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Policy and politics

Conservative government urged to support new models of care in NHS

The Conservative party will not have to negotiate their plans for the future of the NHS, following a shock win in the UK general election. 

No single party was expected to achieve an outright majority in the House of Commons. But the Conservatives have defied expectations and now have enough seats to lead the government without forming a coalition with another party. 

Commenting on the result, Michael Dixon, chair of NHS Alliance, says: “Political stability and increased investment is good news for the NHS, however regardless of what happens over the coming days, weeks or months, it is imperative that the new government doesn’t initiate further unnecessary structural change.” According to Dixon, the NHS requires cultural change, and the new models of care, as outlined in the Five Year Forward View, must be supported in helping to deliver this. “We must develop an NHS that places adequate resource into the primary care sector, with an emphasis on prevention rather than cure,” he adds. 

Rob Darracott, chief executive of Pharmacy Voice, agrees with this sentiment. “Pharmacy Voice will be calling on the new government to be true to its words and place pharmacy at the centre of the prevention agenda — by managing medicines, repeat prescriptions and minor ailments,” he says.

The Royal Pharmaceutical Society (RPS) director for England, Howard Duff, says the RPS will be contacting new and re-elected MPs to promote the role of pharmacy.

In the pre-election manifesto, an extra £8bn a year in funding was promised by 2020. And health secretary Jeremy Hunt said there would be staged increases in the years between. This follows the Five Year Forward View outlined by NHS England.

Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2015.20068516

Readers' comments (3)

  • I for one am not happy for the government to plough more millions in to the NHS without reform of Managaed Repeat Prescription Services by pharmacies.

    I work as a Prescribing Advisor to my local CCG and the GP's within it.

    I have recently become acutely aware of the considerable waste and inefficiencies caused by this conflict of pharmacies ordering their own prescription, purportedly on behalf of their patients.

    Consider the extract from my report, below:

    In what way are pharmacies, ordering their own prescriptions, not going to ensure that the system works to ensure prescription numbers remain at the optimal?

    Pharmacists exist and depend on prescription numbers for their remuneration and profit.
    If prescription numbers were to fall, profit would fall and the pharmacy could become unviable.
    Pharmacies will have targets to increase prescription numbers, and profit, to satisfy managers and ultimately the owners, or PLC.
    Pharmacies are therefore constantly looking out for systems to increase prescription numbers and profit.
    With the advent of EPS, prescriptions will be transmitted directly to a pharmacy of the patient’s choice.
    In order to maintain and increase prescription numbers, pharmacies are vying to sign patients up to their prescription supply services. It makes good business sense to register patients with your particular company.
    Another way of registering a patient with a company’s particular service is to offer more free of charge services that patients will like (e.g. Monitored Dosage Systems [MDS], Prescription Ordering, Collection and Delivery). This also puts the pharmacy in greater control of ordering.
    Pharmacies are now able to request prescription items from doctors’ surgeries on behalf of patients. In what way are pharmacies, ordering their own prescriptions, not going to ensure that the system works to ensure prescription numbers remain at the optimal?
    Patients see the majority of medicines as free (the fact is over 85% of prescriptions are supplied as free of any charge). The default position for patients (because there is no cost) is to have more, not less!
    Patients and pharmacies are therefore happy to see more ordering of prescriptions, not less!
    The only losers, in this equation, are the providers of NHS resource to CCG’s. (i.e. the NHS, that funds the prescription supply service).

    Incidentally, if a patient is put on a MDS system and the medication is changed, pharmacists will demand a completely new prescription, for all items, to set up a new MDS box. This involves more waste! Do we really want more patients on MDS?
    As a result of ordering systems and demand, driven by the need of pharmacies to register patients and sign them up for their Managed Repeat Prescribing Systems, are doctors losing control over their prescribing, and costs?


    In order to test the above, each of the practices were asked, through their practice pharmacist, the following questions:

    How effectively does repeat prescription supply operate?
    (This is the burning issue and is affected by ordering as well as issue of prescriptions)

    Do practices supply post-dated repeat prescriptions (why?)?

    What proportion of pharmacies are operating "managed repeat prescription ordering", on behalf of patients?
    (do we know ones that don’t?)

    What proportion (roughly) of prescription ordering is requested by pharmacies and other third-parties?

    What problems does third-party ordering cause? Is ordering on behalf of patients an efficient system? Does it cause waste?

    What systems do practices and pharmacies have in place to ensure that prescription orders adhere to patient requirements?

    What proportion of patients is now having medicines supplied in MDS packs?

    Results Summary
    26 practices reported before the end of April (4 practice reports are included within this report but are not reported on separately [see appendixes]).

    All practices report problems with pharmacists (or other third parties) ordering on behalf of patients. The main problem was that of checking the patient’s requirements before an order is requested.
    Some pharmacies asked patients to indicate their future medication requirements at the point of collection of their current repeat prescription. This could be up to three months in advance. In a large proportion of cases the person collecting the prescription is not the patient.
    There have been several reports of pharmacies requesting medication for deceased patients.
    Pharmacies have also requested items for patients that have been delisted.
    Patients commonly report receiving items that are not required.
    Over-ordering of as required (PRN) items, (or any items that are not required on a strict 28 day schedule), is common. This is particularly obvious with over-ordering of salbutamol inhalers in asthma, for example, or GTN sprays / tablets, topicals, nasal sprays, etc.
    Problems are unanimously reported with early ordering and there are instances of pharmacies requesting post-dated prescriptions to suit their own system requirements.
    Prescriptions are commonly ordered by pharmacies up to 3-4 weeks in advance of requirements.
    A home delivery company requested and received prescriptions for Fortisip for 6 months but did not deliver the items to the patient.
    Pharmacies send repeat orders and then send multiple faxes stating they haven’t received scripts in the post.
    Pharmacies do not comply with practice systems for ordering repeats and often order acute items or even items that the pharmacist thinks may be suitable for the patient!
    Prescriptions are often reported as going missing which will result in a re-print and possibly duplication.
    It is often not clear which pharmacy the prescription should be sent to, or has been sent to. Commonly, patients are requesting more than one pharmacy to order their medication.
    Patients and pharmacies are commonly duplicating requests. These are difficult to deal with by reception staff ans can cause errors. Duplicate and erroneous prescription requests are usually sent to hard pressed GP’s to evaluate.
    Home delivery companies commonly state that posted prescriptions have not been received resulting in further prescription issues.
    Pharmacies often use old repeat prescription requests or request medications that are not up to date.
    Pharmacies have ordered medications that patients have stopped using. An incidence of over £460 worth of Vesicare was wasted due to inappropriate ordering.
    Another pharmacy were ordering and delivering to a patient who contacted the surgery and wanted to know what to do to stop the pharmacy ordering any more medications. He was only taking one medicine each day. At home he had 315 doxazosin tablets, 78 eprosartan tablets, 56 simvastatin, 75 bisoprolol, 140 furosemide, and 240 lercanidipine!

    On one occasion a homecare company requested some leg bags for a care home patient who wasn't even catheterised!

    The company also returned a prescription saying that the practice had previously sent the wrong item. The returned prescription was actually for a patient at a different surgery! Had they not sent this to the practice, there is a chance that the request for the leg bags may have been issued, leading to waste!

    Some companies are requesting prescriptions retrospective of delivery.
    On one occasion a homecare company requested a silver dressing on behalf of a care home patient. On querying, the GP was told that the requester had misheard the request over the phone and was requesting the wrong item for the patient!
    If prescriptions are taken to pharmacies other than the usual pharmacy conflict can result when the dispensing pharmacy has taken this as authorisation to collect all subsequent repeat prescriptions!
    Medications not delivered to a patient are commonly left on the shelf until such a time as they are put back in to stock without checking with the patient! Some non-required items are delivered to patients and patients think that it is okay to return the items to the pharmacy!

    Discussion and comment
    The ordering of repeat medications by pharmacies is now ubiquitous and accounts for the majority of repeat prescription requests and is reported to be as high as 75% (approx.). It is quite difficult to verify exact numbers as different pharmacies use different forms for re-ordering repeat prescriptions from practices, which in itself causes problems for practices and staff.
    Early ordering (up to 3-4 weeks in advance) can lead to waste and potentially serious clinical harm if a medication regimen is changed in the meantime.

    Very often the medication is delivered without adequate contact with the patient and in a number of cases it is obvious that there has been no attempt to verify a patient’s future requirement before a further prescription request is initiated.
    These ordering systems demand vigilance by practice staff. Practice systems, however, are not particularly robust in identifying over-ordering or supply problems. Prescription numbers and potential queries are so great that practice systems are commonly swamped with work which puts considerable pressure on staff and allows for many potential errors. Practice systems often rely on medication use knowledge to allow appropriate prescription issue. Practice staff does not always pick up cases of over-ordering or inappropriate ordering.
    Reports of pharmacies ordering items that patients do not want are common place. I am aware of an incident where an elderly patient was receiving continual over-supply of warfarin. The patient had difficulty in stopping the repeated ordering and eventually had to take over the re-ordering herself!
    Not all pharmacies are as bad as others. Some pharmacies now employ a member of staff to phone patients to ascertain future prescription requirement. This system works reasonably well but there are commonly difficulties contacting patients. It would be difficult to envisage some of the smaller pharmacies employing this resource to check patient requirements.
    Some pharmacies are diligent about checking patient requirements. Some patients, however, have shown a dislike of these checks and have given their prescriptions to pharmacies that are less diligent in checking requirements!
    Most practices do not have patient consent to send prescriptions to a particular pharmacy and some practices do not record which pharmacies have requested, or received such prescriptions.
    We have to accept that not all over-ordering is down to pharmacies ordering for patients. We also commonly see patients or their representatives not understanding what they are ordering or why.
    Practices are reluctant to report problems as they see this as a reflection on their own performance and have little time or incentive to correct overloaded systems.
    Patients often think that returning items to a pharmacy will avoid the waste. These items are still charged to the CCG as dispensed as they are not allowed to be re-used.

    Patients are being encouraged by GP’s, practice staff, patients and pharmacies to use pharmacy managed repeat ordering systems.
    It has to b acknowledged that these systems are useful to some patients that have difficulties with ordering or collecting their own prescriptions. However this has to be balanced against the potential costs of a “collection for all” policy.
    It is clear that Repeat Prescription ordering and supply is now in chaos. The large number of requests and the variable persons who are using the system is resulting in considerable numbers of mistakes, time wasted in staff checking, inappropriate medication supply, potential inappropriate medication administration and waste.
    The dangerous nature of medications and considerable monetary value make it imperative that the CCG, practices, patients and pharmacies take steps to ensure that all systems are monitored and controlled effectively.
    There are rules and guidelines supplied by CCG’s1,2,3 and these are reinforced in Pharmacy law and ethics4.
    CCG’s will need to ask pharmacies and their regulators (Pharmaceutical General Council, DoH, etc.) to enforce correct operation of Managed Prescription Systems.
    Practices will need to reiterate their requirements and operational procedures to pharmacies to ensure compliance, efficacy and safety within their systems.
    Patients will need to be aware of the consequences of passing responsibility for the ordering of their medicines to a third party.
    Prescribing doctors will need to be made aware of the dangers and consequences of chaotic and inappropriate medication supply.

    Too much waste!
    Too much of this system is unethical.
    It needs to stop.

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  • What an impressive article by John Cross -

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  • Pressed the submit button too soon ! Intended to go on and say that, whilst one might quibble with odd sentence or two the basic premise of over ordering and the responsibility of business targets from pharmacies together with the appalling lack of concern for costs by patients are indeed so very true -unfortunately.
    Time for a very, very real change of policy - in particular free prescriptions for all (let's face it, 85% qualification is as good as 'all')
    As a practice manager I see day on day the burden of repeats which are wrong, early, duplicated, lost, not our patients etc etc. We ring the patient, the pharmacist, the company. We amend, re-issue, duplicate work we did yesterday, the day before, last week. We stand up for the patient to the pharmacy, we interrupt GPs, we hunt through previous requests.
    And then we give in to pressure because appointments have to be made and we let the queries go.
    It is a massive burden on the NHS and nobody seems to want to get hold of it and find a solution. If we stopped the waste we, quite probably, would save the NHS all the money it needs - but unemployment would rise as pharmacies and delivery companies would go out of business !!!
    There are 38 practices in our CCG. we all have the same issues but cannot get anyone in the CCG to work with us to sort out except ------ the locality pharmacy technician - and he stands no chance.
    Why ?
    Seriously. Why ?
    Forget the platitudes and the 'patient need' label (dozens of our patients are frustrated with the pharmacies but have little choice available)
    Many more patients have no idea whatsoever how much their prescriptions cost, they don't pay and 'we're entitled' - so no responsibility there then !
    GPs are under pressure to prescribe sun creams, shower lotions, E45 cream, vitamin tablets - stuff that can be bought cheaper by far OTC than a prescription - but there's no support for the GP to stand up against the demanding patient.
    I dread EPS - not because of anything to do with work.
    I dread it because it will bankrupt the NHS for me in my old age - but worse, far,far worse - for my child when she grows up.
    Any chance of a solution ?

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