Introduction
The latest NHSBSA Estimated prescribing patterns for care home patients aged 65 years and over report highlighted rising paracetamol prescribing costs for care home patients aged 65 years and over in England. This article considers the role liquid paracetamol has played in this trend.
Insights are provided at a national, ICB and Sub-ICB level, with paracetamol prescribing trends shown for the financial years 2020/21 to 2024/25. The insights can help to inform policies, planning and interventions on medicines use in care homes. They may be particularly useful to ICB and Sub-ICB medicine optimisation teams.
Key findings
Liquid paracetamol prescribing costs for care homes patients have increased. The estimated cost of liquid paracetamol prescribing for care homes patients aged 65 and over increased by around £11.4m. This was from £4.7m in 2020/21 to £16.1m in 2024/25, which was a 240% increase.
Liquid paracetamol prescribing costs for care homes patients have increased faster than the number of prescribed items. Only around 100,000 additional liquid paracetamol items were prescribed in 2024/25 compared with 2020/21. This was from 272,000 items in 2020/21 to 371,000 items in 2024/25, which was a 36% increase. This means that costs rose faster than the number of prescribed items.
Liquid paracetamol prescribing has become more expensive. The daily cost of the most-commonly prescribed form of liquid paracetamol in care homes increased substantially over the five-year period. This cost peaked at nearly £4 per patient in late 2022, due to a concession price leading to increased reimbursement costs in 2022/23. This was followed by higher Drug Tariff prices in later years.
More care home patients are being prescribed liquid paracetamol. The estimated number of care home patients aged 65 and over prescribed liquid paracetamol increased from around 21,100 patients in April 2020 to 25,700 in March 2025. The estimated percentage of care home patients receiving prescribing who were prescribed liquid paracetamol also rose, from 6.7% to 7.7% over the same period.
The monthly amount of active liquid paracetamol per patient has increased. The average number of grams of active liquid paracetamol prescribed per patient per month increased by 40%. This was from 3.5g in 2020/21 to 4.9g in 2024/25.
Liquid paracetamol prescribing costs vary by gender and care home setting. In 2024/25, liquid paracetamol accounted for 73.0% of estimated paracetamol prescribing costs for female care home patients aged 65 and over, compared with 68.7% for males. In the same year, liquid paracetamol accounted for 76.7% of estimated paracetamol prescribing costs in nursing homes, compared with 63.9% in residential homes.
Liquid paracetamol prescribing costs vary across geographies. The share of paracetamol costs coming from liquid paracetamol varied widely between ICBs and Sub-ICBs. Comparisons of Sub-ICB values can be misleading without considering local care home profiles. ICBs are best placed to interpret the estimated Sub-ICB costs.
Total paracetamol prescribing costs are sensitive to how much is prescribed as active liquid paracetamol. In 2024/25, active liquid paracetamol made up 15.6% of all active paracetamol prescribed, and total paracetamol prescribing costs were £22.4 million. If the share of active paracetamol prescribed as liquid had risen to 17%, costs would have increased by £1.4 million. If it had fallen to 14%, costs would have decreased by £1.5 million. Small changes in the proportion of active liquid paracetamol can have a noticeable impact on total paracetamol prescribing costs in care homes. This is modelled at ICB and Sub-ICB level at the end of the report.
Background
The most recent version of the Estimated prescribing patterns for care home patients aged 65 years and over report estimated the cost of paracetamol prescribing in care homes to have doubled in 5 years. This was from £11.2m in 2020/21 to £22.4m in 2024/25. The estimated number of paracetamol items prescribed in care homes also increased, from 1.6m items in 2020/21 to 2.0m items in 2024/25.
In contrast, paracetamol prescribing for non-care home patients aged 65 and over (a much larger population) saw a reduction in both cost and items over the same period. The estimated cost fell from £46.8m in 2020/21 to £37.0m in 2024/25, and the number of items decreased from 10.9m items to 9.9m items.
Paracetamol now accounts for over 5% of all prescribing cost for care home patients aged 65 and over. Analysis indicated that liquid paracetamol was a key factor in this trend. This report investigates the role of liquid paracetamol within overall paracetamol prescribing to care home patients aged 65 and over in England. The eight key findings are presented in eight corresponding sections.
Things you should know
Liquid paracetamol is a syrup or oral solution containing the same active ingredient as tablets. It works in the same way to relieve pain but can be measured in millilitres and swallowed more easily. This makes it useful for people who struggle with tablets because of swallowing difficulties, frailty, or cognitive impairment. It may also be preferred over effervescent tablets where sodium content is a consideration.
Liquid paracetamol is particularly important in care homes, where many patients struggle with tablets. Liquid formulations can support easier administration, better adherence, flexible dosing, and more effective pain management.
Liquid paracetamol prescribing levels are primarily driven by patient need, so an increase in prescribing may reflect changes in the care requirements for care home patients. The findings of this analysis do not indicate over prescribing of liquid paracetamol or suggest that prescribing should be reduced. The findings could support cost management efforts to help ensure changing patient needs continue to be met.
1. Liquid paracetamol prescribing costs for care homes patients have increased
The estimated cost of liquid paracetamol prescribing for care homes patients aged 65 and over has increased by around £11.4m. This was from £4.7m in 2020/21 to £16.1m in 2024/25, which was an increase of 240%. This has resulted in total care home paracetamol prescribing costs doubling, from £11.2 in 2020/21 to £22.4m in 2024/25.
2. Liquid paracetamol prescribing costs for care homes patients have increased faster than the estimated number of prescribed items
An estimated 100,000 additional liquid paracetamol items were prescribed for care home patients aged 65 and over in 2024/25 compared with 2020/21. This was from 272,000 items in 2020/21 to 371,000 items in 2024/25, which was a 36% increase. This is contrasted with the large increase in liquid paracetamol prescribing costs.
The cost of liquid paracetamol prescribing in care homes has increased faster than the number of liquid paracetamol items prescribed. The percentage of total paracetamol costs from liquid paracetamol grew faster than the percentage of all paracetamol items that were liquid paracetamol.
3. Liquid paracetamol prescribing has become more expensive
Liquid paracetamol has become more expensive because the price as set in The Drug Tarriff increased between 2020/21 and 2024/25. The Drug Tariff contains monthly prices for commonly prescribed drugs as set by The Secretary of State for Health and Social Care in England. The Drug Tariff price of the two most-commonly prescribed liquid forms and the most-commonly prescribed non-liquid form of paracetamol are used to demonstrate this price increase. These were all generic drugs and accounted for the vast majority of paracetamol prescribing. The Reference section explains how drugs are priced in the Drug Tariff, based on their category (such as A, C, or M).
To meaningfully compare the cost of liquid and non-liquid paracetamol formulations, the number of grams of active paracetamol per formulation was calculated, along with number of days prescribing this offered (assuming a maximum dose of 4g per day). For example, a packet of Paracetamol 500mg 100 tablets containing 50g of active paracetamol offers 12.5 days of prescribing. This was then used to calculate daily cost. For example, a packet of Paracetamol 500mg 100 tablets costing £1.25 and with 12.5 days of prescribing, represents a daily cost of £0.10 (See the Reference section for more detail).
The daily cost of liquid paracetamol steadily rose over the five-year period, peaking at nearly £4 per patient in late 2024. The daily cost of the most-commonly prescribed form of non-liquid paracetamol peaked at £0.28 per patient in late 2020.
The reimbursement price is the amount dispensers get paid for the cost of the drug they have dispensed on a prescription form. The reimbursement price may differ from the published Drug Tariff price where a concession price has been granted in that month. Concession prices are granted where there are issues obtaining a drug at the listed Drug Tariff price.
A concession price led to increased reimbursement costs for the most-commonly prescribed form of liquid paracetamol in 2022/23. This was followed by higher Drug Tariff prices in later years. This contributed to liquid paracetamol becoming more expensive.
4. More care home patients are being prescribed liquid paracetamol
The estimated number of care home patients aged 65 and over receiving any form of liquid paracetamol prescribing increased. This was from 21k patients in April 2020 to 26k patients in March 2025, representing a 21.5% increase. Over the same period, the estimated total number of care home patients receiving any form of prescribing increased from 314k to 332k (a 5.8% increase).
As seen above, the number of care home patients receiving liquid paracetamol and the total number of patients receiving any prescribing both increased. Liquid paracetamol made up a growing share of all care home patients receiving any prescribing, increasing from 6.7% in April 2020 to 7.7% in March 2025.
5. The monthly amount of active liquid paracetamol per patient has increased
The average number of grams of active liquid paracetamol prescribed per patient per month increased by 40%. This was from 3.5g in 2020/21 to 4.9g in 2024/25. This was calculated across all months in which care home patients received any form of prescribing in a financial year. The volume and strength of a paracetamol form was used to calculate the number of grams of active paracetamol in a prescribed item. While the average number of grams of active liquid paracetamol per patient per month may seem low at 5g in 2024/25, its important to remember some patients will have received much more than this and many patients will have received none.
6. Liquid paracetamol prescribing costs vary by gender and care home setting
Liquid paracetamol prescribing varied by patient gender. In the most recent financial year, 73.0% of estimated paracetamol costs for female care home patients aged 65 and over were from liquid paracetamol prescribing, compared with 68.7% for male care home patients.
Liquid paracetamol prescribing also varied by care home type. In the most recent financial year, liquid paracetamol prescribing accounted for 76.7% of estimated paracetamol costs for nursing home patients aged 65, compared with 63.9% for residential home patients.
Patient age and the deprivation of a care home location were explored, but neither of these affected national liquid paracetamol prescribing cost trends.
7. Liquid paracetamol prescribing costs vary across geographies
There was considerable variation across ICBs and Sub-ICBS in the percentage of total paracetamol costs for care home patients aged 65 and over from liquid paracetamol prescribing. The map shows these percentages for Sub-ICBs in 2024/25.
Direct national comparisons of Sub-ICB values can be misleading without considering local care home profiles. ICBs are best placed to interpret the estimated Sub-ICB liquid paracetamol prescribing values. Comprehensive Sub-ICB level data can be downloaded in the analysis Reference section.
8. Total paracetamol prescribing costs are sensitive to how much is prescribed as active liquid paracetamol.
The total grams of active paracetamol can be calculated per financial year, by adding the amount of active paracetamol from liquid and non-liquid paracetamol prescribing. The percent of active liquid paracetamol prescribing per year can then be calculated. This is more useful than the percent of all paracetamol items that were liquid paracetamol, as liquid paracetamol was prescribed in changing volumes and strengths over the analysis period.
The chart shows what care home paracetamol prescribing costs would have been with different percentages of active liquid paracetamol in 2020/21 and 2024/25. If a cursor is moved across a line, changing cost differences can be viewed.
In 2024/25, active liquid paracetamol made up 15.6% of all active paracetamol prescribed, and total paracetamol prescribing costs were £22.4 million. If the share of active paracetamol prescribed as liquid had risen to 17%, costs would have increased by £1.4 million. If it had fallen to 14%, costs would have decreased by £1.5 million. Small changes in the proportion of active liquid paracetamol can have a noticeable impact on total paracetamol prescribing costs in care homes.
The table displays National, ICB and Sub-ICB annual paracetamol cost difference estimates in care homes, from changing percentages of active liquid paracetamol. ICB names and Sub-ICB codes can be entered in the geography search box. All underlying data can be downloaded in the Reference section of the analysis. Small year-to-year changes in LPD within an ICB can lead to cost increases or reductions exceeding £100,000.
The estimated paracetamol prescribing costs resulting from modified percentages of active liquid paracetamol (ALP) for care home patients aged 65 years and over in England
Reference
Prescriptions data overview
Analysis is based on primary care prescription data collected by the NHS Business Services Authority. The data are collected for the operational purpose of reimbursing and remunerating dispensing contractors for the costs of supplying drugs and devices, along with essential and advanced services, to NHS patients. This excludes:
- prescriptions that were issued but not presented for dispensing
- prescriptions that were not submitted to the NHSBSA for processing and reimbursement
- prescriptions issued and dispensed in prisons, hospitals and with private prescriptions
- prescription batches submitted late.
Prescription data relates to prescription batches submitted to the NHSBSA for payment between April 2020 and March 2025. The part month in NHSBSA data relates to the dispensing month for which the prescription batch was submitted. This is generally but not always the month in which the prescription was dispensed.
Patients may receive prescription items that have not been prescribed to them personally and will not be accounted for. This may occur in the case of small volumes of Paracetamol. There is no means of quantifying the extent of this in NHSBSA data.
The NHSBSA do not capture the clinical indication of a prescription and therefore do not know the reason why a prescription was issued, or the condition it is intended to treat. This naturally applies to both liquid and non-liquid paracetamol prescribing.
Prescriptions data quality
Due to manual processes involved in the processing of prescriptions there may be inaccuracies in capturing prescription information which are then reflected in the data.
NHS Prescription Services have a variety of validation streams throughout prescription processing to support accurate capture of the data. In addition, a retrospective sample is completed in the month following reimbursement to identify the accuracy of prescription processing information. The check includes the accuracy of prescriber, practice, and drug information, but does not include the personal details of the patient.
The reported Prescription Processing Information Accuracy for the 12-month rolling period ending March 2025 was 99.9%. The sample may not be representative at a more granular level; as such the level of accuracy is undetermined for specific groups such as drugs, geographies, and time periods.
The identification of errors in the accuracy checking sample does not result in amendments to data held in NHSBSA systems. Further details of Prescription Processing Information Accuracy can be found on the NHSBSA website.
Patient demographic data
The analysis focuses on prescriptions for care home patients aged 65 years and over at the time of prescribing. Patient age was determined using a mixture of patient information from prescription forms and the Personal Demographics Service (PDS).
A single gender was attributed to each patient. The most recent gender recorded against a patient was taken as their gender. Patient gender was sourced from the PDS, which includes four categories: (1) Male, (2) Female, (3) Not known, (4) Not specified. Category (3) consists of patients where gender has not been recorded; category (4) consists of patients who could not be classified as either male or female.
The analysis only includes patients with an NHS number and date of birth verified by PDS.
NHS numbers are captured for 100% of electronic prescription messages. NHS numbers are captured for an estimated 94.7% of paper prescriptions. Overall, the capture rate is over 99% of all prescriptions.
The NHSBSA periodically investigate the accuracy of NHS numbers captured from paper forms. The personal details captured (NHS number, date of birth and age) are compared against those on the prescription form for a random sample of 50,000 prescription forms. The NHS number captured typically matches that on the prescription form for over 99.9% of forms. The results represent the accuracy for all prescription items processed; as such the level of accuracy is undetermined for specific medicines, geographies, time periods and other factors. By contrast, the accuracy of captured NHS numbers in electronic prescribing is estimated to be 100%.
Patient address data
The analysis required that every prescription form had a patient address recorded. Addresses were available for all electronic prescriptions. Address information was not captured directly from paper prescriptions and therefore a process was derived to generate these addresses using a mix of information from the Personal Demographic Service (PDS) and electronic prescriptions across a range of months.
For the 2022/23 financial year, patient addresses could be allocated for 99.9% of paper prescription forms where the patient’s NHS number could be identified, and the patient was aged 65 years and over.
Prescription forms with known non-English patient address information were removed from the analysis. Records with an unknown or missing postcode were included.
Prescription form classification
Patient prescription forms were labelled as being from a care home or not based on address matching process initially used in the NHSBSA Estimated prescribing patterns for care home patients aged 65 years and over. The analysis contains a more detailed summary of the address matching process used to classify prescription forms.
Of the 297 million prescription forms issued to patients aged 65 years and over in 2024/25, 17 million could be categorised as being from a care home.
A complete end-to-end granular account of all data processing steps and the entire methodology can be found here.
Generic drugs
Generic prescribing accounted for over 99.9% of prescribed paracetamol items each financial year.
The generic forms of Paracetamol 250mg/5mls oral suspension 100mls and Paracetamol 250mg/5mls oral suspension sugar free 200mls accounted for 97% of non-liquid paracetamol prescribed items.
The generic form of Paracetamol 500mg 100 tablets accounted for 87% of non-liquid paracetamol prescribed items.
Drug pricing
The Drug Tariff contains monthly prices for commonly prescribed drugs as set by The Secretary of State for Health and Social Care in England.
The reimbursement price is the amount dispensers get paid for the cost of the drug they have dispensed on a prescription form.
The reimbursement price may differ from the published Drug Tariff price where a concession price has been granted in that month.
Concession prices are granted where there are issues obtaining a drug at the listed Drug Tariff price.
Drug categories
Part VIIIA of the NHS Drug Tariff categorises generic medicines to determine pharmacy reimbursement prices.
The commonly prescribed drugs in this analysis fell into Categories A, C, and M.
In summary, Category A uses average generic market prices, Category C is based on a specific manufacturer’s price, and Category M is adjusted by the Department of Health and Social Care to manage community pharmacy retained margin.
Part VIIIA of the Drug Tariff itself contains more comprehensive definitions.
Drug Tariff categories can change over time for the same medicine and presentation.
For example, Paracetamol 250mg/5ml oral suspension sugar free 200ml was Category A in 2020/21 and 2024/25, but Category M in intervening periods. Paracetamol 250mg/5ml oral suspension 100ml was Category M from 2020/21 to 2023/24 before moving predominantly to Category C in 2024/25.
Irrespective of pricing methodology, prescribing costs are ultimately borne by the wider NHS.
Grams of active paracetamol
The amount of active paracetamol in a formulation refers to the total number of grams of paracetamol it contains. Larger bottles and higher-strength formulations therefore contain a greater quantity of active ingredient than smaller bottles or lower-strength preparations.
The number of grams of active paracetamol was used to provide a more comprehensive measure of the volume of liquid paracetamol prescribing. Annual item counts alone may not provide a full picture, as a single prescription item can represent either a fraction or multiple bottles.
Daily cost
The number of days prescribing for a paracetamol form was determined using the number of grams of active paracetamol it contained. This was assuming a maximum dose of 4g per day in line with general clinical guidance.
When considered alongside the changing monthly Drug Tariff price for a paracetamol form, the daily cost of different paracetamol formulations could be generated and compared. The table summarises this process.
Care home type
Care home type information is sourced from the Care Quality Commission (CQC).
Around 8% of patient records could not be allocated a Nursing Home or Residential Home status, due to data linkage limitations.
Data download
- All the underlying ICB and Sub-ICB can be downloaded via the following download buttons.
Further information
More information on the estimated prescribing patterns for care home patients aged 65 and over in England can be found here.
The NHSBSA Data Science Team can be contacted at: dall@nhsbsa.nhs.uk