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Broad spectrum is open to any writer. Contributions
of around 1,100 words, commenting on topical issues, should be
sent to Graeme Smith for consideration
(e-mail graeme.smith@pharmj.org.uk)
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The availability of money within the NHS is finite and the rational
use of limited resources is vital to fair service provision. Over the
past
few decades, pharmaceutical care and medicines management have developed
along various paths to help provide the highest standard of health care
within these fixed budgets, leading to a cost-benefit approach to health
care provision. However, in our view, medicines management has not gone
nearly far enough.
Over £72bn is spent annually on the NHS with more than £6.8bn
(8 per cent) of this consumed by the purchase of drugs. This is equivalent
to over £230 for each of the 29 million UK taxpayers. In the year
ending 31 March 2002, 609 tonnes of medicines were incinerated in the
UK under the “Disposal of old pharmaceuticals” scheme. This
is a 59 per cent rise over the preceding four years although, in the
same period, the number of prescription items dispensed rose by only
20 per cent. Estimates have placed the financial value of medicines that
are not used in the UK at between £30m and £90m per annum
but these are mostly based on extrapolations of medicines returned to
community pharmacies and are likely be gross underestimates.
Owing to the importance medicines have within in the NHS, from both a
therapeutic and financial perspective, ensuring they are used efficiently
is of great importance in the delivery of optimal health care. Since
the Arsenic Act of 1851, UK legislation has set out to protect the public
by restricting access to certain medicines and poisons relative to their
potential toxicity. Despite extensive current controls on medicines supply,
no legislation has been passed regarding waste medicines except from
that covering the environment. Nevertheless, the potential environmental
impact of inappropriate disposal of medicines waste remains significant.
Data from a number of developed countries indicate that pharmaceutically
active compounds, such as carbamazepine, are present in waterways downstream
from sewage treatment plants and there is evidence of medicines leaching
from land fill sites and entering groundwater.
In a different context the actions of Harold Shipman illustrate the potential
for problems with respect to access and use of Controlled Drugs. And
it is also plausible that quantities of waste medicines are consistently
diverted to the black market and traded with obvious consequences for
health. Clearly there are many gaps to exploit.
Medicines management potentially embraces the complete drug use process
from prescribing to patient compliance (or, indeed, non-compliance).
However, despite the wide application of medicines management, monitoring
medicines waste does not appear to have been used routinely to initiate
the management process or as a surrogate marker for prescribing effectiveness.
Medicines waste is a complex and multifaceted problem which may arise
from a number of factors, related to both patients and prescribers, to
excess supply and to over-
ordering. The waste of medicines represents the end-point of sub-optimal
drug use and is the antithesis of good medicines management. Although
usual medicines management processes will undoubtedly be successful in
eliminating some medicines waste because of their cross-sectional approach,
any waste reduction is likely to be incidental. In addition to the obvious
expenditure on drug acquisition and disposal, unused medicines are costly
to society and the NHS in a number of different ways, such as admission
to hospital following treatment failure, poisonings and suicides, environmental
clean-up of pharmaceutically active compounds, policing of black market
medicines and other less tangible elements.
Traditionally, one of the major barriers to the implementation of pharmaceutical
care and medicines management schemes by pharmacists has been the difficulty
in securing sufficient funding for such services.
In our view the foundation of a medicines management process on the reduction
of medicines waste through their improved use provides the opportunity
for a self-funded service with demonstrable cost savings and improved
patient care. It is also possible to demonstrate additional benefits
such as reduced environmental damage, reduction in the risk of poisoning
and lower therapeutic failure rates.
Where should we begin? How patients choose to dispose drugs is important
in the management of medicines because sub-optimal prescribing may be
highlighted. Only medicines returned directly to a patient’s GP
will come to the attention of the prescriber; those disposed of elsewhere
are not recorded formally and no universal procedures exist to rectify
prescribing records. Also, data on the medicines that are wasted and
the reasons they are not used are currently limited in the UK to studies
of medicines returned to community pharmacies. Problems, therefore, that
have led to medicines not being used will often be allowed to continue
unchecked.
Recent pharmacy-centred repeat dispensing pilots may have a significant
impact on this factor because it is more likely that the return of unused
medicines will be highlighted and supplies altered in response.
Medicines management initiatives that take waste as a starting point
can provide a coherent structure to the scheme with wide ranging impact
and ultimately be most effective at reducing the financial burden on
the NHS while improving patient care. The participation of all stakeholders,
from prescriber through to patients in medicines management processes
can help to generate a rational and structured model for the supply and
monitoring of medicines with maximal cost-benefit. In light of all this
the pharmacy practice group at Aston University is currently undertaking
a comprehensive study of medicines waste in primary care and is nearing
the conclusion of the first stages of the research. These data are to
be used to generate generic and local best practice models and improve
the use of medicines through waste minimisation with patient benefit
as the key element. |
