Pharmacists must work with others to roll back polypharmacy culture

More people are taking more medicines than ever before; in England alone, the number of people aged over 65 years taking five or more medicines has quadrupled over the past 20 years, from 12% to 49%^[1]
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Polypharmacy — often used to describe taking five or more medicines^[2] — can be appropriate for particular patients. However, in 2013, the King’s Fund drew attention to “problematic polypharmacy”^[3]
, highlighting that many concurrent medicines can increase the risk of drug interactions and side effects, impair patients’ adherence to their medication and reduce their quality of life. Then later, in 2015, the National Institute for Health and Care Excellence (NICE) published guidance on medicines optimisation^[4] — a practice built on the idea that everyone should get the best possible outcomes from their medicines.

Following this, in December 2018, the Department of Health and Social Care commissioned a review that will look into how overprescribing in the NHS can be addressed^[5]
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The latest medicines optimisation measure was NHS England’s announcement in January 2019 that it will provide funding for each primary care network in England to employ up to six pharmacists by 2024 to carry out structured medicines reviews, with a new service requirement to be published in April 2020.

Deprescribing is not easy, but we believe that connecting and sharing knowledge with other pharmacists and healthcare professionals will lighten the load

Healthcare bodies are taking note, but how do healthcare professionals address the inappropriate polypharmacy problem in practice? What should we do when we identify people who are not getting the best outcomes from their medicines? How do we manage risks appropriately? How do we engage patients in conversations about deprescribing? And how do we optimise medicines when we have not been involved in starting them in the first instance^[6]
?

Deprescribing is not easy, but we believe that connecting and sharing knowledge with other pharmacists and healthcare professionals will lighten the load. So, in June 2019, we launched the English Deprescribing Network (EDeN), which aims to allow healthcare professionals to share ideas, best practice and learning; to shape policy; and to drive a change in culture across healthcare.

Uniting to take action now

We have experience of conducting structured medication reviews across primary and secondary care. Too frequently we have witnessed first hand the difficulties facing patients with complex medication regimens, as well as the challenges of stopping medicines during these reviews.

In March 2018 — during our year out of practice as chief pharmaceutical officer clinical fellows — we led a workshop attended by more than 100 participants from across the pharmacy workforce and national organisations, including pharmacists and pharmacy technicians from community pharmacy, clinical commissioning groups, acute hospitals, community health services, academia, academic health science networks (AHSNs), NICE and the Royal Pharmaceutical Society.

Participants were asked to think of their biggest, boldest idea to make deprescribing part of everyday clinical practice. Obvious themes included increasing connectivity and sharing knowledge on the subject among the pharmacy profession and other professions, and the participants committed to taking immediate action. The idea of a network was well received, and EDeN was born.

A little help from our friends

We scoped out what was happening nationally and internationally to inform our work on beginning and building the network. Keen to avoid reinventing the wheel, we were inspired by our colleagues in Canada and Australia — hosts to their own deprescribing networks, CaDeN and ADeN, respectively.

Those involved in developing CaDeN and ADeN have been (and continue to be) very helpful in sharing advice and their experiences. For example, a patient education programme led by CaDeN resulted in a 27% deprescribing rate over the course of six months.

CaDeN has several threads for members to get involved in; an academic group supports the evidence base and develops guidelines and algorithms, while a nurse-led thread explores what further training could help nurses to drive deprescribing forward. We are keen to replicate this idea in our own network, using the expertise of our members to inform the threads.

We recognised the importance of the network having a ground-up approach, so we consulted healthcare professionals from the chief pharmaceutical officer scheme and national medical director clinical fellow schemes, past and present, to create our executive team. These early-career pharmacists and doctors have a range of experience across specialties from paediatrics to care of older people. They are united by a shared goal of achieving person-centred discussions about the right treatment for the right people. Our executive team has been fundamental in the early stages of our development and has made sure that the network resonates with healthcare professionals in practice.

Research academics from various institutions across the UK are currently providing much needed research on deprescribing and they have pledged their support to the network. Engagement with this group is vital, since it is widely recognised that the evidence base to support deprescribing is much needed^[7]
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We have also sought guidance from an advisory group, comprising national leaders in the field of polypharmacy, medicines review and patient-centred care from NHS England, NHS Improvement and AHSNs. The advisory group acted as a sounding board for our ideas and pointed us in the direction of others in the field of medicine who may be interested in supporting the early development of the network.

Some important messages came come from these conversations: we need to engage a wide range of stakeholders and remember that the culture change will not just be about the pharmacy profession; we need to keep up the momentum; and we need to understand the importance of words and getting the terminology right.

Importance of language

We spent time with our advisory group and executive team to fully consider and evaluate the use of the term ‘deprescribing’. Opponents of the word advised that it can often be viewed negatively by patients and healthcare professionals^[8]
; however, proponents advised that this was the most straightforward terminology that was already familiar with healthcare professionals and those in academia.

Deprescribing is different to polypharmacy; our definition encompasses unwanted or harmful medication, rather than only the amount of medicines

‘Deprescribing’ is already a well-known description of what we are hoping to achieve — the reduction of unwanted or harmful medicines. We decided to use this terminology and, knowing that narrative is important, wrote our own definition: ‘Deprescribing is a collaborative process, with the patient and/or their carer, to ensure the safe and effective withdrawal of medicines that are no longer appropriate, beneficial or wanted, guided by a person-centred approach and shared decision-making.’

Deprescribing is different to polypharmacy; our definition encompasses unwanted or harmful medication, rather than only the amount of medicines.

Bringing members together

Currently, EDeN is a virtual group of healthcare professionals from a range of backgrounds and clinical specialties, as well as academics and policy leaders. Having launched in June 2019, we plan to facilitate discussions on various threads, including academic, education and creation of tools, and good practice.

CaDeN and ADeN helped us recognise the importance of opportunities to meet face to face, and we hope to bring our members together in a conference in the future.

We have started our work with healthcare professionals because we know the difficulties facing healthcare professionals (like us) who want to deprescribe in practice and do the best for their patients. However, any intervention affecting a patient must involve the patient, so we have also enlisted the help of patient groups and representatives.

Measuring the network’s success

EDeN is built on the shoulders of its membership — through their discussions and examples of good practice and connectivity we hope the network will be successful. We will ask the membership to evaluate the network at six months and one year after the launch. We hope to look at a few areas, including knowledge capture: we will ask whether discussions are occurring within the network regularly and whether the knowledge shared in these discussions has made them essential reading for all members. We will look at learning and improvement — does the network need to engage more fully in formal and informal learning? Does the network encourage reflective practice enough? We also hope to review governance and structure — is the network well rounded with a diverse range of members? If not, we will ask how we can encourage important groups (paediatricians or patient groups, for example) to be a part of EDeN.

We will also use our evaluation to understand how EDeN is developing and where we and our members must focus our collective attention and effort to ensure that we have the best chance of achieving the network’s purpose and aims.

It will take time to change polypharmacy culture, but bringing interested parties together is certainly a step in the right direction.