PrescQIPP

Pharmacist-Led Polypharmacy Reviews in Solihull (2018)

Birmingham and Solihull CCG

Introduction

The project aims to reduce inappropriate polypharmacy and optimise medicines for patients in the Solihull Locality. Solihull CCG (now merged with other CCGs to form Birmingham and Solihull CCG) has 25 member GP practices/partnerships with a population of approximately 240,000 patients.

Inappropriate polypharmacy is defined by NICE as 'prescribing of multiple medicines inappropriately, or where the intended benefit of the medicines are not realised'1. It has been well documented that the number of patients with polypharmacy is ever increasing, as life expectancy has increased and there are more patients with multimorbidities. Inappropriate polypharmacy has seen a rise and there is evidence to show that it can lead to increased risk of adverse effects and potential hospital admissions. There is also a significant cost burden to the NHS to fund treatments which may no longer be appropriate. As a side product we would hope to reduce hospital admissions, promote cost-effective, evidence-based prescribing and produce significant cost savings to prescribing budgets (CCG and NHS).1,2,3

How was the project established? / How is it currently being established?

Prior to this project, GPs were doing their own polypharmacy reviews with assistance from Prescribing Support Pharmacists (PSPs), as a part of their contracted Local Improvement Scheme (LIS) with the CCG. It was found over time, that the reviews the PSPs did were of higher quality with more clinical interventions and cost savings. A business case was put forward at STP level for the recruitment of additional pharmacists to carry out medication reviews in practices. This would reduce pressure on GPs to do the reviews and aim to produce further positive outcomes from pharmacist reviews. Using their allocation, Solihull CCG recruited two fixed-term Medication Review Pharmacists (MRPs) at Band 7 level with a two-year contract. They were tasked with completing approximately 30 reviews a week (1000 a year) for practices in the Solihull locality. The medication review process was tailored to each individual practice and done in the way best suited to them (see Appendix 1 - Polypharmacy Proforma). The Practices were asked how they wanted the reviews to be delivered and the MRPs did their best to facilitate them. Each practice had to do reviews on 2% of their baseline population, as per their contract, and the MRPs were to support them with this.

The MRPs targeted elderly patients on the highest number of medicines and raised any issues with the GPs e.g. drug interactions, discharge discrepancies, dose optimisations and overdue monitoring. The reviews were mostly paper-based (with some phone consultations when agreed with GP), and suggestions were made by MRPs which the GPs actioned within the agreed timeframe. Interventions and savings are then recorded once any actions have been completed. Most of the practices agreed to allow remote access to their clinical systems (from the CCG base) which increased efficiency and saved the MRPs travel time, as they were not dependant on room availability at the practices. This allowed them to produce more reviews in a shorter space of time and increase the number of outcomes they achieved. Some of the resources used include: PrescQIPP polypharmacy and deprescribing webkit, King's Fund STOPP/START tool, IMPACT tool, NICE Evidence and Guidelines, Local CCG guidelines and APC formulary.

Who are the main beneficiaries of the project? How would they benefit?

The main beneficiaries of the project would be the patients and their carers. With reduced polypharmacy they would hopefully have an improved quality of life with a decreased tablet burden, reduced risk of adverse effects and hospital admissions and optimisation of their medicines4. The GPs and prescribers would also benefit from the pharmaceutical knowledge and expertise of pharmacists. They can pick up things that may have been missed and provide information using the latest guidance and evidence. This helps educate and influence the GPs to positively change their prescribing habits and benefit other/future patients. Practices benefit from reduced drug expenditure, positive patient outcomes and potential decreased hospital admissions for their QoF Framework. The CCG as a commissioning group also benefit from improved patient outcomes in the locality and improved drug budgets.

What were the main outcomes and / or achievements of the project?

Between July 2017 and April 2018, the MRPs completed 1207 reviews and made 2113 interventions. 1172 (56%) of these interventions were clinical interventions (dose changes, medication stopped/started) and 196 (9%) were potential admission preventions. (For break down and intervention definitions see supporting document 2).

Clinical interventions included:

  • Reducing risk of AKI by reducing NSAIDs and diuretics for example
  • Reducing risk of falls from benzodiazepines, opioids and antidepressants for example.
  • Reducing risk of Bleeds e.g. clopidogrel stopped when over 12 months, NOAC dose optimisation
  • Overordering and overstocking of insulin and inhalers
  • PRN meds taken regularly without patient realising they don't need to take all the time

Drug cost savings (over 12months) totalled £132,382.91 for 2 WTE MRPs, at an average of £109.68 saving per patient reviewed. These savings reduce pressures on practice prescribing budgets and promote cost-effective prescribing.

Feedback from GPs included:

  • ‘The reviews were very helpful’
  • ‘GPs said that the polypharmacy reviews carried out by MRPs last year were much better quality than the reviews done by the GPs themselves. They all said that they learned a lot from pharmacist recommendations and were very pleased that they will be doing more reviews this year’
  • ‘Very useful… [polypharmacy reviews] helped with patient management…. Good for patient safety’

Feedback from Patients included:

  • 'I didn’t know that I didn’t need to take that all the time'
  • 'I'm glad I don’t have to remember to take as many tablets'

As entry level band 7s they have a total wage of approximately £63k a year full time and have managed to save more than double that (from drug-cost savings) in 9 months, which shows that they have been cost effective to employ. The CCG is also now considering a business case to make the MRPs permanent.

The pharmacists recruited as 2 WTE Band 7s had no prior experience of working in a primary care commissioning setting, with their backgrounds from community and hospital pharmacy. They developed the project by building rapport with GP practices and GPs and were able to produce positive clinical outcomes in the first 9 months. The ability to adapt to the individual needs of a practice, helped the MRPs to deliver results in an efficient manner. GPs seemed to engage more when they had input into the way the project was delivered, at their own practice, in a way that suited them and their workload. This engagement allowed the project to produce positive results. The agreement of most practices to allow remote access to their systems was key to enable the project to be delivered efficiently.

Primary care is a niche environment for pharmacists with historically there being very few roles for pharmacists under Band 8 level. Most of pharmacist recruited at Band 8 level have no prior experience of primary care and it's not something usually taught at pre-registration or junior level. This project was also a way of implementing some workforce planning and a way to support pharmacists to start their careers in primary care.The MRPs are now moving onto face-to-face reviews in practices alongside paper-based reviews and are continuing to develop themselves further in primary care.