (Grant reference: NIHR HTA 14/159/07). The views expressed are those of the authors and not necessarily those of the National Health Service, the National Institute for Health Research or the Department of Health and Social Care.
Contact the researchers
Dr Rupert Payne (University of Bristol)
Dr Sarah King (RAND Europe), Dr Ed Wilson (University of Cambridge), Dr Céline Miani (Bielefeld University)