Case-based learning: hyperpolypharmacy and pharmacist-led multidisciplinary continuity in primary care

Global improvements in life expectancy have led to a rise in long-term conditions^​1​. For many, this means managing multiple medications prescribed by different clinicians across fragmented systems of care. As a result, hyperpolypharmacy — commonly defined as the use of ten or more regular medications — is an increasingly common feature of modern clinical practice^​2​.

In England, more than one in five people aged over 65 years are prescribed ten or more medicines, a figure that continues to grow annually^​3​. While each prescription may be individually clinically justified, the cumulative treatment burden can introduce significant risks for patients and the wider health system^​4,5​. This risk is particularly pronounced in older people — for every additional medicine prescribed to individuals aged over 85 years, mortality risk increases by around 3%^​3​. The risks associated with medication have been identified as priorities through international initiatives — such as the World Health Organization’s ‘Medication without harm’ and at national level through the ten-year health plan — with emphasis aimed at reducing preventable harm across the patient journey^​6,7​. 

One such risk is adverse drug reactions (ADRs), which have been shown to contribute substantially to poor outcomes of polypharmacy, accounting for an estimated 6–7% of hospital admissions, many of which are preventable through improved prescribing oversight^​8​. The probability of ADRs escalates with each added medicine, and patients with complex regimens experience higher rates of hospital readmission, especially when communication across care settings is fragmented^​9​. Drug–drug interactions further compromise safety, with combinations such as anticholinergic agents with opioids or benzodiazepines precipitating confusion, constipation and falls.

Shifts in a patient’s clinical background also alter the appropriateness of ongoing therapy; for example, antihypertensive treatment may induce symptomatic hypotension and dizziness in the context of ageing or weight loss^​2​. The clinical uncertainty generated by hyperpolypharmacy challenges clinicians, while patients face adherence difficulties compounded by regimen complexity^​10,11​. 

Patients with hyperpolypharmacy often see multiple specialists, each focused on their own disease domain and not on the effect this may have on others. Without clear ownership of the overall medication strategy, this siloed approach can lead to overlapping or conflicting prescriptions. The result is a regimen that may be technically accurate in each individual setting, but incoherent when viewed as a whole. For patients and carers, the consequences of this fragmentation extend beyond clinical risk. The cognitive and emotional burden of managing ten or more medicines is substantial^​12​. Conflicting professional advice and complex dosing schedules can undermine adherence and erode confidence in the healthcare system^​13​.

Pharmacists frequently encounter the downstream effects of fragmented care, spending considerable time reconciling discrepancies after hospital discharge or specialist review^​14​. Even where medicines are optimised in one setting, the absence of sustained oversight means changes are often reversed or duplicated later. Addressing hyperpolypharmacy demands continuity, coordination and strong clinical leadership across the entirety of the patient’s care. Pharmacists can provide this leadership, supported by the wider pharmacy team whose collective expertise can preserve therapeutic intent across organisations and sectors. Within the MDT, this collaborative pharmacy contribution is central to reducing harm and improving patient outcomes. This article highlights the importance of continuity within the MDT in mitigating the risks of hyperpolypharmacy and proposes a pharmacist-led continuity MDT model.

Case presentation

This case examines samples of interventions from a pharmacist-led MDT of the six-year journey of a female patient with hyperpolypharmacy. The patient is aged 68 years and has prescriptions for 23 regular medications. Her diagnoses include COPD, atrial fibrillation, angina, type 2 diabetes mellitus, chronic pancreatitis with acute episodes, depression, ascites, chronic buccal ulcer and recurrent urinary tract infection.

Over a six-year period, MDT meetings were systematically organised and facilitated by a pharmacist embedded within a general practice. A total of 26 MDTs were convened: 9 were proactive in nature (for example, as part of routine annual care reviews), 11 were reactive (such as being held following patient discharge from hospital), and 6 were conducted urgently in response to identified patient safety concerns. The responsibilities of the pharmacist within the MDT included: 

• Providing clinical guidance alongside lead GP; 
• Oversight on medication management; 
• Supervising all medication changes;
• Coordinating with both secondary and primary care when necessary. 

The pharmacist also provided consistent support to the patient and their family.

Proactive multidisciplinary team meetings

A proactive MDT was initially set up after the pharmacist began working within the general practice, with a lead GP, two additional GPs, two specialist nurses, a healthcare assistant and a pharmacist. A care plan was developed, which included deprescribing opportunities that were identified by the pharmacist. These included multiple laxatives and overtreatment of hypertension, as well as condition-specific management, such as inhaler treatment optimisation (e.g. advising on technique or device selection). The care interventions included within the care plan were then led by the most appropriate member of the MDT in any future appointments (see Box 1).

A core MDT team (consisting of a GP, advanced pharmacist practitioner and specialist diabetes advanced nurse practitioner) was established to provide consistent clinical oversight, maintain awareness of treatment strategies and address potential conflicts across different healthcare systems. The primary focus of proactive MDT meetings was future-oriented condition management planning. This would also include inviting secondary care teams, social care teams and district nursing staff to the meeting when indicated. 

Reactive post-discharge multidisciplinary team meetings

The reactive MDTs were predominantly convened by the pharmacist at post-hospital discharge to address significant new diagnoses or medication-related safety concerns within one week. Examples include:

• An incorrectly prescribed dose;
• 15 clinically inappropriate medications (owing to pre-existing diagnosis or other interacting medications);
• 4 clinically inappropriate doses;
• 5 medication overdoses (where medication was duplicated or high doses were prescribed);
• 4 missing medications from discharge; and
• An instance of no medication provided when discharged. 

Most cases required follow-up with hospital discharge teams to be resolved, with patient safety incident reports completed in response to all instances of identified patient harm. This reinforces the challenges and potential harm where hyperpolypharmacy exists.

Urgent multidisciplinary team meetings in response to patient safety concerns

Urgent MDT meetings were convened on the same day that patient safety incidents were identified. In each instance, these incidents were associated with care transitions across different sectors of the healthcare system, such as following hospital discharge, outpatient clinic visits or attendance at urgent care centres (see Box 3). The pharmacist initiated urgent MDT meetings after recognising significant medication safety concerns that could cause, or had caused, patient harm. Examples of such incidents include overdose, repeated steroid prescriptions without an appropriate tapering plan, and initiation of antibiotics presenting moderate severity interactions with high-risk medications.

Role of the pharmacist within clinical leadership for hyperpolypharmacy

The clinical insights of pharmacists bridge the gap between pharmacology and person-centred care, supporting safer, coherent decision-making across the MDT. Pharmacist-led continuity within hyperpolypharmacy directly supports the complexity of care across organisational boundaries through systematically generating person-centred care plans, proactive deprescribing and communication at transition points. Pharmacist-led continuity is best conceptualised as a cyclical process in patient care, where each interaction builds upon previous encounters. This approach acknowledges the importance of continuity, particularly in complex cases, and enables the development of services that provide appropriate support.

To fully realise the benefits of sustained pharmacist-led continuity, it is imperative to strengthen system-level facilitators while addressing current obstacles. Notable operational challenges include variations in MDT structures. There may be variation across different regions and limitations in resources, both of which hinder broader implementation efforts. 

Enhancing clinical supervision and fostering robust mentorship programmes to support pharmacists in clinical leadership roles may help to address these challenges across regional boundaries. Moreover, future research should establish outcome measures to assess the impact of pharmacist interventions on patient safety and system efficiency. In addition, dedicating protected time for collaborative activities — such as regular MDT meetings that prioritise shared decision-making within care planning — remains essential.

Based on their experience, they propose a pharmacist-led continuity MDT model, which can be seen in Box 4.

This framework adjusts medicines management from a reactive process into a proactive coordinated continuum of care — a key component of the ten-year health plan^​7​.

Conclusion: embedding continuity as standard practice

Hyperpolypharmacy presents substantial clinical and systemic challenges that require a coordinated and sustained response. Issues, such as fragmented care delivery, isolated communication channels and insufficient continuity, increase the risks associated with medication management and place undue strain on both patients and the healthcare system. Pharmacists, when empowered as clinical leaders within MDTs for hyperpolypharmacy, offer a practical solution. Through sustained involvement across the patient journey — spanning medication review, care planning and transitions of care — they can transform medicines management from a fragmented process into a coherent, person-centred practice. These improvements not only enhance individual patient outcomes, but also generate efficiencies across the healthcare system, supporting national priorities related to prevention, safety and integrated care. Achieving these benefits requires dedicated investment in pharmacist-led continuity roles, interoperable information systems and formal recognition of pharmacists as essential members of the MDT.