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Unnecessary medicines can cause unwanted side effects, especially in older people or those who are frail. The NHS direct enhanced service and general practice quality payment have highlighted that deprescribing, where appropriate, is an essential part of the Sunderland Primary Care Network (PCN) pharmacy team’s work plan to help reduce the risk of these harms.
Deprescribing work involves reviewing, reducing or stopping medicines, such as selective serotonin reuptake inhibitors (SSRIs), laxatives, gabapentinoids, opioids and over the counter (OTC) medicines. All patients receive a medication review prior to deprescribing to assess if their medication is appropriate and in their best interest. These are supported by deprescribing guidelines published by Sunderland clinical commissioning group (CCG) in June 2021.
To build confidence, we started our deprescribing work in the care home setting as the residents are in a secure environment and are monitored closely by qualified healthcare professionals.
During a structured medicine review (SMR), which ideally takes around 30 minutes, we look at the patient holistically and review all aspects of their condition, lifestyle and behaviour. This allows us to make an informed decision and to review their medicines effectively and safely. While conducting the reviews, it was noted that many residents were started on medicines, especially SSRIs, when first moving into the care home. Agitation and low mood are common at this time as the patients have had a change in their environment and decline in their health. This commonly resolves within three months but, in most cases, the SSRIs were not being reviewed, meaning the patients remained on them long term.
SSRIs can cause unwanted side effects, especially in older people, including drowsiness, postural hypotension and confusion — all of which increase the risk of falls — so reviewing and deprescribing SSRIs is very important.
All deprescribing involved a slow reduction in line with the care home’s medication cycle. This allowed time for the care staff to monitor any changes in the resident’s behaviour to reduce the risk of relapse. This also reduced medication errors, medication waste and the need for alignment of prescriptions.
Another common theme was that patients discharged from hospital into a care home were often prescribed multiple laxatives and unnecessary pain relief. When reviewing these patients, many suffered with loose stools or had no complaints with constipation or pain. As a team, we have focused on setting up a homely remedy policy in each care home across Sunderland. This allows care homes to give patients certain OTC medicines, including senna, Gaviscon and paracetamol, on a short-term, ‘when required’ basis. This minimises prescribing of unnecessary medicines and reduces waste and cost while allowing patients to receive prompt medical intervention without having to wait for a prescription from the GP.
Once we had built our confidence, we started to review patients in the community. We ran several patient searches to target different patient groups. Our pharmacy technicians took a lead role in reviewing patients using OTC medicines and our pharmacists focused on those prescribed gabapentinoids or antidepressants, starting with the frailest. The team at the Sunderland PCN discharge hub also continued to focus on reviewing appropriate prescribing from hospital discharges; for example, not adding laxatives or OTC medicines to patients’ repeat lists before they have been reviewed.
The antidepressant reviews took a holistic approach as part of a SMR and included the use of the PHQ-9 questionnaire; a diagnostic tool used to diagnose and determine the severity of a patient’s depression. This was another indicator that helped determine if deprescribing was appropriate. In cases that it wasn’t, we could offer additional support by referring them to a GP or social prescriber.
To ensure the patient was seen by the most appropriate clinician, we started to send out the PHQ-9 prior to the appointment, via the AccuRx Florey system. This allowed the patient to fill in the questionnaire privately in their own time. The result would then be forwarded back to the practice where they would be booked in with the most appropriate clinician. For example, those with a high PHQ-9 score would be booked in with a GP, while those with a low to medium score would see the PCN pharmacy team.
The rationale to deprescribe is determined using information gathered during the SMR and that in the CCG guidelines. It is also a shared decision between the clinician and patient. We then form a reduction plan to suit the patient — it is preferred to reduce the dose slowly to reduce risk of relapse and discontinuation symptoms — they are then given safety net information and are followed up appropriately.
During the financial year 2021/2022, we saw a 3.2% reduction in the number of patients prescribed antidepressants in Sunderland; that’s more than 1,000 fewer people in Sunderland taking antidepressants. As a result, we have moved from being the fifth highest prescriber of antidepressants in England to the eighth highest. Further to this, approximately 5,349 OTC items have been successfully deprescribed from February 2021 to February 2022; a cost saving of approximately £28,920.
The PCN pharmacy team have played an essential role in this, alongside GPs, nurses and many other clinicians across the city.
Responses from patients have been extremely positive and they often share their gratitude for the time we have taken to listen to their ideas and concerns. The deprescribing aspect is often taken very positively by patients as they wish to reduce the number of medicines they are taking, particularly if they are no longer clinically indicated. Some, who were a little more hesitant to reduce their medicines, were pleasantly surprised with the effect deprescribing had on how they were feeling, for example, by reducing unwanted side effects.
Overall, it has been very rewarding seeing the reduction in the prescribing figures and knowing that our work has contributed to that.
Victoria Mills is a clinical pharmacist for Sunderland North Primary Care Network
Acknowledgement to Anna Creber, a primary care network senior pharmacist in Sunderland
