Public Accounts Committee

Inquiry into Medicines Management

Note from Visit to Ty Elli Surgery – Llanelli

1. The discussion began with reference to what action could be undertaken to reduce medicine wastage.

2. Patient representatives explained that in some instances the pack sizes medicines are provided in resulted in wastage particularly where disposable equipment used to administer the medication is provided.  For example, syringes might be provided in packs of 60 and a patient may only use half but with the repeat prescription is provided with more which results in stockpiling.

3. A number of examples were provided of whereby upon review some patients were found to have had thousands of pounds worth of excess medication in their homes. The costs involved were described as ‘staggering’.

4. Some patients feel reluctant to refuse excess medication for fear they might not be able to have it re-prescribed at a later date.  This is particularly an issue in surgeries where there are difficulties accessing opportunities to undertake prescription reviews and patients may think it’s simpler to keep medicines on their prescriptions.

5. Participants explained that constant review and updating of prescribing was required and also that there were three main difficulties that needed addressing.  These included:

· Patients ordering medicines they don’t need

· Prescriptions being complex and communication with the pharmacy breaking down at times

· Hospital discharge notes not always reach the GP and mistakes can occur with prescriptions.  Discharge sheets in many instances are still handwritten and cannot always be read by the GP and therefore it is not always clear whether medication has been stopped, increased or whether new medication has been prescribed.

6. Participants explored the idea of itemising the costs of each medicine listed on a prescription sheet as a means of raising awareness of the costs involved.  One participant suggested that this ‘would be a huge way forward’.

7. The discussion moved to a scheme currently being operated through pharmacies in Cardiff whereby pharmacies are receiving payment for identifying unwanted prescribed items.  This is achieved through the pharmacists asking patients questions about the items on their prescription and whether all of the items are required.   Feedback on the scheme has been positive.

8. Participants focused on the importance of pharmacists being able to ‘engage face to face’ with patients to improve the efficiency of medicines management.  However, it was noted that while pharmacists have a key role they face some push back from patients who ask why the pharmacist is questioning them as they are not GPs. Participants also identified a reluctance by patients to talk to pharmacists in detail and don’t like going into consultancy rooms where matters can be discussed in private and in more detail. 

9. Constraints on pharmacists time was also flagged up as a barrier to increased interaction with patients.  Pharmacists are so busy dispensing they do not have time to talk to patients and review their prescriptions with them.  Reference was made to good practice in Norway where pharmacists will always receive the prescription and always dispense it to the patient so a conversations can take place.

10. The issue of the prescribing of antibiotics was raised and participants explained that regular meetings were held with Health Boards to discuss the prescribing of antibiotics and undertake bench marking exercises.  It was explained that Llanelli was one of the worst performing areas with the Hywel Dda Health Board in terms of the levels of antibiotics prescribed although it was noted that this was a reflection of the depravation and demographics within the area rather than any other factor.

11. A key issue regarding the prescribing of antibiotics is that of patient expectation and a marked increase in patients demanding antibiotics and getting upset when they are refused. There has been a marked increase in patients challenging the advice of the GP.

12.  Improved synchronisation of prescribing was identified as another effective means of managing medicines wastage.  It was explained that in instances whereby patients have to order some medicines every 28 days and others every 26 days.  In such case multiple prescriptions are issues which increased the scope for duplication and mistakes.

13.  Participants referred to the increase in prescriptions for medication to treat low levels of depression and that such an increase usage cannot continue.  It was suggested that most patients requesting medication to treat depression were unhappy for other reasons and not diagnosed with clinical depression.  The discussion focussed on the move towards ‘social prescribing’ as means of addressing this issue with GPs encouraging patients to participate in social activities.  A scheme was being used in Llanelli whereby patients are provided with opportunities to undertake volunteering work in exchange for credits that can be spent on various social activities such as visits to theme parks or the theatre. The purpose is to assist individuals to interact and have social occasions to look forward to.

14.  Social prescribing was seen as being vitally important with a view that it wasn’t possible to separate medicinal and social needs.  It was suggested that if social needs could be better met this would reduce the need for medication.

15. There were some discussions around approaches taken in England whereby the prescribing of products that can be purchased, such as calpol, paracetamol and gluten free products, have been stopped.  However, participants raised concerns that in poorer areas such an approach would mean that some people would be unable to afford these products and be forced to go without.

16. This prompted a discussion on prescription charges upon which there were mixed views both for and against.