GP partner Dr Jonathan Inglesfield advise how to improve your practice’s medicines management processes
We all have a responsibility to use NHS resources wisely – arguably now more than ever.
Our prescriptions offer clinical benefit for patients, but at a cost. Having a clear strategy for minimising medicines waste will not only be cost-effective, but should also mean efficient prescribing, reduced clinical risk, and less work in the longer term.
Sometimes it can feel that cost effective prescribing means more work for GPs – something we really don’t need. But I believe robust prescribing systems can not only save money, but also time.
When considering how to achieve this in your practice, it may be worthwhile to follow the patient journey. Promoting self-care through the practice website and other patient contact opportunities may be effective. Consider promoting the Community Pharmacy Consultation Scheme (CPCS) and social prescribing initiatives, as these may reduce practice workload through appropriately supporting people outside of the traditional medical model of care.
You could also embed ‘advice prescriptions’ in your minor illness provision, so that patients are offered electronic or paper-based self-care information for self-limiting conditions. It may be helpful to audit prescribing in this area, and consider it a practice-wide quality improvement (QI) activity.
In addition, you could check practice prescriptions for medicines that are freely available over the counter, with an aim to reduce this year on year.
It’s important to help patients understand why you are making your prescribing decisions (see case study below). Clinicians might assume that patients are keen to take a medicine, but remember this may not be the case.
Patients who have a poor explanation of the rationale for their prescription and its likely impact may have poor concordance, and the medication might be wasted. It can be illuminating when carrying out a home visit to ask to see where patients keep their medicines. There is often no better way to see the impact of poor adherence, and consequent waste, than piles of unused boxes.
When choosing which medicines to prescribe, consider whether your practice is implementing local prescribing guidance and adhering to the local formulary. Is your clinical system supporting cost-effective prescribing? Many medicines management (MM) teams have well-developed prescribing portals offering formulary advice, some with prescribing guidance such as Optimize Rx integrated with the clinical system.
Developing a good relationship with your MM team will be useful. As clinicians, we want to know when a highly cost-effective alternative to a commonly used drug is available. However, being invited to switch lower-volume drugs for savings of a few pence may be less useful. In addition, be aware of mismatches between drugs commonly prescribed by secondary care and the recommended primary care formulary choice. Switching these medicines in primary care is confusing for patients, irritating for GPs, and a waste of resources. Your MM team should be able to help by liaising with hospital colleagues and ensuring that formularies are aligned.
Hospital discharges can also be a source of waste, confusion and clinical risk, so good processes here are essential. A rapid review of discharge summaries at the point of receipt will help. Proactively contact patients discharged from hospital and highlight any changes between the primary care medicines record and the discharge note, so that the patient is aware.
Care co-ordinators, PCN pharmacists and pharmacy technicians, who are widely offered through the additional roles reimbursement scheme (ARRS), have a key role. There are many care co-ordinators who can liaise with patients, checking their awareness and understanding of medication changes and perhaps escalating any issues that need review and reconciliation to the PCN pharmacy team.
If the patient is comfortable sharing a copy of their discharge summary with their community pharmacy, this may help to reduce prescribing risk and waste. Some CCGs, such as Surrey Heartlands, are trialling Transfer of Care and Medicines (TCAM) processes, where discharge information is shared with the community pharmacist.
Asking your acute hospital to routinely supply a third copy of the discharge note could also help enormously.
Check what support is available via your PCN to support discharges. You may find there is an appetite for PCN pharmacists or pharmacy technicians to play an early role in rationalising discharge medication and liaising with the patient.
Encourage patients to adopt a repeat prescribing system, so that paper-based and manual prescribing requests to the practice are eliminated. Some patients may wish to adopt a pharmacy-offered system, whereas others may prefer a self-managed system, such as through the NHS app.
The great advantage of self-managed systems is that the patient can track their own prescribing requests and communicate directly with the practice if needed. Pharmacy-based systems might lead to wastage if medication is ordered on the patient’s behalf when it is not needed, especially medicines that are taken as required. Additionally, placing patients in control of their medicine requests is likely to give them more confidence in the process, and there will be fewer ‘just-in-case’ requests.
When initiating medicines at the practice, consider the balance between efficiency, convenience and cost effectiveness.
Optimising medicine initiation
Offering a patient an extended course of a new drug on repeat prescription brings a risk of wastage, but giving a very limited ‘acute’ supply might be frustrating for the patient and increase the administrative workload for the prescriber. The actual interval of repeat prescribing is a matter for practices, with advice from MM teams. Hopefully your MM team will be pragmatic about this.
Routinely asking practices to prescribe at intervals of 28 days is likely to be inefficient and inconvenient for patients. Traditionally, prescribing intervals for long-term hormonal treatments such as contraceptives and HRT have been quite long – perhaps six months. This seems reasonable if clinically appropriate, given the modest cost of the drugs.
My personal practice is to initiate a drug with a limited supply, perhaps 14 days, but concurrently to authorise a repeat prescription of 56 days. You can explain to the patient that, provided their initial trial of the drug is successful, they will have access to a longer ongoing supply, subject to appropriate clinical review. This system encourages a shared understanding with the patient of cost-effectiveness, clinical safety and efficiency.
It’s always good practice to check that a patient will not experience difficulties in taking their medicines. Patients who are, for example, unable to read, may be self-conscious about disclosing this, and literacy may not be recorded on the patient record. Asking the patient if they will be able to access the patient drug leaflet dispensed with the medicine can be an easy way to screen for potential administration issues.
Consider using a friendly question, such as: ‘Are you okay with the leaflets – they’re always in really tiny print aren’t they?’ Similarly, ‘Are you okay with medicines in the blister packs, they can be tricky to get out sometimes?’ may illuminate any dexterity issues.
Remember the role of administration aids for inhalers, which may improve a medication’s effectiveness, and consider the impact of early or late cognitive impairment. Dispensing packs (dosette boxes) may be helpful. It’s important to liaise with the patient, any carers or care workers, and the pharmacist over these issues.
Case study: initiating statins
A retired postwoman attends for an annual hypertension review. You determine that statin prescribing is indicated. In order to minimise the possibility of wastage, place yourself in the patient’s (well worn) shoes. First, it’s important to explain the rationale for prescribing a statin. This drug is being prescribed not to relieve symptoms, but for prognostic benefit. This may not be clear to the patient, who may not understand why they are being offered it.
The patient may also have heard about potential side-effects with statins, and fear that these are common. Explain that the drug aims to reduce future heart attacks and strokes, and that studies have shown most reported side-effects of statins are not in fact related to the drug itself. You may wish to discuss and agree the duration of the first prescription to minimise any wastage if the drug is not tolerated – perhaps 14 days.
Don’t be afraid to also discuss drug cost. It would be very reasonable to explain that your drug choice is in line with recommendations from NICE, stating that statin prescribing is considered cost-effective. Doing so will invite the patient to work with you in minimising waste.
Empathising with the patient about the burden of obtaining repeat prescriptions may allow you to suggest the NHS app as an easy way of doing this – you may suggest 56 days.
Patients often have queries about new medicines. You could suggest that they approach their community pharmacist if they have any further questions. You may also wish to explain to the patient how they can easily obtain advice from the practice team, perhaps via the electronic consultation portal.
Finally, explain follow-up arrangements, including the rationale for drug monitoring and timely review. Also discuss the appropriate interval for a follow-up lipid assessment, so that the patient is prepared for it and doesn’t raise a query when it becomes due.
Dr Jonathan Inglesfield is a GP partner in Surrey
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