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10 Jun 2008 : Column 58WH—continued
There are large variations between PCTs in the extent to which GPs prescribe lower-cost drugs for the same conditions. Statins are one example. In the second quarter of 2006-07, the proportion of statin prescriptions that were lower-cost versions varied from 28 to 86 per cent.
among PCTs in England. Analysis of the prescription of four common types of medicines, which represent 19 per cent. of the drugs bill, showed that more than £200 million could be saved if all PCTs prescribed as efficiently as the top performing 25 per cent.
In patients’ minds, there remains an incorrect assumption that drugs can be reused if returned. For example, 14 per cent. of patients believe that medication given back to a pharmacist or pharmacy can be redispensed to others who come in with a prescription for the same thing at a later date. Some 26 per cent. believe that unwanted medicines are sent to poorer, underdeveloped countries and can be used by patients who live there, and 14 per cent. of patients appear to believe that the NHS can get its money back when it returns drugs to their original producer. They think that the pharmacist can just send them back to the people who produced them. Those assumptions clearly need to be corrected if we are to reduce the amount of wasted drugs.
On a separate note, the environmental message does not appear to be well understood, either. Some 21 per cent. of patients dispose of waste medication in the dustbin together with their domestic rubbish, and 10 per cent. flush it down the toilet, with obvious environmental effects.
Repeat prescriptions can be administered through automatic reordering. That obviously has its advantages, but it also has its disadvantages. The fact that two different medications prescribed to a patient can have different cycles—for example, one lasting two weeks and the other eight—is not necessarily taken into account on the repeat prescription form. Therefore, each time a patient uses the form to get their next supply of medication, a backlog of unused medicines is collected. Equally, when repeat dispensing takes place, the process perhaps needs to be monitored more for errors.
The negative outcomes of unmonitored repeat prescribing and dispensing include stockpiling and patients taking medication that is no longer required. Should there not be a clear requirement that the patient or carer should request items individually every month? That is a matter for consideration. It is also important to note that our current system allows pharmacists to be paid one fee for each item on a repeat prescription. Perhaps that, too, needs to be considered and its cost-efficiency examined.
On another note, the self-administration of medicines by patients, which allows them custody and administration of their own medicines while they are in hospital, has been proved to improve patient compliance with medication regimes and so prevent treatment failure. In 2001, it was estimated that a quarter of hospital admissions were due to non-compliance with medicines regimes. Self-administration might therefore be encouraged whenever possible.
I wish briefly to mention the impact of medicines packaging on drug usage. Packages are often too large. Therefore, a patient might take only half the medication in any given packet. EU legislation on original pack dispensing stipulates that all relevant documentation should be included in a medicine’s packaging. So, for example, blister packs of pills cannot be halved, as they would not necessarily be accompanied by the drug information found in the original packet.
There is no standardisation of pack sizes. Multi-packs regularly contain 30 pills for what might be a 28-day month. In itself, that is not a large difference, but multiplied across the board it means a fantastic number of wasted drugs. Other solutions such as smaller packets of drugs need to be found, to decrease medicine wastage.
I shall explore briefly how more efficient prescribing might be achieved. GPs’ surgeries and hospitals can play their part, and GPs may need to communicate more effectively with their patients to ascertain whether they are taking their prescribed medication, so that it can quickly be stopped if that is no longer the case. Some patients decide to do as they think fit and not take drugs that they allege are harming them. Some surgeries give repeat prescriptions for two or three months as standard, which can result in huge wastage. Recent studies suggest that the supply of trial quantities of new medications to patients before the prescription of large amounts can help to reduce wastage.
An NAO report on medicines management in NHS hospitals raised concerns that some medical schools’ curricula do not provide thorough enough instruction in medicine administration. About 70 per cent. of prescribing decisions are made by house officers and senior house officers, even though at that stage of their career they may have had little experience of medicines.
Only a small percentage of doctors in training report that their induction dealt adequately with medicines management issues. In addition, not all consultants are aware of the 30-day prescription limit on drugs, such as those for treatment of attention deficit. That suggests that much could be done to make those who prescribe medicines in hospitals more aware of up-to-date prescribing practice, which would encourage more efficient prescribing.
We must also look at the practice whereby prescriptions are passed directly from the GP to a pharmacy, whether it is one attached to the GP’s surgery or another local pharmacy, on the basis of a phone call from the patient. There might have been little checking about whether the patient needed the ongoing prescription. There is also evidence that pharmacists are five times more accurate than doctors in writing discharge prescriptions. Where it is properly planned and supported, investment in clinical pharmacy improves the quality of patient care and reduces costs; I am sure that my wife will take note of that.
Pharmacies also inevitably play a role in this issue, especially in the form of medicines use reviews, which qualified pharmacists often conduct on behalf of individual patients. MURs, as they are known, are designed to help to reduce prescribing costs and wastage. However, MURs come at a significant cost, at around £27 each. They involve a patient having a one-to-one consultation with their local pharmacist about the medicines that they are taking, and in doing so they attempt to ensure that unnecessary wastage of medicines is prevented. Of course, I approve of that.
Furthermore, according to the Pharmaceutical Services Negotiating Committee, local evaluations of patient satisfaction with the service show that patient satisfaction is high. However, it has not been definitively proven that the benefits of that service outweigh the cost. In 2006-07, for example, accredited pharmacies in the Wirral PCT area alone were paid more than £100,000 for providing
about 4,000 MURs. There have been instances where individual pharmacies have exceeded their maximum of 400 claim payments a year for MURs. In 2006-07, the excess payment was £67,650, or about 2,700 claims. It needs to be established that that exercise is necessary and not just an exercise for making money; that is perhaps not a well-chosen phrase.
There have been numerous awareness-raising campaigns locally to try to encourage patients not to waste their medicines. Wirral PCT recently launched a campaign to highlight the problem of wasted medicines, which was very effective. Indeed, I was able to be present when one pharmacy, P. Williams Pharmacy in Lower Heswall, received an award recently for the best window display in that regard.
GPs and community pharmacists joined the overall campaign by producing window displays that encouraged people not to stockpile medicines, only to order what was needed and to take all their prescriptions if they were going to hospital. However, I believe that such local campaigns only go so far, as they do not have the coverage that, for example, a national TV campaign would have. We need to invest in getting the message across, not just locally but across the country. An effectively co-ordinated national campaign and more work by and in relation to hospitals, pharmacies and GPs would increase awareness of this issue significantly.
I should like to comment briefly on the White Paper, “Pharmacy in England: building on strengths—delivering the future”, which was published in April. That White Paper is obviously a very considerable step in the right direction, and its call for a more integrated approach when dealing with patients and their drugs is welcome. However, the White Paper failed to include significant detail about how that aim was to be achieved. In particular, it is crucial that it is explained how the Expert Panel on Health Services Research in Pharmacy will consider the longer-term impact of MURs on compliance with prescribed medicines.
I hope that I have helped to demonstrate that there are many reasons why medicines go unused and many factors that contribute to their wastage. Part of the problem is that there is no uni-professional approach. Various health care institutions have tackled the problem independently, rather than there being a single integrated health service structure situated within a given community. It is perhaps notable that there is no official guidance on the duration of prescriptions—a situation that may not be helpful. I believe that a national awareness-raising programme would be cost-effective in highlighting this issue, both to health care professionals and to patients.
It is fair to say that patients are not fully educated about medicine usage, first about the advantages of patient concordance and secondly about what happens to their medicines if they are not administered, even if they are later returned to a pharmacy. If people were more aware of the waste and the cost involved, surely less waste would occur.
What is needed is not just an approach that raises awareness but a systemic approach. I hope that the publication of the White Paper helps to bring together the strategy needed to tackle the issue of unused medicines, with the result that more money can be spent on health care services that will be used and valued, giving the
taxpayer greater value for money. In health care, perhaps above all else, we cannot afford such high waste. Every penny going into health care needs to be effectively and wisely spent.
1.46 pm
The Parliamentary Under-Secretary of State for Health (Ann Keen): It is a particular pleasure, Mr. Pope, to serve under your chairmanship today. I congratulate my hon. Friend the Member for Wirral, South (Ben Chapman) on securing this debate, and I know that this issue is of great interest to him. He has given a further explanation of that interest in relation to his home life, and I am pleased to see that it is so well cared for and that he is so well-informed.
I can assure my hon. Friend that the Government are concerned about wastage from unused, unwanted and returned medicines. From my own experience working as a district nurse, I am very aware of the importance of community pharmacists and of the explanations that patients receive from them about how to use and look after medication. However, I would be the first to put up my hand and say that we do not have a robust method for determining the scale and cost of medicines that are unused and therefore wasted. The figure of £100 million a year is often quoted for such wastage, but according to some, the figure may be as high as £800 million a year, as my hon. Friend mentioned.
Medicines wastage was highlighted in recent reports from both the National Audit Office and the Public Accounts Committee when they considered prescribing in primary care. The view of both bodies was that a potential saving of £200 million to the NHS could be achieved by more effective prescribing, and that at least £100 million could be saved by reducing the amount of medicines that are wasted. They recommended that the Department of Health should update previous research to produce a more robust estimate of the scale of medicines wastage in England, and better information on why patients do not take their medicines as intended.
We have accepted those recommendations, and I am pleased to announce today that we have recently awarded a contract jointly to the universities of York and London to carry out research to determine the scale and cost of unused medicines and the varied and complex reasons why people do not take their medicines as intended. The findings of that research will inform policy development, influencing both health professionals and members of the public to reduce the amount of unwanted medicines, and providing value for money for the NHS. That research is now under way, and the results are expected to be available in 2009.
My hon. Friend mentioned medicines concordance and I am glad that he did so, as that is about involving patients in decisions on their prescribed medicines. This is another area in which we are working to improve matters, and the National Institute for Health and Clinical Excellence is developing clinical guidance on medicines concordance. It expects to publish its final guidance to the NHS in January 2009.
I agree with my hon. Friend that patients must play a big role in reducing the amount of wasted medicines. As I said, the reasons why people do not take their medicines as intended are varied and complex. Primary care trusts across the country are developing initiatives to raise
awareness about waste medicines. In fact, NHS North West, which includes Wirral PCT—my hon. Friend’s local PCT—carried out a major public awareness campaign toward the end of last year, aimed at achieving a significant reduction in the amount of unused medicines in the region, which would free up resources for local NHS services. We would encourage other areas to follow that example.
It has long been the Department’s policy to encourage the prescribing of medicines by their generic name. That is good professional practice, and it provides opportunities for more effective use of NHS resources. Generic drugs are generally cheaper than their branded equivalents, but just as effective.
As far back as 2000, we recognised that patients used to managing their own medicines while at home should be supported in managing their own medicines while in hospital, if appropriate. Linking the two will create a professional team to raise awareness, and I know that good work is taking place in that area. We also know that non-adherence to medicines can be a cause of hospital admissions, so it is important that we tackle it.
My hon. Friend pointed out that many patients do not realise that returned medicines cannot be reused, and he is right to highlight that. Ministers regularly receive correspondence from Members and the public about that. As my hon. Friend said, we cannot promote the reuse of returned medicines from patients. Recycling of medicines is both unethical and unsafe, as it is not possible to guarantee that any returned medicines are still of good quality. They may not have been stored correctly—medicines left too close to a radiator or in direct sunlight may deteriorate—nor is it possible for a pharmacist to guarantee quality on physical inspection alone.
The code of ethics of the Royal Pharmaceutical Society of Great Britain states that, for reasons of hygiene and safety, medicines returned to a pharmacy from a patient’s home, nursing home or residential home must not be supplied to any other patient. That applies similarly to donating unwanted medicines to developing countries.
Equally, while returned medicines cannot be reused, it is important, as my hon. Friend said, that people return them to their local pharmacy. All pharmacies provide services for the safe disposal of unwanted medicines. That helps to ensure that unwanted medicines are disposed of safely, not flushed down the toilet or placed in the dustbin, thereby helping to reduce harm to the environment.
I have not addressed all the points that my hon. Friend made on packaging and pack sizes, for instance, but research that we commissioned should indicate the extent to which they are a factor in preventing people, literally, from taking their medicine.
Another issue that my hon. Friend raised was over-prescribing. The National Audit Office and the Public Accounts Committee considered that real savings could be made through better prescribing by general practitioners—and now, of course, suitably qualified nurses and pharmacists.
Ben Chapman: I apologise for interrupting my hon. Friend. I wonder whether she might respond to the point about packaging at a later date.
Ann Keen: Of course I will. My hon. Friend raised such important issues and such a variety of questions that, sadly, because of the time, I am unable to deal with them all now, so I would be happy to do that.
The National Prescribing Centre is a nationally funded NHS body that supports the NHS in England in improving the cost-effective and safe use of medicines to the benefit of patients and the service. It has produced good practice guidance on the approaches that the NHS might adopt to secure efficient and effective use of resources across primary and secondary care, including repeat prescribing. The General Medical Council has also produced good practice guidance on prescribing medicines.
Strategic health authorities and primary care trusts employ more than 1,200 prescribing advisers, often pharmacists, to encourage and secure rational and cost- effective prescribing and to provide a source of advice and support for prescribers in their area. Research indicates that the input of a pharmacist can yield £2 for every £1 invested. Many PCTs are encouraging prescribers to issue 28-day prescriptions to help reduce waste, and most GP practices have developed repeat prescribing systems that require them to review a patient’s treatment at fixed intervals before issuing a new prescription. That provides an opportunity to discuss with the patient whether their treatment needs to be continued, and can help to reduce waste by stopping unnecessary treatments.
However, we continue to believe that prescribing is a matter best left to the health care professionals involved in a person’s care. We therefore need to balance that with patient convenience and minimising waste, but we do not think that new regulations are the best approach. Building on the success of the better care, better value indicators on the prescribing of statins, which has already realised savings worth some £80 million a year, the Department and the NHS Institute for Innovation and Improvement are considering developing a composite indicator comprising statins, angiotensin converting enzyme inhibitors, proton pump inhibitors and generic prescribing. However, we would consider issuing guidance to the NHS to tackle waste medicines, if the research that we have commissioned provides clear data that show that such guidance would make a significant difference.
Turning to my hon. Friend’s constituency, I am pleased to learn that Wirral PCT has invested in a medicines management team since 1999. It is responsible for promoting rational, safe and cost-effective prescribing, identifying and implementing areas for improvement, engaging GPs, managing the interface with secondary care prescribing, ensuring that systems are in place for the safe administration and use of medicines, and monitoring and developing community pharmacy services. The PCT has been successful in achieving year-on-year savings of more than 1 per cent. of its prescribing budget, which allows it to re-invest in patient care. The efficiency savings have driven a range of service, premises and educational developments, and I congratulate Wirral PCT on its achievements.
I am pleased that my hon. Friend acknowledges the role that pharmacies have to play in all this. I shall not mention any personal lobbying. Pharmacists, with their specific expertise in the use of medicines, can be capitalised on to tackle persistent problems relating to poor use of medicines, and the safe and effective use of medicines and associated costs.
The new contractual framework for community pharmacy supports a range of initiatives such as repeat dispensing, clinical medication reviews, and medicines use reviews to help patients get the most from their medicines, while at the same time minimising the wastage of medicines by optimising their use.
However, there remains room for improvement. Our White Paper, “Pharmacy in England: Building on strengths—delivering the future”, which was published in April, sets out our proposals for encouraging patients and the NHS to make better use of medicines by achieving further progress on repeat dispensing, by improving the use of medicines and people’s adherence to them, and by supporting people regarding newly prescribed medicines for a long-term condition, which is an exceptionally important area.
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