Collaborating organisations: SEL ICS, The Albion Surgery (Bexley), The Westwood Surgery (Bexley), Kingston University (for evaluation)
Description
The purpose of this mini-pilot was to test the impact of specialist input in supporting generalist PCN pharmacists when undertaking SMRs in patients with complex needs, for example those over the age of 80 years old, on more than 10 medicines or those who are frail.
What problem is it trying to solve to tackle overprescribing?
The identification and prioritisation of people who would benefit most from a SMR is currently inconsistent and not routine practice. There is a lack of confidence across the system to have shared decision-making conversations that facilitate deprescribing, with clinicians reluctant to challenge senior or specialist colleagues, or patients and their relatives/carers, to deprescribe specialist medicines.
Clinical guidelines focus on single long-term conditions and do not account for the complexities or multi-morbidities, frailty, non-drug treatments and deprescribing.
The principles of medicines optimisation and deprescribing through the use of SMRs are not currently reflected in the education, training and professional development of all healthcare professionals.
Intended outcomes:
- For the PCN pharmacists to build their own network to support decision making in complex patient cases.
- To reduce the number of medicines prescribed, or reduce the number of doses prescribed, in the selected patient cohort.
- For the PCN pharmacists to become more confident to deprescribe medicines.
Implementation
The Primary Care Network (PCN) and GP practices that were to participate in the mini-pilot were identified.
The PCN pharmacist was briefed by the SEL ICS Overprescribing Lead Pharmacist on how to approach patient centred SMRs, providing the appropriate resources, tools and guidance.
A process for the PCN pharmacist seeking specialist input was decided, as follows:
- An in-person meeting was arranged so that the set up within the GP practices could be fully understood and the appropriate patient cohort identified.
- A virtual discussion between the PCN pharmacist and SEL ICS Overprescribing Lead Pharmacist was scheduled to discuss patients, both pre and post SMR. Initially, this discussion encompassed all patients and then became more selective based on the self-directed need of the PCN pharmacist.
The methods for evaluation of the mini-pilot were determined:
- Quantitative – collection of data on medicines outcomes and the achievement of patient agreed priorities following SMR, and who within the multi-disciplinary team the PCN pharmacist liaised or referred the patient to.
- Qualitative – interviews conducted with the PCN pharmacists.
Top tips:
- Identify a patient case load and ensure there is the appropriate protected time for the pharmacist to undertake the SMRs.
- Assign a named GP to support the pharmacist to implement changes.
- Ensure there is room availability for conducting face to face reviews.
Outcomes
SMRs were conducted with 18 patients as part of this mini-pilot, with an average age of 87.3 years (81-92 years).
There was a 12% reduction in the number of medicines prescribed to the patient cohort post-SMR (1.4 medicines stopped per patient). A range of different types of medicines were deprescribed.
Realising I don't have to make all the decisions, which can create anxiety as a pharmacist, helped a lot.
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- Using a shared-decision making process meant that all patient priorities were achieved during the SMRs.
- The PCN pharmacists mostly liaised or referred patients to a GP at the practice.
- Feedback from the PCN pharmacists on how they felt their practice was impacted by the mini-pilot was captured as part of the interviews.
