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Dodging the medicines bill

By Dermot - 21st Sep 2017

When inpatients in Irish hospitals are prescribed a new medication, they traditionally access the medication on-site, through hospital pharmacy supplies.

However, reports are emerging that some inpatients are being advised to access their newly-prescribed medications in the community, despite being still in hospital.

The practice has raised more than one eyebrow among community healthcare professionals, particularly GPs and pharmacists, who have highlighted a number of health and safety concerns.

As the costs of high-tech and expensive medication continues to increase in the acute sector, many are of the view that this new practice is an attempt to reduce hospital spending on drugs by transferring costs onto the community drugs budget.

High-tech medicines include anti-rejection drugs for transplant patients or medicines used in conjunction with chemotherapy or hormonal therapy, for example.

Cork GP Dr Jim Harty recently took to Twitter to highlight an incident where an inpatient hospital prescription for an expensive high-tech medicine was presented at a community pharmacy.

A community pharmacist contacted Dr Harty after they were presented with a hospital prescription for an inpatient and sought clarity on the issue.

The patient of Dr Harty’s was still in Cork University Hospital (CUH) at the time but was instructed to access the newly-prescribed medication, denosumab, an injectable monoclonal antibody, from a community pharmacy, despite the medication being due to be administered first in hospital.

A confused relative of the inpatient was sent to the community pharmacy to seek the medication, Dr Harty explained.

Speaking to the <strong><em>Medical Independent</em></strong> (<strong><em>MI</em></strong>), Dr Harty said this was the first time he had come across the practice, which he described as “ridiculous, dysfunctional and inefficient”.

“These are the ridiculous things you find yourself doing as a GP and wasting valuable time. It really shows how inefficient and dysfunctional the system is,” he remarked.

“It’s very interesting as a phenomenon; trying to initiate drugs through the community budget when the drug has not been initiated in primary care.”

According to Dr Harty, his local pharmacist says the practice is widespread, but Dr Harty had never encountered it before.

He asserted that the activity, if more widespread, could be distorting hospital and community drugs budget figures compared to what is happening in reality.

Dr Harty alerted Twitter followers of the incident, tweeting: “Request today to prescribe denosumab for INPATIENT in hospital, ie, GP prescribe to avoid using hospital budget! (& transfer cost to 1 care) [sic].

“Local pharmacy had a confused relative present after being told needs to get the medication from community pharmacy,” Dr Harty added on Twitter.

In response, HSE National Clinical Advisor in Primary Care and GP Dr David Hanlon described the incident as “bizarre”, while Cork GP Dr Nuala O’Connor labelled it as a “most unusual and highly-inappropriate use of GP time”.

A number of GPs contacted by <strong><em>MI</em></strong> said they had never before encountered the practice.

However, Mr Jack Shanahan, Pharmacist at Haven Pharmacy in Castleisland, Co Kerry, said he has come across the practice, which he described as “bonkers”.

“Yes, I have come across it. It seems to be a growing issue and not just high-tech drugs, but other drugs too and they tend to always be expensive drugs,” Mr Shanahan said.

“It’s poor practice, as it does increase the risk of problems and poses supply chain integrity issues. There could also be medico-legal issues here.”

Mr Shanahan said that often, the drugs in these cases are fridge items and cannot be left out of the fridge for very long.

If an individual has a long car journey to make back to a hospital and is inadvertently caught in traffic or is delayed for whatever reason, the drug could be compromised, he warned.

“There are a lot of processes and procedures around ensuring patient safety and effective medicines management. The Falsified Medicines Directive, for example, due to come in the year after next… all of this stuff goes out the window if you’re doing this.”

A CUH spokesperson said it could not comment on individual cases and declined to comment on the practice.

However, they did state that “Cork University Hospital routinely requests patients who are on high-tech medicines in the community to bring these into the hospital, as they have already been charged for in the community. In addition, these drugs, when prescribed for an individual patient, cannot be re-distributed to other patients.”

A HSE spokesperson said that it cannot comment in respect of this individual case.

“The patient’s consultant and the team are responsible for managing patients’ medication during their stay in hospital,” the spokesperson added.

The HSE Medicines Management Programme Director Prof Michael Barry had not responded to requests for comment at the time of going to press.