How to reduce wastage of prescribed drugs — clues from the Isle of Wight

The annual cost of wasted medicines is estimated at £300m in England from a budget of £8,100m. In the Isle of Wight, out of £23m worth of medicines prescribed, around £1m worth is returned to pharmacies for disposal each year, which costs a further £36,000.

In recent times, community pharmacists have introduced managed repeat services to improve patient compliance with prescribed medication and to manage the pharmacy workload more efficiently. These services typically ask the patient which items are taken regularly. These are then ordered from the surgery one week before they are next due to be collected. Locally, concerns had been raised regarding the value and efficiency of pharmacy-based managed repeat services, implying that such services generated medicines waste rather than controlling it. Although the number of prescription items dispensed within the primary care trust had not risen beyond that expected through natural item growth, an audit was designed and implemented through community pharmacy as part of the contractual framework to substantiate or refute the anecdotes.

Method

Patients were asked to review the items on their prescription at the point of collection and the pharmacist or pharmacy team was asked to record the reasons why any items on the prescription had been prescribed when not required by the patient. Where appropriate, the pharmacy then undertook corrective interventions and also educated patients and staff on the problems of medicines waste and the dangers of stockpiling unwanted medicines in their home.

Interpretation of results

It was evident that most items that were not required had been ordered by the patient. Various reasons were given for this including: not understanding the order process; ordering items subsequently discovered unused at home; aiming to reduce patient inconvenience, typified by patients saying “I might as well order these items while I’m here”; and requiring medicines as a stand-by. Most occasions where the pharmacy requested items in error involved inhalers, external creams/ointments and “when required” items. These incidents resulted in pharmacy review of standard operating procedures to prevent recurrence. Other actions have included asking the patient to sign managed repeat requests for “when required” items to take ownership of the medicine order.

Items identified not falling into the above categories were recorded as “other”. Examples of these items were those that had been recently discontinued since the prescription request had gone into the GP practice or items that had been requested by a third party such as a carer, but not the patient the GP practice or the pharmacy.

Outcomes and recommendations

Despite concerns that some pharmacy-based managed repeat services cause items not required by the patient to be dispensed, this project has demonstrated that this is the case for one in 13 occasions. In this sample taken over a typical two-week period, more unwanted items appeared on prescriptions as a result of direct patient requests or transposition errors within GP practices. The local GP practices have requested copies of the report to help them review their procedures.

Discussion of this project with the PCT’s primary care prescribing committee revealed that there was a misunderstanding within GP practices of the different ways that community pharmacies provide patient support for the repeat prescription process. In some instances this takes the form of a fully managed repeat service where the pharmacy acts to manage prescription requests to ensure continuity of treatment and patient compliance. However, in other instances the pharmacy will merely act as a courier service for patients who tick their own requests and hand these in at a pharmacy for onward transfer to their GP practice.

This project has highlighted the need for some pharmacies to review their operating procedures for managed repeat services. Any amendments must be to ensure that only regular medicines required by a patient are ordered. Ordering items such as inhalers, creams or “when required” pain relief should only be done after checking with patients at the time of request.

The project also highlighted some instances where medicines have been issued to patients that have been discontinued but are still listed on their repeat forms. It is recommended that GP practices should review repeat medicines lists for patients in line with the guidance above, and that such reviews take place regularly to ensure that discontinued items are removed from patients’ repeat lists. This will improve patient safety.

The General Medical Council is consulting on its guidance “Good practice in prescribing medicines” as part of its “Good medical practice” guidance. Paragraph 44 specifically covers repeat prescribing highlighting “that each prescription is regularly reviewed so that it is not issued for a medicine that is no longer required”. This practice is rewarded by the Quality Outcomes Framework of the general medical services contract.

Pharmacists should use the opportunity of medicines use reviews to highlight items to the GP for removal. In addition, the PCT commissions two medicines management services as part of the QIPP workstream intended to help manage some of the waste issues but these are not being used by all pharmacies.

The introduction of the repeat dispensing service would reduce the numbers of unwanted “when required” items ordered incorrectly by patients, as it can separate the order process for regular and irregular medicines. In addition, the Regulations concerning repeat dispensing require the pharmacy team to ensure that each item is required at the point of dispensing when provided through this system.