Behavioural incentives gone mad? The report of the National Audit Office into prescribing costs in primary care
The National Audit Office report on prescribing costs in primary care
(BMJ 26 May 2007) endorses a restriction of 28 days as the maximum
prescription length. This policy leaves patients with a life-threatening
medication dependency at the mercy of unreliable pharmaceutical supply
chains, potentially resulting in expensive emergency hospital admissions
or worse. We wish to suggest that many of the problems that currently
arise could be overcome if such patients were issued with six-monthly
The National Audit Office report contains two assumptions of
irrational patient behaviour driving prescription wastage, neither of
which is clearly substantiated. It suggests that patient access to
medication needs to be controlled via 28 day rationing, in part to curb
the costs of patients who:
1. Fail to finish prescribed courses of medication
2. Hoard quantities of unused medication.
It is now more than ten years since Hawksworth and Chrystyn analysed
inappropriate prescribing and prescription wastage in the UK. [See
Hawksworth GM and Chrystyn H, Clinical Pharmacy in Primary Care, British
Journal of Clinical Pharmacology 1998, 46 (5), 415–4]. Many of the
opportunities they identified for GPs and patients to improve treatment
compliance and reduce wastage have already been acted on. Their work,
cited in support of the National Audit Office’s recommendations, does not
obviously support the assumption of widespread patient hoarding.
Tellingly, they found the greatest scope for reduction of prescription
wastage where patients were least empowered to influence their medication
regime – care homes for the elderly.
There is one group for whom the stereotype of untrustworthy patients
wasting medication is particularly frustrating: those who are steroid-
dependent. Steroid-dependent patients must take their medication two to
four times daily, at the right time of day, in order to stay well. In the
event of illness or injury, they must double or triple their normal daily
dose; in severe cases, an emergency injection of 100mcg hydrocortisone and
hospital treatment may be necessary to stabilise their condition.
Steroid-dependent patients have every incentive to comply with their
treatment regime. If they do not, they become critically ill within a
matter of days. A longer period of steroid deprivation would inevitably
result in death.
Fortunately, glucocorticoid and mineralcorticoid replacement therapy
is cheap. A year’s supply of life-giving hydrocortisone and
fludrocortisone for a steroid-dependent patient usually costs the NHS
[Based on average medication requirements of 100mcg fludrocortisone per
day (£15.89 per annum), 30mg hydrocortisone per day plus illness cover of
25% contingency allowance (£31.94 per annum), Efcortesol, 5-vial pack
£4.48 per annum. See http://www.ppa.nhs.uk/edt/May_2007/mindex.htm for
costs and dispensing charges].
Where the patient has a life-long medication dependency, it seems
absurd to claim that restricting the patient to just 28 days’ supply at a
time reduces wastage, especially in respect of steroid replacement
therapy, where an average 28-day supply will cost the NHS less than £3.70.
The dispensing fee on this average 28 day supply is £1.80 or more. Yet the
National Audit Office apparently regards a universal 28-day repeat
prescription limit – as applied by Coventry PCT – as best practice.
The 28-day limit does not currently differentiate between
discretionary therapies and those which are essential for life, nor
between expensive drugs and cheap ones. So Coventry PCT issues its
glucocorticoid and mineralcorticoid-dependent patients with a typical 28-
day supply costing less than £3.70 and pays £1.80 in dispensing fees to do
so, in pursuit of prescription wastage.
If steroid-dependent patients were trusted with six months supply at
a time, as is currently the case for growth hormone and HRT therapy in
parts of the UK, the lifetime dispensing fees and related costs would be
reduced six-fold. It would also free up a lot of time that GP
receptionists and other staff currently spend chasing those 28-day
Finally, the past 18 months has seen a series of shortages affecting
fludrocortisone (Florinef®) and hydrocortisone (Hydrocortone®, Corlan®,
Efcortesol®). These shortages have been caused by: supply dislocation in
countries outside the UK; plant relocation; two unanticipated
manufacturing breakdowns; and distributor renegotiations.
These shortages have left steroid-dependent patients waiting, in some
cases, for three weeks to renew a prescription which is essential for life
and restricted to just 28 days’ supply at a time. This is indefensible.
Steroid-dependent patients should be offered six-monthly repeat
prescriptions on their essential replacement therapy.
Professor John A H Wass
ADSHG Clinical Advisory Panel Chair
Professor John Monson
ADSHG Clinical Advisory Panel
Katherine G White
ADSHG Chair & CAP co-ordinator
Correspondence to: email@example.com
Competing interests: No competing interests