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There are no easy solutions when it comes to managing public demand for medicines – but we can’t just dodge the conversation, writes Malcolm Harrison

When we talk about the pressures facing the NHS, the conversation tends to focus on the ever-familiar themes of funding, workforce and capacity. But there is another part of the equation that receives far less attention, and that is demand.

Over the past two decades, people in England have come to use significantly more prescribed medicines. The average person now receives around 20–21 prescription items each year, compared with around 15–16 twenty years ago.

Yet improvements in health have failed to keep pace. Gains in life expectancy are not matched with healthy life expectancy. More people are therefore spending longer living with ill health, long-term conditions and increasingly complex medication needs.

Community pharmacies see the pressures from demand every day. In the mid-2000s, around 750-800 million prescription items were dispensed annually in England. By 2025/26, community pharmacies alone were dispensing around 1.19 billion items a year. 

It is also worth noting that with around 1,000 fewer pharmacies in England today than there were 10 years ago, the increase in volume is having to be met by fewer locations, amplifying the growth.

Population growth can only explain part of the increases seen. Over the past two decades, the English population has grown by around 12 per cent, while prescription volumes have risen by around 80 per cent. Yet spending has increased by only around 25 per cent.

The rising increase in demand is due to a multitude of factors, including an ageing population, earlier diagnosis, rising levels of chronic disease, greater use of preventative medicines and increasing polypharmacy.

With population projections pointing towards an older population in the decades to come, demand for medicines is only heading in one direction.

This raises a bigger and more uncomfortable question: medicines demand is continuing to grow, attempts to reduce avoidable waste have not solved the problem, and demand cannot increase indefinitely - so how can the NHS manage and afford the public’s growing demand for medicines?

To date the government has absorbed this substantial increase in prescription volumes without a proportionate rise in the medicines bill. This has been possible in large part through the widespread use of generics and successful, competitive procurement by community pharmacies.

However, there is evidence that this model has reached its limits. Governments cannot increase the spend on health and medicines indefinitely. At some point the demand will simply outstrip the available resources - underfunding of the community pharmacy sector for years is showing that already happening.

Keeping the NHS medicines bill down cannot simply mean shifting more cost and risk onto community pharmacy. Keeping prices down is already eroding the resilience of the medicines supply chain. If this continues, the supply chain will be less able to deal with disruptions – wherever they occur around the globe.

The conversation therefore needs to change from simply asking how we pay for rising medicines demand. The NHS needs to look seriously at where there is avoidable demand within the system.

Are repeat medicines always ordered because they are needed, or sometimes simply because they are on the repeat list? Are treatment durations always appropriate? Could medicines reviews do more to tackle unnecessary polypharmacy? How much pharmacy and GP capacity is consumed resolving avoidable prescription queries and administrative problems? How can new prescribing pharmacists act to reduce the population demand for medicines?

Prescription charges are one example of the uncomfortable choices policymakers may need to confront.  In England a levy should be paid by the patient for each medicine they have prescribed.  However, currently around 90% of items prescribed in primary care are exempt from the prescription levy.  The levies paid on the 10 per cent of medicines prescribed to patients who are not exempt raise around £1bn a year for the NHS.  This covers around a tenth of the annual primary care drugs bill. 

The answer is not necessarily fewer exemptions or higher charges, or that charges should become the primary route for managing demand. Such proposals are controversial for good reason: they raise questions about fairness, access and the risk of deterring people from taking medicines they need. But that is precisely why they sit at the heart of the wider debate. If the NHS is serious about managing demand, it must be willing to discuss options that are politically difficult, even if the eventual decision is to reject them.

The last consultation on aligning eligibility for free prescriptions with the State Pension age showed how politically sensitive these questions can be. Whether or not that specific proposal was the right one is for others to decide, however it demonstrates how quickly difficult conversations about demand, entitlement and affordability can become too uncomfortable to pursue.

That being said, considering uncomfortable options is not the same as endorsing them.

The same applies to restrictions placed on prescribing decisions. The NHS already limits the routine prescribing of some products where self-care is considered appropriate. As demand grows, policymakers may need to consider whether the current approach goes far enough. These decisions are difficult, but so are the challenges facing the NHS.

Greater transparency about the cost of medicines and NHS care is another idea that has been raised before. In theory, showing patients the full cost of their medicines could encourage more thoughtful use and reduce waste. However, there are also legitimate concerns that conscientious citizens may forego treatment they critically need in a misguided effort to save the NHS money.

The central question is not whether the current exemptions for prescription charges should be reviewed, or whether any single prescribing policy idea should be adopted. It is whether the NHS can continue to absorb ever-growing medicines demand that we have seen over the past 20 years, without having difficult conversations about managing demand.

The Government and the NHS need to look systematically at what is driving growth, where avoidable demand can be managed, and how medicines can be used more effectively. That means being prepared to have a national conversation about choices that may feel uncomfortable, but which cannot be avoided forever.

Avoiding the demand conversation now will not make the problem disappear. It will simply leave the NHS facing harder choices later.

 Malcolm Harrison is chief executive of the Company Chemists’ Association