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QIPP: Waste not, want not

QIPP: Waste not, want not
13 November 2013

Educating patients is key to reducing the amount of medicine that goes unused

Educating patients is key to reducing the amount of medicine that goes unused
Three clinical commissioning groups (CCGs) in Cheshire have collaborated on an ambitious campaign to encourage patients to use their medicines effectively and reduce the value of wasted medicines by around £750,000 per annum. The ‘Need It? Order it. Use it!’ campaign was developed by the shared medicines management team for NHS Eastern Cheshire, NHS South Cheshire and NHS Vale Royal CCGs in response to feedback from practices, patients and pharmacists engaged in a review of the CCGs’ repeat prescribing policy in 2012/13.
Developed by patients, clinicians and pharmacists the campaign aims to raise people’s awareness of managing their medicines, with an emphasis on minimising waste and getting the most out of the medicines prescribed. The success of the campaign will be judged by the level of behaviour change, and financial savings will contribute to a medicines management quality, innovation, productivity and prevention (QIPP) target of over £5.5 million between the three CCGs.
The total annual budget for the three CCGs is £538 million, of which 14.5% (£78 million) is spent on prescribing. A report published in 20101 estimated the cost of unused prescription medicines in primary care to be approximately £300 million a year in England. It was reported that around half of this medicines waste could be avoided. Translating the scale of waste to a local figure for Cheshire puts the estimated waste at around £3 million per year.
The ‘Need it? Order It. Use It!’ campaign aims to save half of the avoidable waste through raising awareness. This equates to £750,000 (around 1% of our prescribing budget). 
Other elements of the medicines QIPP plan include promoting preferred formulary medicines, improving inhaler technique for patients with asthma and chronic obstructive pulmonary disease (COPD), and using information technology to highlight potential risks associated with medicines to prescribers. Medicines Management faces many challenges to controlling prescribing spend. These include managed entry of new drugs, maximising cost savings using a local formulary agreed between primary and secondary care and medicines waste. 
There are times when medicines waste is unavoidable, such as when there is a change of drug, dose titration, side effects or allergies and when patients pass away. However, the volume of waste in these situations can be minimised by shorter prescribing intervals and so the CCGs have agreed guidance on 28-day prescribing. Avoidable waste can occur through over-ordering – ticking all items ‘just in case’; over-prescribing, such as giving large quantities of short-term analgesics; and not taking medicines as prescribed which may lead to further treatments being added if concordance isn’t achieved. 
Everyone has a role to play in minimising medicines waste, and as a medicines management team (MMT) we recognised that there needs to be a shift in behaviour to achieve this. We wanted to launch a campaign that didn’t point fingers or blame any particular individual in the repeat prescribing process. Last year we worked with practices to ensure their repeat prescribing systems were robust and avoided waste, such as checking for over/under ordering and performing meaningful medication reviews. We are also working with our community pharmacy colleagues to ensure their repeat ordering systems are robust and do not generate waste. The ‘Need it? Order it. Use it!’ campaign is about educating our patients and is being run jointly by GP practices and community pharmacies. We are encouraging patients to ‘only order what you need’ asking them to please check stock at home and only tick items needed at that time. If you need it, please order it but also – please use it! 
We are reassuring patients that it’s OK to talk about their medicines. If they are not using medicines because of problems with them or uncertainty about why they are needed, patients are encouraged to talk to their doctor, nurse or pharmacist. Health professionals want to know if patients aren’t taking their medicines to understand why and hopefully offer a better solution. It’s also about educating patients and dispelling myths that items will be removed from the repeat list if they are not ordered each month. 
Patients need to know that prescriptions can be synchronised to make the ordering process more streamlined. The campaign encourages the community pharmacy medicines use review service to identify opportunities for medicines optimisation and waste minimisation. Box 1 shows points we are asking patients to consider before placing their prescription order. Not all unused medicines are returned to pharmacies for destruction – some will make their way into normal household waste. The campaign signposts the public to their local pharmacy to dispose of unwanted medicines safely. 
We recognised the importance of a joint approach to enable ownership of the campaign at different levels. The passion for tackling waste in the local area was evident and this passion translated into materials developed in partnership with patients, pharmacists and GPs. Prior to the launch of the campaign we ensured, in partnership with the CCGs, that all key stakeholders were advised of the campaign and we met with patient participation groups, practice managers and the Cheshire local pharmaceutical committee (LPC) to gain their support. 
The campaign was rolled out to every GP practice and pharmacy in Cheshire during the month of August to coincide with the bank holiday weekend. The campaign is not time-limited and resources such as banners, leaflets, posters and prescription stickers were circulated. Using the same campaign across all three CCGs that employ the same medicines management team makes sense as the message is consistent across the whole area. East Cheshire NHS Trust pharmacy is also supporting the campaign. Our campaign materials have received very positive feedback and we have already received interest via neighbouring CCGs who would like to use the campaign to implement across the wider North West area. Slight behaviour changes are starting to happen as a result of the campaign. We have received anecdotal evidence from a prescription clerk that the number of patients who are not ordering items on their script as they “have plenty at home” has increased dramatically. Patients have also picked up the small postcards in GP practice waiting areas, taken them into their consultation and asked the GP to take some of the items off their repeat as they are not taking the medication anymore. 
The materials are colourful and informative, containing the messages we want to promote, but these are just one element of the campaign. We have empowered our practices, patient participation groups and pharmacies to promote the messages and feedback any behaviour change. It is important that we get the messages across in a clear way to the right people, which has been strengthened by the input of patients, clinicians and pharmacists. To gauge success of our campaign is to look at a shift in behaviour, which MMT members can help with as they are ideally placed to follow up with practices and pharmacies to record any successes. The success of the campaign cannot be purely attributed to prescribing costs as there are many variables within this, however we expect to see a slowing of the trend of increasing item numbers year on year. 
So how does all this fit with national guidance? The National Institute for Health and Care Excellence (NICE) issued guidance on Medicines Adherence2 in 2009 and our campaign supports the elements of this relating to improving communication, providing information and interventions to increase adherence. The Steering Group on improving the use of medicines3 recommends a national public information campaign to raise awareness of making the best use of the medicines and reducing waste. In May 2013 the Royal Pharmaceutical Society issued good practice guidance for Medicines Optimisation.4 They state “the goal is to help patients to: improve their outcomes; take their medicines correctly; avoid taking unnecessary medicines; reduce wastage of medicines and improve medicines safety”.
Our campaign hopes to address some of these issues directly – empowering our patients to take ownership of their repeat prescriptions. 
 1. York Health Economics Consortium/The School of Pharmacy, University of London. Evaluation of the Scale, Causes and Costs of Waste Medicines (November 2010)
 2. National Institute for Health and Clinical Excellence. NICE clinical guideline 76 – Medicines Adherence. Issue date January 2009 
 3. Report and Action Plan of the Steering Group on Improving the Use of Medicines (for better outcomes and reduced waste) (October 2012)
 4. Picton C, Wright H. Medicines Optimisation: Helping patients to make the most of medicines. May 2013. Royal Pharmaceutical Society

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