A GP practice in Tyne and Wear that conducts medicine reviews for patients in care homes has seen a dramatic reduction in the number of medicines prescribed.
The Village Green Surgery in Wallsend conducts medicine reviews involving the pharmacist it employs and a GP every four to six weeks with patients in the two nursing homes it looks after.
The practice became convinced of the benefits of the service following participation in a pilot that involved 15 other practices across Northumbria, which was supported by a grant from the Health Foundation.
The Shine project saw a total 422 reviews in 20 care homes conducted between GPs and clinical pharmacists, with the result that 17 per cent fewer medicines were prescribed, with no untoward effects reported.
During the 15-month pilot that started in 2013 an average 1.7 medicines were stopped for every resident. The main reasons for stopping were ‘no current indication’ or that the resident requested to stop. Net annualised savings were £77,703 or £184 per person reviewed.
CQC outstanding practice
The eight-partner Village Green Surgery, which was recently rated as outstanding by the CQC, has now continued with this service, integrating it into the core workload of the practice pharmacist Wasim Baqir and the GPs.
Practice manager Philip Horsfield says the initiative was driven by the practice's aim to move from offering a good standard of care to a gold standard.
'Although all the medicine reviews we conducted before were clinically appropriate our practice pharmacist felt we could do better. We wanted to look at, for example, anomalies such as one patient being prescribed laxatives and constipation relief at the same time. Issues like that needed to be ironed out.'
Mr Baqir, who works one day a week with the Village Green, explains there was also concern about overmedication. 'We heard from care homes that it took so long to dispense medication by the time the morning round was completed it would be time to start the lunchtime round.'
Keen to investigate further, Mr Baqir and the then senior GP (now retired) themselves carried out detailed joint reviews on 37 patients in care homes in 2012.
They were taken aback by the excessive levels of medicines patients were taking and which they could easily stop, Mr Baqir explains. So they were keen to test a new way of working.
'We wanted to develop a process that optimised medicines but that was also based on a shared decision framework,’ Mr Baqir says. 'This means decisions on what medicines to start, stop or change are not just taken by the health team but by the patient and their family. All the risks and benefits would be explained and then we would agree together what action to take.'
After securing £75,000 funding from the Health Foundation, the Shine project, involving a much larger practice base, was launched. It adopted the key objective of developing a ethical framework for multi-disciplinary review of medication in nursing homes.
'It can become an ethical debate giving a patient near the end of their life and bed bound a statin that prolongs life,’ Mr Baqir says. 'So conversations are held with the patient and their families to reach a decision. Sometimes families want to keep it going and we respect their wishes.'
The funding covered the pharmacist and management time but GP input was absorbed by the practices.
GP involvement is key
A key finding was that GP involvement in the reviews held with the pharmacist is preferable.
'We tested various models for the reviews: no GP involvement in the review; a GP jointly attending the review with the pharmacist; the GP being involved only at discussion level prior to the review; and the GP being involved at discussion level only following the review,’ Mr Baqir explains.
'The differences were interesting. The pharmacist working on their own or the GP and pharmacist carrying out the reviews jointly worked best. I do think there is real value in having the GP there. There is a lot of learning for everyone in doing it.'
The practice has continued to conduct reviews jointly given the findings of the pilot. Held at the care homes with the patient and families attending, the review involves the following key questions:
- Is the medication currently performing a function?
- Is the medication still appropriate when taking co-morbidities into consideration?
- Is the medication safe?
- Are there medicines missing that the patient should be taking?
It has been kept deliberately simple, Mr Baqir says. 'There are complicated tools out there. We took a different approach and wanted to keep it straight forward.’
Improving patient care
The project is not driven by a need to save costs , he stresses. 'Sometimes medicines are stopped, sometimes they are started. This is about quality improvement in patient care. The savings were consequential but we were, however, taken aback by the level of savings made.'
Mr Horsfield points out that the service hasn’t had an adverse affect on workload. Also feedback from patients has been positive. 'Patients are happier because they are cutting down on the number of tablets they were taking. If they are happier their families are also happier.'
Mr Baqir believes the initiative could be implemented in other practices.
'Not all practices employ a prescribing pharmacist, of course, but where they do this could be built into their core workload. They can take charge of it with no GP input if need be. It would be great to see more use of the shared decision framework.'