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INSIDE HEALTH

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Programme 1.

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TX:Ìý 01.07.14Ìý 2100-2130

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PRESENTER:Ìý MARK PORTER

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PRODUCER:Ìý ERIKA WRIGHT

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Porter

Hello and welcome to a new series of Inside Health. Coming up today:Ìý Improving cancer survival rates – could naming and shaming GPs who miss cancers help reduce delays in diagnosis? ÌýHealth Secretary Jeremy Hunt appears to think so, others are not so convinced.

Recycling medicines – the NHS wastes around £300 million every year on unused drugs, many of which are returned unopened to pharmacies. Why can’t they be re-cycled?

And reflux and heartburn – new draft guidance from NICE advises that GPs should consider referring people with persistent symptoms for an endoscopy. But don’t most of the millions of people in the UK with reflux have persistent symptoms? I know I do.Ìý So I thought I’d find out what is involved. You might want to turn the volume down for this next bit….

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Actuality – Endoscopy

Ah it’s in now, just breathe – are you alright Mark?

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I’ll tell you what I’m never going to be a sword swallower.

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Oh yes you could – 10 out of 10.

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It wasn’t too bad, it’s just the gagging.

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Porter

More on the state of my gullet later.Ìý But first statins. While Inside Health has been off air this cholesterol lowering family of drugs has been all over the news. And the ensuing debate among experts about who should be taking them and who shouldn’t, has led to widespread confusion. And not just among the general public. Joining me to explain why, the Editor of the Drugs and Therapeutic Bulletin, Dr James Cave.

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James, this all started when the National Institute for Health and Care Excellence – NICE – proposed lowering the threshold for offering statins, a move that could mean as many as five million extra people in the UK would be taking them.

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Cave

You know it’s a fascinating time and this is about people, so this is about healthy people who go to see their doctor perhaps and are told – ooh you ought to take a tablet to keep you well.Ìý And I think it’s really important we don’t confuse that with patients who are currently on a statin because they have had some sort of heart disease or stroke because those patients, we know from evidence in the past, actually very good benefit from statins.

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Porter

But this isn’t about giving it to patients is it, it’s about giving it to people.

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Cave

Exactly.Ìý So what’s happened after the success of that things have moved on and we have begun to see sort of mission creep and the use of statins in patients who’ve got a certain level of risk in the future, so they’re not really patients at all, these are people.Ìý And what’s happened recently, largely because actually statins have come off patent and are now cheaper, statisticians have looked at the evidence and said – actually they are now cost effective to give to people who are at low risk of heart disease.Ìý So you and I and seven million people out there we all can take a statin now because it’ll do us good.

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Porter

Now there’s been a big debate going on between doctors mainly – in the journals in the media, some saying this is a good move, some saying it’s a bad move, it’s caused a lot of confusion.Ìý I don’t want to go into the rights and wrongs of that particular debate, that’s still being played out, but do you think that’s had a confusing effect on the public?

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Cave

Well I think really good therapeutics requires you to think of three areas – there’s the drug, there’s the patient or the person in front of you and there’s the doctor – and when you get it right you make sure that you get the right drug for the right person.Ìý And what’s happened here is we’ve forgotten that if you start treating healthy people their values, their approach to life becomes far, far, far more important than their risk in some respects.Ìý And I think we must include the person in this and let them decide whether for them it’s the right thing to do or not.

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Porter

Margaret McCartney’s in our Glasgow studio.Ìý Margaret, this decision by NICE is mainly based on cost effectiveness, it’s a bit like telling me with my car that no you don’t need any new tyres on your car and then ringing me up a week later and saying they’ve just come down, they’re half in price you might as well have a set.

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McCartney

Yeah but that’s exactly right.Ìý So NICE are making a cost effectiveness judgement on what’s worthwhile from their point of view of where to spend the money, I suppose one of my big concerns is that if we’re using statins to try and improve the public health, as it were, we’re kind of relying on people taking these tablets in the long term because we know that the effects are not just in a week or a month, it’s over years that you have to take them to see a difference.Ìý And what we know is that we’ve got this thing called the healthy attender effect where the people who are already the most healthy in society are the most likely to comply with or concord with the doctor’s recommendations.Ìý So we end up with a resource that’s directed towards the public health actually ending up with the people who are the most healthy to start off with and because of that I’m very concerned that health inequalities might actually get bigger because you’re aiming more of your resource at the most healthy and the less healthy are the people who are already going to live less long get left behind.

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Cave

One study recently, over 65 year olds who haven’t had any heart disease who were being given a statin only about 25% of those patients were still taking a statin about a year later.Ìý Patients don’t yet understand what’s going on here and I think until we can explain to people really well what this is all about and explain the public health issues because the problem about public health is what might be great if you’re sitting somewhere in an office in Leeds looking at the whole population and making great big moves on a map about how we’re going to help the population’s health that can be a very different policy procedure for you, as a patient, in front of a doctor talking about a drug.

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Porter

While I’ve got you both here I’d also be keen to hear your reaction to Jeremy Hunt’s proposal that GPs who miss cancers should be named and shamed.Ìý It’s part of an ongoing initiative to reduce delays in diagnosis and improve survival.Ìý At the moment the UK lags behind Europe when comparing survival rates for most cancers.Ìý

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Lynn Faulds Wood is Vice-President of the Patients’ Association and a bowel cancer campaigner.

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Wood

We obviously have an issue with the late diagnosis in the country as the Euro Care Data that compares countries across Europe shows we have.Ìý I used to do Watchdog and I think naming and shaming’s appropriate for villains, I don’t think it’s appropriate for GPs, I think GPs at the moment are really under attack and this is the wrong approach.

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Porter

Looking at your experience because you were diagnosed with bowel cancer, was there a delay in your case?

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Wood

I had nearly a year’s delay 23 years ago but I don’t blame my GPs for that.Ìý I helped to set up the world’s first symptoms database of this disease and symptoms are different than GPs learned in medical school.Ìý I think our guidance is sometimes not evidence based, even today.

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Porter

James Cave, we’ve got some work to do.

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Cave

Without a doubt we do.Ìý Against all international statistics we are really very poor when it comes to life expectancy following a diagnosis of cancer and a lot of that does seem to be focused on our delay in diagnosis.

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Porter

Now there’s lots of factors behind that but of course one factor might be that we doctors are not picking that up.Ìý Margaret, do you think it’s helpful that your performance can be analysed using the data for practice do you think it’s helpful that you’re named and shamed, would that make you a better doctor?

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McCartney

In general when things go wrong in the health service and there are inquiries about it the people who do the inquiries tend to come out and say that a culture of fear, blame and shame does not help anyone, least of all the patients.Ìý The problem that we have in general practice is that an awful lot of symptoms are really, really common.Ìý So, for example, about one in 20 GP consultations will involve a cough but the problem is that we will see lung cancer and a cough can be a symptom of that but we’ll only see one case of lung cancer every eight months or so.Ìý So what we’re always trying to do is find the needles in the haystack, where the choice is between a two week urgent appointment and an 18 week appointment.Ìý Now the urgent criteria are quite clear and a cough on its own that’s not going to be something that an urgent appointment would be granted for, so it’s going to go into the much longer 18 week wait system.Ìý And the problem there is you’re creating an instant delay.Ìý And I think my big concern is that we really do not have good enough tools to sort out who should go into the two week category versus the 18 week category.

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Porter

But Margaret that’s assuming that the GP makes the referral in the first place.Ìý One of the issues, I suspect, is that of continuity.Ìý If you go back and see a different doctor each time the penny may not drop.

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McCartney

Absolutely and we know that continuative care is much better in these kind of scenarios and yet our access system seems to be primed towards allowing people fast access, you know the kind of 48 hour access, rather than keeping going with the same doctor.Ìý So I think there’s lots of things that we could do to try and make this better.

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Porter

James, we have definitive guidance for managing many suspected type of cancers, is it that that guidance is flawed or that doctors are not doing what they should be doing and referring people when they present with those symptoms do you think?

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Cave

Well I think it’s both – our NICE guidance is now almost 10 years old and a lot of it actually has got a very poor evidence base so the positive predictive value, which is the phrase we use to say if you have this symptom this means you’re likely to have this problem, for a lot of the symptoms – for a lot of cancers it’s actually very low.Ìý Even our really quite good new guidelines, so let me take, for example, ovarian cancer, NICE produced some guidance in 2011 on ovarian cancer advising GPs how to use the new CA125 blood test and ultrasound screening to look for patients who have got persistent bloating, for example.Ìý The problem is that NICE guidance actually points out that it will still miss a third of all ovarian cancers.Ìý So a GP, even if they do everything right, will still miss a third.

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McCartney

The problem for GPs is that – maybe going to – I mean our practice is kind of five and a half thousand patients – we’re maybe going to have about 17, I think 16, 17 new diagnoses of cancer last year which is fairly steady.Ìý So if you’re looking at numbers as small as that – so that’s going between five GPs – your numbers actually become tiny.Ìý So actually trying to work out what’s good and what’s bad becomes quite difficult.Ìý And then the other problem is…

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Porter

So if you miss one or pick an extra one you could look very, very good or you good look very, very bad.

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McCartney

I’d look terrible but the numbers are so small that I’m not sure they really are reliable in any way.

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Cave

I think the issue we’re struggling with here is I have no problem with bad doctors being weeded out, that’s not the problem, and there’s plenty of ways you can do that through having them struck off, suing them in the courts, you know all doctors now have to be revalidated and appraised and part of that is looking at complaints.Ìý So all those issues are there to be sorted out.Ìý What we need to do though here is actually follow the leads from other countries in other parts of the world.Ìý So Denmark had a very similar problem here and what they’ve done is that they’ve supported their GPs, they’re developing these new treatment centres or investigation centres which allow GPs a middle way.Ìý We need something where GPs can say look I’m still really anxious about this person, they don’t fit the guidelines, they don’t fit the two week wait but I don’t want them to wait 18 weeks for a routine outpatients’ appointment, I want them seen by someone now and I want them to have a good look at them.

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Porter

James Cave and Margaret McCartney thank you both very much. And if you would like to see the cancer statistics for your local surgery, there is a link on the Inside Health page of the Radio 4 website. As well as one to the proposed changes to statins that we discussed earlier.

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Now time to turn the tables and for me to switch from doctor to patient:

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Actuality – Endoscopy

Please come through and your name sir?

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Mark Porter.

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And your date of birth?

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Twelve eleven sixty two.

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Do you know why you’re here?

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Yes an endoscopy.

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Okay.

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Porter

I have reflux – a condition where a weakness in the valve at the top of the stomach allows gastric acid to travel back up into the sensitive gullet causing heartburn. It’s a common enough problem and easily remedied in most cases by taking an antacid.

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But NICE is in the process of changing the guidance it gives doctors on how to investigate people with reflux. At the moment it advises against routine endoscopies - passing a camera into the stomach of people with reflux - unless they have alarm symptoms like difficulty swallowing. But it is now suggesting that people with persistent symptoms should be referred for further investigation. People like me.

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The main concern is that reflux can alter the lining of the lower gullet and predispose to changes known as Barrett’s disease and that can lead on to cancer.

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My heartburn has been increasingly difficult to control so I was referred to Professor Hugh Barr, a specialist at Gloucester Royal Hospital. Be warned, this report may contain sounds you find disturbing.

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Actuality

I’m just going to check your blood pressure, okay.

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Bit higher than normal I think.

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Most patients’ blood pressure – well it’s usually high because they are anxious.

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Barr

Well hi Mark, so what’s been the trouble?

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Porter

It started when I was about 44, came out of the blue and I’d go out at the weekend, have a bit too much to eat, bit too much to drink or something and I noticed I was getting a bit of heartburn the next day, so I started taking antacids on an ad hoc basis.Ìý I then got to the stage where I was needing to take them every day and in the last 18 months I’ve had to take increasing amounts, so I’m now on twice as much as I used to need and if I go out and I eat or drink too much then I’m getting symptoms.Ìý And I’m a little bit concerned that it’s been going on for that length of time, I’ve never really known what’s going on inside me and my father had similar symptoms and had problems with his oesophagus that needed continual monitoring.

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Barr

Right, well it’s a very typical story Mark, I’m afraid.Ìý The first thing to say is very likely nothing to worry about, most patients are simple refluxers, there’s a [indistinct word] of reflux disease where we’ll need to perhaps make sure that it is – the inflammation’s damped down, then there’s Barrett’s.Ìý Now only one in 10 will have Barrett’s, that’s what we’re looking for, we’re looking for is there a chance, I daresay you’re worried about, of this degenerating to anything more serious.Ìý The chances are very, very small.

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Porter

So what will you – I mean when you’re looking, when you’re doing an endoscopy can you tell almost immediately, just by looking with the naked eye, whether there’s an issue there or not?

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Barr

Yes we’ll be able to tell whether you’ve got Barrett’s, we’ll do this with you awake if that’s okay, can give a little light sedation but it’s fairly straightforward – we spray your throat, have a look down, talk you through it and I’ll tell you what we see as we’re going through.Ìý If I take a biopsy I’ll tell you what we’re doing, we’re taking a little sample of the lining of the oesophagus or other area, that I’m afraid will go to pathology and the big problem is it takes just a few weeks to come back.

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Porter

And in terms of what I’m going to feel during this – I mean obviously something in the back of my throat that’s probably the most unpleasant part – the gagging – but once it’s inside your stomach you don’t feel anything?

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Barr

You’ll feel a little bit of gagging and that’s a little bit variable, we have done sword swallowers who swallow it – self-administer – we’ll go and look at the back of the throat, the oesophagus starts there, then we’ll go all the way down, then when we get to the stomach we’ll blow you up, so you’ll feel distended, the area of most interest with people like yourself, with reflux disease, is where the oesophagus joins the stomach, that’s where the acids builds up – that is the food pipe as it joins the stomach, that is where bad things are starting to happen, particularly in this country.

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Vaughan Davis

My name’s Sarah Vaughan Davis, I’m senior sister in Endoscopy at Gloucester Royal.Ìý We roughly would say to people to expect to be here for a total of three hours, if they’re having sedation.Ìý

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Porter

And what proportion of people would have sedation?

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Vaughan Davis

Probably about 50% of patients will have sedation, it depends on how nervous they’re feeling, if they’re going back to work, if they’ve got things to do in the evening or over the weekend.

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Porter

And what about those who’ve just had the local spray – they can go home almost immediately?

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Vaughan Davis

Yeah, we have a xylocaine anaesthetic spray, it tastes a bit like bananas, so patients who are allergic to bananas they cannot have it, but most patients are able to tolerate the spray, it’s a funny taste and it makes the throat feel quite odd but patients can still swallow.

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Porter

And the idea is of course that that numbs – reduces the gag reflex.

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Vaughan Davis

Yes.

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Barr

Right, we’ve sprayed him up.Ìý It’ll go a bit funny, it tastes like bananas.

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Porter

Well I’m driving home so hope it works.

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Barr

Okay Mark, if you just lie down on your left hand side facing me and then we’ll put in a mouth guard and then they’ll be no more speaking.

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Porter

To stop me biting…

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Barr

Yeah it’s a little bit of an expensive bit of equipment and we mustn’t damage your perfect teeth.

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Nurse

I do apologise about this part.

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Barr

Lovely.Ìý Can I just have a look at the back of your throat – well done Mark, brilliant, fantastic.Ìý Are you sure you’re not a sword swallower?

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Nurse

Okay bear with me.

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Barr

That’s a little bit of belching, I’m putting wind in.Ìý Yes that’s perfect.Ìý It’s in now.Ìý Just breathe.Ìý We’re just resting there.Ìý That’s looking fine.Ìý We’re in the oesophagus – the food pipe now – moving down.Ìý It looks perfect, it looks perfect, it looks perfect, absolutely fine, no hint of any Barrett’s Mark, brilliant, fantastic.Ìý That’s perfect on the inside as the outside, eh, what do you think?Ìý Okay, are you alright Mark?Ìý Fantastic.Ìý Let’s get your immediate response.

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Porter

Blimey.Ìý I tell you what I’m never going to be a sword swallower.

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Barr

Oh yes you could, 10 out of 10.

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Porter

It wasn’t too bad, it’s just the gagging.

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Barr

Take that off.

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Well Mark your endoscopy – absolutely normal, nothing to worry about, there’s no hint of pre-cancer, anything like that.

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Porter

That’s what I wanted to know really that I can take medication ongoing knowing that there isn’t anything under there that I’m covering up or that I should be keeping an eye on.

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Barr

Absolutely right.

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Porter

Which brings me to the point really that there must be tens of thousands, hundreds of thousands of people like me out there who’ve got reflux, they’re middle aged, they’ve been taking very effective medication for years – is it okay for them to go without the endoscopy and just keep taking the pills?

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Barr

This is a matter that NICE is struggling with, Cancer Research UK are struggling with and our patient groups are struggling with.Ìý When should we have an endoscopy for somebody such as yourself?Ìý Why did you not get Barrett’s when you’re refluxing?Ìý The answer is probably in your genes.

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Porter

So Hugh what could you have found that would concern you as a surgeon?

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Barr

We’re looking for changes, particularly in the lower oesophagus, where the lower oesophagus has been subject to a lot of acid reflux and has changed its lining.Ìý Now when it changes its lining it’s to protect itself, in fact some patients lose their symptoms at that point, and it’s protecting itself by becoming a bit more like the intestine, so it resists acid.

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Porter

This is because the stomach has natural protection against acid but the lower part of the gullet going in doesn’t?

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Barr

It shouldn’t be there, the acid shouldn’t be there.Ìý So in those patients, some of them, only a very small proportion, may progress to pre-cancer and even worse actual cancer.Ìý And that is a very difficult cancer to treat, it’s a big problem in this country and it is trying to find the bad Barrett’s is the target of much focused attention at the moment.

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Porter

So to put it very simplistically – one in 10 people with reflux may have Barrett’s and one in – as many as one in 10 of them may go on to get more serious problems.Ìý What we don’t have is a simple way of identifying who’s got the Barrett’s, so like me I thought I might have Barrett’s but unless you scope everybody, hundreds of thousands, possibly millions of people, you’re not going to know are you?

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Barr

We’re not, that is a challenge that we’re struggling with and at the moment we are endoscoping quite a lot of patients, this is a challenge of course but we’ll struggle with this and there’s no doubt the severity of the reflux, if you’re a night-time refluxer, if the reflex is getting worse or indeed if there’s change in symptoms, then we are quite anxious to see people fairly early.Ìý If you’ve got heartburn it is not trivial, it can lead to cancer.Ìý Now who’s going to get the cancer?Ìý We don’t want to hype it up too much and make people anxious but we do want to see you if you’ve got bad heartburn, don’t just go away and ignore it.

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Porter

Because this is something that NICE is struggling with at the moment – looking at their draft guidance they say that we should not be doing endoscopies purely to go looking for Barrett’s disease, early changes, but we should be considering it in people who’ve got persistent symptoms, whose symptoms get worse or whose symptoms don’t really respond well to treatment but still that’s an awful lot of people.Ìý I mean the persistent symptoms – it seems – is there some sort of behind the scenes debate going on here, it seems a very difficult decision to come to?

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Barr

I’m afraid you’re absolutely right, this is a very important issue and everybody’s struggling with it.Ìý We’re really anxious to prevent oesophageal cancer and you’re quite right, you’ve highlighted the problem, the only way we can find the pre-lesion is to look.Ìý So the debate is how much money are we going to spend to prevent you getting oesophageal cancer and is it effective?Ìý NICE will make recommendations and the draft guidelines have excited a frisson of debate from colleagues whose main agenda is to – as mine is – to prevent oesophageal cancer.

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Porter

So where do you sit then – I mean this is just a personal opinion – do you think we do enough endoscopies at the moment or do you think we do too many?

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Barr

I’m a little conflicted because I have been advising NICE.Ìý I sit on the do more.Ìý My agenda and my problem is that I see people with advanced oesophageal cancer and it is very, very difficult for them and their families and we know that if we could just detect this early we could prevent it.Ìý But we will try to provide some degree of clarity.

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Porter

Professor Hugh Barr.Ìý And NICE should be publishing its final decision on who should have an endoscopy, and when, later this year. In the meantime, if you are due to have one don’t be put off by my retching. It sounded much worse than it was, although you might want to consider sedation if it is offered.

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Now, where do you keep your medicines?

Patient

So here’s my little fridge that the NHS supplied me with and here’s my supply of medicines.

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Porter

This Inside Health listener – who wants to remain anonymous – got in touch to ask why more isn’t being done to re-use unwanted drugs.

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Patient

If you’re immune deficient in the sort of way I am you need injections of antibodies and every week I inject myself with six of these phials that I’m carrying in my hand.Ìý I’ll just get one out – little phials that are kept in a fridge.Ìý And these cost the NHS about £65 a phial – it’s a lot of money.Ìý If I stop having home injections or if I die it’s against the law to put these back in the pharmacy for somebody else to use.Ìý And I think that’s absolutely outrageous.

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Patel

My name’s Neil Patel and I’m Head of Corporate Communications for the Royal Pharmaceutical Society.Ìý This is a question that’s being asked in a pharmacy today – I can guarantee a patient will be walking into a pharmacy and asking why can’t these medicines not be used for someone else.Ìý I think it’s probably one of the more common questions that pharmacists get.

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Porter

So what happens to the medicines that are brought back to the pharmacy or indeed a doctor’s surgery – are they destroyed?

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Patel

Effectively yes, I mean there is a very closed system to make sure firstly those medicines can’t leak out in any other areas, so that environmentally there’s no problem of contamination but effectively they’re incinerated.

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Porter

What do the rules say about a patient returning a medicine?Ìý What happens if he or she just walks out of the pharmacy and then realises they’ve got the wrong medicine or it wasn’t what they wanted to order?

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Patel

The rules are very clear – as soon as it’s in the patient’s possession then effectively unfortunately the pharmacy can’t guarantee the medicine has been stored or used in an appropriate way so we can’t use it for another patient.Ìý Now of course if a patient was literally in the pharmacy and said oh I’m going to give you this one back, I think they’d be some discretion there.Ìý But once we go beyond that it’s difficult because we just can’t guarantee what’s happened to that medicine.

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Porter

Margaret, is this an issue that raises its head at your surgery?

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McCartney

Oh totally, I think in common I think with most GP practices – we prescribe something in error or by accident, someone gets two of something when they were only expecting one of it and it’s always gratifying when someone leaves my consulting room, reads their prescription and immediately comes back and sort of says actually you’ve given me the wrong thing – the medication – and then realise well actually they’ve had that before and I didn’t like it for whatever reason.Ìý So I think there is quite a lot of medicines that are dispensed but are not used and they go straight back to the pharmacy in a completely untouched state and it does make you think actually there’s a bit of a waste going on there that really is avoidable in some way.

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Porter

Do we have a figure on the sort of waste involved?

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Patel

Yeah we estimate around £300 million, which is a considerable amount of money.Ìý Now we’ve got to put that in context…

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Porter

These are drugs that end up in the bin?

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Patel

That’s right, that’s the medicines waste total yearly cost. ÌýNow it’s important to recognise, as Margaret has said, a lot of people will use a medicine, perhaps they don’t get on with it and therefore it’s not going to be used again by that person, it might be a part pack, but there are medicines – and I think it’s a really good point to make – that people are perhaps prescribed and dispensed and maybe they don’t quite know what that medicine’s for or perhaps they don’t understand why they’re getting side effects and for me it’s important – and I think this is a real change that’s going on in pharmacy at the moment – pharmacies are spending a lot more time with patients now, making sure when they get a new diagnosis and they get those new medicines they understand what they’re for, hopefully understand that it might take a few weeks for them to work which stops that binning of a medicine in the first few weeks.

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Porter

And if they’re concerned I mean what they should be doing is perhaps opening their medicines at the pharmacy and if they’ve got any queries dealing with them there and then so the medicines don’t end up in the bin.

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McCartney

I think one of the problems is that because we have so many automatic prescribing schemes – so we have monthly dispensing schemes – and sometimes patients end up getting more medicines than they need or want but they get dispensed to them anyway but then they can’t be returned because even though they’re not needed they’ve been automatically generated for them but they’re not actually going to be used.Ìý And I think there is – although the intention of the monthly medication scheme was in essence a good one, trying to reduce waste, my concern is it’s actually increased waste in some ways.

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Patel

The big issue that we have is counterfeiters and unfortunately counterfeiters are getting very clever and the medicines that we’re seeing that are counterfeit look very similar in terms of the packaging, the designs, even the drugs themselves look very similar and providing another route in for counterfeiters is something that concerns us.Ìý So I think if we are going to enter into a discussion about how do we recycle or reuse medicines we’ve got to make sure that we understand it’s not a free medicine, we’re going to have to put an infrastructure in place to check quality and of the same quality as a medicine that was off the shelf of a wholesaler.

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Porter

Margaret, do you think patients would be happy to take a medicine that had been handed back into the pharmacy?

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McCartney

There was one survey done a couple of years ago and they found that 52% of patients would be quite happy to accept a recycled medicine – a medicine that had been handed in from someone else.

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Porter

And 52% that’s still only half isn’t it so we’re basically saying half wouldn’t be happy.

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McCartney

Yeah and I think it depends how’s that sold to people – is it sold to people as something that’s got some kind of risk attached to it, that we’re not very sure about where it came from or what’s happened to it when it’s been away from the pharmacy shelves or is it something which is still sealed, still actually in date, didn’t need to be refrigerated or anything like that, it’s got no kind of storage criteria attached to it.

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Patel

I think really if we’re going to be investing money, NHS money, in medicines we owe it to ourselves, to the patients, to spend a bit more time with people and perhaps avoiding some of the side effects as well and hopefully avoiding the bin.

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Porter

Neil Patel and Margaret McCartney.Ìý And there is more information on returning unwanted medicines on our website. Go to bbc.co.uk/radio4 and click on I for Inside Health.Ìý And please do get in touch if there’s a medical issue that’s confusing you, you can e-mail me at insidehealth@bbc.co.uk.

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Just time to tell you about next week when I will be taking to my bike to learn how your choice of saddle can affect your sex life. And we will be discussing the pros and cons of recording consultations with your doctor.

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ENDS