Wasim Baqir is a Research & Development Pharmacist at Northumbria Healthcare NHS Foundation Trust.
There are currently 405,000 care home residents in the UK aged over 65 taking an average of seven medicines, with some taking double or treble this amount. Research shows at any one time 70% of them have an error with their medication which can occur during prescribing, dispensing or administration. That’s a lot of errors.
I’m a clinical pharmacist working in Northumbria and although these figures are quite well known, they are still pretty shocking.
Medicines use in care homes is problematic: over-prescribing, lack of structured review and little or no resident involvement in decisions are common themes. Despite the evidence (think CHUMS report) and guidance (think NICE guidelines) medicines use in care homes remains generally poor. That’s why I’m backing a new campaign from the Royal Pharmaceutical Society to improve the situation.
For the past three years my colleagues and I have been running the Shine project in local care homes where we’ve developed a medication review process which optimises residents’ medicines. We work as part of the multidisciplinary team (MDT), ensuring that residents and their family/carer are fully involved in any decisions made.
We’ve developed a framework for questioning the appropriateness of medicines being prescribed and therefore significantly changed the review process. Key components are:
- Medication review using general practice and care home notes
- MDT meeting with shared decision making with residents and/or their family/carer
- Follow up to ensure safety.
Whilst there are some tools to support prescribing (e.g. STOPP-START) we have developed a pragmatic approach where we ask three questions:
- Does the medication have a purpose (valid indication)?
- Is the medication appropriate (e.g. are preventative medicines in palliative care appropriate)?
- Is the medication safe?
The answers to these questions are used to develop an action plan that is developed and discussed within the MDT and with the resident and family/carer.
We have also developed three workable models for GP involvement; GP present at the MDT, GP consulted after MDT and GP not involved, where a prescribing pharmacist makes the decisions.
Analysis has shown that the most cost-effective model is the prescribing pharmacist approach which resulted in £3.53 saved on medicines costs for each £1 invested in the service.
Data from the Shine project showed that an intervention is made in over 9 out 10 residents with an average of over 3 interventions made. The most common intervention is to stop medicines (19% reduction) with the main reason for de-prescribing being no valid indication for the medicine. Over 7% medicines were stopped because of safety concerns.
In addition to improvements in quality and reduction in risk, there were significant savings against the medicines budget – £184 saved for every resident reviewed. Additionally, the project demonstrated a reduction in medicines waste and a statistically significant reduction in hospital admissions from care homes.
I want to see a pharmacist-led care home review process that involves residents and/or their representatives in decision making about their medicines as the norm all over the country. We’ve shown it improves quality of care, reduces risk and makes significant healthcare expenditure savings. It’s a no-brainer!