The National Institute for Health and Clinical Excellence has reported that between 30-50 per cent of medicines are not being taken as intended, resulting in a loss in health gain of billions of pounds. Preventable adverse effects of medicines were found to account for 4-5 per cent of all hospital admissions in a study of over 18,000 admissions in 2004 published in the BMJ. The Care Home Use of Medicines Study (CHUMS), published in 2009, found an unacceptable level of errors in prescribing, dispensing, drug administration and drug monitoring of medicines in care homes. Professor Banerjee’s 2009 Report for the Minister of State for Care Services found unacceptable levels of prescribing of antipsychotics in dementia. And a 2009 Care Quality Commission survey found that almost one in ten inpatients felt they had not been given enough information about the purpose of the medication they were to take home. I could go on.
So, where medicines are concerned, the evidence suggests there is clearly scope for improvement, and if pharmacists really are the experts in medicines then we should be best placed to encourage and secure their safe and effective use.
The big wins
Some of the research has focused on the natural consequence of poor practice or inappropriate or ineffective use – waste. Research conducted for the Department of Health by the York Health Economics Consortium, University of York, and The School of Pharmacy, University of London, and published at the end of last year suggested that the cost of waste medicines to the NHS was running at £300m a year, with net savings of around £150m possible from investing resources in tackling waste. More importantly however, this report also suggested £500 million worth of extra value could be generated in asthma, diabetes, high blood pressure, vascular disease and schizophrenia if medicines were used in the most optimal manner.
This is the significant bit – the really big wins are to be had by supporting patients in getting more benefit from their medicines. As the researchers said: “in welfare terms, significantly greater returns could be generated by better medicines use, as opposed to waste reduction per se”.
Opportunities for pharmacists
The evidence gathered from the research suggests opportunities for all healthcare professionals to get involved in tackling medicine waste and improving adherence by:
- Providing support for patients starting new therapies and those on unusually costly and/or difficult to take treatments;
- Encouraging the flexible and informed use of 28-day prescribing and, where it is beneficial to the patient, encouraging longer or shorter prescribing periods;
- Targeting medicines use reviews conducted by pharmacists more towards groups and individuals at special risk of having difficulties with their medicines taking;
- Auditing the use of monitored dosage system medicines taking aids, which help some patients but in other instances cause avoidable waste;
- Further enhancing hospital and primary care liaison to improve the quality of medicines management at around the time of hospital admission and discharge.
Following the publication of this research, the King’s Fund gathered together representatives of patients, health professionals, the NHS and industry to consider its findings and identify practical next steps that might be taken to help reduce waste, optimise medicine taking and improve health outcomes. And Health Minister Lord Howe has recently announced the launch of a Steering Group to Improve the Use of Medicines which will turn those ideas into an action plan by the end of this year.
I am delighted to have been asked to co-chair this multiprofessional and patient and public group, working alongside Robert Johnstone, a trustee of National Voices, the national charity coalition for health and social care. There are lots of good ideas around for how health professionals can provide better support for patients and the public to help them use their medicines more effectively, and I am pleased to say that many people have contacted us already to offer their ideas and experiences.
The Group will no doubt be looking at elements of the pharmacy agenda that seem to have got stuck along the way, like repeat dispensing, or that have never developed beyond local schemes or pilots (rewards for not dispensing, for example), or that stand out as opportunities missed, like aligning GP and pharmacist incentives for good practice in enabling effective medicines use.
For our patient and public representative colleagues, they will be looking for actions to ensure patients are involved as equals in shared decision making processes and are more fully informed about treatment options. The research on which the new medicines service is based tells us that, through appropriate and timely follow up, pharmacists can deal with patient concerns and questions in a way which makes it more likely the medicines will be used effectively, and will thereby achieve better outcomes in the drugs budget.
The Pharmacy Voice blueprint for better health, which we published in February, highlights the importance of new thinking for pharmacy about a medicines pathway, in which services such as the New Medicine Service and Medicines Use Review appear as part of the patient’s journey with a long term condition, and where prevention, self-care and acute crises are part of the same continuum.
The potential for optimising medicines use
In the longer term, we believe that a complete professional understanding of the potential for optimising medicines use across a range of patient pathways will serve as the basis for new thinking about a range of other issues which could improve patient outcomes and/or lead to an improvement in the patient experience. These could include:
- Defining the scope for using advanced skills, including supplementary and independent prescribing, in managing treatment change resulting from a pharmacist/patient intervention;
- The development of specific interventions by pharmacists, designed to improve or resolve longstanding and seemingly intractable issues within healthcare around medicines use, such as the well documented problems which arise when patients are admitted to and discharged from hospital;
- Facilitating thinking on how pharmacists and pharmacy teams might need to work differently, with an increasing role for registered pharmacy technicians in managing the supply and distribution of medicines to ensure none of the quality, safety and cost-effectiveness of the pharmacy service to patients is lost.
The changes to the Community Pharmacy Contractual Framework this October take us a further step on with recognising and rewarding specific interventions designed to optimise patients’ use of medicines, in both NMS and the move to more targeted MURs, which recognise different degrees of risk around medicines in use. But we could go further, and as a science-based profession perhaps we should. For example, the most effective interval for regular repeat medication may vary for different medicines. If we are to really support effective use by patients, then information needs should be met when they arise, and patient profile, pharmacokinetic and safety information could drive service redesign more effectively for patients than pack size or prescription length do now.
I don’t underestimate the challenge but I think we are up for it. The Steering Group provides a chance to suggest how good ideas should be embedded into systems and processes that have historically been more concerned with products than people. This is an important distinction to make. It marks a shift from looking at the medicines budget purely in terms of cost to one of an investment in people’s health. As Lord Howe said about the launch of the Steering Group: “it isn’t just about saving money – most importantly, it is about making sure that patients stay well and get the best outcomes from their medicines.”
Chief executive of Pharmacy Voice and
co-chair of the Steering Group to improve the use of medicines