PJ view: Time to look again at 28-day prescribing limits

As recommended prescribing intervals are doubled in Wales, we look at the evidence supporting current policy in this area.
28-day prescribing limits

From April 2022, community pharmacies in Wales may notice a gradual reduction in their dispensing workload.

Guidance has come into effect that encourages GP practices to double their prescribing intervals from 28 to 56 days. Practices will still have discretion to prescribe shorter durations if they feel they are required, and those taking particular drugs (such as controlled drugs) are exempt, but the guidance, published in February 2022 jointly by Community Pharmacy Wales (CPW) and the British Medical Association’s General Practitioners Committee (GPC) Wales, aims to make 56-day prescribing durations the norm.

The guidance says that the change will free up GP practices and community pharmacies to focus on clinical care. The change was announced following the publication of a government-commissioned review by the University of South Wales in March 2021, which concluded that a change of mindset was needed in community pharmacies in order to “put clinical services work first”.

This may sound like a good idea, considering the pressure that community pharmacies across the UK are under. For example, in Wales, community pharmacies are being asked to take on more work through the ‘Choose Pharmacy’ minor ailment service and independent prescribing is being expanded.

The mantra has always been that longer prescription durations end up causing more waste

Patients are also likely to welcome the resultant reduction in the number of trips they have to make to collect prescriptions, even if they do not have to pay a fee each time, as most people do in England.

However, the mantra has always been that longer prescription durations end up causing more waste, and this has led to many commissioners having policies that quote Department of Health guidance (the source of which is unclear) that states: “A 28-day repeat prescribing interval is recognised by the NHS as making the best possible balance between patient convenience, good medical practice and minimal drug wastage.”

For such a widespread policy, the evidence in this area is pretty weak. A review of 28-day prescribing limits carried out by the National Institute for Health and Care Research in 2017 found no real evidence on how this affected clinical outcomes.

There was some evidence that longer durations were associated with more waste. One point raised by the review was that it could be more likely that a prescription is changed by a GP within the prescribing window. However, the review concluded there was a case to switch to longer prescription durations than 28 days for patients with stable long-term conditions, because they tended to be more adherent to treatment. Plus, for this group of patients, any waste could be offset by the time savings for healthcare professionals in issuing less frequent prescriptions.

Nevertheless, the practical problems in any lengthening of prescription durations for community pharmacies could be considerable. For example, a reduction in dispensing fees means a reduction in income. There is also the problem of ensuring adequate stock, so that patients can obtain their medicines in a timely way.

In Wales, the 56-day duration is being phased in over several months, with GPs instructed to make the change at their next review. The Pharmaceutical Journal understands that a new mechanism is also under discussion to prevent community pharmacies missing out financially.

It is clear from all of the above that more research is urgently needed on what prescribing limits are suitable for which patients. The changes in Wales allow a rare opportunity to monitor the impact of such a big change on a large population, and we urge the NHS to ensure that it does this.

However, the whole idea of a blanket rule still feels anachronistic. Surely, the ultimate goal should be ensuring that prescribing durations can become more personalised, based on the needs of the patient and the expertise of the prescriber? Perhaps it is time for a more nuanced discussion. PJ

Last updated
The Pharmaceutical Journal, PJ, April 2022, Vol 308, No 7960;308(7960)::DOI:10.1211/PJ.2022.1.138989

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