I worked as a primary care pharmacist for many years before deciding to embark on my PhD journey. Much of my time in primary care was spent working with GP practices, reviewing the medication of care home residents.
During these care home visits, I met some memorable residents, but I discovered that most of the decisions about medication were made by their healthcare professionals, without any involvement from the resident themselves.
In 2020, I was able to secure funding from the National Institute for Health and Care Research Applied Research Collaboration East Midlands to allow me to undertake a PhD at the University of Leicester. I wanted to conduct a qualitative research project, looking at if, and how, residents’ goals and preferences were included in decisions made about their medicines.
Care home residents are often living with multiple and complex long-term conditions, resulting in polypharmacy, but approximately half of residents take a medicine that is no longer appropriate for them. This makes care home residents ideal candidates for structured medication reviews (SMRs) to help optimise their medication and tackle overprescribing. However, many care home residents are also living with dementia or severe memory impairment, which can make it challenging to engage in meaningful conversations with them about their medicines.
Guidance regarding SMRs suggests that they should be person-centred and holistic reviews that consider the patient’s goals, preferences and understanding of their medicines. A person-centred approach to care is a professional standard for all pharmacists and is central to the Royal Pharmaceutical Society’s four guiding principles for medicines optimisation.
There are a range of definitions within academic literature associated with person- and patient-centred care; however, there is no consensus regarding what this might mean in relation to undertaking SMRs in a care home environment. Although healthcare professionals accept that a person-centred approach is important, the 2022 NHS GP patient survey showed that patients with long-term conditions often don’t get the chance to discuss what is important to them in their appointments with healthcare professionals.
Although there are many reasons why a person-centred approach might not always be the reality in relation to medication reviews, one explanation might be that different people involved in the care home SMR process may have contrasting views on what a person-centred approach involves.
Through my research, I wanted to answer the question: what does a person-centred approach mean in the context of pharmacist-led SMRs for older care home residents, and what makes this easier or harder to achieve?
To help me do this, I carried out an interview-based study. As my research took place during the COVID-19 pandemic, all my interviews happened virtually or by telephone.
I spoke to a total of 18 pharmacists working in care homes across England, including primary care network (PCN) pharmacists and pharmacists employed by clinical commissioning groups or hospitals that provide a care home service for GP practices. I spoke to staff at five care homes, and residents’ family representatives, about how residents’ goals and preferences for medication form part of the review process.
My findings will explore the issues around the lack of understanding among care home staff and family representatives, regarding the role of the care home pharmacist as distinct from that of the community pharmacist, who supplies the care home medication. In the interviews, pharmacists discussed how a lack of understanding of their role sometimes meant that they were directed to the drugs storage trolley rather than the residents by care staff when visiting care homes to undertake SMRs, limiting the pharmacists’ ability to directly access care home residents to involve them in the review process.
My findings suggest that pharmacists wanting to adopt a person-centred approach to SMRs for older care home residents need to have adequate time in their working schedule, both to undertake the review process in a person-centred way, and to develop good working relationships with care home staff and multidisciplinary teams to support understanding of their role and enable access to, and involvement from, residents in reviews. Pharmacists and care staff interviewed found that the inclusion of the residents’ goals and preferences, and considering their life experiences and identity, made a tangible and positive difference to the reviews. For example, one of the pharmacists interviewed talked of celebrating a review where they felt they were able to positively influence the resident’s care. Through taking time to understand the resident’s history and love of art, they were able to reintroduce her to painting, which enabled them to subsequently reduce her sedative medication: “…when I think back, I think that was one of the good cases where we did kind of make a difference.”
I hope that, after I have completed my PhD, I will be able to secure further funding to continue my research in this area.
The introduction of the Directed Enhanced Service specification for SMRs indicates that PCN pharmacists should now be responsible for undertaking SMRs for all care home residents. I would like to be able to visit care homes and talk to residents and their families about how they would like their goals and preferences to form part of the pharmacist review process.
I would also like to observe SMRs in situ to gain a deeper understanding of the practices that make pharmacist-led SMRs person-centred. This would enable me to inform future practice, to achieve a person-centred approach to SMRs for care home residents and ensure that their goals and preferences for medication can form part of the review process.
Rachel Lewis is a pharmacist and a third year PhD research student as part of the SAPPHIRE research group, Population Health Sciences at The University of Leicester.
This study is funded by the National Institute for Health and Care Research (NIHR) Applied Research Collaboration East Midlands (ARC EM). The views expressed are those of the author and not necessarily those of the NIHR or the Department of Health and Social Care.