Example 3: Medicines optimisation and polypharmacy

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This is one of five examples from our report Making the case for quality improvement: lessons for NHS boards and leaders. Each example illustrates how quality improvement approaches are being used by teams and organisations in different parts of the NHS in England to improve care and value for money.

Multidisciplinary review of medication in nursing homes: Northumbria Healthcare NHS Foundation Trust

What was the problem?

Polypharmacy – the concurrent use of multiple medications by one individual – is common in care homes. It can be harmful if poorly managed and can also affect the individual’s quality of life. But it is not always standard practice to review medicine usage and stop inappropriate medicines. And many prescribing decisions in care homes are taken without the involvement of residents or their families. This project, led by the Northumbria Healthcare NHS Foundation Trust’s pharmacy service and transformation team, aimed to develop a method of improving medicines management while ensuring that all residents were involved in decisions about their medicines.

What did they do?

Prior to the project, reviews of the medicines of 37 residents in a care home in North Tyneside were carried out by a pharmacist, a general practitioner (GP) and a nursing team. They found that two-thirds of residents were taking medicines that were no longer performing a medical function or were inappropriate when other co-morbidities were taken into account. A total of 114 medicines were stopped as a result.

Building on this pilot, a project team designed and tested an intervention with three main components. After a detailed medicines review by a pharmacist, a multidisciplinary team involving a GP, a care home nurse and a pharmacist met to consider whether the medicines were still needed and beneficial. Following the meeting, residents were asked for their views before any final decision was taken. 

The intervention was refined over time, in part to reflect residents’ differing levels of capacity and the extent to which their family members were able to be involved. In some cases it made sense to engage residents or family members at an early stage of the review process – for example by involving them in the multidisciplinary meeting. In other cases, however, neither the resident nor a family member was in a position to be involved, and it was therefore appropriate to bring in an independent advocate to act on their behalf instead. 

What impact has it had?

Over a 12-month period, the medicines of 422 residents in 20 care homes were reviewed. Almost 20 per cent of medicines (n=704) prescribed to residents were stopped as a result of the project. In most cases this was because they were not medically useful (57 per cent), or because residents no longer wanted to take them (17 per cent). A small number of medicines were stopped because of safety concerns (6 per cent). By reducing overprescribing and inappropriate medication, the project generated a net annual saving in the medicines budget of £77,000, or £184 for each resident reviewed.

Building on the success of the pilot, the trust has rolled the model out to care homes across Northumberland through a service commissioned by Northumberland Clinical Commissioning Group and the Vanguard Pharmacy team. The model has also been developed further with the help of Vanguard funding: all new and discharged patients are identified weekly and reviewed by a technician, who refers complex patients on to a pharmacist or a multidisciplinary team. Medicine use reviews are also now being carried out by community pharmacists with support from the Vanguard Pharmacy team. 

In recent years, the model has been referenced in national publications, including guidance produced by NHS England and the Royal Pharmaceutical Society England (NHS England 2017b; Royal Pharmaceutical Society 2016).

Baqir W, Barrett S, Desai N, Copeland R, Hughes J (2014). ‘A clinico-ethical framework for multidisciplinary review of medication in nursing homes’. BMJ Open Quality, vol 3, no 1.

Baqir W, Hughes J, Jones T, Barrett S, Desai N, Copeland R, Campbell R, Laverty A (2016). ‘Impact of medication review, within a shared decision-making framework, on deprescribing in people living in care homes’. European Journal of Hospital Pharmacy, vol 24, no 1. 

The Health Foundation (2015).Pills: reviewing medication in care homes. The Power of People film. The Health Foundation website.