NHS Prescription Research Articles

Pharmacy2U facility rejected from pharmaceutical list dispenses more than 1 million NHS prescriptions per month

Pharmacy2U facility rejected from pharmaceutical list dispenses more than 1 million NHS prescriptions per month

A One-Health environmental risk assessment of contaminants of emerging concern in London’s waterways throughout the SARS-CoV-2 pandemic

The SARS-CoV-2 pandemic had huge impacts on global urban populations, activity and health, yet little is known about attendant consequences for urban river ecosystems. We detected significant changes in occurrence and risks from contaminants of emerging concern (CECs) in waterways across Greater London (UK) during the pandemic. We were able to rapidly identify and monitor large numbers of CECs in n = 390 samples across 2019–2021 using novel direct-injection liquid chromatography-mass spectrometry methods for scalable targeted analysis, suspect screening and prioritisation of CEC risks. A total of 10,029 measured environmental concentrations (MECs) were obtained for 66 unique CECs. Pharmaceutical MECs decreased during lockdown in 2020 in the R. Thames (p ≤ 0.001), but then increased significantly in 2021 (p ≤ 0.01). For the tributary rivers, the R. Lee, Beverley Brook, R. Wandle and R. Hogsmill were the most impacted, primarily via wastewater treatment plant effluent and combined sewer overflows. In the R. Hogsmill in particular, pharmaceutical MEC trends were generally correlated with NHS prescription statistics, likely reflecting limited wastewater dilution. Suspect screening of ∼ 1,200 compounds tentatively identified 25 additional CECs at the five most impacted sites, including metabolites such as O-desmethylvenlafaxine, an EU Watch List compound. Lastly, risk quotients (RQs) ≥ 0.1 were calculated for 21 compounds across the whole Greater London freshwater catchment, of which seven were of medium risk (RQ ≥ 1.0) and three were in the high-risk category (RQ ≥ 10), including imidacloprid (RQ = 19.6), azithromycin (15.7) and diclofenac (10.5). This is the largest spatiotemporal dataset of its kind for any major capital city globally and the first for Greater London, representing ∼ 16 % of the population of England, and delivering a foundational One-Health case study in the third largest city in Europe across a global pandemic.

PS-C36-9: A REVIEW OF THE PHARMACOKINETIC PROFILES OF THE 40 MOST COMMONLY PRESCRIBED CARDIOMETABOLIC MEDICATIONS

Objective: To collate the pharmacokinetic (PK) parameters of the 40 most commonly prescribed cardiometabolic medications from published literature to provide a useful reference source for clinicians when interpreting results of chemical adherence testing. Design and Methods: Non-adherence to medication is a prime cause of treatment failure and costs the UK health system approximately £500 million annually. A recent meta-analysis on adherence to 7 cardiovascular drug classes revealed a non-adherence rate of 43%. Chemical adherence testing (CAT) by liquid chromatography tandem mass spectrometry (LC-MS/MS) is an objective method for testing patient adherence to medication and has been proven to be effective in managing disease progression. To improve result interpretation, factors including dose time, sample collection, and PK need to be better understood. The list of the most commonly prescribed drugs was obtained using the NHS Prescription Cost Analysis 2020/2021. Data on the pharmacokinetic parameters was collected from original papers from the following sources: Lexicomp: Medical Library Goodmans & Gilmans: The pharmacological basis of therapeutics, 13th edition Clarks analysis of drugs and poisons 4th edition Martindale: The complete drug reference All original manuscripts were reviewed, filtered and graded, following a robust criteria. The collected PK parameters focused on the bioavailability, volume of distribution, peak concentration, minimum plasma concentration, time to peak concentration, half-life, clearance and urine excretion. Results: A total of 3004 papers were initially screened for pharmacokinetic data, of which, 274 papers were relevant. These papers were further filtered, a total 84 papers adhered to the criteria for grading. Propranolol was one of the most prescribed cardiometabolic drugs with 6,124,180 prescriptions issued in the UK between 2020–2021. The half-life for Propranolol 80 mg (3.5 h), the peak time (1.5 h), the peak concentration (49 ± 8 ng/mL). Edoxaban was prescribed 1,584,638 times in the time period selected. Mean PK parameters for steady state levels of Edoxaban were: bioavailability (99.7%), urine excretion (44.7 ± 14.8%), clearance (535 ± 15.5 mL/min), volume of distribution (426 ± 30.7 L), half-life (9.2 ± 30.5 h), peak time (2 ± 1.03) and peak concentration (507 ± 17.3 ng/mL). Conclusions: This is one of the first studies to utilise a criteria for collecting and grading of PK parameters from published literature for common cardiometabolic medications. Medications have diverse pharmacokinetic profiles hence; systematic collection of these parameters will be a useful reference for clinicians when interpreting results of CAT for medication presence in patient samples.

Cost of NHS prescribing for diabetes rises by more than £500m since 2015/2016

Cost of NHS prescribing for diabetes rises by more than £500m since 2015/2016

Evaluating nursing opinion and perception of maggot therapy for hard-to-heal wound management.

Maggot therapy (MT) or larval debridement therapy is a recognised, effective but underutilised treatment for the management of hard-to-heal wounds and infected ulcers. It is available on NHS prescription in the UK, where wound management is predominantly nurse-led. Anecdotal reports and published literature suggest that nurses may be reluctant to utilise the therapy. The aim of this study was to evaluate the feelings and opinions of nurses regarding the use of MT. The first stage of this mixed-methods study was a focus group held to discuss MT and opinions of specialist nurse clinicians. Next, an anonymised web-based online survey was launched through the Nursing Times journal and distributed through social media targeting all nurses. Finally, in-depth interviews were held with specialist and generalist nurses. Awareness of MT among all nurses was extremely high. A breakdown of results showed that MT was much more highly regarded by wound specialist nurses than non-wound specialist nurses. The latter exhibited a greater level of reluctance to administer the therapy, with almost one-third of these nurses surveyed saying they found maggots disgusting and that the idea of MT made their skin crawl. In-depth interviews revealed that a lack of knowledge about MT was a prime concern. Wound specialist nurses are more likely to embrace MT than non-wound nurse specialists, who report a varying degree of wariness to MT. Our study highlights a need for better education and training in MT for all nurses, to address issues with acceptance and willingness to treat or help treat patients with hard-to-heal wounds which are suitable for MT.

Low carbon footprint inhalers in England: a review of dispensing data

IntroductionDue to propellants, metered dose inhalers (pMDIs) have a higher carbon footprint than low carbon footprint inhalers (LCFIs), such as dry powder or soft mist inhalers (1). Consequently, pMDIs contribute 3.5% of the NHS’s CO2 equivalent emissions (2). Local and national guidelines (NICE, British Thoracic Society) have attempted to increase use of LCFIs, but their effects and factors influencing success are unknown.AimTo investigate temporal and geographical variation in LCFI dispensing in England over five years.MethodsClinical commissioning group (CCG) dispensed items (March 2016-February 2021) were obtained from openprescribing.net for five classes of inhaler where a choice between pMDIs and LCFIs is available: short-acting beta-agonists (SABAs), long-acting beta-agonists (LABAs), inhaled corticosteroids (ICS), ICS plus LABA inhalers (ICS/LABA) and ICS/LABA plus long-acting muscarinic antagonist inhalers (ICS/LABA/LAMA). CCG population age profiles were obtained from the Office for National Statistics. CCG emergency hospital admission and mortality rates were obtained from Public Health England. CCG formularies and guidelines were reviewed to identify where guidance is available to prescribers.To control for total inhaler dispensing, the key measure used is the %LCFI: the number of LCFI items dispensed relative to the total number of pMDI and LCFI items. Multivariate regression models were used to investigate geographical variation.ResultsThe total annual %LCFI increased from 19.5% to 26.3% over the study period. This was driven by the introduction of ICS/LABA/LAMA inhalers in 2018, as %LCFI decreased for SABA, ICS and ICS/LABA inhalers. %LCFI varied between classes. In the final year, it ranged from 6% for both SABA and ICS inhalers, to 41.2% and 43.9% for ICS/LABA and ICS/LABA/LAMA inhalers, respectively. Interestingly, the cost per item for ICS/LABA and ICS/LABA/LAMA inhalers was similar for both pMDIs and LCFIs, but for SABA and ICS inhalers LCFIs were more expensive.%LCFI in the final year varied between CCGs (10.7% to 30.9%). The North West, and Birmingham and London areas had consistently higher %LCFI for all classes. For SABA and ICS inhalers, both the presence of advice on climate change in CCG guidelines or formularies, and greater CCG asthma prevalence, were significantly associated with higher %LCFI (p<0.05). The proportion of CCG population <15 years had a significant negative association with %LCFI for ICS and ICS/LABA inhalers (p<0.05). There were no clinically significant associations between %LCFI and either emergency hospital admission or mortality rates.ConclusionCurrent initiatives have not been successful in increasing the use of LCFIs, indicating limited implementation of guidelines for unknown reasons. Further action is required to reduce the carbon footprint of inhaler prescribing. Actions to address the financial disincentives to LCFI prescribing, CCG leadership (e.g. guidelines) and the appropriate use of LCFI in young people should be considered. Research into facilitators and barriers to LCFI use would support this. An important limitation is the use of dispensed items data rather than the number of inhalers, although there is no evidence that the number of inhalers per item varies between pMDIs and LCFIs. In addition, the Covid-19 pandemic disrupted prescribing patterns and long-term NHS projects.References(1) Wilkinson AJK, Braggins R, Steinbach I, Smith K. Costs of switching to low global warming potential inhalers. An economic and carbon footprint analysis of NHS prescription data in England. BMJ Open. 2019; 9:e028763.(2) Environmental Audit Committee. UK progress on reducing F-Gas emissions inquiry: Fifth report of session 2017-19. London (UK): House of Commons Environmental Audit Committee; 25 April 2018. Available from https://publications.parliament.uk/pa/cm201719/cmselect/cmenvaud/469/469.pdf: [Accessed 27 September 2021].

Prescription charge frozen for the first time in more than a decade

The standard NHS prescription charge in England will not increase in April 2022, a government minister has said. It is the first time since 2010 that the cost has remained the same for two consecutive years. In a written Parliamentary response, published on 22 March 2022, Edward Argar, the health minister, said: “Prescription charges will […]

Asthma and COPD medicines prescription-claims: A time-series analysis of England’s national prescriptions during the COVID-19 pandemic (Jan 2019 to Oct 2020)

ABSTRACT Background During the pandemic, there have been disruptions to how patients seek care. Research design and methods To investigate monthly prescription claims for asthma and chronic obstructive pulmonary disease (COPD) medicines during the first UK wave, interrupted time series (ITS) analysis was used. A national cohort of community patients’ data were examined. Results Descriptive statistics show salbutamol, aminophylline, ipratropium, and theophylline remain below pre-pandemic levels. Montelukast showed pre-pandemic monthly increase (Est. 67,151 doses, P = 0.05, 95% CI: 1011, 133,291), followed by a jump of 1.6 million doses at March , followed by monthly declines (Est. −112,098 doses, P = 0.216, 95% CI: -293,499, 69,303). Before the pandemic, tiotropium, salbutamol, aminophylline, and ipratropium (P = 0.003) show monthly declines but theophylline and beclometasone showed increases. In March , salbutamol (P = 0.033) and ipratropium (P = 0.001) show a significant jump. After March , ipratropium continues with a downward trajectory (P = 0.001), with a generalized negative trend for all other agents. Salbutamol confidence bounds become negative after March 2020. Some brands were unavailable. Conclusions An ‘unmet’ medical gap is identified. While it is essential to understand the underlying reasons, urgent action needs to be taken to reassess patients and ensure continuity of care. PLAIN LANGUAGE SUMMARIES (PLS) Asthma and chronic obstructive pulmonary disease (COPD) are long-term lung conditions, affecting 6 million & 1.2 million people respectively and causing breathing difficulties. Sufferers are at a higher risk of chest infections including the coronavirus. Regular use of prescribed medication stabilizes these conditions and prevents them from getting worse. It is common to be prescribed a combination of five to eight oral and inhaled medications. We investigated the impact of the pandemic on the dispensing of these specific medicines across England during the first wave. The English Prescribing Dataset was checked from January 2019 to February 2020 (14 months before the pandemic) and March to October 2020 (8 months after its onset). We find that since March 2020, salbutamol, aminophylline, ipratropium, and theophylline have not returned to their pre-pandemic levels. However, for all agents, there is great variability. Further analysis suggests these trends are not reversing, suggesting that people have not been using their medication as anticipated for 8 months, which is concerning. As a consequence of this work, we recommend that doctors specifically call these patients and discuss their health as a matter of urgency, we encourage patients to continue to take their medication. We advise policy changes to waive the NHS prescription levy for asthma and COPD medication and we seek more granular data for further harm quantification. There are several strengths and weaknesses to our analysis, and we need to conduct more studies to ask patients about their experiences.

Adherence Level to Arterial Hypertension Treatment: A Cross-Sectional Patient Survey and Retrospective Analysis of the NHS Prescription Database.

One of the major problems in cardiology practice is poor adherence to antihypertensive medication. This study aimed to evaluate medication adherence; we also aim to investigate the predictors of intentional and unintentional non-adherence. We issued a survey containing questions about patient demographics, blood pressure control, pharmaceutical care, and adherence level to medication. Retrospective analysis of the prescription database of the National Health Service of the Republic of Latvia was performed. The prevalence of non-adherence was 45.9%. The lowest adherence rate (38.2%) was found among patients taking medication for 2–4.9 years. Even though 84.7% of respondents had a blood pressure monitor at home, only 25.3% of them reported measuring blood pressure regularly. There were differences between the groups of adherent patients in terms of the patients’ net income (p = 0.004), medication co-payments (p = 0.007), and whether the pharmacist offered to reduce the costs of drug therapy (p = 0.002). Roughly half of the prescriptions (50.4%) containing perindopril were purchased by patients from pharmacies. The medication adherence level and blood pressure control at home were assessed as low. Intentionally non-adherent respondents discontinued their medication because of fear of getting used to medicines. The pharmacists’ behaviour in terms of offering to reduce the costs of medications used was influenced by socio-economic factors.

Developing a real-world evidence base for prescribed cannabis in the United Kingdom: preliminary findings from Project Twenty21.

The therapeutic potential of medical cannabis to treat a variety of conditions is becoming increasingly recognised. Globally, a large number of countries have now legalised cannabis for medical uses and a substantial number of patients are able to access their medications. Yet in the UK, where medical cannabis was legalised in November 2018, only a handful of NHS prescriptions have been written, meaning that most patients are unable to access the medicine. Reasons for this are manyfold and include the perceived lack of clinical evidence due to the challenges of studying medical cannabis through randomised controlled trials. In order to develop the current evidence base, the importance of incorporating real-world data (RWD) to assess the effectiveness and efficacy of medical cannabis has gradually become recognised. The current paper provides a detailed outline of Project Twenty21 (T21), the UK's first medical cannabis registry, launched in August 2020. We provide the rationale for T21 and describe the methodology before reporting the characteristics of the 'first patients' enrolled in the registry. We describe the health status of all patients enrolled into the project during its first 7months of operation and the sociodemographic characteristics and primary presenting conditions for these patients, as well as details of the medical cannabis prescribed to these individuals. By 12th March 2021, 678 people had been enrolled into T21; the majority (64%) were male and their average age was 38.7years (range = 18-80). The most commonly reported primary conditions were chronic pain (55.6%) and anxiety disorders (32.0%) and they reported high levels of multi-morbidity, including high rates of insomnia and depression. We also present preliminary evidence from 75 patients followed up after 3months indicating that receipt of legal, prescribed cannabis was associated with a significant increase in self-reported health, assessed using the visual analogue scale of the EQ-5D-5L (Cohen's d = .77, 95% CI = .51-1.03). Our initial findings complement reports from other large-scale databases globally, indicating that the current RWD is building up a pattern of evidence. With many clinicians demanding better and faster evidence to inform their decisions around prescribing medical cannabis, the current and future results of T21 will expand the existing evidence base on the effectiveness of cannabis-based medical products (CBMPs).

An update on medical cannabis prescribing in the UK

In November 2018, legalisation of medical cannabis in the UK was announced, following media reports about children with unmanageable epilepsy being denied the drug. Over two years on, the number of patients who have received NHS prescriptions for licensed cannabis medicines is estimated to be in the low hundreds, but the number of prescriptions issued for unlicensed products has been vanishingly small. This article examines the reasons why, and discusses the future role of medical cannabis.

Medical cannabis and epilepsy in the UK – A qualitative analysis of the carers’ perspective: “We're asking for quality of life for our children”

Despite the legalisation of cannabis based medicinal products (CBMPs) in the UK in November 2018, today there remains a scarcity of NHS prescriptions, and many patients continue to face unsustainable financial costs to acquire their medicines. Following on from our previous quantitative study highlighting the effectiveness of CBMPs to treat severe intractable childhood-onset epilepsy, for the present study, we used a narrative, open-ended approach to interview parents/carers of these patients. 11 families were interviewed to understand their current situation in more depth, and to contextualise the previous findings. Although these families have found CBMPs to be the most effective treatment for their child’s condition, access to these medicines remains severely restricted, causing serious challenges in their day-to-day life. Participants discussed a broad range of issues associated with medical cannabis. These included the regulation and policy surrounding medical cannabis, the anger and desperation related to these policies, and the benefits and harms of it. Evidently, the benefits of medical cannabis for these patients far outweigh any associated risks. Many of the issues raised in our study go beyond the science of medical cannabis per se. Rather, they are political issues, related to the wider issue of trust and power in society, and associated challenges of the doctor and patient relationship. The findings highlight the importance of including patients in decision-making about their medical plans and the value that should be given to their reported outcomes and wishes. We conclude by offering implications for further research and for policy making so that these families, and others like them, can finally receive the medications they so urgently require without crippling financial costs.

More than a fifth of English pharmacies sign up to digitally check patients' eligibility for free NHS prescriptions

A scheme allowing pharmacists to check patient entitlement to free NHS prescriptions has been rolled out to around 2,400 community pharmacies — more than 20% of the total in England, pharmacy negotiators have said. In a statement on its website, the Pharmaceutical Services Negotiating Committee (PSNC) said the Real Time Exemption Checking (RTEC) scheme will be […]

More than 75% of pharmacies can digitally check patients’ eligibility for free NHS prescriptions

Staff in more than three quarters of community pharmacies in England are now able to digitally check patients’ entitlement to free NHS prescriptions, pharmacy negotiators have said. In a statement on its website, issued on 25 May 2021, the Pharmaceutical Services Negotiating Committee (PSNC) said the ‘Real Time Exemption Checking’ (RTEC) scheme was saving time […]

Government proposes raising qualifying age for free NHS prescriptions to 66 years

People in England aged 60–65 years could be expected to pay for prescriptions, under a new proposal from the Department of Health and Social Care (DHSC). Currently, patients aged over 60 years are exempt from prescription charges, but the DHSC has proposed raising this to align with the state pension age (SPA) of 66 years. […]

Brexit and the geography of depression: A reply to Liew et al. (2020).

Liew et al. (2020) recently published a paper in this journal that analyzed antidepressant prescription trends in the context of the 2016 Brexit referendum and the sociopolitical discord that followed. They present a novel finding that Leave-majority constituencies in England seemed more adversely affected by that discord than Remain-majority constituencies. I offer criticism of their findings and methodology. Using the complete set of available NHS prescription data shows that the trend the authors detect dates from at least mid-2010 and is not associated with the referendum. In terms of methodology, I critique the potential ecological fallacy and issues of false equivalence in their study design. The former stems from the inability to adequately control for demographic heterogeneity within constituencies, and the latter stems from the fact that the populations from which they draw their data are not equivalent in potentially important ways. Finally, I conclude that the key trend the authors detect seems to merely be a geographic artifact. The set of Remain-majority constituencies unintentionally oversamples the areas of England with the lowest rates of antidepressant prevalence, Greater London and the Southeast. Remain-majority constituencies outside of those two regions have roughly the same antidepressant prescription levels as Leave-majority constituencies in all of England. In itself, that is a troubling fact of social epidemiology, but Brexit is associated with it neither spatially nor temporally.

Medical cannabis in the UK: From principle to practice.

Background:In the UK, medical cannabis was approved in November 2018, leading many patients to believe that the medicine would now be available on the NHS. Yet, to date, there have been only 12 NHS prescriptions and less than 60 prescriptions in total. In marked contrast, a recent patient survey by the Centre for Medical Cannabis (Couch, 2020) found 1.4 m people are using illicit cannabis for medical problems.Aims:Such a mismatch between demand and supply is rare in medicine. This article outlines some of the current controversies about medical cannabis that underpin this disparity, beginning by contrasting current medical evidence from research studies with patient-reported outcomes.Outcomes:Although definite scientific evidence is scarce for most conditions, there is significant patient demand for access to medical cannabis. This disparity poses a challenge for prescribers, and there are many concerns of physicians when deciding if, and how, to prescribe medical cannabis which still need to be addressed. Potential solutions are outlined as to how the medical profession and regulators could respond to the strong demand from patients and families for access to medical cannabis to treat chronic illnesses when there is often a limited scientific evidence base on whether and how to use it in many of these conditions.Conclusions:There is a need to maximise both clinical research and patient benefit, in a safe, cautious and ethical manner, so that those patients for whom cannabis is shown to be effective can access it. We hope our discussion and outlines for future progress offer a contribution to this process.

Enough is enough – is it time for the Scottish Antimicrobial Prescribing Group (SAPG) to develop the third age of antimicrobial stewardship in primary care in Scotland?

Background From 2008 the SAPG focused on ‘what to prescribe’ to tackle Clostridium difficile infection and from 2013 on ‘whether to prescribe’ to tackle unnecessary prescribing for self-limiting infections. Following these successes SAPG is now moving to the age of ‘how much to prescribe’ to ensure correct duration of therapy. We aimed to compare current prescribing practice with guidance from Public Health England (PHE)/NICE which recommends five days’ treatment for most common community respiratory infections (RTI). Methods The durations of antibiotic courses for treatment of respiratory tract infections was derived from data on dispensed prescriptions in 2018 from the Prescribing Information System, a national database of all NHS prescriptions dispensed in Scotland. Observed course durations were compared to course lengths recommended by PHE/NICE and modelling was undertaken on the impact on antibiotic use if durations were in line with guidance. Results For antibiotics recommended for RTI, the most common length of treatment used was seven days. For amoxicillin the proportion of five day prescriptions varied across health boards from 1.8% to 68.7%. Modelling estimated if 75% of seven day prescriptions for antibiotics recommended for RTI were changed to five days this would deliver a 4.1% reduction in antibiotic use. Conclusion SAPG has agreed to lead work to encourage the use of five day courses of antibiotics where indicated. Switching to five day courses would support reduction in total antibiotic use to achieve the ambitions of the UK AMR National Action Plan.

10-year trends in English primary care glaucoma prescribing.

In 2018 NHS prescriptions in England cost £8.83 billion. Within ophthalmic prescribing, glaucoma is the most costly indication. The 2017 glaucoma NICE guideline shows there is little evidence for clinical preference of particular molecules within a therapeutic class, yet the cost of these products varies greatly. We aim to describe trends in glaucoma prescribing and its relation to recent NICE Guidance. Prescription cost analyses for England from 2009 to 2018 were reviewed and data concerning items for the treatment of glaucoma were extracted. Costs and prescription frequencies were normalised for inflation and population. The 2018 cost of glaucoma prescribing was £114.2 million. This cost is 18.1% lower than in 2009 but the annual number of items prescribed per 10,000 people has increased from 1382 to 1668 (20.7%). This is despite an increased prescription of combination drops from 265 to 478 per 10,000 (80.4%). Preservative free item prescriptions rose from 1.7% of total spend in 2009, at £3.4 million in 2009, to 13.9%, in 2018, at £22.5 million. Generic items represented 11.7% of prescriptions in 2009 and 55.2% in 2018. Around half of glaucoma spending is accounted for by the use of preservative free or branded items in the place of the cheapest item in each therapeutic class. Glaucoma prescribing costs the NHS a great deal. There is a broad trend to generic prescribing as per recent NICE guidance, but significant further costs could be saved with no robustly evidenced clinical consequence.

Costs of switching to low global warming potential inhalers. An economic and carbon footprint analysis of NHS prescription data in England

ObjectivesMetered-dose inhalers (MDIs) contain propellants which are potent greenhouse gases. Many agencies propose a switch to alternative, low global warming potential (GWP) inhalers, such as dry powder inhalers (DPIs). We...