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CASE NOTES
Tuesday 9 May 2006, 9.00-9.30pm
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BRITISH BROADCASTING CORPORATION


RADIO SCIENCE UNIT



CASE NOTES
Programme 1. - Prescriptions



RADIO 4



TUESDAY 09/05/06 2100-2130



PRESENTER:

MARK PORTER



CONTRIBUTORS:

BRIONY HUDSON

JANE THORNTON

KEVIN GIBBS

TOM BANNING

PROFESSOR SHAKIR

HUGH MCGAVOCK

RICHARD LEWIS



PRODUCER:
ERIKA WRIGHT


NOT CHECKED AS BROADCAST





CLIP

Okay, well what we're going to do is we're going to put some paracetamol on to the conveyor and then the robot will then move it to the area that it'll read the barcode, that's it reading the barcode. And it's just checking that it's the right product, it's saying is this the right barcode, does it fit the right size? Yes it does. And then it puts it away onto a shelf.



PORTER
The very tidy, very fast and very efficient new robotic shelf-stacker and dispenser at the hospital pharmacy at the Bristol Royal Infirmary - to where I'll be returning a little later to find out how robots could soon be coming to a high street chemist near you.



Today's programme is all about prescriptions. Around a billion of them are dispensed every year on the NHS - that's more than one a month for every man, woman and child living in the UK. A little green slip of paper that's often the first step on the road to recovery.



VOX POPS
Psychologically you do start to feel better as soon as you've got that bit of paper in your hand because you think you're on your way to wellness.



When I get a prescription I keep hoping that it'll be magic and so that's it, I have a fair idea that it won't be magic but on the other hand there's a chance. The last ones weren't magic, so I stopped taking them.



I don't like getting prescriptions at all, it's a last resort because I tend to think that I could do without them, I put it off, I don't like getting them at all.



I guess I do feel a sense of relief when I've got them because I know it's going to make me better because I've got asthma, so I read them properly and understand them because it's always a bit scary taking medicines.



Oh yes, yes we check it every time, oh yes you have to. I can't pronounce the Latin words but I know which is which.



PORTER
In 2004 prescribed medicines cost the NHS more than £8 billion in England alone, yet 4 out of 10 people prescribed medicines by their doctor don't take them regularly enough to derive any benefit. I'll be finding out about the financial and social costs of not taking medicines properly, and what can be done to stem the wastage.



And I'll be discovering where your £6.65 prescription charge goes - and why people who live in Wales will soon be getting their prescriptions for free?



But first, where did it all start? Briony Hudson is Keeper of Museum Collections at the Royal Pharmaceutical Society.



HUDSON
We know that the oldest written prescription in the world dates from about 2,000 BC and was found in what's now Iraq, written in cuneiform on a clay tablet. We know the Egyptians used prescriptions written on papyrus. In Britain we're really not quite sure when pharmacists and doctors started communicating in a written form, rather than orally giving instructions. We know that the word prescription in a medical sense was first used probably in about the 1570s but it's very unusual to find written prescriptions that still survive much earlier than the 18th Century. I've got a couple of prescriptions here and both date from the 1840s, they were written in Latin, as would be expected at the time, by a doctor who we only know as CW, he's just initialled them. One is a mixture for spasms and the other is a mixture for coughs and they follow a very typical format - they start with the abbreviation RX at the top, which stands for recipe - which is take thou. And then the ingredients for the mixtures are given in Latin abbreviations with the amounts of each ingredient that would be used to make up the medicine and then an instruction is given as to how the medicine is made up and how it's taken. Both the prescriptions are written in pretty challenging writing, as we might expect, and of course they use Latin abbreviations for both the ingredients and the instructions. For example, a first ingredient - Polvray is powdered rhubarb on the spasm mixture. The cough mixture prescription gives the instructions for making up the mixture in Latin as well, including pro ranata, which is still an abbreviation used today - PRN, meaning when the occasion arises. There are lots of other Latin abbreviations still used today even though the emphasis is on using English in prescriptions and they include things like N for nocte for night; PC for after food; AC for before food and TDS ...



VOX POPS
TDS? No idea. Something service is it? Dispensary service? Yes that's right isn't it. What's the T for then?



Take dosage stated or something I suppose, I have no idea what that would mean.



No I honestly wouldn't know what it meant.



Well it's the Latin isn't it - it means three times a day.



Oh law is it, oh well we don't have anything three times a day, just twice a day one of them.



HUDSON
It does seem amazing that Latin abbreviations are still part of today's prescriptions but I suppose they're so much part of the vocabulary and so much part of the way that pharmacists and physicians communicate with each other, they were really sort of cloaked in mystery - the patient didn't know what they were being prescribed, what the ingredients were and it remained that way until very recently. It's quite amazing to think that it wasn't until 1972 that the name of a medicine actually had to be written on the patient's prescription. Medicines themselves would simply be marked something like the pills or the mixture until way into the 20th Century and even the price that the prescription cost was often coded so the patient didn't know until they got to the till what they were going to be charged.



PORTER
Briony Hudson on why prescriptions are often unintelligible to the untrained eye.

But it's not just the language that can be confusing - poor handwriting can make them unintelligible to the trained eye and lead to the wrong drug, or the wrong dose, being dispensed. Mistakes that are much less common today than they used to be, thanks to the introduction of computerised prescribing and printed prescriptions - assuming the GP presses the right buttons in the first place. And soon you may not even get a piece of paper at all, the latest electronic prescriptions can be e-mailed direct to the pharmacist and possibly in the not too distant future even direct to a robot in the pharmacy.



A robot like the one recently installed in the Bristol Royal Infirmary - new technology that has been introduced to speed up dispensing, free up pharmacists' time, and improve safety by reducing the likelihood of giving out the wrong drug. Jane Thornton is the Pharmacy Operational Manager.



THORNTON
We're standing in the middle of the robot, inside the robot, which isn't recommended but is okay for the moment. It's about three metres high and about eight metres long and if you imagine on either side there are rows and rows of glass shelving.



PORTER
It's almost like an aisle in a library isn't it.



THORNTON
Exactly.



PORTER
And almost as tall and we're surrounded here by drugs.



THORNTON
Absolutely and they're randomly put away by the robot. So there's no system to the naked eye that you can understand, the robot decides where it's going to put everything in the most efficient way that it particularly wants to do it and in the most efficient way that it thinks it can then pick them back off the shelves and take them back to the dispenser.



PORTER
So all that matters is that the robot knows but how does it get the medicines to load the shelves - you just feed it and it stacks itself?



THORNTON
It's got a very, very little nifty conveyor belt, just here, and it reads every barcode on every pack, so it automatically then recognises which product it is and thinks oh this is a paracetamol and we always use lots of those, I'm going to put that there and it'll put them all away.



PORTER
Why have you switched to the robot?



THORNTON
Well there's about three main reasons to be honest. Space, because it's used an area that was an old stairwell which originally wasn't used at all. It's fast and it picks about 600 items per hour.



PORTER
Compared to what you might you be able to do manually?



THORNTON
If you imagine you - sort of in the time that it would take you stand up, walk over to a drawer, open a drawer, take the item out and walk back to where you're dispensing.



PORTER
So it's a lot, lot quicker than a pharmacist.



THORNTON
Yeah. The other issues are things like safety.



GIBBS
My name's Kevin Gibbs, I'm the clinical pharmacy manager for the trust. One of the problems with dispensing is that companies produce products and drugs in packaging that looks very similar and it's very easy when you've got them lying next to each other on a shelf to pick the wrong one.



PORTER
We've got an example here: at first glance they look identical, they're yellow and white boxes.



GIBBS
And the same drug, with the same strength but they're used very differently clinically - one acts for 12 hours, one acts for 8 hours - so you don't want to give the wrong one to the patient.



PORTER
And this is a drug used to treat epilepsy, so if you gave them the wrong one?



GIBBS
Then they may potentially have a fit if you don't treat them properly. And the National Patients Safety Agency is currently looking at this and is talking with the industry to provide some guidance on what is safe packaging and design.



THORNTON
It was very easy to make picking errors, whereas the robot doesn't care about what packaging it's in.



PORTER
It's just going solely by the barcode.



THORNTON
Absolutely.



PORTER
But does it not make mistakes?



THORNTON
No, it'll give you exactly what you ask it for. If you ask it for the wrong thing it'll give you the wrong thing. But it'll only give you exactly what you ask it for.



PORTER
Alright, well let's see at work. I think we'd better get out otherwise we'll end up being picked ourselves.



THORNTON
I love the sound - absolutely love the sound of it, the arms whooshing up and down.



PORTER
Hard work without you having to move you mean. It's got the things on the shelves now.



THORNTON
It can hold up to 25,000 packets at any one time. There's some things that it can't hold - it won't hold say 250 mil bottles and tubes.



PORTER
Is that a handling problem?



THORNTON
It's a handling problem.



PORTER
Because it's got like a pair of fingers on the ends for pincing and presumably bottles are a bit risky, they slip out.



THORNTON
Exactly.



PORTER
We're requesting it to pick the paracetamol - it goes straight off, goes to the shelf, can't tell whether it's the right one from here or not, we'll find out in a minute when it comes out of the chute.



THORNTON
There you go. So when you're sitting at your terminal there's a chute right next door to your terminal, so it literally will be delivered right next to you at your terminal.



PORTER
So not only is it - do you tell it which drugs to go and get but it also knows where you're sitting so it delivers them to you.



THORNTON
Absolutely.



PORTER
Well I suppose this is the acid test - is to have a look and see what it's actually given us. Paracetamol 500 - haven't caught it out yet then.



THORNTON
He's clever.



PORTER
Presumably one of the other advantages to this is rather than disappear off into the back, if you like, to get the drugs, the pharmacist is basically front of house.



THORNTON
Absolutely, the roles of pharmacy are changing so quickly. We're now expecting pharmacists to spend much more time on wards with patients, clinically checking items actually at the ward level. You're going to have technicians and pharmacy assistants working down here in the dispensary really doing the dispensing process.



PORTER
Obviously we're in a hospital unit here but I mean one of the criticism in the community pharmacies, which many of our listeners will be familiar with, is there's a so called lick and stick, where the pharmacist is at the back, basically counting pills. Can you ever envisage a day where larger community pharmacies might be employing systems like this?



THORNTON
Well interestingly when we did our visit, looked at all of these robots, the Siemens robots are very well established in Germany and they're all in community pharmacies, all the ones that we saw are working in community pharmacies.



PORTER
Well there are no robots in the Lloyds community pharmacy that dispenses most of my prescriptions here in the market town of Wotton-Under-Edge in Gloucestershire where everything's done by hand.



BANNING
My name's Tom Banning and I'm the pharmacist manager here in Wotton-Under-Edge and have been for about two years now.



PORTER
So Tom how many prescriptions do you get here at the pharmacy in Wotton?



BANNING
Here we can do sort of anywhere between sort of 100 and 400 really, depending on how busy they are at the two surgeries we have here in Wotton.



PORTER
What can you write a prescription on - presumably the vast majority of prescriptions that you get here are the standard green form NHS type?



BANNING
Yeah, we do have the occasional private prescription from private doctors who could be anywhere in the country, they can be written on anything. Normally it's headed paper but I have seen them on things such as post-it notes.



PORTER
Now if I write a prescription for my patient and it arrives here what's the first thing you do with it?



BANNING
The first thing here is obviously make a record that the prescription has arrived in store and then dispensed by Cherry or Liz here. And then checked again my myself. When the patient has actually left and we have the green prescription that is filed away until the end of each month, where it's then sent off to the prescription pricing authority. If we have taken a charge off the patient for that prescription they then take it back off us to feed it back into the NHS.



PORTER
So how do you get your money for the drug bill that you've dispensed here - say you dispense a statin which costs - cholesterol lower drugs - £15 a pack but you only got £6.65 off the patient?



BANNING
When the green prescription has gone to the pricing authority the prescription charge that the patient pays, that is the NHS's, so they take that, they will then reimburse us for the cost of the actual drug plus a dispensing charge.



PORTER
And the Prescription Pricing Authority isn't the only group interested in prescriptions once they have been dispensed. The Drug Safety Research Unit is an independent charity that monitors side effects in newly released drugs using a system called Prescription Event Monitoring (known to most doctors as the green card system).



New drugs are often only tested on a few thousand people at most before launch, meaning that rarer side effects may not become evident until they have been on the market for years and taken by hundreds of thousands, or even millions of people.



A method for reporting and collecting concerns about side effects - the yellow card system - was introduced in the sixties following the thalidomide disaster, but most doctors agree it's flawed and underused. The system remains in place today, but Prescription Event Monitoring is now used to complement it and close some of the chinks. So how do the two systems differ? Professor Shakir is Director of the Drug Safety Research Unit in Southampton.



SHAKIR
We now have a system which is called the Spontaneous Reporting System which started in the mid-60s in the UK and is available in many other countries, where initially doctors were asked to report any suspected adverse reactions about their patients.



PORTER
But that requires me as the GP to a. spot there's been a problem in a patient; b. remember to send the card off and c. for somebody at the other end to draw all the links together. There's been gross under reporting in the past using that system hasn't there.



SHAKIR
That's absolutely true. The initial action is for the doctor to make the suspicion. It is estimated that probably less than 10% of adverse reactions get reported.



PORTER
Well how does the newer green card system differ from the yellow one?



SHAKIR
The system which we do - the so-called green card system - Prescription Event Monitoring - is that we ask doctors to report all events that occur to the patient after they receive the drug, regardless whether they suspected that it is an adverse drug reaction or not. So when a patient takes a medication and they go to hospital to get something like appendectomy, or they fall and fracture their arm, these events are reported and analysed whether these could have been adverse reactions or just events which would have occurred regardless of taking the drug are done by us. So the element of suspicion in the mind of the doctor is removed.



PORTER
So what you're doing is proactively writing to doctors who've prescribed particular drugs and asking them to report on any adverse reaction that that patient has had during a period, whether or not it be related to the drug?



SHAKIR
That's right.



PORTER
So what's the sort of return rate from the profession - are we good at sending these forms back in?



SHAKIR
Yes, I think GPs are good. We get 60% response, fairly high considering how busy GPs are.



PORTER
Can you give me some examples from the last decade perhaps of drugs that you've identified a worrying trend in?



SHAKIR
Quite a few, for example in the mid-90s there was a drug used for epilepsy called Vigabatrin and that was a new drug for this rather difficult disease and we were among the first to identify an impairment of visual field defect, people had tunnel vision - they developed. More recently we contributed to the debate of anti-inflammatory agents which are called COX-2 inhibitors such as Vioxx where we identified, like other groups did in various parts of the world, that there were differences in the likelihood of getting events such as heart attacks and strokes among people who used these products.



PORTER
What about the fact that as many as half of the patients who are prescribed a drug by their GP might not actually be taking it properly?



SHAKIR
Well this is a technical problem in our research but one of the measures which we use in our studies - because we are studying over a six month period or a one month period we use as an indicator of compliance or concordance the fact that the patient went for a repeat prescription because it is more likely that a person who goes for a repeat prescription is taking them although they would be a very small number of people who may still won't take that.



PORTER
And poor compliance - or non-concordance to give it its politically correct name - isn't just a problem for drug safety campaigners like Professor Shakir. Studies have shown that as many as 9 out 10 cases of rejection in people who have had kidney or heart transplants happen solely because they don't take their pills properly. And if they don't follow instructions, after all they have been through, then what chance do the rest of us have.



VOX POP
I'm asthmatic and have been for quite some time and I'm supposed to take the preventative inhaler every day and the reliever. I'm not even sure when I'm supposed to take the reliever but sort of as and when is how I think about it. And essentially I don't - I don't take the preventative. I use the blue inhaler when I'm feeling a bit wheezy. But for most of the time I don't feel as if I'm asthmatic, so I don't think about it. I mean it's just that really - unless I'm wheezy it doesn't cross my mind to think oh I'd better take it. And the other thing is like many people I sort of don't want to take anything that's unnecessary. And occasionally doing that I come completely unstuck. I had an incident recently - I run - I was quite a long way from home and I tripped and fell and slightly jarred my ankle and couldn't carry on running, so I had to get to a bus stop and wait for a bus. And the bus didn't come for about 40 minutes and I got freezing cold - absolutely freezing cold - and by the time I got home my chest had clamped down in a really scary way. And I was in real trouble that night - blue finger nails - and it took me until probably 4 o'clock that morning to even start to not be frightened.



PORTER
Professor Hugh McGavock from the School of Biological Medical Sciences at the University of Ulster has a particular interest in compliance - or rather lack of it!



MCGAVOCK
About 20% of the population take their medicines properly and they get the full benefit. Another 40% take their medicines well enough to get some benefit - which is good. But 40% of people with diabetes and asthma and schizophrenia, high blood pressure, don't take their medicines at all or they take them so erratically as to get no benefit and some harm.



PORTER
So that's nearly half the people who are prescribed medicines in the UK aren't taking them regularly enough to get any benefit, which means that - I mean the drug budget in the UK is something like £8-9 billion, half of that is being wasted.



MCGAVOCK
Yes, I've been doing my sums on this and these are approximate figures but last year UK GPs issued approximately 1 billion prescriptions, costing approximately £12 billion. If 40% of that is indeed wasted and we are fairly sure it is, that means that non-compliers are wasting somewhere around £5 billion per annum, that's eight times the current hospital overspend that's causing so much fuss in the media.



PORTER
But of course it's not just the financial - direct financial implications, these people have got long term conditions, many of them, that aren't being properly treated and that presumably has additional costs both to the health service and to the individual.



MCGAVOCK
Absolutely, people with these long term diseases they are getting sick much, much earlier in life than they should and they're dying earlier. And as they get sicker, more sick than they should, they're taking up hospital beds and services, which is a vast waste to the NHS. And I have to emphasise - it's the same in the USA, Sweden, Australia - any country where it's been researched.



PORTER
And what does the research suggest are the underlying reasons for such poor compliance?



MCGAVOCK
Oh it's quite complicated. There are the people who intend to comply but manage not to, the unintentional non-compliers, these are the confused elderly, the forgetful people who are taking more than three medicines at a time, people with poor eyesight who can't read the small type on the medicine bottles. So those are the people who would comply but for various reasons are not doing so. We really come to the major problem of the people who make up their mind not to take their medicines and there has been a lot of research done there, starting in the USA but over the last 10 years particularly in England. First of all some people believe that their bodies will cure themselves, to a little bit of an extent that's true but not for these serious conditions I've mentioned. Secondly, some people doubt whether the medicines will work. Some people fear that they will become immune to a treatment if they take it for a long time, or indeed that they might become addicted to a blood pressure treatment or a diabetic treatment. Quite a lot of people dislike handing over control of their bodies, of their lives, because they perceive that medicine taking is doing so and then some people imagine that a one month's course for blood pressure or diabetes or asthma will actually cure it.



PORTER
But presumably we must take some of the blame as healthcare professionals for some of this non-compliance, I mean are we not explaining the medicines enough, are we allowing myths like how you become immune to your medicines to be perpetuated? What can we do to address this?



MCGAVOCK
Well again one can turn to research done in London which showed that somewhere around 70% of patients could not remember the doctor's instructions one minute after they had left the doctor's consulting room. And so the message has got to be repeated by the doctor and the importance and benefit of medication's got to be stressed at every visit. Then by the receptionist, then by the pharmacist. And there really is a limited amount one can do. One certainly cannot force people to take medicines and nobody's suggesting that but my general hunch is that the National Health Service and probably the drug industry need to get together to promote a sustained media campaign - Take your medicines - Take your medicines right, right dose, right time of day, right length of time and you'll be alright - that sort of thing.



PORTER
What about the fact that four to five prescriptions in the UK are free - do you think it makes any difference that the medicines that we're supplying people don't have to pay for them?



MCGAVOCK
This is a very interesting point and is something that we all thought oh yes it's one of the downsides of a welfare state, people abuse it. But the figures in America are almost identical ...



PORTER
Where they're paying large sums of money for their medicines and to see the doctor.



MCGAVOCK
People who are re-mortgaging their house to pay for their medicines are still not complying. It is part of this strange, strange creature called mankind.



PORTER
Strange indeed. But the authorities in Wales think that cost may be a factor - so much so the Welsh Assembly froze prescription charges after devolution in 2001, and have since reduced them to £3 an item - that's half as much as the rest of the UK - and they hope to abolish them completely by April next year.



A move they estimate will cost around £40 million pounds a year - less than 5% of the drug budget in Wales. And roughly the same proportion that prescription charges raise in England and Scotland. Sadly neither is planning on abolishing their charges. So what convinced the authorities in Wales?



Dr Richard Lewis, is Welsh Secretary of the British Medical Association - an organisation that favours radical review of what is often perceived as a tax on the sick.



LEWIS
There's been quite a bit of work done by the Consumer Health Council and Community Health Council's MORI polls which have suggested that when patients have to pay for their prescriptions, particularly if they're on multiple items, up to 30% don't always cash in all their prescriptions. So there is a knock-on effect where if patients are obviously not taking their medication they may well be worsening their medical conditions and therefore put an extra burden on the health service. So this is an up front payment for a longer term health gain for the patients in Wales.



PORTER
How's it been received by doctors and patients?



LEWIS
Well patients obviously have received it very well. There was some concern by general practitioners that potentially people would be asking for medications that they would not now have to pay for across the counter.



PORTER
Things like paracetamol?



LEWIS
Yes really, so that people could just stock their cupboard up with medication for a rainy day. That doesn't really seem to be happening in the way that people had feared.



PORTER
What about people who live just the other side of the border - my family in Ross-on-Wye, which is 10 miles from Monmouth, what's to stop them seeing their GP in Ross and then driving down the road and picking up their drugs free across the border?



LEWIS
The Welsh Assembly government have made it quite clear and agreed with the profession in Wales that the patients who are eligible for free prescriptions have to be first of all registered with a GP practice in Wales and the prescription has to be cashed by a pharmacist within Wales too. For those patients who perhaps live in England but are registered with a GP in Wales they will be given an entitlement card which will allow them to still access those free prescriptions. However, prescriptions would not be free for patients who are registered with a GP in England but try to sort of take their prescription to a pharmacist in Wales.



PORTER
Dr Richard Lewis on the demise of the prescription charge in Wales.



That's, all we have time for today. If you want any more information on the issues discussed today - including details of pre-payment certificates which can save you a fortune if you are on regular prescriptions - then do call our Action Line on 0800 044 044 or visit our website at bbc.co.uk/radio4



Next week I'll be looking at the latest developments in keyhole surgery.




ENDS

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