“Good for you, good for us but is it good for everybody?”
Overprescribing within the NHS – October 2021
The NHS is currently the 5th largest global employer; with over 1.3m employees and receiving around 10% of the UK Government’s annual spending. It is estimated that the NHS deals with 336 million ‘patient visits’ per year, – many of whom will receive some form of at least one ‘prescription’ per visit and at a current charge in England of £9.35 per item .
In the most recent review investigating the use of prescription drugs by the Department of Health & Social Care (DHSC), published in September 2021, a culture of over-prescribing ‘prescription medications’ within the NHS was identified. The review found that the average number of prescriptions had doubled between 1996 and 2016, from 10 to 20 per head of population per year.
To put this into context, there are over 1.1 billion prescription items dispensed each year in England alone, worth around £10.3 billion. Perhaps most worryingly, the DHSC report also suggested that at least 10% of current medicines issued during this period were overprescribed. If that were the case, the cost to the NHS of over-subscribing in England alone could be the region of £1 billion. COVID-19 has seen the NHS under unprecedented levels of stress, both in resources and funding. There are clearly significant gains to be made, both financially and from a patient care perspective, from opening meaningful discussions on the systemic problem of overprescribing in the UK.
So, what exactly is over-prescribing?
Quite simply, overprescribing is when a patient is prescribed medicines which either they don’t need or don’t want. In many cases, this can lead to the harm outweighing the benefits of these medications. The issue of over-prescribing isn’t specific to the UK either; it’s a problem in every healthcare system in every country around the world and there are several key reasons why it occurs.
Some typical examples include:
- When a patient is prescribed a medicine when an alternative method of treatment would be more appropriate. For example, a patient is offered antidepressants when talking therapy could be more beneficial, or if someone is prescribed blood pressure medicine when they could alter their diet and lifestyle.
- Another common way medicine is over prescribed is when a medication is no longer appropriate. For example, a medication being prescribed to a patient for a condition in their 60’s, might not still be the most appropriate option for them when they reach 90 and above.
You can see how there could be a multitude of ways in which medication is overprescribed to patients. The review also gives light to how this predominantly affects older people, ethnic minorities and those in more deprived areas.
It is important to consider what causes medical professionals to overprescribe in the first place if we are to begin resolving the systemic issues at play.
The DHSC review conducted interviews with a number of doctors and patients, and found that some of the most mentioned causes of overprescribing include; lack of continuity, shorter doctors’ appointments, medical professionals unable to access full patient care records easily, longer wait time for non-medicine treatments, repeat prescriptions and treating a patients symptoms rather than identifying the root cause.
In the UK, there is a historic culture of ‘doctor knows best’, and the DHSC found patients are extremely unlikely to question a prescription. They also found doctors are unlikely to question or challenge another doctor’s decision. In order to overcome this culture of overprescribing we need equality, information, knowledge, confidence and the ability to challenge. The goal is summarised in the below quote from the review:
“The key to stopping overprescribing is medicines optimisation: ensuring that patients are prescribed the right medicines, at the right time, in the right doses.”
This concept provides a clear framework for all healthcare professionals to make sure overprescribing is reduced as much as possible. To achieve this shared objective, the following four core principles should be applied to medicines optimisation:
- Aim to understand the patient’s experience
- Evidence-based choice of medicine
- Ensure medicine use is as safe as possible
- Make medicine optimisations part of routine practice
This review is not the first to identify the scale of the overprescribing problem. Several initiatives starting in the 1990’s have been actioned within the primary care system to tackle overprescribing which saw considerable improvements for specific classes of medicines.
For example, between 2013-2018 the UK began the first five-year plan to nationally reduce the prescribing of antibiotics to reduce antimicrobial resistance which showed a significant reduction, with the rate of prescribing falling from 678 to 559 per 1,000 population.
Another example is the initiative STOMP (Stopping Overmedication of People with a Learning Disability, Autism or Both), which aimed to use medication only as a last resort for this group of patients, encouraging a greater utilisation of specific support schemes for families.
In 2015, NHS England commissioned a number of sites where pharmacy professionals were integrated within care systems in order to show how medicines optimisation can work. They saw significant improvements, particularly within care homes whereby emergency admissions were reduced, resulting in meaningful savings of £249 per patient over one year.
In 2019, the NHS set out a long-term plan to combat overprescribing in the next decade. Looking forward, learnings from COVID-19, along with increased electronic prescribing and telemedicine will be crucial in realising this plan. This inclusive strategy hopes to see an increase in personalised care and a reduction in health inequalities, alongside increasing shared decision making to create a better prescribing culture.
The plan hopes to see continued work on medicine optimisation, and an increased presence of pharmacists within the primary care system. There will also be work on social prescribing for alternative methods of treatments and plans to improve sustainability in waste medicine management.