I am delighted to open, on behalf of the Health and Sport Committee, the debate on the report of our inquiry into the supply and demand for medicines.
I start by thanking all those who gave evidence to our committee in person or in writing, the committee’s clerks, the Scottish Parliament information centre researchers and other parliamentary staff who assisted. We could not have made the report without all those people. All our recommendations were agreed unanimously by all members from all parties.
I am sure that members will all agree that I should extend our thanks to all the people who work in health and care, who have done so much to keep so many people from harm in recent months. The report is focused on what needs to change to give those dedicated staff the best chance of success in the future, although the Health and Sport Committee has never lost sight of the vital work that is done every day in the care sector and in the national health service.
Our core job as a parliamentary committee is to support those who work in our public services and those who use them by seeking ways to strengthen services, both by improving services to the public and by delivering them more effectively and efficiently. That scrutiny is right at the heart of our parliamentary democracy.
The well-earned respect for our health and care workers must not be used as a barrier to scrutiny and constructive criticism of health and care systems as a whole. Our job is to ask difficult and searching questions, and to draw conclusions from the answers, which will help to make a difference.
The Government’s job is to respond to those conclusions; in this case, extracting a full response from ministers to this substantial report has proved to be a challenge in itself. It is important to put on the record that the Government’s full response to the recommendations of our report—which was published in June—was received by committee clerks and members only yesterday afternoon. The proper working of Parliament’s committee system requires the full engagement of Government ministers with the work that we do, and it is a fundamental requirement of a democratic Government that it be fully accountable to Parliament at all times. Ministers did reply to our recommendations before our debate today, but it is disappointing that it took them until the last possible day to do so.
This is a large and substantial report that covers a range of complex topics—drugs budgets, prescribing practice and dispensing and consumption of medicines. Each of those four areas could easily have justified a major report in its own right. However, we took the view that they are so interrelated that change in one area would inevitably lead to change in the others.
We wanted to shine a light on the reasons for the continuing rise in the cost of medicines to the national health service, which now stands at more than £1.8 billion per year. Our attention was soon drawn to a report by KPMG, which showed that up to half of all medicines that are prescribed and dispensed were not actually consumed as directed. That is clearly an enormous and annually recurring issue, yet we could find little evidence of anyone taking any concerted action to address it.
Altogether, we made 129 recommendations on how medicines management in Scotland can be improved—from straightforward adjustments to more fundamental changes in how the system performs.
Much of the process of approving new medicines is done at United Kingdom level. Therefore, we also looked at reserved areas. Scottish ministers, or their representatives, had a seat at the table in every area that we examined. The decisions that they take, the input that they make and the influence that they wield make a difference and have real-life consequences here in Scotland. They are therefore accountable for those actions to this Parliament. It is one of the great strengths of parliamentary committees that we are free to follow the evidence wherever it takes us, so I encourage ministers to welcome our scrutiny on that basis.
The most important conclusion of our report is that the system of supply and demand for medicines in Scotland does not focus on patients. It is therefore disappointing that at no point in the very substantial response from the Scottish Government is that conclusion addressed. Perhaps the minister will indicate in his speech whether he agrees with the committee on that central point.
Throughout our inquiry we were presented with issues that pointed to that conclusion, and many of the issues appeared to go beyond medicines to point to wider-ranging problems in the NHS. The most prominent of those are the way that information about the patient experience is collected and the infrastructure that is used to store, share and analyse the information.
Lack of information on the outcomes of prescribed medicines is of huge concern. The impact on individual patients of taking medicines is not examined and—even worse—is not routinely sought. Patients in primary care are not receiving follow-up care to ensure that the medicines that they have been prescribed are effective, or even to find out whether they are taken at all.
We found that the lack of effort to understand people’s experiences of taking medicines impacts on the system at every stage. Evidence described the improvements that could be gained from collection of outcomes data during research and development, through to consumption by the patient. As we stated at the beginning of our report, we are clear that gathering, analysing and sharing that information in a comprehensive and systematic way across Scotland would be the single most beneficial action to result from the inquiry, so we urge the Scottish Government to highlight how it will do that.
A lack of suitable data and information technology has the potential to cause harm to patients. Systems that are designed to transition people between primary and secondary care are not sophisticated enough: the then chief pharmaceutical officer told us that most harm happens on the crossing of boundaries between care settings. We welcome the work that is being done on that, but we are concerned about what is happening for patients in the meantime.
We found that patients who were ready for discharge from hospital could face hours of delay—sometimes resulting in an additional night spent in hospital—because of delays in preparing their medicines. When we challenged the lack of action on that, we were given a list of reasons to explain why a doctor’s prescription in hospital takes so many hours to fulfil. That glaring example of lack of patient focus seems currently to be beyond the ability of NHS leaders to resolve.
We have recommended that relevant medical records be made available to all health professionals who need them, and we have again emphasised that it should be patients who own that data. We note the speed with which record sharing has rightly been put in place to meet the challenges of the Covid-19 pandemic; we want to see equally swift and decisive action to make records fully available to all professionals at all times.
Our report considered the implementation of the hospital electronic prescribing and medicines administration, or HEPMA, system. Its commendable core purpose is to generate data and outcomes. The business case was agreed in 2016, but not a single health board is yet in a position to gather that data. Many boards are still in procurement and many are using different software. The few systems that are in use are not being fully utilised to analyse information on outcomes.
The cabinet secretary wrote to us earlier this month and said that
“good progress is being made in implementing HEPMA,”
and that the implementation date across the country is not, in fact, March of next year. Perhaps the minister could clarify when he expects all boards to have functioning systems delivering information and when they will all be using that tool to its full effect.
HEPMA is a perfect example of one of the other key concerns that arose throughout the inquiry: a lack of effective leadership in the NHS. Evidence that was presented to us by senior health leaders detailed issues and problems throughout the system, but rarely explained how those problems would be addressed. We heard repeated acknowledgements that systems and governance were not in place to cover the various aspects of a medicine’s journey from research to patient. We also observed a lack of willingness to take responsibility to deliver change.
We heard that reviews of prescriptions are not taking place as a matter of course, which contributes to potential harm to patients, as well as to waste. One director of pharmacy told us:
“A medicine that is prescribed but which goes to waste is, in effect, the most expensive medicine we could buy.”—[Official Report, Health and Sport Committee, 4 February 2020; c 2.]
We also heard evidence that a lack of knowledge about non-medicine options leads to a continuing failure to maximise the potential of social prescribing.
In this year’s budget inquiry, we found that just over £19.5 million out of £8.5 billion that was allocated to integration joint boards will be spent on social prescribing. That is less than 1 per cent. Our report in February recommended that that figure should be at least 5 per cent, and the Government accepted that recommendation.
We found in a number of areas gaps between Scottish Government expectations and what happens in reality in general practitioners’ surgeries. Those areas include prescription reviews, social prescribing and realistic medicine. That caused us to wonder how the policy objectives that are set by the Government are communicated, measured and evaluated.
The obvious vehicle for requiring behaviour change is, in the view of the committee, the general medical services contract. The contract does not, however, appear to require adherence to those policies. Evaluation of the contract seems to be a long-term project; it will be three years before monitoring and evaluation priorities are even determined, and not all the changes that were made to the contract in 2018 will be subjects of monitoring and evaluation.
We are concerned by the lack of evaluation of both the role that GPs play in our primary care system and of the freedom that they have to decide whether to adhere to national policy. They are the recipients of almost a billion pounds of public funding, but the levels of accountability for GPs are surprisingly low.
The report recommends consideration of how the contract can be amended to require better systems—for example, for prescription reviews. Similarly, the committee believes that the community pharmacy contract could do more to require pharmacists to undertake monitoring and evaluation to maximise the work that they do in communicating with patients on their medicines. Many excellent opportunities for data to be collected on the patient experience are not being taken, simply because that is not mandated by the contract.
I will not speak for the minister—he will speak for himself—but the Government’s response to many of our challenges appears to be defensive. However, I hope that, on reflection, ministers will agree with our central proposition, which is that if patients are truly put at the heart of the system for supply and consumption of medicine, we will get a more efficient system and deliver a better service to patients.
On that basis, I will move the motion in my name on behalf of the Health and Sport Committee.
I move,
That the Parliament notes the conclusions and recommendations contained in the Health and Sport Committee’s 6th Report 2019 (Session 5), Supply and demand for medicines (SP Paper 774).
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