A simple screening question to tackle medicines waste, improve adherence, and cut carbon emissions across care settings.
The issue
NHS England estimates that medicines and prescribing account for 17% of NHS carbon emissions. Research from 2016 estimated that unused medicines cost the NHS £300 million a year, with £100 million worth of medicines returned to pharmacies and 90 million unused prescriptions stored in people’s homes. This doesn’t measure the individual or economic impact of untreated long-term conditions, or the risks of taking medicine incorrectly.
The biggest waste of medicines is those that are never taken. Furthermore, appropriate prescribing decisions cannot be made without knowledge of the actual medications that a patient is taking. The widely accepted ‘structured medication review’ does not currently include the physical act of looking at someone’s medication in their home.
The solution
We devised a simple screening question, to be asked on routine visits by community staff, to identify problems with adherence to medication. This was paraphrased as ‘Show me your meds, please?’ (SMYM).
The approach can be undertaken by anyone but may include GPs, pharmacists, occupational therapists, physiotherapists, paramedics, nurses etc. Asking the screening question will help pick up patients who may not be taking their medications as prescribed (eg stockpiled meds, unused or out of date medication, or patient uncertainty over how they are taken). This then needs appropriate onward referral or follow-up. Additionally, arrangements need to be made to return excess medications to the pharmacy for disposal.
A series of pilots demonstrated positive outcomes in detecting non-adherence and targeting patient-centred interventions, leading to simplification of medication regimes, referral to social support, and large cost and environmental savings. The approach has been successfully piloted in multiple clinical settings such as community services, residential care and acute sites. The current phase of the project allowed us to scale the project across an integrated care system, and we are now working towards national spread and adoption.
The impact
This project helps to reduce medicines waste and save resources for the NHS. Medicines optimisation – the safe and effective use of medicines to enable the best possible outcomes (NICE guideline 5) – is the source of our CO2 calculations.
During a 3-month pilot at a Primary Care Network in south Somerset, we identified 40 patients who were not adhering to their prescribed medication regime; this accounted for one in every four people we assessed (25%).
Overall, we identified 1,049 individual months of unused prescription items and the total amount of wasted medication was valued at £10,866. It is estimated that every pound spent on pharmaceuticals generates greenhouse gas emissions of 0.1558 kg CO2; therefore, these wasted medicines represent 1,693 kg of avoidable CO2 emissions. During the pilot, 39 medicines were stopped, providing a predicted cost saving over the next 12 months of £3,529, and 549 kg CO2 emissions prevented.
In more than 50% of cases, medication regimes were simplified – eg reducing a patient’s medication from three times a day to twice a day, or if the person needed care to prompt the medication, structuring their regime around care visits.
From this we can extrapolate Somerset ICS savings based on the population size of 571,600:
- Individual months medication: 68,396
- Carbon savings 12 months: 110,596 kg CO2
- Cost savings Somerset 12 months: £720,260
Next steps
Having implemented SMYM across the system in Somerset, we have started to expand to other areas and agencies across the UK. We are focusing on UK adoption to fully realise the savings to the NHS in reduced prescribing costs, environmental benefits and improved patient outcomes. To do so, we are taking SMYM to conferences and events to increase awareness of the approach.
We have developed and evaluated the toolkit (and continue to do so) to ensure it is meeting the needs of adoption sites. We also plan to engage with academic partners to calculate more granular detail in terms of carbon and cost savings. Current values are based on average savings across all medications. It will be interesting to reflect specific savings for medications to reflect the large variance between medication types.
Contributors: Victoria Welsh and Deb Gompertz
Institution: Somerset NHS Foundation Trust