Prescribing issues and concordance

Drug treatment is the most common form of treatment in primary care. Prescribing is the most common intervention in the NHS across all sectors, and after staffing costs, accounts for the second highest area of expenditure in the NHS.

Although prescribing is an important part of primary care, it has frequently been described as unnecessary and wasteful. Polypharmacy is an increasing problem associated with an ageing and multimorbid population.¹

Prescribing statistics

The NHS Business Services Authority (NHSBSA) collects and publishes prescribing data and analyses prescribing trends in England. The latest report from 2021-2022 shows:²

• The cost of prescription items dispensed in the community in England was £9.69 billion. This was a 0.87% increase of £83.7 million from £9.61 billion in 2020/21.

• The number of prescription items dispensed in the community in England was 1.14 billion. This was a 2.58% increase of 28.7 million items from 1.11 billion in 2020/21.

• Atorvastatin was the most dispensed drug in England in 2021/22 with 53.4 million items, while apixaban was the drug with the highest cost of £401 million.

• FreeStyle Libre 2 Sensor kit was the presentation with the largest absolute increase in cost between 2020/21 and 2021/22 of £69.8 million - from £2.84 million to £72.6 million.

Elsewhere in the UK:

• Similar trends can be found on the Public Health Scotland website. In 2021-2022 106.6 million items were dispensed in Scotland, with number of items also increasing year on year (except a dip in 2020-2021 - likely pandemic-related).³ Generic prescribing has also been increasing steadily.

• Annual dispensing statistics are published by calendar year by the Welsh government. 82.8 million items were prescribed in the community in Wales between 2021-2022.⁴ There is a long-term trend for an increase in the number of items prescribed, but the rate of increase is slowing.

• In Northern Ireland, statistics are published by calendar year by the Business Services Organisation. There were 43.2 million prescription items dispensed in 2021-2022.⁵

An ageing population has led to the increased presence of multiple morbidity, and inevitable polypharmacy. Several community-based studies of older adults in Germany have shown polypharmacy (defined as >5 medicines) rates of around 47%.⁶ A cross-sectional analysis of the Survey of Health, Ageing, and Retirement in Europe (SHARE) database showed that the prevalence of polypharmacy, defined as taking five or more medications concurrently in older adults aged 65 years or more, was between 26.3% and 39.9% among 17 European countries and Israel.⁷

There are many pressures to prescribe from differing sources. The drive to meet GP contract targets has encouraged GPs to prescribe increasing numbers of medicines and to chase patients who decline to take them as advised.

This might in part explain the comment in the 2009 guidance from the National Institute for Health and Care Excellence (NICE) that between a third and a half of medicines that are prescribed for long-term conditions are not used as recommended.⁸

Another influential factor is the "pill for every ill" culture which has been fuelled by the media and is now firmly embedded in the nation's psyche. New guidelines and diagnostic criteria have been accused of medicalising normality in many clinical areas and fuelling prescribing.^{9 10}

Prescribing information

Prescribing Analysis and Cost (PACT) is a series of reports which tells GPs what they have prescribed and how much their prescribing has cost. This is now produced in England by NHS Prescribing Services in electronic web-based format (ePACT).¹¹ Data can be compared by prescriber, by practice and by organisation in order to inform on prescribing costs and trends. It is updated monthly, six weeks after the end of the prescribing month.

Clinicians are encouraged (within the GP appraisal process) to be aware of their own prescribing practice and review it with a view to 'Quality Improvement' activities within their surgery.¹²

Prescribing guidelines

There are many guidelines to safe responsible prescribing available.

• The General Medical Council (GMC) issued "Good practice in prescribing and managing medicines and devices" in 2013.¹³ This has detailed guidance about good medical practice with regards to prescribing. It includes sections on:
  

  • Keeping up to date.

  • Shared prescribing.

  • Repeat prescribing.

  • Reporting adverse reactions.

  • Remote prescribing.

  • Prescribing of unlicensed medicines.

  • Prescribing for yourself or those close to you.

  • Consent.

  • Sharing of information.

• The British Medical Association (BMA) website contains further guidance on prescribing.

• The BNF contains essential prescribing information and detailed instructions about all the drugs used by the NHS, as well as how to write prescriptions.¹⁴

• Clinical guidelines from NICE and Scottish Intercollegiate Guidelines Network (SIGN) provide specific prescribing advice in some areas.

• The Medicines and Healthcare products Regulatory Agency (MHRA) provides regular drug safety updates and alerts.¹⁵

Repeat prescriptions

Repeat prescriptions are estimated to account for two thirds of primary care prescriptions and 80% of medicine costs.¹⁶ A benefit of repeat prescriptions is that they reduce patient inconvenience as well as the professional workload.

A disadvantage is the reduction of patient-doctor contact, resulting in potential clinical problems. Some patients may be eligible for a repeat dispensing scheme, whereby they can obtain repeat prescriptions for up to a year from their community pharmacy without having to contact their GP surgery. The pharmacist monitors the ongoing need for the prescriptions and checks they continue to be appropriate.

When reviewing each repeat prescription, consideration should be given to the following:¹⁷

• Is it effective?

• Is it necessary or still required?

• Will the patient take it?

• Is the present formulation appropriate?

• Does it provide the most cost-effective treatment available?

• Has the patient had a clinical review within the previous 15 months (or shorter if clinically appropriate)?

In its guidance on Medicines Adherence, NICE also recommends considering the following at review:⁸

• Offer repeat information and review, especially when treating long-term conditions with multiple medicines.

• Review at agreed intervals patients' knowledge, understanding and concerns about medicines and whether they think they still need the medicine.

• Ask about adherence when reviewing medicines. Clarify possible causes of non-adherence and agree any action with the patient (including a date for follow-up).

• Bear in mind that patients sometimes evaluate prescribed medicines in their own way (for example, by stopping and starting them and monitoring symptoms). Ask the patient if they have their own way of weighing up their medicine.

Electronic prescriptions¹⁸

The majority of GP practices now use the Electronic Prescription Service (EPS). This allows prescriptions to be sent electronically to the chemist or dispenser of the patient's choice. This should improve both efficiency and convenience for all concerned.

Access to the relevant system is through the use of smart cards. A GP applies an electronic signature to the prescription by using the PIN number for their smart card. A prescription can be cancelled at any point up until it is dispensed.

Concordance¹⁹

In recent years there has been a move away from the term "compliance", which suggests an element of compulsion, to "concordance", in which prescriber and patient enter into a partnership concerning the use of medication.

The cornerstones of concordance include:

• The level of information given to patients.

• Side-effects.

• The costs of medication.

• The effect on lifestyle.

NICE guidance refers to the term "non-adherence" and identifies two types: intentional (the patient decides not to follow the treatment recommendations) and unintentional (the patient wants to follow the treatment recommendations but has practical problems).⁸ Guidelines advocate a non-judgemental discussion in which the patient's perceptions and preferences are explored. These two types can overlap.

The discussion should, where relevant, include:

• What will happen if they don't take the medicine.

• Non-pharmacological alternatives.

• Reducing or stopping long-term medicines.

• Fitting medicines into their routine.

• Choosing between medicines.

The patient should also be given adequate information covering:²⁰

• What the medicine is, how to use it and likely benefits.

• Likely adverse effects and what to do if they think they are experiencing them.

• What to do if they miss a dose.

• Whether another prescription is needed and how to obtain further supplies.

Although not evidence-based, NICE recommends considering the following interventions if there is a specific need:

• Suggesting patients record their medicine-taking.

• Encouraging patients to monitor their condition.

• Simplifying the dosing regimen.

• Using alternative packaging.

• Using a multi-compartment system of medicines.

• Considering options to reduce prescribing costs if this is an issue.

Special clinical scenarios

Children

• Parents are mainly responsible for the administration of medicines to their children, so both the concordance of the parent and of the child should be considered.

• Concordance in children is influenced by the formulation, taste, appearance and ease of administration of a preparation.

• Prescribed regimens should be tailored to the child's daily routine.

• Treatment goals should be set in collaboration with the child/parent.

The elderly
Important principles include:

• Effective communication.

• Keeping regimens simple.

• Giving reminder charts, concordance aids and special written instructions.

• Consider monitoring concordance by counting returned tablets or checking plasma drug levels.

• Review medication regularly. Stop medication which is unnecessary, or causing harm. A '5Ms' approach is age-friendly.²¹

• Consider potential practical difficulties such as difficulty in opening child-proof containers, poor vision, difficulty swallowing, and means of accessing repeat prescriptions. Discuss solutions where appropriate such as blister packets, pre-filled dosette boxes, non child-proof containers, large print labels, liquid formulations, delivery of medication, etc.

• Consider anticholinergic drug burden and assess for possible risks.²²

• Awareness of problems of polypharmacy. This is more common in the elderly, and the 2013 Kings Fund report made recommendations for improvements needed.²³ They included longer GP appointments to deal with polypharmacy, more research as most studies exclude patients with multiple morbidities, and consequent changes to guidelines where appropriate. Although use of multiple items of medication may extend and improve life, there is a risk of increased interactions, side-effects, concordance issues and potential for reduction in quality of life.

• NICE produced Medicines optimisation guidance in 2015.²⁴

One study found that large numbers of medicines, confusion and lack of knowledge as to why a medicine had been prescribed, contributed to non-compliance.²⁵