Public Accounts Committee

Medicine Management visit– 12 June 2017

Stanwell Surgery, Penarth

Stanwell Surgery have taken a proactive approach to not prescribing items which can be purchased easily over the counter. This initiative has come from a Health Board direction, but has not been taken up by all the surgeries. To help with the implementation of this policy, the surgery has produced a letter to give to patients, there is also a letter from the Health Board – which can provide some additional cover to the potential questions about why items are not prescribed.  This was broadly welcomed with patient representatives expressing concerns about being prescribed things which could be easily brought. (Note of caution – items are not just prescribed to save patient money, in some instances these seemingly easily purchased drugs are included to ensure that patients are aware they need them, and that they are being taken)

Lots of patients have drugs prescribed on historic prescriptions and don’t realise that they can buy them. There is a need for consistency across Health Boards amongst those prescribing, and at present the message is not really targeted properly.

The surgery carries out regular (at least annual) medicine reviews to keep on top of the number of repeat prescriptions. This was complemented by the work of the pharmacists, who talk to patients about the items on their repeats and whether they are necessary.

De-prescribing is a challenge, it is a lot more difficult to stop something on a prescription than start it – it would be useful to have guidelines around how to have difficult conversations around stopping medication, and ensuring these are done in a respectful way.

Electronic prescribing within a primary care setting is necessary. Currently all scripts are signed by hand, which takes up a significant amount of time. There is little safeguard in continuing with hand signing (often an argument used for not introducing electronic prescriping), as the checks and balances are in place with pharmacists.

There is often a lack of understanding with patients regarding what medicines do – which causes concern and worry. Lot of work done by pharmacists to explain what the drugs do, and why they are needed or not in the instance of repeat prescriptions. Patients need help taking medicine, often embarrassed by things like needing to use a dosset box. In some instances district nurses are being utilised to help patients take medication which is not a very efficient use of resources – although they are then able to check on any potential stockpiles, which is useful as accessing patients homes to check the quantity of medicines can be difficult.

The question should be posed of why the NHS contract for certain drugs is so much more expensive than the supermarkets.  The differentiation between the tariff price and the concession price can be quite substantial and subject to significant fluctuations.

The restriction of medicines to one type can be problematic for the patient as once size does not fit all e.g. needles for diabetics, there needs to be a balance and some choice.  Medicines are not effectively managed without spending some time and resource to identify ways to save resources.

The interface between primary and secondary care needs better management. Often patients are prescribed the ‘new and more expensive’ drugs in hospital – as there are not the same incentives to consider the cost of medication in hospitals, and it is difficult to take someone off a certain medication as patients think ‘…but my consultant prescribed that’. 

It can be frustrating that people are sent in with medication lists and then on discharge there often appears to be no reconciliation with the original list. Furthermore, if drugs have been omitted, the reason for the omission is not always clear and whether it is intentional. Although MTED does provide some information, there was a reluctance to put too much faith into it as often in the more complicated cases GPs will want to meet and discuss the medication with patients.  There appears to be a lack of understanding about the costs of certain prescriptions from hospitals – they can end up costing GPs £1000’s.     

There was support for better linking of IT systems and information, including access to the GP patient records, as there are a large number of interactions with patients. Often pharmacists would not know the background to prescriptions, which would help answer a number of queries. Conversely, pharmacists accessing the patient record would be able to help GPs know how much of a prescription is dispensed.