Primary Care
Medicines are a cornerstone of healthcare delivery. As the single most common intervention in the NHS today, medication helps patients manage health, reduce pain, prevent and cure illness every day.
However, in recent times medicines optimisation has increasingly been identified as a priority the health system needs to ‘to get right.’
The cost of prescription medicines to the NHS budget in England has risen to new highs – 17.2 billion according to reports. Around 50% of adults take one prescribed medicine. While polypharmacy affects 1 in 3 people aged 65 and older who take 5 or more medicines every day.
With objectives to reduce prescribing spend, and at the same time, continue to improve patient outcomes, there are a range of issues.
From medications not being taken as prescribed through to overprescribing and medication errors. At the same time, medicines optimisation can often be a complex, time and resource-intensive process. And both of the latter, as we know, are in short supply for many teams at present.
With primary care increasingly looking to double-down on medicines optimisation, we explore the scale of the problem and possible solutions as services seek to deliver value in prescribing.
Firstly, let’s look at how medicines optimisation may be defined.
Rather than simply looking at acquisition costs or ways to make cost-saving medication switches, we must assess the true value medicines are delivering to the patient.
As stated by NHS England:
“It is about ensuring people get the right choice of medicines, at the right time, and are engaged in the process by their clinical team.”
NHS England has identified 4 key principles of a patient-centred approach to medicines optimisation which are: (1) aiming to understand patient experience; (2) providing evidence-based choice; (3) ensuring medicine use is safe; and (4) making medicines optimisation part of routine practice.
Value is multifaceted and involves a consideration of both clinical outcomes as well as costs. It's looking at how medicines impact the individual and their quality of life. Additionally, medicines optimisation also represents an opportunity to reduce duplicate processes which can persist for example with chronic multimorbidity and polypharmacy.
Effectively scaled medicine optimisation programmes not only promise better patient outcomes, but better care experiences for patients, physicians and prescribers too. Streamlined medication processes can go hand-in-hand with efficiency gains.
To support medicines optimisation, structured medication reviews with clinical pharmacy working as part of the primary care team have become part and parcel of general practice today.
But how do teams identify interventions that will have the biggest impact and who is in the greatest need?
The key is data. Analytics can both pinpoint variation in prescribing and where action is required. This can be done proactively with simple searches and risk stratification tools. Data-driven medicines optimisation can improve safety, address non-adherence and reduce costs.
High-risk patients should be prioritised by frailty, care homes, polypharmacy, taking potentially addictive medications and those regularly associated with errors. And a number of tools can support analyses such as PINCER, the electronic frailty index and ePACT2.
While such initiatives can be time consuming and resource intensive, investing in the necessary skills to support data-led prescribing improvement programmes is vital.
Suvera provides an end-to-end service for condition management including data analytics. Our team helps you proactively identify patients who need support. We conduct searches, segmenting registers by risk, birth month and overlapping comorbidities to guide efficient, timely intervention.
It’s estimated that 237 medication errors occur in England every year and an associated 712 deaths. 1 in 20 prescriptions has an error while 1 in 550 is a serious error.
It’s no surprise that errors are more likely to occur in elderly patients and individuals with chronic multimorbidity due to multiple medications. It’s also common during transfer or care. One study found that 43% of patients experienced medication-related harm post-discharge of which 52% was preventable.
Accurate medicines reconciliation, good governance and record keeping are integral to reducing error. In primary care, as recommended by NICE, reconciliation for all people discharged from hospital or another care setting should happen as soon as is practically possible before a prescription or new supply of medicines is issued and within one week of the GP practice receiving the information.
As well as embedding optimal processes, we can also build greater confidence in prescribing by developing and sharing specialist skills in pharmacy across the system.
“To support clinicians to prescribe the optimal medicines, systems should invest in training for prescribers and ensure capacity is in place to take on new responsibilities. This aligns with optimised pathways, providing capacity and knowledge to prescribe in the optimal care setting.”
To that end, increasingly commentators have called for a ‘one medicines team’ approach at ICS level. In a roundtable chaired by the HSJ on how ICSs implement medicines optimisation, collaborative working emerged as a consistent theme involving pharmacists as well as colleagues spanning care pathways, from community and acute to primary care and beyond.
Scaled medicines optimisation with one team working across a footprint also offers the capability to bridge capacity gaps, with resources able to be dynamically redeployed based on emerging needs and demand.
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We know a quarter of the population is living with a long-term condition, while similarly 25% of people aged over 60 are living with two or more. Ongoing management can involve complex medication regimens.
Of course, the taking of multiple medicines may be appropriate for certain patients’ medical conditions. However, it becomes problematic when medicines are no longer optimised to the individual.
This has been broadly defined by the Royal Pharmaceutical Society as ‘where the benefit does not outweigh the harm or where the combination has the potential to cause harm.’ Additionally, it can also be when the practicalities of taking a particular regimen have become too great a burden and unmanageable for the patient.
Deprescribing programmes featuring multidisciplinary team-models have been shown to be successful in reducing polypharmacy in everyday practice. Four core components are identified as essential for successful deprescribing in people aged 65 years and older according to new research.
These must be clearly defined. For example, medication reviews led by pharmacists and overseen by GPs for final decision. In addition, teams should look to draw on other expertise including nurses and social prescribers.
Education and development on deprescribing can give clinicians guidance on how to stop treatments safely. Such training should also include team discussion and shared decision making with patients and carers.
Deprescribing should be discussed with patients upon initiation of treatment. Medication reviews should be tailored to the individual with safety netting advice given to patients.
Keeping patients and carers involved is essential. It is said that ‘patients and carers who trust their clinicians are more likely to accept deprescribing’ or why a drug may be stopped or reduced.
This article points to some core considerations for delivering value in prescribing. Data analytics is foundational to identifying opportunities for medicines optimisation. Developing skills in both polypharmacy and analytics can also support success. At a system level, continued development of multidisciplinary teams not only presents opportunities for collaboration but also knowledge sharing which may build greater confidence in prescribing, improving safety and costs.
Suvera provides an end-to-end chronic condition management service for practices, PCN and ICBs that supports medicines optimisation. From care delivery and case finding through to data analytics, care coordination and medicines management.
For a complimentary free data search, contact our team on partnerships@suvera.co.uk.
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