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Prescribing - Real Costs and Waste

I am a little tired of hearing about the benefits of 28 day prescribing cycles. If we examine these claims they only hold true for some medicines, and in general only work if the value of doctors' time, and of the work of their General Practice is valued at zero. This is of course the value that prescribing advisers are prone to apply to our time and effort, but it goes further than that, as the patient's time is also clearly valued at zero.

However, worse than the reckless dissipation of value from anyone else's budget that is being engaged in, is the reduction in quality that comes with too frequent signing of FP10s.

Costing the act of Prescribing

Recently a patient who used to be mine asked me for a private repeat prescription for Sildenafil. His new NHS GP had found various excuses not to continue his effective treatment, he had always come under Mr Dobson's prohibition, and therefore I had provided him with free private prescriptions for his medicine as my NHS patient. Now however his care was no longer covered by any of the allowances or fees I receive from the NHS, and therefore he received treatment as he requested on a private basis.

Pause a moment, and price the repeat prescription he received - what would you expect to bill him, or him to be billed?

As a one-off our fee was £10 for issuing a repeat.

Now consider an NHS repeat prescription.

If the opportunity cost to the practice, or the value of this action were less than for that private repeat, it would not be clear to me why this might be the case.

In fact, asking around, I received an estimate of cost of £11.50p per item on FP10 which seems a reasonable estimate to me.

Test the claims: cost

The claim by our local prescribing advisers has always been that prescribing 28 days reduces cost below that of prescribing 56 days. I increased my routine prescriptions to 84 days for some items and conditions, and to 112 180 or 366 days for others, and saw my cost/budget ratio fall by the measures they employ and report, but perhaps this might not hold for everyone? Last quarter my PACT report approached being interesting.

The sources of waste are death and changes of treatment.

There is no suggestion that any difference be attached to different drugs, indeed the assertion is strongly made and repeated regardless of dispute that any difference in the repeat durations or date due for different medications itself constitutes "waste".

Consider then Digoxin. Digoxin tablets are 1p each, near enough.

On average a patient will waste half of a treatment period plus their float (or minimum stock level) when they die.

For 28 days obtained 7 days ahead of expiry we will therefore lose 28/2 + 7 = 21 tablets at 21 pence.

For 56 days ...................................................................................... 56/2 + 7 = 35 ...........at 35 pence

and one can go on, but the difference here is alleged to be a saving of .............................. 14 pence

However, the cost of issuing and signing these FP10s is

For 28 days ................... two prescriptions ........................................................................ at £23

For 56 days ....................one prescription .................................................... ...........at £11-50

Difference .............................................................................................................................. £11-50

Dispensing fees of course come from a pool system like our own outgoing one, and therefore the cost to the NHS is the same, of course, but to the Pharmacist is more for 28 days than it is for 56 days,

and of course if we assume the patient requires two or three trips lasting a total of a conservative extra hour for each request - collect sequence then value their time at £5 per hour (perhaps we should instead charge it at the rate prescribing advisers get?)

For 28 days ................... two jobs ................................................................................. at £10

For 56 days ................ one job ........................................................................................ at £ 5

Difference .............................................................................................................................. £5

Totalling this up we find that prescribing Digoxin by 28 day amounts saves 14 pence for each patient who dies while taking it, but loses a value of £16-50 * 6 = £97-50 for each year they manage to survive while taking it.

Caveats: I believe that any actual profit the NHS makes on collecting the prescription tax is actually wrung from the income of Phamracists anyway, and that few enough people pay it who receive regular medicines to make it significant. Rework it yourself if you like.

Now, we can run a spreadsheet for various drugs, from the penny ante common stuff to the £30 000 per year of one of my patients continuous infusions, which, alas, is not personally dispensible. What we find is that there are optimal maximum amounts for different medications, and these are the amounts we should be providing per dispensed package, for economic rationality. Oddly enough, experienced GPs know this.

Test the claims: quality

The single most limited and limiting resource the NHS has is doctors' time, more specifically, doctors' thinking time. High quality thought is among the most valuable product or perhaps tool of the NHS. Only actually doing things to patients can rank higher, and one hopes that involves thought as well. Only doctors currently authorise repeat prescriptions.

Any factor which improves the use of doctors' thinking time will improve quality, any which reduces it or provides conditions in whch thinking is not done efectively will reduce quality.

Routinely signing a tall stack of FP10s is not a component of quality.

Repeat prescriptions are in general not a sensible idea - conditional or irregualr repeats may be, but regular repeats ae in fact a bastardised form of repeat dispensing, rendered harder and more expensive in order to discoourage patients from receiving their treatment, and has little to do with thinking. However, if the number of items to be thought about is halved, the thinking time for each is more than doubled since thinking time is the time left between acquiring the item and discarding it. Tripling the interval produces an even larger relative increase. The saved thinking time can be used for considering the patient's treatment.

The inevitable conclusion is that setting the conditions under which a prescription may be refilled (as is common American English has a more suitable term) and a period during which it may be refilled then leaving patient and dispenser to get on with it is more sensible.

Instead of changing stupid arrangements for the benefit of patients, pharmacists and doctors alike, the prescribing advice industry has focussed on adding a hundred pounds to save 14p and contributed to the administrative top-hamper that will capsize primary care unless it is hacked loose.

Complicated Considerations

So, for a cheap drug the quantity provided should be large.

For an expensive drug prone to sudden deaths and frequent changes of regime the quantity should be small - if indeed it is being repeated in the usual sense of the word.

There is little advantage in cost or convenience in synchronising prescription items, especially when rules on packaging tend to produce dispensing in original packs and frustrate such efforts. Fractional prescriptions are clearly considerably more expensive to process and produce than repeats of whole quantities.

We can therefore produce a mathematical function or at least lookup table for the range of quantities and durations which apply to different preparations, and prescribing advisers who do this may expect some respect from the GPs in their area.

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