Thoreya Swage investigates the issues surrounding how medicines are prescribed and used.

In the National Health Service in England over 900 million prescriptions are dispensed annually to patients in primary and community settings. Of those, it is estimated that the gross cost of unused medicines is about £300 million a year, half of which could potentially be economically recoverable. In addition, around £50 million of the £300 million worth of unused medicines is estimated to be due to inefficient practices in residential and care homes. Clearly this is an area that could benefit from more effective action.

Problems with medicine use

The following problems have been identified with how medicines are prescribed and used in the community setting.

  • Repeat prescribing in general practice — these are prescriptions issued without a consultation between the prescriber and patient and account for about 60–70% of the cost of prescription items in primary care. About half of registered patients in England receive repeat prescriptions and this is increasing as the number of people with chronic conditions grows. Waste occurs when there is no review process and poor management of issuing repeat prescriptions. In addition, there are great risks with regard to medication safety.

  • Medicine-use reviews — this involves a structured discussion between the pharmacist and the patient about the use of their medicines and has been part of the community pharmacist contract since 2005. This is particularly useful for patients who have just been discharged from hospital; however, this service is not as efficient as it could be due to fragmentary working between pharmacists and hospitals. Furthermore, patients with chronic conditions could also benefit from such a review.

  • The management of people in care homes can often be fragmentary with many different healthcare professionals visiting. Continuity of care and prescribing can be piecemeal as communication can be poor, with the needs of patients not being fully addressed.

The key areas to consider when assessing an individual patient and their use of medicine include the following.

  1. Are patients actually taking their medication?

    • A small percentage (16%) of patients who start a new medicine take it as intended, have no problems, and receive all the information they need.

    • Almost one third of patients are not taking their medicines as they should after 10 days of starting a medicine, 55% do not realise that they are not taking their medication correctly, and 45% have stopped.

  2. How well are medicines used?

    • Medication errors are common; over two thirds of residents in a study in a care home were found to be exposed to one or more medication errors.

    • The National Patient Safety Agency (now part of NHS England) reported over half a million medication errors between 2005 and 2010, 16% of which involved actual patient harm.

    • In 2010, it was estimated that 1.7 million serious prescribing errors occurred in general practice.

  3. Are we getting best value from prescribing?

    • About £300 million per annum of medicines are wasted in primary care of which £150 million is avoidable.

    • It is estimated that at least 6% of emergency re-admissions are due to entirely avoidable adverse reactions to medicines.

  4. Are patients receiving the right medicines for them?

    • The NHS Atlas of variation (2011) identifies variations in the prescribing of hypnotics across England, a group of drugs that become less effective over time and may cause psychological dependence.

This evidence demonstrates that medicines are not prescribed and used to best effect, leading to much wastage and poor clinical care and outcomes for patients.

Medicines optimisation

The Royal Pharmaceutical Society, together with NHS England, the Royal College of General Practitioners, the Royal College of Nursing, the Association of the British Pharmaceutical Industry and Academy of Royal Colleges, has published a good practice guide for healthcare professionals in England on how to help patients make the most of their medicines or “medicines optimisation”.

Medicines optimisation is about ensuring that patients receive the correct medication at the right time, and this involves a holistic approach by healthcare professionals working in partnership with patients. It is also about examining how patients use medicines over time, and this may include stopping some medicines, starting others, as well as considering lifestyle changes and other nonmedical therapies to reduce the need for medication.

The aim of the guidance is to encourage professionals to make medicines optimisation part of routine clinical practice.

Four guiding principles of medicines optimisation

The following four guiding principles have been identified to help patients and professionals make the best use of medicines.

  1. Understanding the patient's experience.

    In order to improve the outcomes from medicine, it is necessary to be clear about the patient's understanding of their medication through continuing dialogue, as this may change over time, even when the medication remains the same. This is particularly important, for example, in patients with mental health conditions where their lifestyle is at odds with the regularity of timing of their medication and they may miss taking their medicine.

    It is vital that patients feel able to discuss their beliefs, preferences and experiences about taking medication and a shared understanding is achieved with the healthcare professional.

  2. Select medication that is based on the evidence.

    Selecting the medicines that have been assessed as clinically and cost effective leads to better outcomes for patients. Using guidance published by the National Institute for Health and Care Excellence (NICE) and locally agreed formularies enhances the use of evidence-based medicines and reduces the chances of using treatments that have limited clinical effect.

  3. Medicine use should be as safe as possible.

    This underlies the principle of patient safety in “doing no harm” and covers unwanted effects and interactions, safe processes and systems and good communication between different healthcare professionals. The aim here is to reduce the incidence of avoidable harm from medicines, encourage patients to ask about their medication, have systems for safe disposal of drugs in community pharmacies, identify and report potential side effects and reduce admissions and re-admissions to hospital due to incorrect medication usage.

  4. Ensure that medicines optimisation is part of routine practice.

    The aim here is to embed the practice of medicines optimisation as part of routine clinical practice between healthcare professionals and patients. This will make it easier for patients to discuss their medication with healthcare professionals and receive a consistent message due to better team liaison, will reduce medicines wastage, and will enable the NHS to achieve better value for money.

Examples of medicines optimisation

The Royal Pharmaceutical Society has published examples of medicines optimisation applied to different conditions including cardiovascular disease, diabetes and schizophrenia using the four guiding principles outlined above.

Below is the example for managing patients with asthma.

  1. Understanding the patient's experience.

    The areas to be considered include:

    • how asthma affects the daily activities, including sleep patterns, of the patient

    • how the patient uses their inhaler including a demonstration of their technique

    • having a personalised asthma action plan with instructions on adjustment of their therapy according to their symptoms or peak flow readings

    • what beliefs and feelings the patient has about taking or not taking the medication.

  2. Select medication that is based on the evidence.

    The areas to consider include:

    • ensuring that the patient is using the inhaler and/or device correctly

    • ensuring that the patient is aware how to use their personalised asthma action plan in response to their symptoms or peak flow readings

    • referring to the British Thoracic Society guidelines to the stepped approach to steroids (inhaler and/or oral) if the asthma worsens.

  3. Medicines use should be as safe as possible.

    This includes:

    • ensuring that there is the correct use of medication, for example avoiding excessive use of reliever medication and under use of regular therapy

    • a discussion with the patient about avoiding or dealing with side effects

    • ensuring that the personalised asthma action plan is kept up to date and includes contact details that can be used if their condition deteriorates.

  4. Ensure that medicines optimisation is part of routine practice.

    This includes:

    • discussing with the patient their peak flow readings and how this can support better management of their asthma using their personalised asthma action plan

    • checking that the patient knows what to do if they have an asthma attack

    • having regular asthma reviews with their doctor or asthma nurse

    • giving the patient a steroid card if they are on high doses of steroids.

Reflecting and improving on practice

It is important that practitioners reflect on their prescribing practice and below are some key questions that can be asked to help the health professional to focus on this.

  • Was there a discussion with the patient about their experiences in taking their medication?

  • Was there a discussion with the patient or colleagues on how to improve the safety of medication usage?

  • Has there been a review of the clinical and cost effectiveness of the medication prescribed?

  • Has there been any liaison with other professionals about improving the use of medication? For example, close liaison with the community pharmacist who can provide supporting information about the use of medicines.

  • Was every opportunity taken to apply the principles guiding medicines optimisation?

  • Has any data been recorded on medicines optimisation? This information could be used to add to the evidence base on this topic.

When discussing medication use, the practitioner should also explain the need to come back to an identified health professional if the patient:

  • is considering stopping a medicine, or not continuing with the medicine prescribed

  • is finding it difficult to continue with the prescribed medicine

  • is concerned about any side effect experienced.

Similarly, patients should be encouraged to ask health professionals about their medication in order to help them improve their medicines usage. The types of questions that could be asked include the following.

  • What is the medicine for?

  • If I have a new prescription, does this mean I stop my other medication?

  • When, how, and for how long do I take this medication?

  • When will the medicine take effect and how will I know?

  • Should I avoid any specific food, drink or other medication when I'm taking this medicine?

  • What are the side effects and what should I do if I experience any of these?

  • What action should I take if I miss one dose?

  • Where do I go to get more medication when I run out?

  • Who can I talk to if I need any more information about taking this medication?

Medicines optimisation dashboard

NHS England has produced a medicines optimisation dashboard for Clinical Commissioning Groups to assess how medicines optimisation is being implemented in their locality. A first set of indicators has been identified to facilitate the debate about how well patients are supported in their use of medicines.

Indicator

Metric

Prescribing safely in the community setting

Percentage of practices using PINCER audit tool.

This is a system that identifies patients who are prescribed drugs that are commonly associated with medication errors enabling corrective action to be taken

Support for patients with long-term conditions

The indicators chosen are those where there is significant variation in outcomes and good achievement is demonstrated by enabling patients to adhere to their medication regimes and they are monitored regularly.

The long-term conditions identified for this indicator include epilepsy, mental health, diabetes, atrial fibrillation and osteoporosis

Prescribing indicators

The drugs included are non-steroidal anti-inflammatory medicines and antibacterials

Support in the community for patients taking medication

This includes the uptake of the new medicine service and medicine use review

Repeat prescribing

Use of electronic prescribing

Medication safety in hospitals

Patient safety indicators include medication never events, medication safety incident reports and medicine reconciliation, as well as summary care records

Availability of novel medicine approved by NICE

Novel oral anti-coagulants have been approved for use by NICE as options for treatment. There is a large variation in uptake of these medicines

References

Further information about medicines optimisation can be found on the Royal Pharmaceutical Society website and the medicines optimisation dashboard can be found on the NHS England website.

Last reviewed 17 July 2014