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.