Saturday, May 19, 2007

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The BBC and the Guardian have both run a story about £100m worth of drugs being wasted each year by patients. I'm shocked. Shocked that it's only £100m per year. The real figure is going to be far higher. I have returned medicines collected every couple of months by a contractor. They normally take away seven or eight sackfuls of drugs - thousands of pounds worth. As an example, I have had two boxes of Casodex (at £240 per box), two seretide 250/25 inhalers (£75 each) and 30 diamorphine ampoules returned recently. Once something has left the pharmacy it can't be reused. There are two reasons for this. Firstly I don't know how it has been stored, and secondly I have already claimed payment for the drugs.

Some waste is unavoidable - people die, patients react badly to certain drugs. But waste can be reduced. The easiest way to reduce waste is to prescribe a months worth at a time. This also has the useful benefit of training the patients in how long it takes a prescription to be generated - they tend to forget if they only have to do it once every three months. Two or three monthly prescribing falls down because patients stockpile drugs and GPs don't always change their records. For example, someone is started on a new blood pressure tablet and is given 28 days supply (which is reasonable enough). They tolerate this new drug and their blood pressure comes down to target. However, the surgery forget to change the quantity to three months on the repeat screen. So Mrs Smith ends up with 28 days of bendroflumethiazide, 84 days of ramipril, 56 days of simvastatin, 84 days of omeprazole and 100 aspirin on her repeat prescription. And these all get ordered every month because Mrs Smith ticks all the boxes (or doesn't tick any and the surgery issue everything). This doesn't get picked up by the GP signing the prescription, and is tough for the pharmacist to pick up as well - I deal with 10,000 items per month; I don't have the time to look at every patient's records to see when they last had their drugs.

28 day prescribing also saves money - it stops people going to their GP for prescriptions for hayfever treatment for example. It is cheaper to pay the £6.85 prescription charge for two or three months worth of cetirizine than to buy it over the counter. If the prescription is only for 28, it is cheaper to buy it over the counter. I have been seeing lots of prescriptions recently for 90 cetirizine or 2 beconase nasal sprays, and it irritates me greatly.

Also mentioned in the above stories was the fact that £200m was wasted by GPs prescribing branded drugs over generic ones. The National Audit Office looked at prescribing of statins, ACE inhibitors, PPIs and clopidogrel, which account for 20% of prescribing costs between them. There are cheap and effective generic statins, ACE inhibitors and PPIs available. For example, simvastatin 40mg daily reduces cholesterol by about the same as 10mg atorvastatin daily. But simvastatin costs £3.50 per month while atorvastatin costs £18 per month. So it makes sense to use simvastatin, other than in those patients who genuinely can't tolerate it. There is also more evidence to support the use of simvastatin than atorvastatin, such as the Heart Protection Study. Clopidogrel is more interesting. It does the same job as low dose aspirin, and is often used in combination with aspirin for a year after a heart attack. Except that the combination often carries on for more than a year. Clopidogrel is also used as an alternative to aspirin for those who can't take aspirin. However, clopidogrel is actually quite similar in terms of side effects when compared with aspirin. Clopidogrel costs around £30 per month, while aspirin costs around £1 per month.

For some reason I decided to read the comments on the BBC website. That was a bad move. It is just as well I am young, otherwise I may have had a heart attack, though I definitely feel the need to bash my head against a brick wall. My neighbours may be worried about me given the amount of abuse that was coming out of my mouth, and there were times I felt like chucking my laptop out of the window. Just to address one major point that came up. There is (virtually) no difference between generic and brand name drugs. It is not unusual for them to be manufactured by the same company - Merck owns Generics UK for example. There are certain drugs which should be prescribed by brand name, and there are a few people who are sensitive to different excipients in generics, but the vast majority of patients have no problem with generics. Generics should be used whenever possible because they are far cheaper than the original brand.

237 Comments:

Blogger The Welsh Pharmacist said...

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Sometimes I wish I lived in England. Not Norfolk though. Newcastle is nice.

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Blogger Mary said...

I'm on several different types of medication, including ibuprofen and paracetamol. They are on my repeat prescription, although I rarely tick for them since my income stabilised (when I was living off £15 a week it was another matter).

Conversation with Locum GP writing a list of my meds for a form:
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HER: Why on earth are you doing that? You get income support, don't you? You don't have to pay.

If a doctor tells you that, there's very little incentive to keep paying out...

PS John, most pharmacies will make an arrangement to sort out your repeats for you if you ask them, so all you have to do is collect the bag once a month. If you are so ill and isolated that you can't manage a once-a-month trip to the nearest pharmacy and have no one you can trust to go for you, then quite a few of them also offer a delivery service for housebound patients.

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Anonymous Anonymous said...

The ibuprofen question is a tricky one...as in an emergency it would be important for someone to know that it is actually prescribed for me, rather than being something that sits next to the rest of my medications and gets taken occasionally.

Using the prescription also allows the GP to see that I am taking it at the dose I am supposed to be (and unfortunately as I need liquid form, OTC would cost more than prescription charge).

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Blogger Jonathan said...

[off-topic]
"The ibuprofen question is a tricky one...as in an emergency it would be important for someone to know that it is actually prescribed for me"

I'm not totally sure which emergency situations would require people knowing you're on ibuprofen. (PDA being closed..?)

[back on topic]
UK Community Pharmacist - much of your argument does make sense, and may well work out cheaper overall for the gov't/NHS, although as people have pointed out there is arguably-unnecessary hassle involved in collecting monthly medicines when they're on long-term stable doses.

You probably also should state a Conflict Of Interest that monthly scripts mean more foot-traffic in your community pharmacy and three scripts for 28 days supply of a drug gets three dispensing fees (about £3?) compared to one script for 84 days (about £1?)

Some of the problem is that there's a conflict between patients wanting minimal costs and minimal hassle (one script for six months or a year), and pharmacists wanting (a) to stay in business, and (b) to make profit - and the best way of doing that is with e.g. monthly or weekly scripts.

And there's (as far as I know) no payment system that recognises workload - e.g. while GPs will be paid ~£50/year to see a patient, the pharmacist will only be paid when an "item" is dispensed - so GPs will generally gravitate towards wanting less patient contact (one script, three months supply, but the patient wants it all in dosette boxes please!) and the pharmacist can only make money in exactly the opposite scenario (weekly scripts please) - leaving the patient stuck in the middle.

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Anonymous Hoddy said...

"It is cheaper to pay the £6.85 prescription charge for two or three months worth of cetirizine than to buy it over the counter. If the prescription is only for 28, it is cheaper to buy it over the counter. I have been seeing lots of prescriptions recently for 90 cetirizine or 2 beconase nasal sprays..."

I object!

I have quite severe allergies, including hayfever. I am also a higher rate tax payer and have BUPA cover for non-pre existing conditions. I think I do more than most people to support the NHS/ reduce the burden I put on it.

If the NHS is going to stop helping me with my hay fever (which, without Cetirizine, is bad enough to prevent me using the PC - i.e. - it stops me working) then it is letting me down.

Would you deny me an epipen on the ground that I should avoid foods with nuts in? No?

Then why deny me an _adequate_ supply of the drug which allows me to continue working - and giving 40% of what I earn to the overment to spend on the NHS if they so desire? The idea of forcing people to buy their drugs, by 28 day prescribing, is simply invidious.

I _could_ buy Cetirizine. I suppose I _could_ buy all my drugs, if we got rid of the need for prescriptions entirely. I prefer to take powerful antihistamines with the knowledge and approval of my Doctor and, having paid for the NHS (taxes) and the Prescription itself, I think I have every right to do so. Without clever, short term prescribing forcing me to alternatives!

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Anonymous Anonymous said...

[off-topic]
"The ibuprofen question is a tricky one...as in an emergency it would be important for someone to know that it is actually prescribed for me"

I'm not totally sure which emergency situations would require people knowing you're on ibuprofen. (PDA being closed..?)

[back on topic]

Um...lack of thought by doctors? I recently ended up in A&E not very with it - someone had to go and get my various meds from home, as apparently one didn't exist in the specified preparation (it was news to them that you can get different preparations via special order meds), and they refused to believe that the ibuprofen suspension dose was right.

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Blogger UK Community Pharmacist said...

John: there is a relatively new system if repeat dispensing. Your doctor can authorise up to one year's worth of prescriptions (i.e. 13 x28 days). These prescriptions can either be held by yourself or the pharmacy, so you don't have to request a prescription each time.

Johnathan: I'm only an employee, so although it would increase my workload it wouldn't neccessarily increase my income. Though it would be a useful negotiating position for a pay rise. The Scots have introduced a capitation payment for their minor ailments scheme. Hopefully the contract in England will evolve and open up income streams that aren't based on prescription volume.

Hoddy: just a small point: you pay 40% tax on your income over the higher rate threshold, not your entire income. You're a higher-rate taxpayer, you have BUPA cover. You're obviously not on the poverty line. Cetirizine is hardly an expensive drug. The NHS has a finite pot of money - should a portion of it be spent on drugs that are cheaply available over the counter? Your comment about epipens is irrelevant as they are prescription only (except in an emergency). Also cetirizine is not what I'd call a 'powerful antihistamine'. Your doctor does not really need to know whether you take it or not.

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