Reducing NHS medicines wastage and the global challenge of preventing drug counterfeiting

7/29/2019 Reducing NHS medicines wastage and the global challenge of preventing drug counterfeiting

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Mezzanine Floor, BMA House, Tavistock Square, London WC1H 9LPT: 020 7874 1270 F: 020 7378 5693 www.pharmacy.ac.uk

Not for publication before 11.00 hours Thursday January 17th

2013

A UCL School of Pharmacy Pharmaceutical and Health Policy Briefing

Reducing NHS medicines wastage and theglobal challenge of preventing drug counterfeiting

Significant problems which demand serious attention, but should not be exaggerated relative toimproving health care access and outcomes

Medicines wastage in the NHS and pharmaceutical falsification (counterfeiting and alliedcrimes) across the world are controversial topics which receive frequent media coverage. Therehave been allegations that poor prescribing, unnecessary dispensing and inappropriate patientuse of medicines (in part, some suggest, related to the fact that most NHS prescription drugsare throughout the UK supplied free of charge) are leading to levels of wastage that areundermining health service finances. Some sources also claim that up to 100,000 people a yearare being killed by illegal and sub-standard medicines1.

However, research undertaken at the UCL School of Pharmacy indicates that although bothmedicines wastage and medicines counterfeiting represent significant problems, there aredangers in exaggerating their scale and impacts. This could distort priorities and lead to

counter-productive public policies. There is in fact no evidence that NHS medicine users behaveless responsibly than those who pay for treatments, or that levels of drug wastage are higher inBritain than in other relatively rich countries. At the same time it has been observed thatcharges can lead vulnerable people (and others) to stop taking therapies.

Similarly, progress is across the world being made in the field of preventing medicinesfalsification, in part because of the work of agencies such as the WHO and, for example,Chinas State Food and Drugs Administration (SFDA). Against this background this UCL Schoolof Pharmacy Pharmaceutical and Health Policy Briefing provides updates relating to these twoareas, and seeks to identify positive ways forward with regard to protecting public interests andpromoting better public health.

Research on medicines waste and the importance of taking medicines to optimum effect

Medicine wastage is normally measured in terms of the physical volume and (pack pricedefined) cost of drugs which have been dispensed but not taken, and are ultimately eitherincinerated after being returned to pharmacies or discarded via rubbish bins or the drains. Non-adherence in medicine taking is much a broader concept, which includes the incorrect use ofmedicines as well as simply not taking them. (Some studies include not having prescriptionsdispensed as a form of non-adherence.) Even in the context of life threatening conditions suchas cancers and AIDS drugs may be fully consumed, but not in the ways that lead to the greatestpossible health gains.

1See, for example, PHAKE by Dr Roger Bate, published by the American Enterprise Institute


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In 2007 the National Audit Office suggested that in the order of 10 per cent of all the NHSmedicines dispensed in the community (including care homes) in England are wasted, implyingin todays terms a cost of almost 1 billion. But research undertaken by the School of Pharmacyand the York Health Economics Consortium, published at the end of 20102, found that the true(physical) wastage total is about 4 per cent (1 in every 25). The represents a total of between300 and 350 million. Of this 50 per cent was regarded as unavoidable, because it stemmedfrom factors such as patients conditions changing. Hence the savings to be made from furtherimproving the NHS record in reducing medicines wastage in England are in reality (allowing forthe costs of new measures, such as providing better health and linked social support for

vulnerable people living alone in the community and who are experiencing problems withmedicines taking) unlikely to be greater than 100 million.

This is an appreciable amount, but it is small (less than 0.1 per cent) as compared to the 110billion annual cost of the health service in England. It is also of note that despite recentadvances in areas such as cancer and HIV care, overall hospital and community prescriptiondrug costs have fallen as a proportion of NHS spending during the past decade. They stand atabout 10 per cent of total health service costs. This is about the same proportion as thatrecorded half a century ago, in the mid 1960s. Falling pharmaceutical costs have been due tothe genericisation of medicines, which has raised the relative cost of health service labour as

compared to that of the average medicine dispensed in the community.

By contrast, the School of Pharmacy/York analysis found that in just five therapeutic areas(including asthma and diabetes treatment, and the prevention of heart disease and strokes) thehealth gains and cost savings to be derived from better use of supplied medicines amount to500 million in England alone. Such observations underline the importance of investing in betterpharmaceutical/health care delivery by pharmacists and/or other professionals and takingmedicines to optimal effect, rather than concentrating narrowly on reducing dug wastage. Thisfinding is in line with more recently published research presented to a meeting of HealthMinisters held in The Hague in October 2012, which suggested that better use of medicinesworld-wide could generate global health care efficiency gains of up to $US 500 billion3.

Following the publication of the School of Pharmacy/York Health Economics Consortium reportthe Department of Health organised a roundtable meeting, held at the Kings Fund at the start of20114. This in turn led to the establishment of a Steering Group to Improve the Use ofMedicines. Its report, Improving the Use of Medicines for Better Outcomes and ReducedWaste5, was published at the end of December 2012.

As its title implies, this analysis argues that cutting material medicines waste (that is, the cost ofdiscarded medicines) is a secondary goal as compared to improving health outcomes. It

2Webreference http://php.york.ac.uk/inst/yhec/web/news/documents/Evaluation_of_NHS_Medicines_Waste_Nov_2010.pdf

3See

http://www.responsibleuseofmedicines.org/2012/10/advancing

responsible

medicine

use

is

ahalf

trillion

dollar

global

imperative/

4Makingbestuseofmedicines:ReportofaDepartmentofHealthroundtableeventhostedbytheKingsFund

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_1282835http://www.dh.gov.uk/health/2012/12/medicinesreducedwaste/


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suggests building further on developments such as the introduction of Medicines Use Reviewsby pharmacists and the more recent launch of the New Medicines Service in England. This lastis largely based on School of Pharmacy research that showed that when pharmacists payspecial attention to resolving the medicines taking related problems people may experience inthe first few weeks after they start taking treatments intended for long term use adherence ratesimprove, opening the way to better outcomes and reduced waste.

The recommendations made in Improving the Use of Medicines for Better Outcomes andReduced Wasteincluded:

improving repeat prescribing and dispensing processes, in part via the greater use ofarrangements already available for enabling pharmacists to take greater clinicalresponsibility in instances where patients are on stable long term therapeutic regimens.This can reduce GP practice workloads and enhance pharmaceutical care;

providing incentives for encouraging pharmacists not to dispense PRN (take whenrequired) prescription items when patients already have adequate stocks at home. InSheffield, for example, there is a local not dispensed scheme which pays pharmacies 4per item judged not to be required, plus 10 per cent of the cost of each specific medicine

not supplied;

targeting additional medicines taking support on individuals identified as being at specialrisk of having particular problems, including individuals with complex and multipleconditions known to be living alone and/or with disabilities that restrict their opportunitiesfor accessing resources such as community pharmacies; and

building further on successes in areas such as encouraging more patients to bring themedicines they are taking with them when admitted to hospital and to go on taking themnormally unless their treatment is changed (PODs schemes). This can be done by, forinstance, improving discharge procedures and pursuing opportunities for re-using

medicines that have been supplied to wards but not given to patients. Provided the latterare in date, have been stored properly and have not been out of the hospitalssupervision there is no reason to discard such stock. It is possible that annual savings ofin the order of 10-20 million could be achieved by changes of practice in this context.

However, no change in policy in relation to resupplying NHS medicines returned to communitypharmacies, either to other NHS patients or to poor communities abroad, has beenrecommended. There is evidence that many members of the public would like to see returnedmedicines re-issued in this way, but the costs involved in achieving this safely would normallybe greater than the supply cost of the medicines involved. That is, outside hospitals it is usuallymore cost effective to incinerate returned medicines and to purchase new supplies for use

domestically or abroad.


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To put this (for some people surprising) conclusion into perspective, a typical medicine costs alittle less than 10 for a months supply in this country. Employing a health professional in theNHS often costs 10 for 10 minutes working time. Such figures highlight the relative importanceof using labour prudently in the pursuit of better public health, and wherever possiblerecognising the abilities of NHS service users to take more independent control over the use oftheir medicines, as well as adopting healthy life styles in order to protect their health.

For example, although 28 day prescription durations are normally considered good practice, itcan be argued that in instances where medicines are stable when stored in home conditions

and health service users want longer intervals between needing to collect their treatments thereis good reason for respecting such individual preferences. The tangible dispensing relatedsavings generated by such flexibility are likely to be limited. But any resources released mightbe channelled into providing better, more individualised, medicines taking support and care forpeople at the highest risk of isolation and neglect in the community.

Medicines falsification and world health

Some estimates suggest that 100,000 deaths a year are caused by illegally supplied counterfeit

or otherwise falsified/sub-standard medicines. It is in addition sometimes (incorrectly) said thatthe WHO has stated that 10 per cent of all the worlds medicines are counterfeit. It is alsofrequently claimed that over a half of all medicines supplied via unregulated internet sites arecounterfeit. Studies by experts such as Dr Paul Newton of Oxford University have drawnparticular attention to the hazards caused by counterfeit malaria medicines, up to a half of whichhave in some localities been reported to be in some way falsified and lacking the correctamounts of (or any) active ingredient6. In some cases this has caused people given suchtreatments to die, and it may in addition increase the risk of drug resistance developing.

There is good reason to be concerned about the harm that medicines counterfeiting and alliedcrimes cause, and to take robust preventive measures wherever possible. However, a new

report entitled Falsified Medicines and the Global Publics Health7

from the UCL School ofPharmacy and the independent research agency Matrix Insight (which has undertaken studieson behalf of bodies such as NICE and the European Commission) urges caution with regard toaspects of the public debate on medicines falsification.

For instance, any claim that 10 per cent by value of the worlds medicines are counterfeits (asdefined in terms of being deliberate made fakes, produced in unregulated environments) islikely to be a marked exaggeration. The UCL School of Pharmacy/Matrix Insight reportemphasises the uncertainties involved, but suggests the true figure is likely to be closer to 1 percent. It also stresses that many more people across the world die or are disabled because theylack affordable access to modern health care, as opposed to being harmed by falsified or sub-

standard medicines.

6See http://www.ox.ac.uk/media/news_stories/2012/120116.html

7Copies of this document are in the press pack containing this Policy Briefing


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The Schools analysis highlights the ongoing need for more reliable data on the scale ofmedicines falsification and sub-standard treatment provision. It also indicates that countriessuch as China, Nigeria, India, Brazil, Russia and Turkey have made significant efforts toimprove the quality of medicines supply over the past decade. The preliminary findings of largescale empirical surveys by leading researchers like Dr Harpakash Kaur of the London School ofHygiene and Tropical Medicine in addition suggest that the quality of anti-malaria medicinesavailable across a number of sub-Saharan countries is better than in the past.

There are unquestionably continuing problems with counterfeiting (and pharmaceutical quality

more broadly), especially in the poorer parts of the world. Even in countries such as the UKthere are significant risks associated with unregulated internet medicines supply. But the workby the UCL School of Pharmacy and Matrix Insight team emphasise the importance of buildingand maintaining trust in low cost generic medicines supplied by reputable manufacturers.

Following the effective closure of the WHO linked IMPACT (International Medical Products Anti-Counterfeiting Taskforce), a meeting involving delegates from 76 Member WHO Member Statesheld in Buenos Aires was held at the end of 2012 to discuss the establishment of a newmechanism for addressing the problems caused by substandard and falsified medicines. In thiscontext the UCL School of Pharmacy and Matrix Insight report offers a blueprint for a multi-tier,

globally coordinated, approach to protecting the world public. It calls on governments across theworld to collaborate constructively, and to involve informed stakeholders such as patient groupsand other voluntary sector organisations as well as pharmaceutical companies whenever theyhave knowledge and expertise to contribute.

For further information and contacts relating to the topics covered in this UCL School of

Pharmacy Pharmaceutical and Health Policy Briefing please contact Professor David Taylor on07970 139892 or at [email protected]

Documents

Reducing NHS medicines wastage and the global challenge of preventing drug counterfeiting