It’s not like me to criticise those in power about their solutions to the waste of medicines in the NHS. It is not like me to suggest that they don’t fully understand the reasons. And it’s not like me to suggest that if they came to the coal face and spoke to people then they might know some of the answers. But….
There is no doubt that there is significant waste of medicines in the NHS. £300million, if you believe the York and School of Pharmacy report, but we all know that this is the tip of the iceburg and it is a little more complex than that.
I know that sometimes a prescribed medicine just doesn’t work or it has side effects that lead to discontinuation and this is the acceptable face of waste.
But sometimes medicines are prescribed too quickly before the patient is ready and there is too little support during the early phase of the patient medication experience. See my blogs on the patient medication experience and the art of prescribing (saying no quickly and yes slowly). Some patients don’t even collect their prescriptions; others do with no intention of taking the medicines in the first place. Some instinctively know that the prescriber hasn’t listened and this little pill is not the solution to their real problem.
And then there is the awful prescribing dispensing cycle that leads to the largest component of waste in the NHS. Of course a part of this is stockpiling – or the excess capital investment in medicines. When in hospital we worked to a turnover of 12 – ie we had to turnaround the total stock within the pharmacy twelve times a year. It was a struggle (and we almost reached 12 in the pharmacy), but when we looked to include all medicines throughout the hospital to reduce our capital investment we fought hard to reach 10.
The grandees of the profession say – talk to the patients – encourage them to comply with their medicines. But I have done that and you have missed the point – yet again.
Patients tell me that they are not in charge of their medicines – they are in charge of their prescriptions – and this is not the same. Medicines come altogether, in a group, like busses – did you not know that.
Here is an example of a conversation:
“I tick all the boxes and I get all the medicines”.
“But you don’t have to; you could pick and select the ones that you need”
“It’s not as easy as that, don’t you understand the system – the game we play”
Well here is my lesson that I am sharing. There is a prescription with six items on it. They are all intended to be prescribed for a month. But two are flexible through direction (one upwards and one downwards from the prescribed quantity), two are flexible because the patient says so and two are just right (the patient’s definition because he wants to take them ‘just right’. They all have 6 repeats on the basis that the patient will visit the GP in six months’ time for a formal check-up.
“So some months, when I am less well I have to order the prescription a little early – I can do that without too much hassle”. “If I just order the one that I am short, then it’s a separate triple round trip for me (doctor, doctor, pharmacy) and I am out of sequence and they call me in for my check early”. OK so what happens if you don’t order the one that you don’t need? “That is also OK, but if I forget and don’t order it twice I think that they might cross it off my repeat (actually this did happen about three years ago)”.
“So I tend to order them all about every 20 days”.
So how many boxes do you have in your cupboard at home? “Oh probably thirty to forty or so – for some I am about four or five months ahead, some I am bang on time and there are some that I will never use”. “I have about 10 boxes of stuff that was stopped at my last review that I should bring back to you.”
So I have asked the patient, found the answer and I hold my head in my hands – how can I sort this out with the system that we have? All that I have been told is perfectly reasonable and reflected by the next patient and the next and the next.
So there you are, by my very rough calculations, the NHS has about one billion pounds of capital invested in medicines in the bathroom cupboards around the country. And some of this will be needlessly wasted.
It is so ridiculous that I don’t know whether to laugh or cry. It’s like ordering the same monthly grocery delivery without ever changing it. It’s like a supermarket ordering so much stock in that its shelves are bursting until they put it all in the bin, because nobody is buying it.
We must put the patients in charge of their medicines and not their prescriptions. We must build the system around their needs and change the archaic system that we have. Don’t expect the humble pharmacist to reduce waste when, in the main, it is the system that is to blame.
Why can’t we all sit around a table – GPs, Pharmacists, IT experts, leaders and just talk this through with a whole load of real patients – and sort the thing out the way that they want it.
Will the electronic transfer of prescriptions project be part of the solution – well perhaps – in my opinion it is currently part of the problem, but the solution is there (often over-ridden) if it develops and pushes through with much greater speed (they do know this – they are clever people – they could save the NHS £1b).