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New solution for old problem: how to
reduce the volume of waste medicines
In this article, Liz Breen, Ying Xie and Kuljit Thiaray describe how a reverse logistics framework based on customer relationship management
strategy may encourage customer involvement in the reduction of waste medicines in the community, thus lowering risks and saving money
I
The authors
t has been estimated that £8.2 billion is
spent each year on prescription drugs in
the NHS of which at least £100 million
can be attributed to unused or wasted medication.1 On 31 March 2008 there were
10,998 community pharmacies in England
providing NHS pharmaceutical services. In
the NHS throughout the UK disposal of unwanted medicines is an essential service under
community pharmacy contracts.
Primary care trusts, which commission
these services, monitor compliance.
Medicines retrieved from patients cannot be
reused and must be disposed of. Close monitoring of returned medicines can be a useful
source of information for prescribers. Safety is
paramount when broaching pharmaceutical
management and storage. Accidents can happen if products fall into the hands of children
or individuals who wish to abuse the product
or support a grey market for product exchange or sales.
Pharmaceuticals that are returned by patients are destined for final disposal and have
no legitimate residual value. But the return of
these products does have a value: it removes
the product from circulation and from the
domestic environment, reducing the risk of
accidental injury or product abuse; and it provides information that can be used to assess
the efficiency of the prescribing process, such
as who the prescriber is, the nature of the
product and quantity dispensed.
Reverse logistics has been defined as “the
process of planning, implementing and controlling the efficient, cost-effective flow of
raw materials, in process inventory, finished
goods and related information from the point
of consumption to the point of origin for the
purpose of recapturing or creating value or
for proper disposal”2 and has attracted attention from academia and industry.
The three main drivers of reverse logistics
are economics, corporate citizenship and the
law.3
Liz Breen, PhD, CMILT-UK, is senior lecturer,
Bradford University School of Management.
Ying Xie, PhD, is senior lecturer, University of
Greenwich Business School. Kuljit Thiaray,
MBA, MRPharmS, is senior lecturer,
Bradford University School of Pharmacy.
Correspondence to: Dr Breen at Bradford
University School of Management, Emm
Lane, Bradford BD9 4JL
(e-mail [email protected])
www.pjonline.com
The economic incentive to engage in reverse logistics activities lies in minimising cost
and improving profitability by reducing
waste, reusing materials, remanufacturing, recycling or product refurbishing.4
Companies that value their own standing
as good corporate citizens adopt an approach
of sustainable development. They handle the
reverse logistics of hazardous materials efficiently and effectively from an environmental
and social point of view. Developing an
image as a good corporate citizen could open
a huge potential market, which eventually
makes profit.5
The laws and policies imposed by any jurisdiction dictate the legal obligations of a
company to take back the returned products.
It is possible that effective reverse logistics
could save UK business up to £500 million a
year.6 Can it be applied to medicines supply
in community pharmacy?
A previous study focusing on reducing
waste in community pharmacy suggested that
closer professional management at the point
of dispensing and an understanding of patient
experiences can help reduce the amount of
unwanted medicines collected by patients.7
The study did not investigate medicines retrieval strategies. A thorough review of the
literature indicates that there is little research
and practice on medication recycling from a
supply-chain management perspective.8
Customer relationship management
Community pharmacists sit near the end of
the pharmaceutical supply chain close to patients, which means they have a good opportunity to build relationships with them.
Patient engagement can be transactional or, if
the patient has had a long relationship with a
community pharmacy, it can result in something akin to loyalty. It is this element that
community pharmacy management needs to
secure and build upon to ensure the success
and sustainability of a new reverse logistics
system.
Loyalty can be developed by relationship
marketing as opposed to transactional marketing. Customer relationship management
includes all activities undertaken by an organisation to identify, select, develop and retain
customers.9 The basis of customer relationship management is in knowing customers
and this relies heavily on data provided by information management systems. Customer
information can be analysed to identify traits
and characteristics by which they might be
categorised, opening up the possibility of developing individualised approaches.
Consideration needs to be given by industry to designing a supply chain that works for
both customers and suppliers.10 Social marketing has been proposed as a means of understanding the pharmaceuticals market.11 It
is based on the premise that social causes can
be marketed like any product. Social marketing can be used to promote socially desirable
behaviour, such as recycling, seat-belt use,
family planning and AIDS prevention.12
Pharmaceutical recycling would be perceived
as a socially acceptable cause and would encourage engagement with a reverse logistics
system and positively influence compliance.
In community pharmacy, patients are also
customers and therefore it could be posited
that a blanket approach to customer relationship management is needed rather than a focused approach. As financial return/customer
profitability for this venture is not a factor it
can therefore be hypothesised that the categorisation of customers could be used for information dissemination purposes. The level
and nature of information given to customers
could be group-dependent: for some a flier is
sufficient to indicate the purpose and action
necessary in the reverse logistics system, but
others need a one-to-one explanation. A
blanket approach, however, would be easier.
Managing customers’ perception and loyalty is critical to the success and sustainability
of a reverse logistics system, therefore consideration needs to be given to its objective and
design.The final design needs to incorporate
the essential elements of both managing customers and managing return logistics.
Environment, economics and safety
The focus on pharmaceuticals in the NHS is
mainly on their therapeutic value, but consideration also needs to be given to their impact
from an environmental, economic and safety
perspective. Studies indicate that the presence
of pharmaceutical ingredients in our water
supplies and products made using water are
potentially harmful to us and our eco-system.
A review of related studies indicates that
harm can be economic and environmental.
The economic costs include the cost of
collection and disposal of medicines, the scale
of which is indicated by the quantity of medicines returned to PCTs, and costs arising
from ineffective prescribing.
There is an important safety element,
where safe methods of practice can reduce
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the risk of harm, including accidental deaths
due to innapropriate medication.Therefore, a
properly designed pharmaceutical reverse logistics system for medicines recycling must
take account of all of these factors.
In order to introduce an integrative customer relationship management strategy to
facilitate effective reverse logistics in community pharmacy, the following three objectives
need to be realised:
Recycling centre
Management
information
system
Medicines
use review
▼
General practice
■ An understanding of customer roles in the
reverse logistics system in community
pharmacy
■ Identification of the drivers for increasing
customer compliance in returning unused
medicines to community pharmacies
■ Identification of how to support customer
involvement
Reverse
logistics
▲
▲
Forward
logistics
Information
flow
Figure 1: A proposed pharmaceutical recycling system for community pharmacy
have been wasted across a single health authority, if figures produced from a study of
four pharmacies over a two-month period are
representative of overall performance.14 The
findings from a waste audit conducted by
Rowlands Pharmacy (personal communication) indicated that when extrapolated, the
total cost of returned medicines for a year
would have been £4,690,428.The results indicated that the main reason for customers returning a medicine was that they had stopped
taking it (49 per cent of returned items). So
what role can customers play in reducing
waste in this system?
Unlike the traditional model of recycling,
where goods can be recovered and reused,
■ Access to recycling services
■ Environmental knowledge
■ Recycling experience
■ Vouchers given for the return of medicines
■ Exchange for other medicines
▲
▲
Financial
incentive
Concern about the hazard posed to children or vulnerable people by medicines
left in households
▲
▲
Individual
circumstances
Concern about potential harm to the environment posed by disposal of medicines
▲
▲
Health
and safety
Reduced production costs or packaging costs
▲
▲
Environmental
considerations
Positive impact on community and society of recycling medicines
▲
Economic
concerns
■ Laws governing disposal of household pharmaceutical waste
■ National regulations on the disposal of prescription medicines
▲
Corporate
citizenship
pharmaceutical products take a different recycling pathway, that is, to final disposal by a
third party. Individual customers can make a
strong contribution by returning medicines.
All customers are different, so there is no single definitive skill set or expertise that community pharmacies can draw on to design
their reverse logistics systems.
The role of the patient in the management
of pharmaceutical waste has been a passive
one in some respects, as it is controlled by
professionals. Under the reverse logistics system proposed in Figure 1, where customers
return the medicines to community pharmacies, GPs or recycling centres via different
channels, there a need for active participation
▲
Legal framework
▲
▲
Operational
Text, telephone call, e-mail
▲
Drivers
▲
▲
▲
▲
▲
Perceptional
Customer
Community pharmacy
▲
▲
Roles of customers Previous research has
examined industrial reverse logistics practice
in business-to-business and business-to-customer relationships (including pharmaceutical
wholesalers and manufacturers) to determine
the financial and operational impact of customer non-compliance in returning equipment to its source.13 The study found that the
efficacy of reverse logistics can be undermined
by a lack of customer compliance, with business-to-business losses of up to £140 million.
Non-compliance of this nature can carry a direct cost for manufacturers and distributors. It
was advocated that suppliers in industry need
to acknowledge this issue and manage their
reverse logistics more effectively.
While focusing on efficiencies and reducing waste in the NHS, another study concluded that approximately £800,000 could
▲
▲
▲
▲
▲
Figure 2: Drivers of customer compliance (adapted from De Brito et al3)
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and decision-making about product returns.
The return process can take the form of a single, clean-sweep event, whereby individuals
send their unwanted medicines to a recycling
centre — successfully implemented in
Maine15 — or via a drop-box in GP surgeries
or community pharmacies.
The outcomes of the audit at Rowlands
Pharmacy led the chain to recommend that
patients should be asked why they return medicines and to instigate a medicines use review
(MUR). GPs should also be consulted about
the patients involved, and an efficient management information system is proposed to help
GPs to monitor patients’ progress and remind
them, by text, telephone call or e-mail, to return unwanted medicines. In the management
information system, patients’ consultation and
personal details will be recorded, together with
the MUR results. Similar conclusions were
reached in other studies.16
Communication and encouragement on customer compliance
Internet, media (TV and newspapers), pharmacy or NHS leaflets
Customer relationship
management strategy
Customer support
Customer enquiries
Customer service
Customer feedback
Product management
Product life cycle
management
Reverse logistics network
for returned drugs
Product design
and packaging
GP’s prescription
period
Inventory
management for
returned drugs
Return channels
Medicines use
review
Drivers of customer compliance
Economic concerns, individual circumstances, health and safety, citizenship, legal framework
Figure 3: Components of an effective reverse logistics system
Drivers of customer compliance New
guidelines have been published outlining the
need to improve patient involvement in decisions about their medicines and thus promote
adherence.17 The pharmaceutical reverse logistics systems should be designed in such a
way that customer compliance is enhanced
through customer recycling behaviour.
Customer recycling behaviour is driven by
various factors, and it is necessary to develop
a model (Figure 2) for better understanding
of these drivers before constructing the pharmaceutical reverse logistics system.
The drivers of generic reverse logistics system are corporate citizenship, economic concerns and the legal framework,3 which are
also identified as the drivers of customer
compliance in pharmaceutical reverse logistics system, as shown in Figure 2. In addition,
environmental considerations, health and
safety, individual circumstances and financial
incentives are identified as the other four
drivers to customer compliance. The legal
framework, corporate citizenship, economic
concerns, environmental considerations, and
health and safety are classified as perceptional
drivers, while individual circumstances and financial incentives represent conventional operational drivers. The environmental,
economic and safety considerations have
been justified above.
Legislation governing the disposal of
household pharmaceutical waste can impose
a legal obligation on customers to return unused medicines. In Jefferson County,
Wisconsin, prescription medicines have to be
be separated from household pharmaceutical
waste when being returned, and the medicines accumulated from more than one
source have to be disposed of according to
national regulations.18
Corporate citizenship requires customers
to handle pharmaceutical waste from an environmental and social point of view. Having
the initial motivation for environmental protection, customers recycle unused medicines
properly. If individual customers have positive
environmental attitudes and active concerns
www.pjonline.com
about health and safety, then higher levels of
recycling behaviour should happen.
Considering the hazards that out-of-date
and unused medicines pose to children and
other vulnerable people, customers will have
enhanced compliance in recycling the excess
medicines in households to reduce the risks.
Customers should not need training and education to perform their role as reverse logistics agents (delivering part of the service on
behalf of the pharmacy) because they cannot
be expected to separate out hazardous waste.19
The responsibility for decision-making on
medicines resides with pharmacy staff so all
patients should be advised to return unused
medicines.
Supporting customer involvement To
make the reverse logistics system operate
properly, individual circumstances have to be
taken into account when encouraging customer compliance. From a customer’s perspective, individual circumstances refer to:
■ Access to recycling services via the medicines retailer, the manufacturer, or other
providers: maximised recycling provision
should result in enhanced customer compliance.
■ Socio-demographic variables, such as age
and knowledge: individuals with greater
environmental consciousness and more
knowledge on how and what to recycle
should have enhanced compliance.
■ Recycling experiences: positive experiences can promote enhanced customer
compliance.
It should be noted that incentive schemes
can underpin and stimulate compliance, for
example, customers could be rewarded, by
giving them vouchers for returning unused
medicines, or perhaps exchanging them for
other medicines.
The same logic can be applied to internal
reverse logistics practice. In 2005, Coventry
PCT introduced a local enhanced service
called the “not dispensed” scheme.This service allowed pharmacists at the time of dispensing a prescription to ensure the patient
needed all the medicines. For every “not dispensed” noted on the prescription an extra
fee could be claimed from the PCT.20 The
same practice has been adopted elsewhere.
Pharmacists in the Republic of Ireland, for
example, can claim a fee of £1.87 for not dispensing a prescription after the “exercise of
professional judgement”.21
Some might believe this to be a regressive
action since it does not tackle the root cause:
ineffective prescribing.They might argue that
the action taken by pharmacists in this example masks the problem and incurs a double
cost — the cost of prescribing more medicines that may be unnecessary and not used,
and the cost of rewarding pharmacists.
System framework
Based on the drivers identified in Figure 2, a
framework has been developed to provide
key components to be considere in the design
of a pharmaceutical reverse logistics system
(Figure 3). Considering the unique characteristics of the medicines, five central areas are
recommended in designing a reverse logistics
system for community pharmacy:
1. Customer advice and support
Customer compliance in returning unused
medicines should be advocated and stimulated via different communication channels,
such as the internet, broadcast and print
media, and pharmacy or NHS leaflets. The
need for more visual information such as recycling logos and alerts such as “Keep out of
reach of children” should be considered to
maximise the usefulness of the packaging and
raise customer awareness of the product they
are handling.
2. Customer relationship management A comprehensive customer relationship management programme based on the
reverse logistics system can have a significant
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impact on increasing customer compliance. It
is needed to provide customer support and
service, answer customer enquiries, and take
customer feedback when handling the returned medication.
A sustainable pharmaceutical supply chain
cannot succeed without the contribution of
its customers. Customers are already asked to
return medicines, but no effort is made to encourage or manage their involvement.
Customer involvement must be prompted and
supported through the use of information systems and technology. Indeed, findings from a
Swedish study indicate that a customer-centric approach — which a reverse logistics system should be — should be devised.22
Customers have more power collectively
than as individuals,23 however an individual
approach to managing the customer could be
facilitated with better technological resources. From an operational point of view
the more standardised the approach the better, as it would require less resources and
funding.
3. Product management Medicines
should be designed to facilitate the returns
process:
■ The design and packaging should facilitate
carriage and return.
■ GPs should write prescriptions for shorter
periods. Shorter prescription periods
(seven to 14 days) have been successfully
trialed in Canada.24
■ Reviews of the use of dispensed medicines
are regularly conducted by GPs and community pharmacies as part of their NHS
contract obligations. These should help to
reduce unnecessary medicines in circulation and promote informed decisions
about pack sizes and synchronisation, as
advised by the National Prescribing
Centre.
■ Allowing customers to collect repeat prescribed medicines from community pharmacies without consulting a GP each time
allows pharmacists to ensure patients are
taking their medicines correctly and find
out if they are experiencing any side effects. Such a service reduces the amount of
medicines in circulation.
4. Effective inventory management
Returned medicines need to be properly
classified, stored and disposed of. Therefore,
proper inventory management should be in
place in the reverse logistics system.
5. Drivers of customer compliance
Enhanced customer compliance, spurred on by
the drivers of environmental concerns, individual circumstances, health and safety, corporate
citizenship and legislation, will help ensure the
success of a pharmacy reverse logistics system.
Conclusion
The aims and objectives of any reverse logistics system need to be realistic.While the return and recycling of pharmaceuticals is
desirable in reducing waste and encouraging
efficiencies in prescribing, especially in the
light of the economic downturn, where the
NHS is facing a reduction of between £8 billion and £10 billion in the three years from
2011,25 it is not a critical objective for the average household. UK families have more
pressing issues. This being the case, there
needs to be a concerted effort for the reverse
logistics agenda for pharmaceuticals to plug
into personal agendas to ensure that returns
actually take place.
Consideration needs to be given to the
breadth of this issue. Ultimately, the focus of
this article is the reverse logistics system. If
well designed it could provide a safer, medicine-free domestic environment and help lead
to more effective prescribing, thereby generat-
ing cost savings.A broad approach needs to be
adopted in relation to medicines design, manufacture, distribution and disposal.
We cannot forget that there is a cost to designing and delivering an effective reverse logistics system. Pharmacies encourage patients
to return medicines, but do not reward them
for doing so. Considering that costs are incurred in designing and publicising such activities and there are charges for final disposal, the
purpose of the reverse logistics system for
pharmaceuticals in community pharmacy
could be questioned. Not everything servicerelated can be costed.The potential savings derived from prescription data and reduction of
potential hazards or accidents are valuable considerations. In summary, an effective reverse logistics system can influence the following:
■ The return of potentially hazardous materials to pharmacies, reducing the risk of
accidental injury, misuse or abuse
■ Awareness and social consciousness of
medicines recycling
■ Patient engagement with the NHS
■ Improved prescribing practice whereby
patients are prescribed medicines more
frequently, ensuring more contact time
with health professionals
■ Information gathering, by providing valuable information, which can promote effectiveness in practice and efficiencies for
the NHS
■ Improved collaboration among medicines
supply chain stakeholders
The success of a reverse logistics system
lies in its execution and this is dependent on
the approach taken by the NHS to managing
customer involvement and behaviour.
ACKNOWLEDGEMENTS Thanks to
Rowlands Pharmacy for permitting access to
and use of its waste audit results for 2009.
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