As part of its restructure of the NHS in England, which came into effect in April 2013, the UK government set a target of making £20bn in efficiency savings by 2015. On 30 October 2014, Earl Howe, Parliamentary Under Secretary of State at the Department of Health, said in parliament that the NHS is on track to fulfil this ambition, delivered through the QIPP (quality, innovation, productivity and prevention) challenge. According to QIPP, it seems quite obvious to say, efficiencies can be made by focusing on boosting the quality of care rather than just cutting costs.
Yet a recent report from the Academy of Medical Royal Colleges claims around a fifth of mainstream clinical practice brings no benefit to patients and that wasted prescribed medicines cost the NHS in England around £300m a year.
The £300m figure is not new. It comes from a November 2010 report from the then University of London School of Pharmacy and the York Health Economics Consortium, a consulting and research organisation. Regularly quoted, the sum includes unused prescription medicines retained in patients’ homes, returned to community pharmacies and binned in nursing homes. The catch is that only half is estimated to be avoidable. Indeed, the authors of the 2010 ‘Evaluation of the scale, causes and costs of waste medicines’ report say waste should not be regarded as a serious systemic problem in the NHS, but as a routine challenge to be tackled.
No simple solution
It is tough to suppose exactly what action should be taken to address medicines waste, specifically.
Patients can have medicines switched or stopped for a variety of reasons, including the treatment not working, side effects being unmanageable or their condition having resolved. The leftover medicines they have at home may not be retrievable and cannot be reused in any case — or wasted. In some cases the ongoing saving from the medicines stopped may exceed the waste remaining at home.
Within hospitals, the waste from parenteral medicines (infusions stopped or vials partly used, for example) can rarely be mitigated
Pills left behind after patients fail to finish the course of, say, an antibiotic might be considered wasteful, too. Yet this does not represent a saving that could ever be realised by the health service. Of greater concern would be the potential for antimicrobial resistance or ongoing costs of care if the infection is not treated effectively.
Within hospitals, the waste from parenteral medicines (infusions stopped or vials partly used, for example) can rarely be mitigated. Some hospitals, often paediatric centres, have developed so-called centralised intravenous additive services — where a single vial of a high-cost drug is split into several bags or syringes in an aseptic unit — but there are labour, consumables and administrative costs involved in making such savings.
Poor adherence to prescribed medicines is another known source of waste. Some non-adherence is unintentional. It might be associated with no waste, and may inadvertently lead to savings if patients pick up their prescriptions less frequently, although these patients may be putting their health at risk depending on the condition. Pharmacists will be well aware that some patients continue to pick up their prescriptions and have them dispensed without any intention of taking the drugs — maybe because they do not want to disappoint the doctor.
Invest to save
Community pharmacy interventions like medicines use reviews in England, discharge medicines reviews in Wales and the chronic medication service in Scotland provide opportunities to spot poor adherence and have frank conversations with patients about their beliefs and intentions around medicines use. The UK health departments’ investment in such services could never be made on the basis of waste-reduction alone, or indeed at all.
A year’s supply of the new oral anticoagulant dabigatran, for argument’s sake, costs almost £800; easy to see how poor adherence can add up. But consider, instead, the blood pressure drug enalapril, with an annual cost of around £15 — a meagre saving if you identify a patient who is refusing to take it. Nonetheless, in both cases, the patient will be at risk of cardiovascular events with associated hospital admissions and after-care.
The focus must be on quality and outcomes, on ensuring each patient is engaged with their treatment — this might mean additional adherence support, choosing a more acceptable but pricier treatment or stopping the drugs altogether. Using words like “wasteful” to describe the NHS may prompt the usual headlines, but does not reflect the complexity of the matter, nor is it helpful.