What a waste! by Dot Kirkpatrick

It cannot have escaped your attention that the media has been writing about food waste. The Guardian recently reported the latest figures, showing that UK households are throwing away £13bn of food each year. This equates to 7.3m tones of household food waste. Of this, 4.4m tones were deemed to be avoidable. This set me thinking about my own food waste. I can honestly state that apart from the occasional out of date yogurts caused “buy” 2 packs for £3 scenario, I either cook and freeze or make the ingredients into soup! I am not precious about sell by dates unless associated with a dairy product, fish or chicken, apart from when I am having people for dinner! I can’t be poisoning the guests? A plaque in my kitchen states… “Many people have eaten here and lived!”

Dot 2This brings me around to the purpose of this blog. Medicines waste. I feel a bit of a turncoat as I have given many a presentation clearly stating that you cannot compare the difference between Kellogg’s cornflakes and a supermarket cheaper own brand with branded drugs and their generic equivalent. However in this instance there is an analogy.

A report by the Department of Health estimates that unused medicines cost the NHS around £ 300 million every year, with an estimated £ 110 million worth of medicines returned to pharmacies, £90 million worth of unused prescriptions being stored in homes and £50 million worth of medicines disposed by Care Homes.

These figures don’t even take into account the cost to patient’s health and well being if medications are not being correctly taken. If medicines are left unused, this could lead to worsening symptoms and extra treatments that could have been avoided.

Due to the complexity of the causes of medicines wastage, a multifaceted and long-term approach across all healthcare sectors is required including partnership working with third sector organisations, public health, voluntary groups and local councils.  Coming to a surgery, pharmacy, library, council office near you soon, will be posters(designed and printed by our local council)  letting you know that each year in Dumfries & Galloway, we waste £3m worth of medicines of which over half is avoidable.  Look out also, for twitter feeds, Facebook postings and press releases. The posters and social media messages will attempt to engage with the public on how we can work together to reduce medicines waste. Simple tips such as “Only order what you need”; “Check before ordering”; “Don’t stockpile medicines” will feature in our waste campaign. With £3m required to be saved from our drugs budget this year, we cannot afford to ignore the unnecessary cost of waste.

Dot 1Waste campaigns have been featuring on the Prescribing Support Team’s remit for many years. There was Derek the Digger whose sole purpose in life was to pick up medicines waste by the ton. Then there was our Big Red Bus Campaign. We had a range of items with catchy slogans e.g. erasers stating “Wipe out Medicines Waste”. Last but not least was our ferret, carrying a bag of drugs out of which coins were leaking and going down a drain This time our Waste Campaign will be ongoing. The posters will change, the messages will vary but our mission will stay the same. Medicines cost money and we do not have an endless supply of resources. We need to use our allocated funding for medications where it will benefit patients by improving health outcomes.

And back to the analogy. I must admit that my husband randomly buys jars of chutney despite having adequate supplies in the cupboard. There are far worse faults and I can live with that.  I however know what is in my fridge/cupboards/freezer and so I don’t stockpile resulting in wasting food supplies. I think what I need, I buy what is necessary and I don’t buy items that I don’t want. Simple no waste!

It is everyone’s responsibility to promote the messages around using medicines responsibly and I hope we can rely on your support by promoting our campaign.

Dot Kirkpatrick is a Prescribing Support Pharmacist at NHS Dumfries and Galloway

Tour de Finance by Jeff Ace

This summer, unlike the many thousands of fellow Welsh folk heading south to France for one of our regular appearances in a major football tournament, I decided to head west, then east, then sort of north east. Together with our Finance Director, Katy Lewis, I recently undertook a tour of the region to try to talk directly to as many staff as possible about the challenges we were facing and to hear first hand their experiences and ideas for improvement.

In three days we travelled over 400 miles, met over 400 staff and heard from nurses, AHPs, domestics, GPs, consultants and others on issues ranging as wide as the region itself. At a number of the meetings, it was great to see social work staff in attendance, reflecting our ever closer working relationships.

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I asked Katy to open each session with a presentation on the financial situation – my thinking being that pretty much anything I then said would come as light relief. The 2016/17 numbers are grim and substantially worse than anything we’ve faced up until now. In summary, we estimate our costs will increase by around £16.5M in the year (largely driven by drug cost increases and pay / price inflation) whilst the increase in our allocation for health services is around £3.6M. The gap between these figures of about £13M (or 5%ish of our running costs) will have to be found from efficiency savings. This would be a tough ask at the best of times but, as most of you will be well aware, it comes after four years of delivering large annual efficiency savings targets.
And of course the financial problem does not sit in isolation. In each of the discussions across the region we heard of pressures caused by difficulties in attracting staff or by increased service demand driven by an ageing population. At times it felt as though we were describing a perfect storm of crises in money, recruitment and demography that threatened to overwhelm us as surely as Storm Frank had submerged parts of Dumfries.

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But just as the pub in this picture was open for business only two days later (it felt longer), things often brightened up pretty quickly in a lot of our discussions. The staff that we met were keen to highlight potential solutions, things that could change services for the better and stand up to our triple challenge.
We’re going to write up the key points raised and create a plan for delivery but some of the common themes were;

  • The right I.T. can transform the way teams work, but we need to make it connect faster and more reliably across the region.
  • We need to get far better at sharing appropriate information between health, social work and third sector colleagues.
  • We need to be quicker at admitting that some vacancies won’t be filled and to redesign and retrain teams to provide services differently.
  • Local teams need to be empowered to make locally appropriate decisions and as much resource as possible needs to be devolved to operational levels.
  • Coordinated support to teams around improvement techniques and methodologies would be helpful.
  • We need to work more closely with carers and families.
  • We need to celebrate team successes and better spread their ideas and learning.

It’s also important to remember that we’re not on our own in trying to work our way through the financial, demographic and recruitment problems. In our meetings we highlighted some of the huge amount of work ongoing at national and regional level at the moment to try to identify high quality and more sustainable models of service delivery across Scotland. Two particular strands of work have the potential to help us transform the landscape;

  • The National Clinical Strategy (written by Angus Cameron, our Medical Director) sets out a clear direction for closer working between Health Boards aimed at improving safety and effectiveness of care within their wider region.
  • The Chief Medical Officer’s work on ‘Realistic Medicine’ points to how genuinely person centred care can lead to better patent outcomes whilst reducing waste and unnecessary expenditure.

So, both locally and nationally, there are grounds for cautious optimism that we can come through these uniquely challenging times in a way that allows our teams to continue to deliver excellent health and care services for our population. It is clear though that to succeed in this, the pace of change around redesign of service models and ways of working will have to be dramatic. Whilst there’ll be a few giant leaps (it’s just over a year until we receive the keys to our new acute hospital…) most of this change will be smaller scale and driven by the local teams that we talked with on our regional tour. Our success will depend on how well we support these teams and ensure they have the skills and confidence to adapt their services in ways that allow us to deal with the financial, demographic and recruitment complexities.
Thanks to everyone who came along to speak to us on our tour.

Jeff Ace is the Chief Executive Officer for NHS Dumfries and Galloway

The Power of a Fly by Heather Currie

Acceptably, an unusual title! The reason will be become clear but essentially, the message is that something very small can make a huge difference.

Following on from Ross McGarva’s blog last week on reducing waste and CRES, let’s look at how we as clinicians can make a difference. A recent report from the Academy of Medical Royal Colleges, “Protecting resources, promoting value: a doctor’s guide to cutting waste in clinical care” was published with the aim of supporting doctors and other clinicians to ensure that the resources of the NHS are used in the most effective way possible to provide the best possible quality and quantity of care for patients—one doctor’s waste is a patient’s delay or lack of treatment. (The report can be read by clicking here) The following is a summary of the key messages of the report with my observations on relevance to ourselves in Dumfries and Galloway.

It is becoming increasingly clear that use of NHS resources in the current form is unsustainable and without major changes the safety and quality of patient care will decline. Therefore waste must be reduced. Most waste within the NHS lies within clinical practice and models of care. Estimates suggest that around 20% of mainstream clinical practice brings no benefit to the patient as there is widespread overuse of tests, interventions, prescribing, hospital beds, clinics and theatres. According to a report in 2010, the cost of prescribed medicines wasted is estimated to be around £300 million each year. Influences that affect how a doctor uses clinical resources include:

  • Individual practices
  • Defensive practices
  • Time pressures
  • Responding to senior or patient pressures
  • Inefficient pathways

Before we explore some of the specific examples as discussed in the report, let’s have a think about our own experiences of the above non-exhaustive list.

Are you completely sure that you are following best practice, is it different from your colleagues, if so why? Could one of us be wrong?!

Have you ever arranged tests or started treatment “just to make sure” when, with full clinical assessment the likelihood of the test or treatment being helpful is very small? How often does a seemingly simple “routine” test lead to even further unhelpful tests?

We are all affected by time pressures and it may be a short term fix to ask the patient to come back another day to complete assessment/treatment when a little more time could prevent another visit.

Am I simply doing repeat tests to prevent being caught out on the ward round, even though it may not be clinically indicated? A recent spot check in our own hospital revealed that of over 25 blood form requests, very few contained any clinical details—what thought had gone into making these requests?

Are we making the best use of clinics, hospital beds, and theatres? Do we bring patients back to clinics inappropriately when we could write to them, phone them, or let them contact us directly if they have a problem? Do our clinics start on time and do we book the full clinic session? Are patients coming to the hospital more than once because of an inefficient pathway? Have you examined the pathway of your patients recently? Do we cancel clinics or theatres at short notice because of lack of forward planning? Every clinic which is cancelled with less than 6 weeks’ notice leads to at least 2 hours of time for Patient Focussed Booking staff to contact patients and rearrange appointments, let alone the inconvenience and reorganisation required by patients.

Do we ever ask patients to attend their GP to have blood tests, collect prescription, get results of tests that we have carried out or requested or to be referred to another hospital specialist? All of these can be done or arranged by ourselves in secondary care saving precious time for both patients and our GP colleagues.

With waiting time guarantees extreme pressure and scrutiny of pathways is constantly applied, especially to patients referred with suspected cancer. While this is to be applauded, time and effort is often wasted by leaving out the clinicians in the process; we know our services best and are able to adapt to accommodate urgent patients as required, talk to us not about us!

At all times, with every patient encounter, we should ask ourselves “Are there points of delay and waste in any stage of the process due to duplication, lack of resources or availability of information, or inefficient use of clinical and patient time. Could we do better?”

Specific areas of waste discussed in the report include prescribing, inappropriate investigations, staff and patient movement, maximising capacity in theatre, and reducing inappropriate interventions.

Reducing prescribing costs

GPs are well aware of need for generic prescribing, and use of low cost options, but are we as aware in secondary care? With increasing provision of prescriptions from clinics for reduced inconvenience to patient and GP, we in secondary care also need to be aware of cost and generic formulations. Why not develop a list of commonly prescribed medicines in generic form to have available in clinic?

Reducing inappropriate laboratory investigations

Blood tests

CRP testing has risen dramatically in recent years with many patients now being subjected to daily measurements even if levels remain low. National benchmarking showed a 31% increase in CRP requests over 1 year in one region. Disease related protocols were agreed and requests reduced by 85%. Minimum re-testing interval for CRP of 3 days, with exceptional requesting still possible and overseen by a senior clinician, was introduced in Borders leading to reduction in testing of 30 to 40%.

Minimum re-testing interval for Vitamin D of 1 year led to reduction of 50%.

Minimum re-testing interval for HbA1C of 3 months led to levelling off of rising trend.

Local experience–Patients presenting with infertility have frequently had blood tests taken for renal, liver, and thyroid function along with hormone profile, androgen screen and prolactin despite the woman having regular menstrual cycle. With a regular, 21 to 35 day cycle in a clinically well woman, significant renal, liver, thyroid, hormone, androgen or prolactin problem is extremely unlikely. Provision of information to primary care colleagues and publication of infertility assessment guideline to easily accessible Guidelines area on HIPPO should reduce unnecessary tests.

Does your specialty have similar examples of inappropriate tests being taken before referral for which guidance could be made available?

Imaging

Some radiological investigations contribute little to clinical management, particularly lumbar spine and knee radiographs. Guidance notes provided alongside the report of every relevant radiograph reduced referrals for knee and lumbar spine radiographs by 20%. If applied nationally this could save £221 million per year (presumably in England). While we are working towards improved MSK pathways in Scotland, are all imaging requests absolutely required? In gynaecology we often find that a scan for an uncertain reason leads to further scans due to the finding of a probable insignificant feature.

Staff and Patient Movement

Separate sites for outpatient clinics increases travel time and reduce numbers of patients that can be seen. While recommendations encourage clinical care to be closer to home, rethink of use of peripheral clinics would be reasonable. Review of reasons for clinic appointment, especially return appointment and increasing use of telehealth clinics (telehealth incudes option of telephone follow up) and video-conferencing is already taking place in D & G.

Maximising capacity in theatre

Each week around 15 to 18 hours of theatre time is wasted due to late starts. Many late starts are significant and recurring. While the majority of patients are now admitted on the day of theatre instead of the day before as in the past, do we plan appropriate time and do we use space efficiently so that patients can be seen before theatre early enough and theatre starts on time? Occasionally cases are cancelled on the theatre day because the operation was not needed—have we ensured that the patient was fully assessed before theatre by a senior doctor?

Reducing inappropriate interventions

Many interventions may be unnecessary or harmful. NICE “do not do’s” identifies clinical practices that should be either discontinued completely or not used routinely. Are we sure that we have studied areas relevant to our speciality? To read the NICE document click here.

To conclude, while at times it feels like we are all working harder and under greater pressure than ever before, there are small changes that we can all make. Much of this article refers to the practices and actions of doctors, but hopefully there is something of relevance to everyone. Just take a few moments to think about our practices, tests, pathways, processes, and most of all, what is best for each patient.

Heather Currie 1

To finish on a light-hearted, but pertinent point and to explain the significance of the title, the urinal shown above was developed at Schiphol airport to include a fly in the basin. This simple act reduced urinal spillage requiring frequent floor washing by 80%, proving beyond doubt that simple changes can indeed make a huge difference.

Heather Currie is an Associate Specialist in Obstetrics and Gynaecology and is Clinical Director for Women and Children at NHS Dumfries and Galloway