A Scottish Parliament Committee inquiry into the supply and demand for medicines found an ‘incoherent system’ which fails to ‘put patients first’.
The inquiry, which makes 129 recommendations, highlights the dismal failure of NHS Scotland to modernise systems, collect and share data, or provide any meaningful analysis of the impact of medicines on individual patients.
The Health and Sport Committee’s report describes a system ‘burdened by market forces, public sector administrative bureaucracy and under-resourcing, inconsistent leadership and a lack of comprehensive, strategic thinking and imagination, allied to an almost complete absence of useable data.’
The ‘role of community pharmacy pharmacists in dispensing medicines was clear and well defined’, however, there were some areas that the authors felt required attention:
“We heard a wealth of evidence on the other benefits community pharmacists could bring in ensuring the cost and clinical effectiveness of medicines in Scotland. However, the lack of structure surrounding their relationships with both patients and the rest of the health services means they are failing to exploit their skills, knowledge and position for the benefit of patients.
The report expresses alarm that discussions by community pharmacists with patients on the effectiveness of medicines, and whether they were being taken, were at best recorded on Post It Notes and at worst disappearing without record.
“Discussions on whether and how medicines were taken, and the effects of these, are at best being recorded on Post It Notes and at worst disappearing without record. Patients expect and deserve a better system than this.”
“The Committee also wants to see community pharmacists play a far greater role in patient care, saying a lack of formal structure means their skills and knowledge often go to waste.”
The fundamentals of medicine supply in Scotland were highlighted and the report highlighted that the current system does not involve the patient enough:
“In undertaking this inquiry into the supply and demand for medicines, we were anticipating exploring issues relating to the efficiency of the system and the levels of waste generated. However, in considering the themes raised with us a fundamental problem has become apparent – the system of supply and demand for medicines in Scotland does not have a focus on patients.”
A number of factors relating to the systems and stakeholders involved were highlighted in the report however there was a firm message around the lack of reliable data associated with the delivery of medicines to patients in Scotland:
“The system is burdened by market forces, public sector administrative bureaucracy and reported under-resourcing, inconsistent leadership and a lack of comprehensive, strategic thinking and imagination, allied to an almost complete absence of useable data.”
“The lack of data collection and analysis on outcomes achieved via the prescriptions of medicines is of huge concern. The impact on individual patients of taking medicines is not being examined and worse, it is not routinely sought. Patients in primary care are not receiving follow up care to ensure the medicines prescribed were effective or even to ensure they were used.
“We found the lack of care taken to understand people’s experience of taking medicines impacted the system at every stage. We are clear that gathering, analysing and sharing this information in a comprehensive, systematic way across Scotland would be the single most beneficial action to result from this inquiry. This needs to be prioritised as a matter of urgency, which will require strong leadership.”
In addition to a lack of data around the patient journey, the report found that the information technology solutions to deliver care in Scotland were poor and needed to be improved. Of particular note was how the information technology systems handled patient data as patients move through the health system:
“We are extremely disappointed that once again all roads lead to the dismal failure of the NHS in Scotland to implement comprehensive IT systems which maximise the use of patient data to provide a better service. Comments on patients’ surprise at how badly information is handled, particularly at junctions of care, were casually made, once again exposing attitudes not focused on patient care. Worse still, where a lack of patient focus was acknowledged, this was not followed by a solution or plan to take action, but simply left hanging for us to add to the list of issues with medication management.
“We again urge the Scottish Government to consider the IT and data requirements of the NHS across the country in a strategic way and design systems with long term utility as a matter of urgency. We recognise this is a large undertaking but similarly, we cannot keep concluding in reports as we have for the last 4 years that savings, efficiencies and above all better patient care are possible with modern IT, capable of data gathering, analysing and sharing, without demanding urgent action in this area.”
Senior leadership in Scotland came in for criticism. A lack of direction and, in particular, a lack of desire by leaders to take responsibility for instigating and delivering change in the system was cited:
“Little detail was offered as to how change might actually be brought about, let alone at a pace proportionate to the prize to be gained. Nobody seemed willing or able to take on responsibility for driving forward the change many identified as essential. These issues are not new and we heard little by way of solutions and strategies from senior leaders within the health service about what would actually be done to address them at the pace and scale required.
“We propose energetic, imaginative, accountable, focused leadership is required in order to achieve the changes required. We strongly recommend the Scottish Government examine the lack of accountability for improvement allied to the reasons why leaders at all levels are not proposing innovative, coherent and comprehensive solutions which many told us would deliver efficiencies and savings.”
The level of participation of Integrated Joint Boards (IJBs) was criticised:
“Given their responsibility for developing a plan to implement the National health and wellbeing outcomes framework, we were surprised to hear little of the role of Integrated Joint Boards (IJBs) in more cost and clinically effective use of medicines. For bodies with such a fundamental role to be notable by their absence in this inquiry again suggests a lack of strategic oversight in this area.”
The report criticised the role of prescribers and also their practise in relation to medicines. It was indicated that there was a tendency to rely on the ability to prescribe and that activities like medicines reviews were being poorly administered. In particular, practise around polypharmacy and the management of long-term prescriptions came in for significant criticism:
“The relationship between prescriber and patient was stark throughout the inquiry. The power of the prescriber to determine the clinical and cost-effectiveness of a patient’s treatment was described as almost absolute, and it is clear prescribers are instinctively reaching for the prescription pad, and are not taking the time to discuss medicines with patients to a degree that ensures the clinical and cost-effectiveness of the prescription.
“Nor are comprehensive reviews of polypharmacy or long-term prescriptions taking place and there is nothing in place to monitor, evaluate or mandate this, resulting in at best waste and at worst harm to the patient. It also appears to us there is not strict adherence to the principles of realistic medicine, patients are not equal partners in discussions on their treatment. One of the areas this is most exposed is social prescribing and prescriptions for non-medicine alternatives.”
“We believe the Scottish Government’s contract with GPs is failing to mandate these behaviours and actions and must be revised. In the long term, without systematic changes, the Scottish Government should consider whether the system of GPs being external contractors works well for patients. An approach which pays GPs from the public purse with no monitoring or evaluation of their actions is not acceptable.”
“An urgent overhaul of the system is needed to allow for the robust collection and analysis of data, which would ensure the best possible patient outcomes and cost savings for the NHS.”
Lewis Macdonald MSP, Health and Sport Committee Convener, said:
“The failure to adapt, improve and modernise the current system goes beyond the supply and demand for medicines.
“We found the lack of care taken to understand people’s experience of taking medicines impacted the system at every stage. The almost complete absence of data collection, or data sharing across the health service before the current COVID-19 crisis, or analysis of a medicine’s impact on patients, is staggering. Quite simply, patients deserve a better system than this.
“Our evidence has made clear once again the profound failings of current health IT systems. These need to be completely overhauled so that data can be gathered, analysed and shared in a systematic way across the NHS. The scale of this task is undoubtedly great, but it is essential to quickly deliver a fit for purpose system which would improve patient outcomes, increase efficiency and reduce costs.”
“Again and again throughout this inquiry we have seen that the default position of medical professionals is to reach for their prescription pad rather than consider lifestyle-focussed alternatives to medicines, and this cannot continue. Our report last year detailed the value of social prescribing but it’s clear that despite its many benefits, it is still considered a second-class option if it is considered at all. This must change as a matter of urgency.”
Matt Barclay Director of Operations at Community Pharmacy Scotland commented:
“Community Pharmacy Scotland welcomes the publication of the recent inquiry of the Health and Sport Committee in Scotland into Medicines.
“While we will look at more detail at the recommendations, we are happy that the contribution of the community pharmacy network was recognized throughout the inquiry in the four main areas and the recommendations reflect the need to include community pharmacy.
“As a network, we will reflect on the recommendations and work in partnership with stakeholders including the Scottish Government to take forward what is required to support patient care and the wider NHS.”
Chair of the Scottish Pharmacy Board Jonathan Burton MBE commented:
“This is a long report, with much to consider. RPS has been calling for all pharmacists to have full read and write access to patient health records and for better IT systems that allow interoperability across primary and secondary care for many years.
“We will be studying the report commentary on these issues and others and will then discuss the next steps with the Scottish Pharmacy Board.”
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