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Some PCTs recommend GPs limit prescriptions to 28 days

BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d2410 (Published 13 April 2011) Cite this as: BMJ 2011;342:d2410

The pot of gold at the end of the rainbow?

Patients hoarding unused medicines is an attractive target for PCT
cost savings in the current economic climate. Rationing patients' access
to drugs by restricting repeat prescriptions to 28-days supply also
signals to GPs that they must be frugal in their prescribing habits.

Sadly, PCTs are chasing a mythical pot of gold at the end of the
rainbow with this kind of thinking. A number of studies have shown that
the extra processing costs on short repeats more than outweigh the cost of
the unconsumed drugs foregone by patients, for repeat prescribing lengths
of less than 84 - 100 days.

The Department of Health's recent independent report on waste
medicines concluded that avoidable medicines waste in England has a likely
value of less than GBP150 million a year, or less than 1.9% of English
spending on primary and community care medicines - substantially less than
the likely additional prescribing cost from shorter repeats.[1]

The Waste Medicine report's finding that 28-day repeat prescribing
drives up supply side costs reinforces the point made by another recent
analysis of UK medicines wastage. This found that pharmacy costs now make
up around one-third of the cost of most prescription items, which are
dispensed as generics with an average net ingredient cost of around GBP
3.83.[2] This study identified that if all 842.5 million prescriptions
issued by the NHS in England in 2008 had been 28-day repeat-dispensing
items, it would have added a projected GBP 700 million to the actual
pharmacy costs of around GBP 1.5 billion, to reach a total of GBP 2.2
billion on pharmacy costs.

Earlier studies in New Zealand[3] and the United States[4] came to
similar conclusions: there are more additional supply costs than there are
savings from rationing patients' access to long-term medications.

No one seems to have advised PCTs of this and many are reportedly
continuing to promote 28-day repeat prescribing as a cost-saving
measure.[5] To try and capture GBP 150 million of avoidable medicines
waste, PCT managers are potentially committing the NHS to an additional
GBP 700 million in pharmacy supply costs. There is, in reality, no pot of
gold at the end of the rainbow.

Preventing such an escalation of pharmacy supply costs will need
urgent, co-ordinated action. The Department of Health and Pharmaceutical
Services Negotiating Committee will need to work jointly to introduce
greater flexibility in the prescription lengths available through the
repeat dispensing scheme, with extended prescription lengths of 2 - 6
months being made available for suitable therapeutic regimes. PCTs and
GPs will need to be more explicit with patients about the actual cost of
generic and branded drugs, so that they are able to act responsibly in
managing their home supplies of long-term medications without either over-
stocking or running out.

Rationing drugs through a blanket 28-day repeat prescription length
contributes to significant health losses among patients who depend on long
-term therapies to control endocrine, cardiovascular, mental health or
other conditions. The risks to patient safety from restricted access to
essential medication are particularly severe for steroid-dependent
Addison's patients, who have been know to die less than five days after
running out of their steroid medication.[6]

The Waste Medicines report concluded that lost therapeutic outcomes
significantly outweighed the value of material losses associated with
wasted medicines for all the long-term conditions it analysed. As the
authors advised: "In the context of residual medicines there is a danger
that a 'zero tolerance' approach could undermine awareness that the core
purpose of healthcare is to increase as cost-effectively as possible
health and wellbeing, rather than to make savings to standalone budgets
like those for community pharmacy and/or primary care pharmaceuticals."

Yours sincerely,

Professor John Wass,
Chair, Addison's Clinical Advisory Panel

Katherine White,
Chair, Addison's Disease Self-Help Group

1. Evaluation of the Scale, Causes and Costs of Waste Medicines, York
Health Economics Consortium and The School of Pharmacy, University of
London, November 2010

2. White, K. G. (2010), UK interventions to control medicines
wastage: a critical review. Int J Pharm Pract. 18:131-140. doi:
10.1211/ijpp.18.03.0002

3. Pharmaceutical management agency: changes to the frequency of
medicine dispensing, New Zealand Office of the Controller and Auditor
General 2005, http://www.oag.govt.nz/2005/pharmac

4. Domino ME et al. Restricting patients' medication supply to one
month: saving or wasting money? Am J Health Syst Pharm 2004; 61: 1375-1379

5. O'Dowd A, Some PCTs recommend GPs limit prescriptions to 28 days,
BMJ 2011; 342:d2410

6. For example, see: An untimely death, Addison's Disease Self-Help
Group website, November 2010, www.addisons.org.uk

Competing interests: No competing interests

17 April 2011
Katherine G White
Chair
Professor John A H Wass
Addison's Disease Self-Help Group