PJ Online | News feature: How pharmacists can help to prevent wastage of prescribed medicines
How pharmacists can help to prevent wastage of prescribed medicines
Wasteful prescribing costs the National Health Service millions of pounds every year. How can it be prevented and what roles can pharmacists play in improving the situation? Clare Bellingham finds out
Wasteful prescribing is expensive, not only in terms of cost for the NHS but also cost for patients who are subjected to unnecessary and potentially harmful medication. The two main areas of waste are in prescribing a drug that is not clinically indicated and in unnecessary repeat prescribing.
The cost of wasteful prescribing accounts for between 10 and 20 per cent of the NHS prescribing budget, according to Stuart Emslie, head of controls assurance, Department of Health. Considering the NHS prescribing budget is £6bn this is a huge sum. It includes not just waste but also the financial consequences of drug errors leading to harm.
In order to tackle the problem of unnecessary prescribing, it is useful to understand doctors' psychology surrounding prescribing. This was addressed at a recent conference on wasteful prescribing held by the Drug and Therapeutics Bulletin in London on 14 November (see below).
A role for pharmacists
Tackling wasteful prescribing provides pharmacists with an ideal opportunity if they wish to expand their role and improve relationships with other health care professionals. Wasteful prescribing is a major problem and NHS organisations and GPs will welcome help to reduce it.
"GPs should seek the regular co-operation of clinical pharmacists if this widespread waste and risk is to be controlled," according to Professor Hugh McGavock, visiting professor of prescribing science, University of Ulster. He suggested that clinical pharmacists working in GP surgeries can:
So what specifically could pharmacists be doing?
Pam Grant, pharmaceutical adviser to Poole Central and North Primary Care Trust and Poole Bay PCT, a delegate at the DTB conference, suggests that pharmacists can audit waste through drugs returned to the pharmacy and feed back information on non-compliance to GPs. A particularly important example of this, because of current increases in their prescribing, is statins. "In my experience, a lot of people are returning statins to pharmacies either because they cannot tolerate them or because they do not feel any obvious benefits in terms of symptom relief so do not take them," she said. Statins are often initially prescribed at low doses and, when a blood test reveals that the cholesterol level has not gone down, the doctor might increase the statin dose without checking compliance. Pharmacists can prevent this by providing information on which patients are not taking their statins.
Ms Grant said that an audit she carried out revealed that another group of drugs commonly wasted is analgesics. This could often be explained by the quantities in which they are prescribed for acute self-limiting conditions, eg, 100 co-proxamol and 100 diclofenac 50mg tablets, representing two weeks' supply of one drug and a month's supply of the other.
Pharmacists can also contribute to reducing waste by identifying compliance problems through talking to patients. This could be at the time prescriptions are handed out, or through medicines management reviews. Ms Grant said that community pharmacies need a private area in which to conduct reviews and that patients need to bring all their medicines into the pharmacy so that what is actually being taken can be examined.
Pharmacists often see large volumes of regularly prescribed medicines being returned to the pharmacy as waste. It is commonly the doctor's receptionist who takes requests for, and writes, repeat prescriptions, with the doctors signing bundles of repeat prescriptions at a time. Many patients on long-term medicines do not see a health professional about their medicines for months or even years at a time.
This all adds up to a strong case for repeat dispensing: allowing patients to order their repeat prescriptions from pharmacies and pharmacists to monitor what medicines patients are taking. Professor McGavock believes it does. Speaking after the DTB conference he said: "In my opinion, the greatest benefit of repeat dispensing is that the patient must see a highly trained professional every time they get their medicine." He added: "Repeat prescribing is not only a source of great waste but is also a quite unacceptable compromise of professional standards by both GPs and the Department of Health which allows it to continue."
Professor McGavock added that repeat dispensing should be instituted as soon as possible throughout the United Kingdom. "It is a relatively simple system to administer and is not any more costly than the present system." He explained that a repeat dispensing system requires the production of special triplicate prescription pads. "The UK government has no reason to fear repeat dispensing: it has been normal practice in the Republic of Ireland for 10 years where all health service repeat prescriptions take this form," he said.
Professor McGavock also suggests that pharmacists could provide an additional service for GPs. "If pharmacists were present at meetings between GPs and drug company representatives, they could provide a brake on inadequate and biased information," he said.
The problem for pharmacists is that they cannot be in two places at once. In order to provide a dispensing service and conduct medication reviews or visit GP surgeries, two pharmacists are needed. And this costs money.
However, Professor McGavock thinks that the savings pharmacists could make in terms of wasteful prescribing would far outweigh the costs. "And more importantly, it would mean the provision of a safer service for patients," he added.
Ms Grant said: "PCTs should be providing funding, after all, the savings are beneficial to the NHS not to individual GP practices. Funding is needed at a national level to enable pharmacists to carry out these roles." She added that although there have been pilots demonstrating the financial benefits of pharmacists in reducing prescribing costs, there is a lack of research that measures the contribution made to improving patient care and that perhaps this is needed. In general, there appears to be a shortage of published evidence that supports the roles of pharmacists in reducing waste in prescribing.
If funding is a barrier, it is often the cost of locum cover to allow pharmacists time to carry out these roles that is the biggest expense. Ms Grant said: "We need a more innovative approach to employment with more short-term locum cover to provide pharmacists with a few hours each morning to, for example, visit surgeries during the time that repeat prescriptions are generated. There is a real need for pharmacists, perhaps those who are at home with children, who are prepared to work on an occasional, short-hours basis."
Perhaps from experience or from reputation, pharmacists are sometimes fearful that GPs will not value their input in the surgery. Professor McGavock disagrees, saying that the majority of GPs are in favour of pharmacist input. Ms Grant thinks that it is important to approach GPs in the correct way: by offering support rather than being critical or competitive.
Another barrier is ensuring that pharmacists have sufficient training and clinical knowledge to take on these new roles.
Barriers can be overcome. The important message is that there are opportunities for pharmacists to become involved in reducing wasteful prescribing and that their help will be welcomed.
Citation: The Pharmaceutical Journal URI: 20005527
Recommended from Pharmaceutical Press