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The Pharmaceutical Journal Vol 267 No 7175 p741-742
24 November 2001

News feature

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

Medicines returned by patients represent just some of the cost of wasted prescribing

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).

Why do doctors prescribe when it is not necessary?

Dr Marjorie Weiss, a researcher in sociology at the University of Bristol, described three reasons why doctors prescribe a drug that is not clinically indicated: in response to patient demand, to conclude a consultation or to convey the impression that a diagnosis is more certain than it actually is.

In the case of a demanding patient, giving a prescription represents taking the line of least resistance, avoiding a discussion and the fastest way to get the patient out of the door, she says. Some GPs said that they prescribed more towards the end of the day, when they were busy and when they were stressed. Issuing a prescription is also used as a way of asserting professional prowess, as proof of expertise, particularly in areas of medical uncertainty.

Prescribing could be used as a safety net against potential future litigation or as a symbol of demonstrating care to manage a patient's distress. It could also be used to maintain a particular doctor-patient relationship. Another reason for continued repeat prescribing when it is not indicated is when a precedent has been set by a patient's previous doctor prescribing it and the new doctor not wanting to disagree with this decision.

Professor Colin Bradley, professor of general practice, University College Cork, said that just because a medicine is not pharmacologically indicated, it is not necessarily wasteful to prescribe it because there might be other justifications for its use. In any case, whether or not something is indicated is a relative thing, he said. "Some medicines are clearly indicated, such as insulin for diabetes where the patient would die without it, but others are less essential. Another complication is that a medicine might not be essential for every person with the same condition. For example, antihypertensives are beneficial in some patients and not others, but it is difficult to identify which, and the benefit is seen in terms of the population rather than on an individual basis."

Professor Hugh McGavock, visiting professor of prescribing science, University of Ulster, and member of the Committee on Safety of Medicines, explained that there are three models of prescribing in general practice:

1. Effective drugs used for specific diagnoses. These are drugs prescribed for an exact diagnosis where their use is pharmacologically clearly understood, eg, anticoagulants, drugs for asthma and thyroid conditions.

2. Symptomatic drugs for self-limiting conditions or for adjustment to specific diagnoses, eg, expectorants, antacids, hypnotics and mild analgesics.

3. Presumptive prescribing. This is prescribing of drugs used without specific, proven diagnosis, usually either drugs of little use or those that take a blunderbuss approach, eg, proton pump inhibitors, and anxiolytics.

In order to have truly rational prescribing to avoid waste and reduce waste, an accurate diagnosis, thorough knowledge of common conditions and an adequate knowledge of pharmacological agents relative to general practice is needed, Professor McGavock said. "We have a very serious problem. The days of the omnicompetent GP are over: there is too much for a single human brain. We need the help of pharmacists."

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:

Improve the quality of treatment, particularly through medication reviews
Reduce GPs' workload
Help to share responsibility (pharmacists have far greater pharmacological knowledge than GPs and GPs are experts in diagnosis so they should work together, each contributing these skills)
Save the NHS money
Help avoid iatrogenic disease
Add to professional satisfaction through sharing of knowledge

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.

How pharmacists can become involved

Tackling waste prescribing is an area that needs pharmacy input to save money for the NHS and to improve patient care. So what can pharmacists do?

Be proactive: contact primary care trusts/groups and local pharmaceutical committees and find out what local priorities are in wasteful prescribing and how funding for services can be obtained

Improve relationships with local GPs: approach them in a constructive, supportive way and explain how pharmacist input can provide assistance

Demonstrate the value pharmacy can offer by conducting pilot studies of monitoring waste in patient-returned medicines

Talk to patients about compliance when handing out prescriptions

And what should the profession as a whole be doing? Professor McGavock suggests that meetings should be held at a regional level between pharmacy bodies, including the Royal Pharmaceutical Society, and representatives of the British Medical Association and faculties of the Royal College of General Practitioners. Such meetings could facilitate the introduction of pilot studies of pharmacists working to reduce wasteful prescribing.

Repeat dispensing

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 barriers

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.

The costs

The annual cost of loss to the NHS is £7�9bn, or between 16 and 20 per cent of the total NHS budget. This can be broken down as:

• Adverse patient events (leading to prolonged stays in hospital): £2bn
• Staff sickness and absence: £2bn
• Crime: £1�3bn
• Hospital acquired infection: £1bn
• Medication errors: £300�600m
• Wasteful prescribing: £300�600m
• Clinical negligence: £400m (with potential liabilities of between £2bn and £4bn)
• Malnutrition: £230m
• Occupational health and safety: £150m
• Avoidable management and legal costs: £100m