How we reduced anticholinergic prescribing by 52%

In 2018, I attended one of the the first workshops of NHS England’s ‘Medicines Optimisation in Care Homes’ training pathway. This 18-month scheme for pharmacy professionals was facilitated by the Centre for Postgraduate Pharmacy Education, in partnership with Health Education England, and energy was high. 

As part of this, we were expected to undertake a quality improvement project (QIP) and during a discussion about anticholinergics, falls, cognitive decline and increased mortality of older people who are vulnerable to side effects, I had an idea for my own QIP: reducing the anticholinergic burden (ACB) score for care home residents.

Returning to work, I calculated the total ACB score for the medicines taken by every resident in a 20-bed care home and triaged them for medication review. I presented this QIP to my tutor and colleagues, sharing my vision of a ‘whole-systems’ piece of work, which would link all sectors and social care in reviewing and highlighting the use of anticholinergics. 

This small QIP then began to take on a life of its own, enabling collaboration with East Lancashire Clinical Commissioning Group (CCG) and East Lancashire Hospitals NHS Trust, supporting and up-skilling many other healthcare professionals along the way. It spawned a social media platform, allowed multiple disciplinary relationships to form, provided professional development for colleagues and united pharmacy teams.

While undertaking medicine reviews for care home residents, I worked in partnership with clinicians and patients seeking to deprescribe anticholinergics that were no longer indicated or tolerated, and seeking alternative treatments. I was not prepared for the positive, tangible results that I soon witnessed, as each individual patient’s quality of life was improved. 

The positive patient outcomes continued including testimonials from grateful staff and relatives, such as: “Thank you for giving me my Mum back”; “I no longer need my walking frame”; “This lady is more stable on her feet and her appetite has increased”; and my personal favourite: “The nurse heard a voice on the unit that she did not recognise, the resident had begun to talk.” 

By 2019, ACB triage had now become our team’s approach and motivation, and we used data from ECLIPSE — the risk stratification software — and GP systems to support us triaging more than 3,000 care home patients. 

An e-learning module was commissioned by East Lancashire CCG from PrescQIPP, a not-for-profit provider of training materials, to raise awareness of ACB and this was promoted to all GPs and primary care network pharmacists by East Lancashire CCG’s medicines management team. 

In 2020, our outcomes in the community meant that we were given the opportunity to integrate the project onto the wards of East Lancashire Hospitals NHS Trust. 

The hospital pharmacy professionals engaged fully with our work and we shared a common purpose that unified our teams. The COVID-19 pandemic changed the way we worked but the goal remained, and the pharmacy ward service was redesigned embedding ACB scoring into the medicines reconciliation admissions process and adding scores to hospital discharge summaries to support GPs.

This work meant pharmacy technicians felt upskilled, empowered and confident to make recommendations to prescribers that could have positive impacts for patients. Their expertise was valued.  

By September 2021, East Lancashire was among the areas with the lowest prescribing of anticholinergics in people aged over 75 years, well below the England average. Prescribing of anticholinergics was down 52%, between January 2018 and September 2021, compared with a national fall of 28%.

Crucially, the percentage of people over 75 years prescribed ten or more unique medicines had also fallen, down 12% over the same time period, compared with a national fall of 4%.

In October 2021, we were very proud to be awarded the PrescQIPP Gold award and we continue to be bold and support other NHS trusts and areas to learn from our experience. We presented recently to Association of Pharmacy Technicians UK, ELHT acute clinical practitioners, care home providers and an advanced clinical practitioners forum across the Lancashire and South Cumbria Integrated Care System (ICS). 

We eagerly await ELHT’s forthcoming United Medicines Record, which will prominently display ACB scores at the point of care (e.g. emergency department medicines reconciliation). This will make medication reviews to reduce ACB even easier and hopefully ensure it becomes consistently incorporated into practice.  

System collaboration is challenging; however, this focused work has delivered considerable improvements to the quality of life for some of our most vulnerable members in society and — even more excitingly — has presented us with a model and opportunity which can be replicated.

Our project to reduce anticholinergic burden continues to be delivered with focus and energy — a task that is much easier when you feel empowered and know that your work makes a real and lasting difference. 

Jane Shanahan is senior medicines optimisation care home pharmacy technician at East Lancashire Hospitals NHS Trust