The impact of prescription charges on people living with long term conditions

A survey of over 4,000 people with long-term conditions on prescription charges, has found the charge is a barrier to accessing medicine | Prescription Charges Coalition

The findings come following the UK government’s announcement that the prescription charge will rise on 1 April 2023. The Prescription Charges Coalition, which brings together around 50 organisations and professional bodies to campaign to scrap prescription charges in England for people with long-term conditions, conducted the survey between February and March.

The survey shows that people with long-term health conditions that cannot afford their medication are seeing an increase in GP visits, trips to accident and emergency, and hospital stays. Some survey respondents reported they had to stay in hospital for up to 6 weeks. Not being able to afford medicine has also led to mental health issues and increased time off work. 

Full report: Continuing to pay the price. The impact of prescription charges on people living with long term conditions

See also: Prescription charges are a barrier to keeping people well and in work, survey reveals | Parkinson’s UK

HRT Prescription Prepayment Certificate (PPC) guidance

On 1 April 2023, the Department of Health and Social Care (DHSC) will introduce a new Prescription Prepayment Certificate (PPC) to reduce the cost of hormone replacement therapy (HRT) for patients. The certificate will be valid for 12 months and covers an unlimited number of listed HRT medicines for the cost of two single prescription charges. Patients could save money if they pay more than two HRT prescription charges within 12 months. The HRT PPC will be available to buy in one single payment online at http://www.nhsbsa.nhs.uk/hrt-ppc, or in-person at some pharmacies.

Guidance on the HRT PPC is available and includes details for prescribers (chapter 5) and dispensers (chapter 6): Guidance on the Hormone Replacement Therapy prescription prepayment certificate: Handling NHS HRT prescriptions.

See also: HRT prescription prepayment certificate (PPC) from 1 April 2023 | National Pharmacy Association

Healthcare Inequalities: Access to NHS prescribing and exemption schemes in England

NHS Business Services Authority

This report looks at health care inequalities in relation to NHS prescribing and exemption schemes in England. It considers uptake in deprived and other under-served communities, providing actionable insights with a focus on three clinical areas of prescribing: chronic obstructive pulmonary disease (COPD), hypertension, and severe mental illness (SMI).

Full detail: Healthcare Inequalities: Access to NHS prescribing and exemption schemes in England

Appropriate prescribing of antipsychotic medication in dementia

NHS England – October 2022

Intended audience: To support Integrated Care Systems working with providers: GPs, GP practice pharmacists, Primary Care Network (PCN) pharmacists, Trust clinicians, staff in care homes, acute hospitals, Memory Assessment Services (MAS) and Community Mental Health Teams (CMHTs). It may also be a useful source of information and support for people living with dementia and carers.

There is concern over the high rates of antipsychotic prescribing in people with dementia due to the associated risks often outweighing the benefits. As such, antipsychotics should only be considered as a last resort in dementia.
This toolkit provides expert, evidence-based practical advice and guidance on risk reduction when using these agents and support with deprescribing where appropriate.

The aim of the resource is to provide guidance and information to address:
• uses, risks and alternatives to antipsychotic medication
• risk reduction in antipsychotic prescribing
• support for local systems to deliver best practice in antipsychotic prescribing and de-prescribing where appropriate.

Full Resource – Appropriate prescribing of antipsychotic medication in dementia

New national guidance for expanding scope of prescribing practice

Royal Pharmaceutical Society

This guidance has been commissioned by Welsh Government, for the benefit of all prescribers across the UK. Based on collaboration with multi-professional stakeholders, the document is a guidance tool for prescribers wanting to expand their prescribing scope of practice. It provides a structure to support prescribers to identify their developmental needs, highlights ways in which these needs can be met, and offers guidance on how to document the process and outcome. A number of case studies across a range of professions and settings are provided to illustrate the process.

Full guidance: Expanding scope of prescribing practice

Press release: New national guidance for expanding scope of prescribing practice

The rise in prescribing for anxiety in primary care

British Journal of General Practice | DOI: https://doi.org/10.3399/BJGP.2021.0561

Anxiolytic prescribing increased substantially between 2003 and 2018, according to new research. Increases may reflect better detection of anxiety; increasing acceptability of medication, or an earlier unmet need. However, some prescribing is not based on robust evidence of effectiveness, may contradict guidelines, and there is limited evidence on the overall impact associated with taking antidepressants long term. As such, there may be unintended harm.

Full research: Rise in prescribing for anxiety in UK primary care between 2003 and 2018: a population-based cohort study using Clinical Practice Research Datalink

Continuity of GP care for patients with dementia: impact on prescribing and the health of patients

British Journal of General Practice | February 2022 | vol. 72 (715): e91-e98. DOI: https://doi.org/10.3399/BJGP.2021.0413

Higher continuity of GP care (CGPC), that is, consulting the same doctor consistently, can improve doctor–patient relationships and increase quality of care; however, its effects on patients with dementia are mostly unknown. The aim of this study was to estimate the associations between CGPC and potentially inappropriate prescribing (PIP), and with the incidence of adverse health outcomes (AHOs) in patients with dementia.

The authors conclude that higher CGPC for patients with dementia was associated with safer prescribing and lower rates of major adverse events. Increasing continuity of care for patients with dementia may help improve treatment and outcomes.

.Full paper: Continuity of GP care for patients with dementia: impact on prescribing and the health of patients

Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans

Objective To examine the associations between stopping treatment with opioids, length of treatment, and death from overdose or suicide in the Veterans Health Administration.

Design Observational evaluation.

Setting Veterans Health Administration.

Participants 1 394 102 patients in the Veterans Health Administration with an outpatient prescription for an opioid analgesic from fiscal year 2013 to the end of fiscal year 2014 (1 October 2012 to 30 September 2014).

Main outcome measures A multivariable Cox non-proportional hazards regression model examined death from overdose or suicide, with the interaction of time varying opioid cessation by length of treatment (≤30, 31-90, 91-400, and >400 days) as the main covariates. Stopping treatment with opioids was measured as the time when a patient was estimated to have no prescription for opioids, up to the end of the next fiscal year (2014) or the patient’s death.

Results 2887 deaths from overdose or suicide were found. The incidence of stopping opioid treatment was 57.4% (n=799 668) overall, and based on length of opioid treatment was 32.0% (≤30 days), 8.7% (31-90 days), 22.7% (91-400 days), and 36.6% (>400 days). The interaction between stopping treatment with opioids and length of treatment was significant (P<0.001); stopping treatment was associated with an increased risk of death from overdose or suicide regardless of the length of treatment, with the risk increasing the longer patients were treated. Hazard ratios for patients who stopped opioid treatment (with reference values for all other covariates) were 1.67 (≤30 days), 2.80 (31-90 days), 3.95 (91-400 days), and 6.77 (>400 days). Descriptive life table data suggested that death rates for overdose or suicide increased immediately after starting or stopping treatment with opioids, with the incidence decreasing over about three to 12 months.

Conclusions Patients were at greater risk of death from overdose or suicide after stopping opioid treatment, with an increase in the risk the longer patients had been treated before stopping. Descriptive data suggested that starting treatment with opioids was also a risk period. Strategies to mitigate the risk in these periods are not currently a focus of guidelines for long term use of opioids. The associations observed cannot be assumed to be causal; the context in which opioid prescriptions were started and stopped might contribute to risk and was not investigated. Safer prescribing of opioids should take a broader view on patient safety and mitigate the risk from the patient’s perspective. Factors to address are those that place patients at risk for overdose or suicide after beginning and stopping opioid treatment, especially in the first three months.

Reference: BMJ 2020;368:m283

Association between gifts from pharmaceutical companies to French general practitioners and their drug prescribing patterns in 2016

Objective To evaluate the association between gifts from pharmaceutical companies to French general practitioners (GPs) and their drug prescribing patterns.

Design Retrospective study using data from two French databases (National Health Data System, managed by the French National Health Insurance system, and Transparency in Healthcare).

Setting Primary care, France.

Participants 41 257 GPs who in 2016 worked exclusively in the private sector and had at least five registered patients. The GPs were divided into six groups according to the monetary value of the received gifts reported by pharmaceutical, medical device, and other health related companies in the Transparency in Healthcare database.

Main outcome measures The main outcome measures were the amount reimbursed by the French National Health Insurance for drug prescriptions per visit (to the practice or at home) and 11 drug prescription efficiency indicators used by the National Health Insurance to calculate the performance related financial incentives of the doctors. Doctor and patient characteristics were used as adjustment variables. The significance threshold was 0.001 for statistical analyses.

Results The amount reimbursed by the National Health Insurance for drug prescriptions per visit was lower in the GP group with no gifts reported in the Transparency in Healthcare database in 2016 and since its launch in 2013 (no gift group) compared with the GP groups with at least one gift in 2016 (−€5.33 (99.9% confidence interval −€6.99 to −€3.66) compared with the GP group with gifts valued at €1000 or more reported in 2016) (P<0.001). The no gift group also more frequently prescribed generic antibiotics (2.17%, 1.47% to 2.88% compared with the ≥€1000 group), antihypertensives (4.24%, 3.72% to 4.77% compared with the ≥€1000 group), and statins (12.14%, 11.03% to 13.26% compared with the ≥€1000 group) than GPs with at least one gift between 2013 and 2016 (P<0.001). The no gift group also prescribed fewer benzodiazepines for more than 12 weeks (−0.68%, −1.13% to −0.23% compared with the €240-€999 group) and vasodilators (−0.15%, −0.28% to −0.03% compared with the ≥€1000 group) than GPs with gifts valued at €240 or more reported in 2016, and more angiotensin converting enzyme (ACE) inhibitors compared with all ACE and sartan prescriptions (1.67%, 0.62% to 2.71%) compared with GPs with gifts valued at €1000 or more reported in 2016 (P<0.001). Differences were not significant for the prescription of aspirin and generic antidepressants and generic proton pump inhibitors.

Conclusion The findings suggest that French GPs who do not receive gifts from pharmaceutical companies have better drug prescription efficiency indicators and less costly drug prescriptions than GPs who receive gifts. This observational study is susceptible to residual confounding and therefore no causal relation can be concluded.

Trial registration OSF register OSF.IO/8M3QR.

Reference: BMJ 2019;367:l6015

Variation in responsiveness to warranted behaviour change among NHS clinicians

Objectives To determine how clinicians vary in their response to new guidance on existing or new interventions, by measuring the timing and magnitude of change at healthcare institutions.

Design Automated change detection in longitudinal prescribing data.

Setting Prescribing data in English primary care.

Participants English general practices.

Main outcome measures In each practice the following were measured: the timing of the largest changes, steepness of the change slope (change in proportion per month), and magnitude of the change for two example time series (expiry of the Cerazette patent in 2012, leading to cheaper generic desogestrel alternatives becoming available; and a change in antibiotic prescribing guidelines after 2014, favouring nitrofurantoin over trimethoprim for uncomplicated urinary tract infection (UTI)).

Results Substantial heterogeneity was found between institutions in both timing and steepness of change. The range of time delay before a change was implemented was large (interquartile range 2-14 months (median 8) for Cerazette, and 5-29 months (18) for UTI). Substantial heterogeneity was also seen in slope following a detected change (interquartile range 2-28% absolute reduction per month (median 9%) for Cerazette, and 1-8% (2%) for UTI). When changes were implemented, the magnitude of change showed substantially less heterogeneity (interquartile range 44-85% (median 66%) for Cerazette and 28-47% (38%) for UTI).

Conclusions Substantial variation was observed in the speed with which individual NHS general practices responded to warranted changes in clinical practice. Changes in prescribing behaviour were detected automatically and robustly. Detection of structural breaks using indicator saturation methods opens up new opportunities to improve patient care through audit and feedback by moving away from cross sectional analyses, and automatically identifying institutions that respond rapidly, or slowly, to warranted changes in clinical practice.

Reference BMJ 2019;367:l5205