What is the 28 day prescription rule?
The 28 day prescription rule is a policy, predominantly followed in the United Kingdom, that standardizes the dispensing of repeat medications to a 28-day supply. While not a strict, universally mandated law in all healthcare systems, it is a recognized best practice by many health organizations, including the National Institute for Health and Care Excellence (NICE). The rationale behind this interval balances patient convenience with clinical governance, cost-effectiveness, and patient safety. The rule dictates that patients with long-term conditions should receive enough medication to last for 28 days, ensuring that all their repeat medicines will run out at approximately the same time.
In the United States, a similar, informal “28-day rule” exists but applies specifically to how early a 30-day prescription for a controlled substance can be refilled, typically 1 to 2 days before the 30-day mark. This differs from the UK's broader standard for chronic condition management, as US regulations for prescribing are more complex, involving federal and state laws, as well as insurance policies.
Reasons and benefits of the 28-day cycle
The implementation of a standardized 28-day prescription cycle provides a number of important benefits for both patients and the healthcare system. These advantages primarily revolve around improving safety, reducing waste, and enhancing medication management.
Improved safety through regular reviews
One of the most critical aspects of the 28-day cycle is that it facilitates regular medication reviews. For patients on repeat prescriptions for chronic conditions like diabetes or hypertension, this provides healthcare professionals, including pharmacists and general practitioners, with a consistent opportunity to check on the patient's health. These reviews can identify potential issues such as:
- Ineffective or inappropriate medication.
- Adverse side effects.
- Drug interactions.
- Changes in the patient's condition that require a different treatment plan.
Reduced medication waste
Significant amounts of medicine are wasted each year, with estimates in the UK reaching into the hundreds of millions of pounds. The 28-day rule helps to minimize this waste in several ways:
- If a medication is changed or stopped due to side effects or ineffectiveness, only a small quantity remains unused.
- It discourages the stockpiling of medicines at home, which can lead to confusion and potential mistakes.
- Patients are more likely to use up their current supply before ordering a new one, preventing the accumulation of unused drugs.
Enhanced medication management
For patients taking multiple medications, a standardized cycle can simplify the process. By synchronizing all repeat prescriptions to the same 28-day schedule, patients can collect all their medicines at once, reducing the number of trips to the pharmacy. This synchronization also makes it easier for healthcare professionals to track adherence and spot any missed prescriptions. Many pharmaceutical companies also produce medicines in 28-day 'calendar packs' to support this daily routine.
Potential drawbacks and challenges
Despite the benefits, the 28-day prescribing policy is not without its critics and presents several challenges for patients.
Increased patient burden and dispensing fees
For patients who pay for their prescriptions, a 28-day cycle can increase their total annual costs, as they will be charged for more prescriptions over the course of a year compared to a longer 90-day supply. Additionally, more frequent visits to the pharmacy for collection or ordering can be inconvenient, especially for individuals with mobility issues or those living in remote areas. For the healthcare system, the cost-effectiveness can be debated; while wastage is reduced, the increased frequency of dispensing and administrative tasks may raise total operational costs.
Adherence issues
Some studies have indicated that longer prescription lengths (e.g., 90-day supplies) can be associated with better medication adherence for patients with stable, long-term conditions. A longer supply removes the need for frequent renewals, reducing the risk of patients running out of medication. Conversely, the frequent nature of the 28-day cycle could be a point of friction that leads to non-adherence for some individuals.
Exceptions to the 28-day rule
Recognizing that a one-size-fits-all approach is not always appropriate, there are several common exceptions to the 28-day rule. These are typically made for specific types of medications or patient situations.
Medications with longer pack sizes
Certain medications, such as some combined oral contraceptives and Hormone Replacement Therapy (HRT), are often manufactured and supplied in larger, multi-month packs. For these items, a longer supply of up to three or six months may be prescribed to align with the manufacturer's packaging and scheduled clinical reviews.
Controlled drugs
Prescriptions for controlled drugs (CDs), particularly those in Schedules 2, 3, and 4 (e.g., opioids and certain sleeping tablets), are strictly limited. In the UK, a supply of no more than 30 days is typically recommended, and these prescriptions have a validity period of 28 days. In the US, refill waiting periods for controlled substances are longer to reduce misuse, but exact rules vary by state and drug schedule.
Acute prescriptions and variable doses
For newly initiated treatments or medications where the dose is still being adjusted, a shorter, acute prescription of 7 or 14 days may be issued to monitor for side effects or effectiveness. Similarly, 'as-required' or variable-dose medications may also be exempt from the standard 28-day cycle.
Comparison of 28-day vs. 90-day prescribing
| Feature | 28-Day Prescribing | 90-Day Prescribing |
|---|---|---|
| Waste Reduction | Significantly reduces the amount of unused medicine when treatment is changed or stopped. | May lead to higher wastage if the medication regimen is altered during the 90-day period. |
| Patient Adherence | Requires more frequent interaction with pharmacies, which can either be beneficial for oversight or inconvenient for some patients. | Evidence suggests better adherence for stable patients, as it reduces the frequency of refills. |
| Safety & Monitoring | Facilitates more regular medication reviews and oversight by healthcare professionals. | Reduces the frequency of interactions with healthcare providers, which could delay identifying new issues. |
| Cost (for patients) | Can result in higher overall prescription charges due to increased dispensing fees. | Typically more cost-effective for patients who pay per item, resulting in fewer total charges per year. |
| Convenience | Requires more frequent pharmacy visits, which can be burdensome for some patients. | More convenient for stable patients, as it reduces the number of pharmacy trips. |
Conclusion
The 28 day prescription rule represents a deliberate strategy by healthcare systems, particularly the NHS, to balance patient needs with clinical and financial best practices. While it offers substantial benefits in minimizing waste and enhancing patient safety through regular reviews, it also presents challenges related to cost and patient convenience. For stable, long-term patients, alternatives like Electronic Repeat Dispensing (eRD) can mitigate some of these issues by reducing administrative burden. Ultimately, the policy is a flexible guideline, with exceptions made for specific drug types and patient circumstances, ensuring that medication dispensing remains clinically appropriate and safe. Regular communication with pharmacists and general practitioners is essential for patients to understand how the rule applies to their specific care plan.
References
- Clapham Park Group Practice. Medicine Supply For British Nationals Going Abroad. Available at: https://www.claphamparkgp.com/medicine-supply-for-british-nationals
- National Institutes of Health (NIH). Clinical effectiveness and cost-effectiveness of issuing longer versus shorter duration prescriptions in primary care: A mixed-methods study. Available at: https://www.ncbi.nlm.nih.gov/books/NBK470089/
- Stowhealth. Medicines Waste: Only Order What You Need. Available at: https://www.stowhealth.nhs.uk/2024/07/09/medicines-waste-only-order-what-you-need/
- NHS Business Services Authority (NHSBSA). Electronic repeat dispensing (eRD). Available at: https://www.nhsbsa.nhs.uk/pharmacies-gp-practices-and-appliance-contractors/prescribing-and-dispensing/electronic-repeat-dispensing-erd
