The number of prescriptions in English primary care dropped for the first year on record, with some 1 million fewer prescriptions an savings of £73m, new data has revealed.
In 2017/18, £8.25bn was spent on 1.095 billion primary care prescriptions in England, according to new quarterly NHS clinical commissioning group (CCG) prescribing figures. The reduction in spending and items dispensed follows consistent annual climbs, with this increasing in 2016/17 by some 23 million prescriptions compared to 2015/16.
The decline comes as a result of new prescription bans and ongoing medicines optimisation efforts to reduce prescribing in key areas including analgesics and oral nutritional supplements.
‘Minimising fluctuations in costs’
Royal Pharmaceutical Society (RPS) English board chair Sandra Gidley said: ‘Pharmacists across sectors are undertaking greater numbers of medication reviews with patients, reducing polypharmacy where appropriate for improved patient care, which is reflected in a slowing of the rate of prescription growth nationally.
‘A substantial amount of community pharmacy work has ensured continuity of supply for patients and minimised fluctuations in medicines cost, even when faced with shortages of medicines. As a number of well-established medicines lose patent, community pharmacy has ensured that appropriate use of lower-cost generic medicines has freed up money for the NHS, whilst ensuring high quality patient care.’
Drug trends: Analgesics are down, but antidepressants are up
Among the most-dispensed items were lipid-regulating drugs (73 million), prescriptions for hypertension and heart failure (71.6m) and antidepressants (67.9 million), all of which saw increases from the previous year.
The largest changes were seen in analgesics (-2.9 million), antidepressants (+2.8 million) and emollient and barrier preparations (-2.2 million).
Pharmacists are not the only health professionals to monitor prescribing trends over the past few years.
Dr Andrew Green, British Medical Association General Practitioners Committee (BMA GPC) prescribing and policy lead, said: ‘GPs have been working very hard to ensure that their prescribing is appropriate, and the reduction in overall numbers of prescriptions is on the whole encouraging. Some of this may represent work by our CCGs, as they try to ensure proper prescribing of such things as nutritional supplements.’
He added: ‘I am also heartened by the decrease in analgesic prescribing, which hopefully recognises the very limited role for analgesics in chronic pain. The relentless increase in antidepressant prescribing is, however, of real concern and I await the findings of the Public Health England (PHE) review of drugs with potential for dependence and withdrawal with great interest.’
A spokesperson for charity the Health Foundation explained that the spending drops on prescription items reflect a reduction in purchasing costs, combined with a shift to generic medicines and through CCG work with medicines optimisation teams.
The charity explained that NHS England’s restrictions on prescribing would also drive prescription numbers down. Last year NHS England removed 18 products including analgesics such as immediate release fentanyl.
Andrew Rideout, committee member at membership body the Association for Prescribers (AFP), added: ‘Many of the items that will no longer be prescribed are available from community pharmacists as general sale list (GSL), over-the-counter (OTC), or pharmacy-only (P) items, and so will be available to pharmacists as a way of maintaining income streams, whilst providing expert, individualised advice for members of the public.
‘However, while GSL medications can be purchased much more cheaply at supermarkets, many members of the public, also facing tighter budgets, will probably choose to shop there rather than with their pharmacist.’
APF’s Matt Fitzpatrick attributed some of the reduction to effective patient reviews: ‘seeing what can be stopped and in a more timely fashion’. He added that the trend was positive ‘financially’ but also in helping patients with ‘dependence and resistance’.
CCG spotlight: A north/south divide
Sandwell and West Birmingham CCG saw the largest drop in prescription items in 2017/18, with some 9.97 million prescriptions – 364,000 fewer than the previous year. The biggest drops were seen in analgesics (-48,000), emollient and barrier preparations (-24,000), reflecting the national trend, but also in diabetes drugs (-23,000). A spokesperson from the CCG said it had been an early adopter of the NHS England OTC guidance and has been working on a chronic pain project since 2015.
Primary care clinicians have targeted analgesic prescribing as a problem area, working with secondary care integrated nociceptive and neuropathic pain pathways. Sandwell Dietitians and nutrition professionals have helped the CCG reduce oral nutrition supplements (ONS) prescribing, with healthcare professional training and mandatory malnutrition screening for patients.
Bradford Districts CCG recorded 244,000 fewer prescriptions. Dr Carsten Grimm, a GP and clinical board member, said the drops were down to new patient online ordering systems and an oral nutritional project with a limited formulary and template to manage malnutrition.
Dr Grimm said: ‘Enabling patients to be in charge of their medication and order only what they need ensures that healthcare professionals are aware what patients actually need is important.
‘Pharmacists, working with general practice, play an important part in this, often reviewing medication use and offering additional support for people who struggle to leave their house.’
The number of prescriptions per patient population in the north far exceeded southern and urban spots. In Blackpool there was an average of 34 prescriptions per patient, and in Durham Dales, Easington and Sedgefield (DDES) CCG there were 33 prescriptions per patient, over three times the level of London CCGs Camden (10), Islington (11) and City and Hackney (11).
A spokesperson for NHS Blackpool CCG said: ‘Blackpool is well known for having high levels of patients with multiple long term conditions many of which are connected to the levels of deprivation in the town. This is the main driver of our higher item numbers and the CCG is looking at how we can optimise patients’ medication to reduce the number of prescriptions issued.’
Durham Dales, Easington and Sedgefield (DDES) CCG told The Pharmacist that it had moved to shorter period prescriptions produced for monitored dose systems (MDS). This aims to reduce medicine use and wastage, however, prescriptions are more frequent. The CCG said the reduction in costs (-£2.1 million) reflected these efforts. The CCG also said the region has a higher rate of respiratory diseases such as COPD, at 2.7% in Durham against a national average of 1.7%.
Dr Graham Jackson, co-chair of NHS Clinical Commissioners (NHS CC) and clinical chair of Buckinghamshire integrated care system, welcomed the overall decline in prescriptions dispensed. He said: ‘This prescribing data is the first piece of evidence that the new national commissioning guidance on items of low priority for NHS funding, introduced in November 2017, is having its intended effect which is good news.’
Dr Jackson noted the revised prescribing guidance released in March should see further declines. Dr Jackson said: ‘It is important that we carry on having honest, open conversations on what the NHS can and should provide with the funding it has, so that we can continue to deliver high quality care.’