Medicines optimisation: Spotlighting suboptimal treatment and prevention led investment

Previously, I challenged the idea that the prescribing budget should be managed as a cost centre.

I argued instead for medicines to be seen as strategic investments that deliver long term system value through better outcomes, fewer non-elective admissions and improved patient outcomes.

But if we truly want to unlock the potential of medicines optimisation, we must go a step further.

We need to confront the pervasive issue of suboptimal treatment, not as a clinical curiosity but as a daily operational and financial burden felt across the NHS.

Because every missed opportunity to optimise treatment isn’t just a patient care issue, it’s an avoidable outpatient visit, an unnecessary emergency department attendance, and a potentially preventable non-elective admission.

The good news is these patterns are predictable, identifiable and fixable.

Read my blog – If I Was Wes Streeting, This Is What I Would Do – here.

Four faces of suboptimal care

Across my work, I’m seeing four common patterns emerge, usually easier to identify in outpatient care, and each is a clear example of how patients, while engaging with the system, are falling through the cracks of the optimisation agenda.

I hasten to add that no healthcare professional ever deliberately suboptimally treats a patient. This happens over time and for a variety of reasons. But if we find ways to better utilise the prescribing budget and the medicines optimisation teams and correct this, the win for the patients and the NHS is significant.

1. Correct diagnosis, but no longer on treatment

These are patients who were appropriately diagnosed, often started on treatment, but for various reasons are no longer actively managed. Sometimes that’s due to poor follow-up. Other times, side effects led to discontinuation, but no alternative has been offered. In some cases, patients simply stopped collecting their prescription, a silent off ramping from care.

In respiratory disease, we see this frequently. A patient diagnosed with COPD is initiated on inhaled therapy, receives a care plan and attends the first few reviews. Then, for whatever reason, life circumstances, poor inhaler technique or loss of motivation, they stop. Months later, they present at A&E with an exacerbation that could have been avoided if adherence and support had continued. They weren’t “lost to follow-up” in a data sense but, in a therapeutic sense, they absolutely were.

2. Correct diagnosis, wrong (outdated) treatment

Many patients are on treatment but not the right one. They were diagnosed correctly and started on what was once considered best practice. But as guidelines evolve, treatment options improve, and outcomes data accumulates, their therapy no longer reflects current evidence.

Take type 2 diabetes. Despite NICE guidelines highlighting the role of SGLT2 inhibitors in patients with heart failure or high cardiovascular risk, many patients remain on sulfonylureas or metformin monotherapy. Why? Often, because the “old gold standard” has simply not been reviewed, or because there’s fear that updating treatment regimens will drive up cost. But the true cost is in the strokes, MIs and hospitalisations that might have been prevented with newer therapies.

The same is true in dermatology, where patients with moderate to severe atopic dermatitis still languish on topical steroids and antihistamines, despite clear eligibility for biologics that could dramatically improve their quality of life and reduce dermatology outpatient demand.

3. Correct diagnosis, right treatment, poorly optimised

Then there are patients who are on the right molecule, but the delivery, adherence, dose titration or engagement strategy hasn’t kept pace. This is optimisation’s blind spot. It’s easy to tick a box that says “on treatment” but much harder to know whether the patient is actually getting benefit.

This is painfully evident in asthma. A patient may be on an inhaled corticosteroid and a LABA, technically, correct therapy. But are they using it correctly? Are they adherent? Has their inhaler technique been checked recently? Is their asthma control being assessed via ACT scores or exacerbation history? Too often, the answer is no.

The result? Preventable outpatient attendances, steroid bursts, missed workdays and eventually non-elective admissions.

This isn’t about prescribers doing anything “wrong”, it’s about systems not being configured to support optimisation across time, touchpoints and settings.

4. No diagnosis: patient still requires work-up

Perhaps the most overlooked group is made up of patients who haven’t even had the benefit of a full diagnostic work-up. Their symptoms are well known to the system, perhaps they’ve had multiple primary care visits, several A&E attendances or recurring presentations at outpatient clinics. But for one reason or another, no formal diagnosis has been made.

These are patients with breathlessness who’ve never had spirometry. Patients with vague gastrointestinal symptoms who bounce between empirical treatments without a structured referral. Patients with fatigue, weight loss or pain where investigations are started but never completed. Without a diagnosis, no optimisation is possible. These patients float in clinical limbo, frequently using NHS resources without ever entering a pathway that could offer control or resolution.

Lack of diagnosis isn’t just a missed clinical opportunity; it’s a system inefficiency. It results in repeated contact with services, inappropriate prescriptions and preventable escalation of symptoms that could have been addressed earlier with structured assessment and timely referral.

These are all real world examples from 20 years of working with the NHS. My most recent example came in a cardiovascular, renal and metabolic diseases project where the consultants across the specialities kept count for one month of the reason patients were in outpatients. A total of 80 per cent were in one of the categories above.

The opportunity in prevention led investment

Medicines optimisation, when done right, is prevention in action. The right medicine, taken properly, can halt disease progression, avoid crisis episodes and allow patients to live fuller, healthier lives. But prevention isn’t just a philosophy, it’s a practice that demands investment.

So where are the bright spots? Where have systems or companies invested in medicines optimisation as a route to prevention?

Examples of prevention led investment I’d like to hear more of

I’m looking to both NHS systems and pharmaceutical companies to share examples of prevention-led investment through medicines. You can message me privately, and if you don’t want to be named, I will respect that, but I am looking for great examples we can share across my network to see if we can start to stimulate the debate and then see some action.

From the NHS, we want to hear:

• Where have ICBS invested in medicines optimisation to prevent admissions?
• Which systems have moved beyond cost savings to commission outcome driven pathways that include medication review, adherence support and condition specific optimisation?
• Have any Health Boards embedded structured medicines optimisation as a lever for reducing waiting list backlogs or cutting unnecessary outpatient appointments?

From Pharma, we want to see:

• Real world evidence programmes showing reduced emergency attendances or bed days following adoption of newer therapies.
• Value based or outcomes based contracting models where pharmaceutical companies share risk with NHS systems to drive better health and system outcomes.
• Nurse/pharmacist or other healthcare professional led optimisation services or pathway redesigns co-developed with the NHS to tackle long-term condition management more proactively.

These examples exist, but they remain the exception, not the norm.

The need to reduce General Practice and hospital demand is now mission critical

We are at a turning point in the NHS. The financial pressure is intensifying, and the workforce is stretched to its limits.

If we don’t optimise medicines, we’ll continue to treat the consequences of suboptimal care at much higher cost, both in financial and human terms. But if we do, we unlock a triple win: better outcomes for patients, reduced pressure on services and smarter use of public money.

This isn’t theory. It’s operational reality. Optimised prescribing, when embedded in system planning, reduces avoidable appointments, referrals and non-elective admissions, it frees up clinical capacity and builds a more resilient health service.

Working toward a whole system view

The challenge is breaking out of the silo. Prescribing budgets sit in one pot. Admissions costs sit in another. But patients don’t live in silos and neither do the consequences of poor treatment decisions.

To change this, we need:

• Joint budgeting and shared outcomes. Medicine optimisation should be co-owned by primary care, secondary care, and system finance leads. Shared outcome frameworks can break down turf wars over who ‘pays’ and who ‘benefits’.
• Better use of data. Systems need analytics that link prescribing decisions to downstream impact; outpatient referrals, emergency department attendances, hospital admissions and patient reported outcomes. This requires improved interoperability and data sharing agreements.
• A new conversation about value. Every new medicine needs to be judged not by price per pill but by impact per patient. That means looking at quality of life gains, disease control rates, avoided escalation and avoided downstream workload, not just cost savings in the prescribing budget, which are not savings if the ICB or Health Board is overspent.

System wide buy-in needed to make the most of this opportunity

We already know that medicines can be one of the most powerful tools for prevention in the NHS. What we need now is system wide commitment to harness that potential.

Let’s stop asking if the medicine is cheap. Let’s start asking if it’s effective. Let’s identify patients who are being left behind, not due to lack of diagnosis but due to failure to act on it.

And let’s celebrate and share the examples, from NHS systems and industry alike, where a prevention led approach to medicines is already delivering better outcomes at lower system cost.

Because when we move beyond the myth of cost savings and embrace the real potential of medicines optimisation, we don’t just balance the books. We rebuild the NHS, one patient, one prescription, one outcome at a time.

Scott McKenzie helps pharmaceutical, medical technology and device firms get their products and services in front of the right NHS decision-makers. In 2023 alone, he helped land 53 new NHS projects, and he added a further 28 in 2024. His 12-month coaching and mentorship programme – revamped and expanded for 2025 – offers tools, NHS customer insights and direct decision-maker introductions to get your projects over the line. Scott’s support is grounded in real world experience of what gets approved, funded and sustained across systems, places and provider collaboratives, turning strategy into impact and frustration into progress. Find out more here.