Medicines wastage

Medicines waste affects both patient care and NHS resources. This page explores the scale of the issue and the role of better medicines use in reducing unnecessary waste and improving outcomes.

Published: 14 October 2021

This was published when the organisation was the Royal Pharmaceutical Society.

Policy topic

The total medicines bill for the NHS was £13.3bn in 2013/2014. The majority of this is in the community; over 1bn items were dispensed in the community last year, but up to 50% of medicines are not taken as intended.

This presents a problem not just for the patient’s care, but also is a huge area of wastage in the NHS. As part of the medicines optimisation agenda, the Royal College of Pharmacy (RCPharm) looks to tackle medicines wastage through reducing unnecessary prescribing, encouraging proper medicine adherence, and proper disposal of unused medicines.

An estimated £300m of medicines go unused, of which approximately half is recoverable.
There is an estimated £500m opportunity cost from people not taking their medicines as intended.

There are many case studies of pharmacists taking the lead in this field, improving patient care and reducing costs:

In Leicester city, pharmacists found 56% of Asthma sufferers had poor technique, and were trained to provide advice on the proper use of inhalers.
In Medway pharmacist intervention led to a reduction or withdrawal of highly potent (and dangerous) antipsychotic medicines from 61% of care home residents.
In Northumbria, for every £1 invested in pharmacist interventions saved £2.38 from the medicines bill at a care home (£184 per person reviewed).

In July 2015, the Government revealed plans to put the price of medicines worth over £20 on the packets to encourage medicine adherence. RCPharm welcomes moves to increase adherence, but is concerned by any risk that people will stop taking or collecting their medicines because of this move. RCPharm maintains pharmacist consultations with patients and improved understanding of medicines is vital to tackling the problem of medicines wastage.

Click on the links provided to download a PDF copy of the full vision or the executive summary. Executive summary Introduction The vision: professional roles in pharmacy Achieving the vision: underpinning infrastructure Acknowledgments and strategic links Introduction Every health and care profession, every health service provider and every government has been influenced by the COVID-19 pandemic. It has caused everyone to reflect on whether the strategic directions set five or 10 years ago are still right for a post-pandemic future. Pharmacy is no different: it feels like the right time to set out a new professional vision, building on what has been developed previously to create something that describes the new future. Describing a vision for the future is challenging: some pharmacy teams are already pushing boundaries and delivering care that for others seems a distant dream. What this vision recognises is that everyone is on a journey, and it aims to support all of pharmacy to move forward to a new level of professional practice. It is an evolution from where we are now, not a revolution. The future of pharmacy By 2030, the traditional boundaries between pharmacy sectors will be broken down. Pharmacy teams will work together, both within pharmacy and with the wider multidisciplinary team, to deliver seamless care for patients. Pharmacy teams will take a person-centred approach and care will be provided holistically rather than by clinical condition. They will ensure high quality, safe, effective, cost-effective and sustainable prescribing in all settings. In addition, they will drive high standards of medicines governance, and ensure every aspect of prescribing and dispensing processes are effective and efficient. For pharmacists, this will mean being recognised as medicines experts who take leadership of prescribing in all care settings and who optimise therapeutic outcomes for individual patients. There will be a shift away from checking other professionals’ work towards pharmacists having a clinical, prescribing role to manage the care of individual patients. Pharmacy technicians will lead medicines management processes, both in technical roles focused on the safe and efficient supply of medicines, and in patient-facing roles to support patients’ use of medicines. The breaking down of boundaries between pharmacy sectors will be demonstrated through two key shifts. The first is that seamless patient care will be standard. As a patient moves between care settings, such as at hospital discharge, pharmacy teams will work together to ensure patients’ medicines-related care is supported and to avoid duplication of tasks in the patient’s journey. The second shift is that pharmacy will be more dynamic. Many pharmacy professionals are now actively seeking a portfolio career, working across different sectors. By 2030, a core generalist role for both pharmacists and pharmacy technicians will be developed to enable this flexible portfolio working. This change will be driven by digital and technology developments to enable whole-team working, and clear pathways of professional development which apply to all sectors of pharmacy. “Pharmacy will work together with patients and the multidisciplinary team, using their expertise to make the best use of medicines” The vision: professional roles in pharmacy Being the experts in medicines — "Ensuring the quality and safety of medicines use" The key role of pharmacy professionals, that distinguishes them from other health care professions, is expertise in medicines. This will remain at the centre of pharmacy in 2030, with pharmacy teams ensuring the quality and safety of medicines use through both patient-facing and technical expertise. In 2030, pharmacists will be the clinical lead for safe and effective prescribing within all care settings. Most pharmacists will work in patient-facing roles, consulting with patients: assessing, prescribing, monitoring and reviewing medicines for individual patients. They will be autonomous professionals working within multidisciplinary teams, prescribing in their own right, and managing caseloads of patients who take high risk medicines or who have complex therapeutic needs. These pharmacists will be known as “advanced generalist pharmacists” and will be able to move flexibly between care settings. Some pharmacists will choose to specialise in particular clinical or technical fields, and will become “advanced specialist pharmacists”. Some will develop further into consultant pharmacists who have an influence beyond the individual service to leading whole system improvements. In 2030, pharmacy technicians will lead and be experts in safe and secure purchasing, storage, dispensing and supply of medicines. This will include managing services and providing assurance on safe and effective processes. Pharmacy technicians working in patient-facing advanced level roles will consult with patients, undertake technical aspects of medicines reconciliation and medication review, triage patients, monitor and review blood results, provide patient education, administer medicines (if enabled by legislation/governance arrangements) and liaise with cross sector pharmacy teams. Optimising therapeutic outcomes — Prescribing, monitoring, reviewing, adjusting and stopping medicines n 2030, pharmacy teams will ensure every patient receives high quality prescribing of new medicines and timely, systematic medication reviews. All patients will receive the right care at the right time and the right place. Therapeutic outcomes will be optimised through prescribing, monitoring, reviewing, adjusting and stopping medicines. Pharmacy input will be targeted at: key stages in a patient’s journey such as at transitions between care settings, when patients are acutely unwell, patients who receive high risk medicines and complex therapies, and frail patients. This will improve medicines safety, help manage risk and reduce unnecessary polypharmacy. Optimising outcomes will include delivering greener, more environmentally sustainable services. Pharmacy teams will consider the environmental impact of medicines when prescribing and reviewing medicines, and take action to reduce medicines waste. Providing person-centred holistic care — Empowering patients to make shared decisions about their medicines The core role of pharmacy teams in 2030 will be to provide care for patients holistically, focused on the person rather than their clinical condition or medicines. They will enable person-centred care by having positive conversations with patients and their families/carers, and empowering patients to make shared decisions about their medicines and health. Prescribing decisions will be taken using a Realistic Medicine approach by asking patients “what matters to you”. Pharmacy teams will have regular conversations with patients about medicines. These conversations will be enhanced by pharmacy teams being trained in effective, inclusive communication to address inequalities caused by low health literacy. Pharmacy teams will have essential roles in preventing ill health by taking a holistic approach to care that goes beyond medicines. This will include the provision of health improvement services such as harm minimisation to reduce drug deaths, mental health support, brief interventions to reduce alcohol use, vaccination services and lifestyle advice including using a social/green prescription approach. Improving access to care — Achieving equity of access to pharmacy services Before 2030, all pharmacy teams will proactively offer services in a way that delivers equity of access. They will identify vulnerable patients who need specific support and adapt services for them. A service of particular importance in improving access to care is the NHS Scotland Pharmacy First service: the public’s first port of call for common clinical conditions. By 2030, the vast majority of community pharmacists will be independent prescribers, enabling the Pharmacy First service to be further developed, and it will also be extended into populations who cannot currently access it. By 2030, pharmacy services will be planned alongside wider NHS clinical service provision to ensure equitable access to pharmacy services is achieved across the 7-day period. This does not mean that a full pharmacy service is needed in all settings 24/7 but that patients requiring immediate care, particularly in hospital and out of hours services, are not disadvantaged by the day of the week or time they access services. More generally, access will be improved by enabling services in the way patients want. Pharmacy teams will routinely offer patients a choice of remote consulting, asynchronous consultations and other digital services, as well as in-person care. Similarly, medicines supply will be offered by in-pharmacy collection, delivery services and remote collection, but in all cases, patients will have an opportunity to consult with a member of the pharmacy team, including a pharmacist, every time a medicine is supplied. Leading medicines' governance — Ensuring high-quality prescribing, supply and use of medicines through robust governance Pharmacy teams already play essential roles in medicines governance, focusing on ensuring the safe and effective use of medicines. The crucial difference between the future and today is that in 2030, this will be recognised by others as a leadership role. Currently pharmacy teams both define and implement medicines governance processes: in future, the wider health care team will be involved in implementing the processes. Pharmacy teams will ensure standardised robust work processes, and good governance around the supply of medicines and high-quality evidence-based prescribing. They will consistently implement lean processes to achieve accurate prescribing, dispensing and use of medicines. The supply of medicines will be modernised by 2030. Pharmacy technicians will be the professional leads for the assembly, distribution, and safe and effective supply of medicines. Pharmacists will continue to have an essential role in the medicines supply process through the clinical check. Every prescription for a medicine that is new or has been changed will be clinically checked by a pharmacist, and this will include a conversation with the patient. Accuracy checking will be automated through scanning technology to reduce workload and increase safety. Leading evidence-based practice — Involved in research and strategic leadership to shape service development The creation of a recognised evidence base to underpin the use of medicines and pharmacy practice will continue to be essential in 2030. By then, most pharmacists and pharmacy technicians will have developed research capability and will be involved in research, service development and quality improvement. Pharmacists working in academia and industry will play a leading role both in conducting research and in supporting the development of research skills in others. This evidence will be essential in enabling pharmacists to develop prescribing guidance. By 2030, such guidance will include consideration of the environmental impact of different medicines. Altogether this work will reduce harm, waste and variation. Pharmacists will also have an important role to play in strategic leadership to shape services and models of care in NHS boards and other organisations, wherever medicines are used. Achieving the vision: underpinning infrastructure Using data to deliver high-quality services — Data will underpin personalised care for patients and improved service planning By 2030, data will be used to enhance pharmacy services in a number of ways. Clinical data will be used to target and support decisions. Data will enable provision of personalised care and medicines for patients, including in pharmacogenomics. Decision support software, including artificial intelligence tools, will provide data that will be used to improve the quality and safety of care and prescribing. Data will also be used to make population-based decisions to plan services and prioritise pharmacy resources in response to local needs. In 2030, a national dataset will be available, which will demonstrate the effectiveness and quality of pharmacy services in all settings, enabling the impact of pharmacy services on improving population health to be determined. Clinical outcome measures will be developed, linking patient outcomes with prescribing and administration data. In addition, systems will be developed for obtaining feedback from patients and colleagues about pharmacy teams’ performance to drive continuous service improvement. Harness digital technology and innovation — A single shared electronic patient record will transform health and care services The biggest digital transformation of pharmacy and health care by 2030 will be the introduction of a single shared electronic patient record across all health and care services. This will be a universal patient record into which every professional both reads and writes information, using their existing clinical system as the entry point. Each professional group will have a different view, according to what is appropriate for their role. This record will release clinicians’ capacity, improve safety and enable the provision of better care for patients. Another significant digital development will be full electronic prescribing and transfer of prescriptions across all care settings, removing the need for paper prescriptions. Electronic systems will underpin the recording of administration of medicines in all relevant care settings, including hospitals, care homes, care at home services and prisons. Hospital Electronic Prescribing and Medicines Administration systems (HEPMA) will support triaging of patients to allow clinical pharmacists to target those high-risk patients who need pharmaceutical input as a priority. Technology will also be harnessed to develop patient-facing services including digital consultations and remote monitoring. Developing the workforce — Continual professional development will be embedded across the whole pharmacy workforce By 2030, career development pathways will be in place for all members of the pharmacy team to support professional development, enabling people to flourish and feel fulfilled in their roles. For pharmacists, professional development will be aligned to the RPS curricula for foundation, advanced and consultant practice. Some pharmacists will also choose to complete higher degrees. For pharmacy technicians, professional development will be shaped by a suite of frameworks similar to those for pharmacists. All patient-facing pharmacists will have advanced clinical assessment and consultation skills, and be independent prescribers. Across both pharmacy professions, there will be a cultural shift to a system that is committed to continual professional development. All pharmacy professionals will have a role in supporting the education and development of others. Protected learning time and peer support networks will enable professional development and underpin reflective practice. Leading and participating in research and quality improvement will be a normal professional activity. By 2030, the pharmacy workplace culture will be inclusive, celebrate diversity, create a sense of belonging and be supportive of team members’ wellbeing. Pharmacy professionals will have rest breaks during the working day, flexible working options including portfolio careers, access to wellbeing services and a proper work-life balance. Workforce planning will be carried out across Scotland to ensure that the right skill mix and staffing levels are present in every pharmacy team. This will optimise the roles of pharmacy team members, maximise the time for clinical care, motivate staff and deliver optimal care for patients. Delivering seamless care — All pharmacy professionals will work together across transitions of care By 2030, all pharmacy professionals from all sectors will work together to deliver seamless transitions of care for patients as they move around the health service. Pharmacists will stop being described by their location but by their skills. Care will be planned around patients, for example transforming the supply of medicines on discharge from hospital so they are supplied by the patient’s community pharmacy instead of waiting in hospital. Seamless care extends beyond pharmacy to the wider multidisciplinary health and social care team. Pharmacy will be embedded in multidisciplinary teams and will have well-established referral pathways in and out of pharmacy services. Pharmacy will also play a central role in the new National Care Service to ensure the safe and appropriate use of medicines in care services. Acknowledgments and strategic links Achieving the vision: Key enablers Create a single shared patient record into which every professional both reads and writes information, using their existing clinical system as the entry point Make electronic prescribing, transfer of prescriptions & medicines administration systems available in all settings Improve skill mix within pharmacy teams, combined with effective workforce planning to ensure safe, effective and appropriate pharmacy staffing Support all patient-facing pharmacists to train as independent prescribers NHS Scotland to align the pharmacist post-registration development pathway to the RPS curricula for post-foundation, advanced and consultant practice; and equivalent professional development and credentialing pathways developed for pharmacy technicians Introduce protected learning time for all pharmacy teams to enable professional development and research activities Provide equipment to enable patient-facing digital services and training to maximise its use Establish a national data set to demonstrate the effectiveness and quality of pharmacy services Embed the use of data, such as pharmacogenomics, to help guide treatment decisions and deliver personalised medicine Further embed pharmacy into the wider health and social care multidisciplinary team and develop clear referral pathways in and out of pharmacy services. Acknowledgements We are hugely grateful to all the pharmacists and pharmacy technicians across Scotland who contributed to this vision by participating in focus groups, and sharing their views through surveys, emails, phone calls and meetings. We are also grateful to the pharmacy and non-pharmacy stakeholders who met with us through the consultation period and commented on numerous drafts. This vision was shaped by every single person who was involved: it could not have been created without them, and this final version belongs to them all. Strategic links To make this vision relevant to the strategic direction of travel in Scotland, documents produced by Scottish Government, NHS Scotland and other stakeholders were referenced. The section below highlights some key quotes from some of these documents: Achieving excellence in pharmaceutical care “The evolving focus of pharmacy practice to ensure that people have an understanding of what to expect from their medication requires an acknowledgement that people and their carers rightly wish to be active partners in treatment options." “Pharmacy resource can be targeted through a triage model, focusing on high risk and complex cases.” “Hospital discharge can be a difficult time to support people with adherence to new medication regimens. There is a role for pharmacists and pharmacy technicians in supporting this transition by taking on a greater part in managing care prior to and during discharge.” Scottish Government. 'Achieving excellence in pharmaceutical care: a strategy for Scotland'. August 2017. Scotland’s national clinical strategy “The contribution of pharmacists can be considerably enhanced, with their expertise in ensuring that people with complex medication regimes have their care optimised, and the potential for side effects or harmful interactions reduced." Health care teams should “provide care that is person centred rather than condition focused.” NHS services must “collect and use more information on outcomes, especially those that matter most to patients, rather than clinical data such as biochemical or other surrogate markers”. “While medicines can bring great benefit, they can also cause significant harm. Older people tend to experience worse side effects or consequences of treatment. That is why we should strive to actively manage risk associated with polypharmacy by regularly reviewing and rationalising our patient’s medications.” “Serious harm can result if we don’t listen to the people we care for, and if they are not given the information and support they need to make informed decisions about their care.” “NHS Scotland is a significant contributor to the climate emergency. It emits a large amount of greenhouse gasses, consumes huge amounts of resources and produces copious amounts of waste. We have a moral obligation to help tackle the greatest threat to human health by reducing our impact on the environment. Responsibility rests with us all.” Scottish Government. 'Recover, restore, renew — Chief Medical Officer for Scotland Annual Report 2020-2021'. March 2021 The ALLIANCE’s report on health and wellbeing priorities for the future Care should be “flexible, person-centred which recognises the holistic nature of individuals” and that “being involved in the decision-making process and treated as an expert in their own life circumstances and care” is of the utmost importance to people. “For many people the innovative and accelerated implementation of virtual services improved access, made it quicker and supported more choices for the individual. People have welcomed the use of this technology, and its wider implementation and use should continue.” ALLIANCE. 'Health, wellbeing and the COVID-19 pandemic: Scottish experiences and priorities for the future'. February 2021. The NHS Scotland recovery plan 2021-26 “We will design services so that we minimise unnecessary travel and increase the focus on ‘net-zero’ approaches.” “We will continue to support the move to more health care being provided in the community and closer to home.” We will design a new sustainable system, focused on reducing inequality and improving health and wellbeing outcomes, and sustainable communities." “We will develop and introduce a new pharmacy woman’s health and wellbeing service through our public health services.” “We will also establish a community pharmacy hospital discharge and medicines reconciliation service to help speed up the process for people being discharged from hospital.” “We are investing in developing new digital solutions such as ePrescribing and eDispensing to make the prescribing process paperless.” Scottish Government. 'NHS recovery plan 2021-26'. August 2021 Scottish polypharmacy guidance “With up to 11% of unplanned hospital admissions being attributable to harm from medicines and over 70% of these being due to elderly patients on multiple medicines, there are significant opportunities to reduce this burden by timely and effective interventions.” Scottish Government. 'Polypharmacy guidance — realistic prescribing', Third edition, 2018.