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The benefits of this project
Benefits for Your Patients
- Improved Quality of Life for patients – 7.4 QALYs per 100 reviews
- Reduces adverse drug reactions (ADRs) - a fifth of hospital admissions in >65 year olds are due to ADRs
- Reduces non-adherence – patients on >4 medications have only 50% adherence
Benefits for Your Practice
- Reduced prescription administration - SMRs shown to reduce prescriptions by 2.7-9.9% (19.5% in care homes)
- Fiancial savings
Benefits for The Planet
- Reduced prescribing means lower environmental impact
Opportunity for improvement
- Problematic polypharmacy is associated with poor clinical outcomes including increased rates of falls, hospital admissions and death. Alongside the burden on the individual, the environmental impact of medicines is huge; medicines account for 25% of all NHS carbon emissions and 60% of primary care’s. This is why addressing problematic polypharmacy is one of the 16 National Medicines Optimisation opportunities.
- Tackling over-prescribing will save clinician, pharmacy and care staff time and money as well as lead to reduced carbon emissions and waste.
- Suggested reading: National Medicines Optimisation Opportunities 2023-24: Addressing Problematic Polypharmacy.
- This QIP aims to reduce problematic polypharmacy and its related complications, by upskilling team members to conduct the structured medication reviews (SMRs) with a focus on deprescribing using validated tools (see disclaimers). The aim is for these to be performed within the existing medication review process of each surgery, therefore only requiring a small additional time commitment for deprescribing, data collection and follow up.
- This project has the triple benefit of reducing the NHS carbon footprint, improving quality of life for patients and reducing pressures on the NHS and its staff.
- You might like to create SMART goals for your project such as completing SMRs for 50% of your patients on 10 or more regular medications within a 6 month period.
How to carry out this project
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Investigate
- Find out who is already doing SMRs in your practice.
- Meet as a team with these staff (and perhaps any others who could be trained in this area).
- The aim is to conduct this QIP within the existing medication review process and develop sustainable improvements in practice.
- Do staff have any training needs around deprescribing?
- Consider local and national training offers
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Plan
Agree a template – eg Arden’s, SystmOne or BRISMED’s. Decide which additional tools to use during SMR, options include:
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Training
For ALL prescribers, run training session on importance of problematic polypharmacy and “Quick Tips” to Make Every Contact Count. Include the importance of documenting stop dates for medications needed only for a specified duration.
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Identify patients
- Identify a cohort of 100 patients and start with those on 10+ medications. These could include only patients >65 years, living with frailty, vulnerable groups, care home patients, or those taking certain medications (deprescribing.org) depending on your local demographic.
- Initial Search Suggestion – Search for “patients with 10 regular medications” PLUS “Frailty” code/or “Rockwood score 5 or above” PLUS “age>65”. Option to add “care home resident” and/or “recent admission within 6months” depending on numbers returned.
- We hope to provide downloadable IT searches for EMIS & System 1 soon. In the meantime, you could use our EMIS and SystmOne search guides to create your own. Open Prescribing and EPACT2 track prescribing data and may be another way to track the impact of your project.
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Baseline data
Take baseline measurements, including patient age, location (care home/own home), number of medications taken and whether these are on repeat prescription.
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Patient Resources
Share resources with the patient prior to their review if appropriate, these can be digital or on paper – examples found here.
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Coduct SMRs
Conduct 20-30 minute structured medication review with each patient using the agreed template, consider:
- Is this medication being taken?
- Is it needed? Is there duplication?
- Is there a risk of harm? Are there side effects?
- Can it be reduced?
- What matters most to the patient in terms of health and the future?
- Are there any medicines they are unsure of why they are taking or how to use them?
Deprescribing focused SMRs may take slightly longer than standard SMRs but this is counter-balanced by time saved from reduced future patient harm from overprescribing and reduced prescription administration.
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Post SMR data collection
- Record any medications stopped, and their Medicine Carbon Footprint using MCF Formulary.
- Inform the patient about how they can seek help with issues or questions following their SMR.
- Consider when to repeat the SMR for the patient e.g. 12 months.
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Study
Review the results, summarise learning, share with practice team + decide if any changes are needed to improve the process. Use the Project Monitoring form to keep track of the project and when it might need repeating.
Many practices run automatic searches at regular intervals – speak to your practice team about including this project in those searches.
Top Tips
Take a whole team approach and involve all practice staff. This will help to embed a culture of medicines optimisation and help to make any changes more sustainable.
Deprescribing SMRs may take slightly longer than standard SMRs but create a host of benefits so keep highlighting these benefits and help prescribers get protected time to do SMRs.
How to scale this project up or down
| Please note - Use of this project requires NetworkPLUS membership. If you would like to share this project with others, please invite them to purchase their own membership—access must not be shared with non-members. |
This could be done across a PCN, especially if pharmacists work between practices, and learning should be shared between practices – particularly on those vulnerable groups thought to benefit most from the SMR.
Feedback to your Federation, ICB (England) or Cluster, Health Board (Scotland or Wales) or GP federation, Health Trust (Northern Ireland), any specific learning points and suggestions for future funding or pilot projects, so the learning can be shared and the project easily implemented by other practices too.
Case study
This QIP was carried out in Central Liverpool PCN over 9 months. 81 patients underwent SMRs, 37 medications were stopped (3.1% of all items), 32 (2.7%) were reduced (vs 16 items stopped and 8 reduced in the control group). It took 7 minutes longer per deprescribing-focused SMR, but these saved £914.47 more than standard SMRs. If deprescribing SMRs were the norm for all 4878 patients on >=10 medications in this PCN, an additional £55,071.42 would be saved per year. Of the 22 items stopped that had carbon ratings, 72% were rated as having a medium to high carbon footprint.
Central Liverpool PCN
Have you completed this QIP?
Tell us a little about your project and enter your data in order to generate a certificate showing the probable benefits. This project may help with CQC evidence submission (see disclaimers).
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