2011 BMA policy states:
That this Meeting recognises the huge waste that occurs by the inability of patients to return dispensed but unopened medications to pharmacies; it calls on the BMA to explore whether it is possible for some medications to be safely returned to pharmacies, for re-use by new patients.
This briefing paper:
- Gives an overview of the current rules governing dispensed but unopened medication in the UK
- Outlines the current data on medicine waste in the UK.
- Identifies the causes of medicine waste.
- Identifies schemes in place to address the issue.
Rules on dispensed but unopened medicine
Pharmacies are obliged to accept unwanted medicines back from patients. The Department of Health (DH) however, states that medicines returned to pharmacies cannot be reissued to other patients.
The Royal Pharmaceutical Society's Code of Ethics for Pharmacists states that 'medicines returned to a pharmacy from a patient's home, a nursing or residential home must not be supplied to any other patient'. These medicines cannot be used again and have to be destroyed.
The reason for this is that once the medicine has left the pharmacy, storage conditions cannot be guaranteed. Some medicines are sensitive to heat, light or moisture and can become less effective if not stored properly. It is also not possible to guarantee the quality of medicines on physical inspection alone.
The cost of medicine waste to the NHS
A 2010 independent study commissioned by the DH looked into the scale, causes and cost of medicine waste. The report published by the York Health Economics Consortium and the School of Pharmacy at the University of London, found that unused prescription medicines costs the NHS at least £300 million per year in England and £150 million of this waste is avoidable. Medicine waste across Greater London is estimated to be £50 million per year.
In Wales, more than 250 tons of out-of-date, surplus and redundant medicines are returned each year to pharmacies and dispensing General Practitioner (GP) surgeries, representing an estimated annual cost of £50 million. In September 2010, the Welsh Assembly Government launched a major campaign to reduce medicine waste and also issued a toolkit to help health professionals reduce medicine waste.
In Northern Ireland, the cost of unused medication in the health and social care service is estimated to be £2.5 million per year. The DH Social Services and Public Services (DHSSPS) has put a programme in place to improve medicine management, and is working to ensure that issues of overprescribing are dealt with.
Medicine waste in Scotland is estimated to be £44 million per year. The Scottish Productivity and Efficiency Strategic Oversight Group has a key aim to reduce prescribing waste and further work is about to begin to deliver on this aim.
The causes of medicine waste
According to the World Health Organisation, there is only 50 per cent adherence to prescriptions in long term condition medications globally; this figure refers to medication which is taken incorrectly, as well as that not taken at all.
The 2010 York report makes the point that not all medicine waste is avoidable or a result of poor practice. Much of the waste identified was not caused by failures on the part of either patients or professionals but by factors such as progression in illness and changes in treatment.
The causes of medicine waste identified by the York evaluation were:
- Patients recovering before their dispensed medicines have all been taken.
- Therapies being stopped or changed because of ineffectiveness and unwanted side effects.
- Patients’ conditions progressing so that new treatments are needed.
- Patients’ deaths, which as well as serving to reveal previously unused medicines may involve drugs being changed or dispensed on a precautionary basis during the final stages of palliative care.
- Factors relating to repeat prescribing and dispensing processes, which may cause excessive volumes of medicines to be supplied, independently of any patient action.
- Care system failures to support medicines taken by vulnerable individuals living in the community, who cannot independently adhere fully to their treatment regimens.
Other causes of medicine waste:
- Medicines prescribed during a hospital stay, such as antibiotics, are continued unnecessarily when the patient returns home.
- Some patients tend to stockpile “just in case” medicines and re-order repeat medication that they do not need.
A significant amount of prescribed drug wastage is inevitable. Reducing the volume and cost of avoidable waste will require multiple complementary measures aimed at enhancing health and pharmaceutical care quality. Research from the York evaluation concludes that the optimal use of prescribed medicines in just five therapeutic areas – asthma, diabetes, high blood pressure, vascular disease and schizophrenia – would generate up to £500 million of extra value.
Community and pharmacy based interventions
A number of pharmacy-based interventions have been shown to improve medicine adherence and reduce waste. Most pharmacies in England and Wales now provide medicine use reviews (MUR), where patients have an opportunity to discuss their medication with a qualified pharmacist.
Another approach that has been widely used is ‘Waste Awareness Campaigns’. The aim is to raise awareness of the issues leading to medicine waste among patients. According to Dynamic Advertising Group, over 95 Primary Care Trusts (PCTs) in England have implemented awareness campaigns targeting GP surgeries, Pharmacies and Care Homes, reaching both professionals and the public.
Medicine waste recycling schemes
Medicine waste recycling schemes collect unused packs of drugs with suitable expiry dates and send them to populations in need elsewhere in the world. This, however, is an area of ongoing debate and international agencies such as the World Health Organisation (WHO) do not support medicine waste ‘recycling’ because of questions relating not only to safety but also appropriateness and cost effectiveness. The Royal Pharmaceutical Society's Code of Ethics precludes the reuse of returned medicines.
In January 2009, the BMA, the Pharmaceutical Services Negotiating Committee (PSNC), and NHS Employers jointly published two pieces of guidance for GP practices. These were ‘achieving best value from the community pharmacy medicines use review service’ and ‘guidance for the implementation of repeat dispensing’.
Guidance for GP practices: Achieving best value from the community pharmacy medicines use review service
The MUR service is a structured review that is undertaken by an accredited pharmacist, in premises that have been accredited, to help patients to manage their medicines more effectively and provide patients with appropriate information and advice about their medicines. The purpose of carrying out a MUR is to improve the person’s knowledge, understanding and use of the medicines that they have been prescribed.
To gain maximum value and benefits from the MUR service, it is important that effective communication and reporting processes are agreed between GP practices and community pharmacies providing the service.
This guidance highlights the benefits of MURs, both to GP practices and patients. It stresses the importance of effective communication and reporting procedures between the GP practice and community pharmacy as well as providing a series of top tips that will be of interest to the whole healthcare team.
Read Achieving best value from the community pharmacy medicines use review service
Guidance for the implementation of repeat dispensing
Two thirds of prescriptions generated in primary care are for patients needing repeat supplies of regular medicines and as such, account for a significant workload for practices. Many of the patients receiving these prescriptions have relatively stable conditions.
The repeat dispensing (RD) model offers potential benefits to prescribers, practices and patients for the safe and efficient continued supply and management of regular medicines. The model is designed to ensure clinical supervision is maintained by means of appropriate patient selection criteria and robust standard operating procedures within the pharmacy.
This guidance explains briefly but clearly what repeat dispensing is, how suitable patients might be identified and the potential benefits. It also gives the tops ten tips for successful implementation; which have been suggested by GPs, practice managers and pharmacists.
Read Guidance for the implementation of repeat prescribing