Carry on prescribing: who is responsible for co-ordinating patients’ medication?

Over the past decade, the combination of more guideline-based management of chronic disease, emergent therapies and the preventative treatment of asymptomatic people has led to a global rise in prescribing. In the UK, between 2001 and 2011, GP prescriptions increased by 64 per cent, twenty two per cent of the population now take more than five medicines, and 5.8 per cent are on ten medications a day – a 3.1 fold increase since 1995.

With 45 per cent of all prescriptions issued to over 65 year olds, and 16.4 per cent of this age group on more than 10 medications, it is older people who are most at risk from problematic prescribing. People are now taking more drugs than ever before, but who is responsible for ensuring each patient’s prescriptions are appropriate?

Last week I went on a home visit to see an 88-year-old man who had been discharged from hospital. The discharge summary mentioned that while in hospital he had been diagnosed with Parkinson’s disease and asked that the GP increase the dose of his new medication.

A review of his records showed he now had 12 diagnoses, covered by eight separate National Institute for Health and Care Excellence (NICE) guidelines. In the past five years he’d seen three cardiologists, a cardiac specialist nurse, a heart failure specialist, two nephrologists, two gastroenterologists, an ophthalmologist, a urologist, an orthopaedic surgeon, and now a neurologist. Other than a fracture clinic visit, every hospital contact had resulted in a change of medication. Only one of his 10 medicines had been started by his GP, yet the responsibility for continuing his prescriptions, and therefore his long-term management, now lay entirely with primary care.

Historically, cases of such medical complexity would have been reviewed in outpatients, but with up to 78 per cent of all GP consultations involving patients with multiple long-term conditions, and a trend to discharge patients from hospital early, without any scheduled follow-up, this scenario is now so common in general practice as to be the norm. Such fragmented care leaves the GP to ‘carry on prescribing’ drugs started by a hospital colleague, who no longer has any on-going involvement, role or responsibility in monitoring the effects of treatment they initiated.

The lack of communication at the interface between acute and primary care compounds errors. In a survey of GP practices by the Care Quality Commission, 81 per cent reported that hospital discharge summaries are incomplete or contain medication inaccuracies 'all' or 'most of' the time, and only 53 per cent of those summaries are available when GPs first review patients post-discharge. Consequently, sometimes medications that should have been started are omitted and those that should have been stopped are continued. This contributes to the estimated £150 million worth of avoidable NHS drug wastage that occurs in the community every year.

Electronic prescribing helps, but with repeat items accounting for 75 per cent of prescriptions, logistical difficulties mean obtaining medication remains a poor experience for patients, and the NHS is only starting to develop apps to give them more control.

So what are the barriers to improving this process? With the exception of the HYVET trial and British Geriatric Society studies, clinical research often involves patients with isolated medical conditions, making the results hard to apply to those with multi-morbidity. The same is true of NICE guidelines, which, while valuable, remain disease-specific and therefore fail to reflect the medical complexity faced by clinicians.

Similarly, research tends to focus on when to start drugs, providing little evidence on when to step down or stop treatment, and despite competence-based education, UK medical training lacks the pragmatism evident in the World Health Organization Guide to Good Prescribing, leaving doctors poorly prepared to make these decisions.

Polypharmacy, long a byword for poor practice, reflects the complexity of modern health care, and is here to stay, as is explored in a new report published by The King’s Fund today. The plan to make hospital specialists more generalist and GPs more specialised may help make clinical practice more patient focused, but needs to be combined with development of an integrated structure that includes dedicated teams to co-ordinate care for patients with complex problems not just leave this to GPs. Until this is addressed, polypharmacy will remain problematic.

This blog is also featured on the Health Service Journal website

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Comments

#41151 Neal Patel
Pharmacist
Royal Pharmaceutical Society

I strongly believe it’s time to build a fully functioning multidisciplinary team in primary care to properly address the needs of the growing number of people with two or three or more long-term conditions.

The clinical skill-mix of this team needs careful consideration, with clearly defined roles for doctors, nurses and pharmacists working coherently. The needs of older people along with those who take many medicines, often for many different conditions, needs to be at the heart of this thinking.

There are already specialist pharmacists who work with community based teams including GPs, nurses, community pharmacists and social care professionals to make sure the needs of older, often housebound people are met. Crucially, these roles are focused on keeping older people well, in their own homes or their care homes by optimising the use of their medicines.

I believe a pharmacist must have overall responsibility for medicines use in the care home.

Pharmacists working in this way will keep people safe from preventable harm from medicines. The expectations from treatment must be set by patients and their carers supported by expertise from pharmacists and other health professionals.

Too often patients receive treatments which, although complying with NICE guidance, do not match their own wishes and health goals. Now is the time to ensure that older people, as well as others taking many medicines, are given access to regular patient-centred medication reviews by pharmacists to improve their health and prevent adverse reactions.

I'd encourage commissioners and health professionals to look at how patient care can be improved using new models of integrated care including pharmacists www.rpharms.com/futuremodels

#41152 kathie smallwood

I too have Parkinson's and it worries me that I take a number of drugs but no-one checks the general state of my health from time to time. Surely they should at least check liver and kidney function every 2 or 3 years. I do not think that I have been checked in the 7 years since I was diagnosed

#41160 john kapp
director
Social entewrprise Complementary Therapy Company (SECTCo)

The bottom line is that prescribed drugs have become the third or fourth biggest killer, yet they are supposed to cure not kill, and doctors who prescribe them swear the Hippocratic oath to do no harm. Complementary therapy never killed anybody, so the remedy is medication to meditation (the active ingredient in complementary therapy) The Mindfulness Based Cognitive Therapy 8 week courses is NICE recommended, so patients have the statutory right to it if their doctor says it is clinically appropriate. As one in three patients in primary care present with anxiety or depression, commissioners should commission more courses by opening up the market. This would reduce the waiting time from 20 years (in Sussex) to 28 days, as called for in the report ‘We still need to talk’ published on 29.11.13 by 13 mental health organisations, see http://www.rethink.org/media/869903/We_still_need_to_talk.pdf...

#41168 Fran Husson
retired

As an elderly patient with LTCs and comorbidities, I could add my own sorry tales of harmful non communication between primary and secondary care to Duncan Hockey's excellent blog. A new development though now enables patients to keep track of the drugs which have been prescribed "here and there" and to manage all their regular and occasional medicine intakes. This development is "My Medication Passport" [ available at http://goo.gl/5YFfk ] which many health care professionals [including dentists who face huge obstacles in accessing their patients' GP surgery medical records] welcome as this is -- currently -- the only way to get a comprehensive overview of a patient's medication.

#41182 Mona Sood

"The bottom line is that prescribed drugs have become the third or fourth biggest killer". Care to provide a reference for this comment, John? And whilst your at at positive proof that "complementary therapy never killed anybody", or was associated with an opportunity cost?

Regulated systems have to provide a proof of concept, and cannot make spurious claims in this way. Having argued the case for evidence-basedpharmaeutical nteventions for years, I find the way in which unsubstantiated claims can be bandied about without accountability or repercussion quite perplexing.

#41629 Andy Riley
Pharmacist

GPs and Patients need help coordinating treatment for multiple medical problems and pharmacists are ideally placed to provide the professional advice, guidance and practical support that patients need.
Whether the treatment was initiated in hospital or not, it is the responsibility of the prescriber to ensure that the prescribed medicine is indicated and that patients are responding well or the anticipated goals of treatment wont be realised and patients will be exposed to all the risk and none of the benefits. 'Therapeutic review' by pharmacists should be integrated into a 'treatment review' by prescribers. The 'medication review' currently in the GMS is clearly insufficient as it tends to continue with treatment without strong justification. Pharmacists can monitor patient's treatment, especially in the early stages, to ensure that there is a good response and can address concerns patients may have with appropriate reassurance about minor side effects and prompt a GP led treatment review if major side effects begin to occur.

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