The great patient medication returns debacle

Johnathan Laird Serial Nudger

The amount of money drained from the NHS via the oversupply of medication must be staggering and largely unmeasured.

I’m talking about the at times mountainous piles of returned medicines that get handed into community pharmacy for disposal.

The great patient medication returns debacle.

If you’ve ever worked in community pharmacy you’ll know the routine. The bin bags approaching up the middle aisle usually unfortunately from a bereaved close relative. In my experience, these great excesses of prescription drugs handed back to the community pharmacy usually come to light after the passing of a patient. The sadness of the moment is balanced by the mortification of the family members returning said medicines.

The empathetic shake of hands happens as you try your best not to raise an eyebrow at the three bin bags of returned medication about to be handed over.

Insulin, inhalers and dressings are expensive patients returns but the winner is usually the unused diabetic test strips and lots of them.

This problem needs to be tackled. It’s a classic lose-lose situation all around.

At the beginning of my career, I really did get irate when this happened. And on occasion, I will admit this probably clouded my mood so that I did not provide the highest level of patient-centred care. These situations would often involve offering condolences which in my more formative years was difficult through a mist of outrage. I’m not really proud of these occasions because family members deserve the care of their community pharmacist at that moment shortly after a bereavement.

I’ve often wondered what the public would think if the amount of money that the NHS wastes in this way. What is the average prescription item value these days? Something like £10-£12 per item? I honestly think the general public don’t have any idea about the scale of this problem. Perhaps putting the problem into context might help.

And on the flip side the problem really is conveniently difficult to measure because the system assumes that every patient will be adherent to their medication all of the time.

Well as pharmacists we know that even the most engaged patients will struggle to achieve 100% adherence.

The causes will be multifactorial but no doubt free access to medicines drives a certain amount of volume. Market forces are at play too. There is also the trend towards ‘managed repeat’ services but that’s whole other opinion article altogether. I think any conversation about waste must bring the desire for pharmacy contractors to sign up loyal repeat prescription patients. A patient on a managed repeat prescription service will I’m told generate higher annual dispensing sales compared to those patients not using such a service. I guess it’s easy for me to pontificate given that I don’t currently own a community pharmacy that still depends on prescription volume for profit.

One of the reasons I decided to write this article was the link from this topic I made with the charge that was initiated for plastic bags supplied from retailers in recent years.

I remember working in a community pharmacy in Scotland when the plastic bag charge was initiated. I found it absolutely hilarious the lengths some folk would go to to avoid the 5p investment in a bag to ensure their walk to the car was comfortable. Instead that first year there was some heroic resistance to splashing out on the bag charge. Things have moved on from then because any form of the plastic bag would surely be frowned upon now due to environmental considerations.

Now that’s all very interesting to you I’m sure but the bottom line about the plastic bag charge idea was that it actually worked. The number of bags used by the pharmacy absolutely plummeted. I’m guestimating here but I’d say in the six months after the charge came in the usage of plastic carriers bags in the pharmacy dropped by as much as 80%.

The difference before and after implementation of the charge was stark.

I think that was probably an example of nudge theory. I highly recommend the book, surprisingly called ‘Nudge’, where these ideas have been articulated.

The first chapter of that book involves a little story about a school headmaster. Basically this headmaster was tasked with improving the levels of healthy eating amongst the youngsters at lunchtime. The headmaster was given no extra budget and his brief required student choice to be respected. His solution was to rearrange the cafeteria. He put the fresh fruit, veg and healthy options at the front and the chips, burgers and other less healthy options behind the screen at the far end of the room.

Much like in the plastic bag example the plan worked and he began to ‘nudge’ the children towards making healthier options.

So what is the ‘nudge’ solution that could be applied to our patient medication return problem?

Well unlike our headmaster striving for healthier eating choices we can’t really make it more difficult for patients to access or re-order their medicines in the first place but perhaps we could disincentivise it. At the very least I’d like to support patient education to such an extent that the decision to order is at least considered. There has always been the argument that some kind of charge on prescriptions would be draconian and to be honest I agree.

But the lever in the plastic bag success story was a monetary one albeit a very low-level charge. Perhaps the solution could be something simple like making the price of the medicine really clear to our patients or enforcing a nominal 5-10 pence charge per item.

I’m not sure what the answer is but what I am fairly sure of is that things can’t get much worse. Wouldn’t it be great if we could stumble upon a low cost ‘nudge’ type solution that tackles this issue once and for all?

This amount of waste has to stop so come on clever people answers on a postcard, please.

Johnathan Laird is a pharmacist who likes to think he is a serial nudger but probably often doesn’t realise he himself is being nudged.