Review of NHS Pharmaceutical Care of Patients in the Community in Scotland

The Need for Change - Patients and Their Medicines

9. The changing demography of Scotland, the associated changes in morbidity and the continuing health inequalities set major challenges for pharmaceutical care in the future. The proportion of over 75s, who are the highest users of NHS services and for whom prescribing can be particularly complex, will increase by over 25% in the next 10 years, and the number of over 75s is likely to have increased by almost 60% in the next 20 years⁶ . The pattern of disease will see a continuing shift towards long term conditions, with growing numbers of those with multi-morbidity, co-morbidity of physical and mental disorders, and resulting complex needs. In a recent Scottish study⁷ an analysis of a database of the over one and three quarter million patients found that nearly a quarter were multimorbid (i.e. with two or more disorders), that onset of multi-morbidity occurred 10-15 years earlier in people living in the most deprived areas compared with the most affluent, and that the presence of a mental health disorder increased as the number of physical morbidities increased. The study illustrates the challenges to the traditional single-disease framework by which most health care has been configured and underlines the importance of generalist clinicians providing personalised, comprehensive and continuous care.

10. Medicines are the commonest form of treatment in the NHS. The total volume of prescription items dispensed in the community in Scotland in 2010/11 was 91.1 million items, with a total (net) cost of almost £1.14 billion⁸ . However, medicines can harm as well as help. The sources of harm are adverse reactions to the medicines themselves, the errors made by healthcare professionals and carers, and failure by patients to adhere to the prescribed regime of treatment (non-adherence). These three sources of harm are often inter-related. These harms cause avoidable misery, unnecessary ill health, and sometimes death. These consequences also represent a significant drain on Scottish Government resources, such as increased hospital admissions, inappropriate escalation of treatment, increased waste and additional staff time. Studies have found that between 1.4% and 15.4% of hospital admissions were drug related and preventable; the commonest causes were prescribing and monitoring problems (53%) and non-adherence (33%)⁹ .

11. Non-adherence has been estimated to be responsible for 48% of asthma deaths, an 80% increased risk of death in diabetes and a 3.8-fold increased risk of death following a heart attack¹⁰ . Another manifestation of non-adherence is failure to collect prescriptions. Two small studies show that 2.9 - 5.2% of items prescribed were not dispensed¹¹ , although they were conducted before prescriptions became free. Although one pound in every eight of NHS spending is on medicines, up to half of all the medicines prescribed are not used as the prescriber intended¹² .

12. Waste medicines result predominantly from non-adherence, changes in prescribing and changes in the patient's condition. A study¹³ of waste medicines in England in 2010 found that medicines worth in the order of around £300 million were wasted per year and about £150 million could be saved in cost effective ways. The proportionate equivalent for Scotland would be wastage of £30 million and savings of £15 million. The study concludes that 'the greatest social and economic returns are to be gained when reducing medicines waste can be effectively linked to improving care quality and health outcomes'.

13. Care homes residents have particularly high levels of co-morbidity and polypharmacy; seven out of ten residents receive some form of medication error each day (mostly a result of factors outside the control of the home). While many errors are of little or no clinical consequence this high prevalence results in adverse events and emergency admissions to hospital.¹⁴

14. A recent study for the GMC¹⁵ suggests that around one in eight patients have prescribing or monitoring errors, involving around one in 20 of all prescription items. As is common with errors, the vast majority had no, or only a mild or moderate, effect. However, one in 550 items was associated with a serious error. Some factors that increased the probability of an error were the patient's age (<15, >64) and the number of items prescribed. Monitoring errors (failure to monitor for the adverse effects of certain medicines) tended to have more serious consequences than prescribing errors. The most frequent forms of prescribing error were 'incomplete information on the prescription' and 'dose/strength errors'; the most common monitoring error was 'failure to request monitoring' (69%). In care homes¹⁶ errors were more frequent; 39% of residents had one or more prescribing errors. Errors were prevalent everywhere; for every act (drug prescribed, or dispensed, or administered) there was an 8-10% chance of error. Monitoring errors, the errors most associated with harm, occurred in nearly 15% of relevant medicines.

15. Specific problems have been identified with the transfer of information at the primary/secondary care interface. A survey of GPs in Glasgow found that 58% were not satisfied with the information received from the hospital on patients' discharge therapy. In a medication record review study in England, no dose changes made in hospital and only 8% of new prescriptions started were highlighted in the discharge communication. Following discharge, 28% of the 87 drugs newly prescribed by the hospital were either not continued, or there was some discrepancy between the prescribing advice of the hospital and the subsequent prescription. For the medications that had been stopped by the hospitals, none was restarted by the practice within a month of hospital discharge. In Forth Valley, a medicines reconciliation project which tested the transferring of medication and care record history from and to community pharmacies as well as GPs found that in 35% of cases pharmacists stated that the data reduced the risk of inappropriate supply and in 10% of cases the information prevented a call to the hospital or GP.¹⁷