Polypharmacy: Getting our medicines right

• There is access to help from the pharmacy team in all settings where medicines are used, including access to a pharmacist where appropriate
• All healthcare organisations have systems in place to ensure people taking multiple medicines (especially those taking 10 or more medicines) can be identified and highlighted as requiring a comprehensive, structured, holistic medication review OR systems in place to ensure that the individual is highlighted as being at risk from harm caused by polypharmacy to their registered GP practice, with the expectation that the GP practice will follow that up and make arrangements for the person to undergo an appropriate medication review
• Healthcare organisations that provide medicines on a repeat basis ensure that those repeat prescribing systems are safe, well organised and do NOT contribute to problematic polypharmacy by allowing medicines to be prescribed on a repeat basis without regular medication review
• All healthcare organisations should ensure that where medication reviews occur, that they are person-centred and engage fully with the individual and/or their carer to discuss the taking of multiple medicines and the impact on that particular person
• Actions to stop medicines safely are clearly communicated with the person as well as all healthcare and social care professionals and organisations involved in the prescribing, dispensing and administration of their regular medicines
• Healthcare and social care organisations support health and social care professionals to refer people with very complex polypharmacy issues to those with particular expertise in addressing these issues; such expertise may include a pharmacist or consultant pharmacist, a care of the elderly consultant or people with suitable skills, for example a clinical pharmacologist
• Healthcare organisations should develop “Polypharmacy communities of practice” or similar to ensure a multidisciplinary forum, which includes patients, to share problems and solutions, share best practice, share resources developed to tackle polypharmacy and redesign care pathways to support patients to get more from their medicines. See section 7.81

* includes GP practices, community pharmacies and social care settings where medicines are used.

Questions for health and social care systems (for example, CCGs, STPs, Health Boards, ICSs) to ask in order to self-assess their approach to polypharmacy

• How well do we work together as a system to address polypharmacy?
• Do we have, at very senior or board level, clearly identified leaders responsible for reviewing the issue of polypharmacy at organisational level and accountable for delivering a strategy aimed at addressing problematic polypharmacy?
• Do our pathways include all those who might be able to identify and address problematic polypharmacy, for example community pharmacy, community nursing, physiotherapy?
• Do our pathways enable referral to clinicians with the appropriate skills and expertise to carry out holistic, person-centred medication reviews, for example, GPs, clinical pharmacists, community care of the older person consultants and clinical pharmacologists?
• Do individual healthcare professionals have the support they need to carry out person-centred holistic polypharmacy medication reviews and escalation processes if needed?
• How are we engaging with people under our care to discuss the issues of problematic polypharmacy and what we are doing to address this?
• Do our staff (especially prescribers) have access to good quality resources that accurately set out the efficacy of medicines, for example NHS Scotland NNTs.

• People are involved in decisions about their medicines
• People (or their carers – which includes paid and unpaid carers) receiving medicines share information with their healthcare professional when medicines are causing problems; such problems may arise from:
  • A lack of understanding of what the medicine is for
  • Side effects of the medicine
  • The inability to take the medicine properly (for example, due to size of tablet or timing of doses), or
  • Problems caused by the number of medicines being taken
• People are honest with their healthcare professional about their willingness to take the medicines as prescribed. Tools such as the ’me and my medicines charter’ can help people and their healthcare professional to have such conversations. See Appendix 5
• Whilst people taking medicines have a responsibility to share where multiple medicines taking is becoming problematic, it is recognised that some people will find this especially challenging. Examples include those with learning difficulties, cognitive impairment, drug addiction, young people and children. For these groups, healthcare professionals and healthcare organisations should make special arrangements to facilitate the sharing of issues related to polypharmacy.

• All prescribers have access to accurate and up to date therapeutic information to enable a complete assessment of the efficacy of any medicine, for example NHS Scotland Step 3 or NICE guidance.
• All prescribers use tools and resources available to support high quality consultations which enable shared decision making and focus on the person in the consultation
• Those involved in direct work to address polypharmacy are aware of and use, where necessary, data and risk stratification tools that are available to help identify those people who are at the greatest risk of polypharmacy, and anyone identifying a person who may benefit from a polypharmacy review should signpost to an appropriate healthcare professional for a review
• All prescribers assess a person’s adherence with their medicines before any decisions are taken about treatment failure or adding extra medicines
• All prescribers make a full assessment about whether it is safe and appropriate for medicines to move into a ‘repeat prescribing system’ and are assured that checks and reviews are in place to highlight when a repeat medicine should be stopped
• All prescribers consider the ‘treatment burden’ associated with the medicine or medicines that they are prescribing, which may include the requirement for monitoring and other appointments
• All prescribers can demonstrate they have undertaken training to ensure that their consultation skills are such that they enable high quality person-centred discussions about medicines. See section 6.6 on examples of tools to support healthcare professionals improve their consultation skills.

All prescribers are reminded of the RPS Prescribing Competency Framework

Medical prescribers are also reminded of their responsibilities under GMC Guidance Good Practice in prescribing and managing medicines 

This includes community pharmacists, those working in community health / intermediate care services, those working in GP practices and other environments, for example prisons

• Pharmacists working within GP practices use systems that are available to them to systematically identify people who are regularly taking large numbers of systemic medicines, for example
  • NHSBSA polypharmacy prescribing comparators or Quality and Outcomes Framework database in England,
  • SPARRA score (score that considered medicines and risk of admission to hospital) in Scotland,
  • Prescribing Indicators in Wales,
• Pharmacists screen for potential adverse drug reactions (ADRs) and take steps to reduce the risk of harm, this should include the identification and reporting of suspected ADRs using the Yellow Card Scheme 
• Pharmacists should ensure that where a person presents with prescriptions, or a request for multiple, regular medicines, that there are processes which enable opportunistic review to understand how they are managing the ‘pill burden’ and if any medicines are no longer needed and if polypharmacy is problematic for that patient
• Pharmacists should participate in any locally or nationally agreed systems in place to support collaborative working to address polypharmacy, this might include a regular feedback to prescribers highlighting any person that is thought to be taking a large number of medicines and may not be coping well with taking them
• Pharmacists should ensure that when a medication review is carried out and the person is found to have very complex medicines issues, that mechanisms are in place to refer to their GP or a geriatrician or other services that are able to manage their conditions (for example, intermediate care services)
• Pharmacists undertake ongoing training to ensure that their consultation skills enable high quality person-centred discussions about medicines. See examples of tools to support healthcare professionals consult their consultation skills

• Where it is not possible for a person taking multiple medicines to be supported with a holistic person-centred medication review (for example, if a person is only in hospital a short time), pharmacists flag that a review is required with the GP practice and community pharmacist
• Pharmacists in hospital settings raise concerns with prescribers when they identify people taking multiple medicines (especially those taking 10 or more) and more long-term medicines are planned, further increasing the pill burden for that person
• Pharmacists screen for potential adverse drug reactions (ADRs) and take steps to reduce the risk of harm, this should include identification and reporting of suspected ADRs using the Yellow Card Scheme 
• Factors such as the person’s situation (for example, do they live alone, do they have a carer?) are known to the prescriber before more medicines are added
• Factors such as current adherence with medication regimes are tested before additional medicines are added in; if this is not possible (for example, due to the nature of the admission or visit to hospital), any concerns about adherence are flagged with the person’s hospital prescriber, GP practice and community pharmacist
• Pharmacists in hospital have undertaken ongoing training to ensure that their consultation skills are such that they enable high quality person-centred discussions about medicines
• Those working in a hospital setting should be fully aware of the risk of error, misunderstanding and confusion around medicines at discharge and mechanisms and pathways to improve on transfer of care around medicines should be in place
• See examples of tools to support healthcare professionals improve their consultation skills.

• Pharmacists in care homes provide medication reviews regularly, where possible, within a multidisciplinary team and with the input of people using medicines, as well as carers if the situation allows
• Particular attention is paid to medicines or combinations of medicines that are known to have higher risks for older people or those with mental health problems or learning difficulties
• Pharmacists in care homes screen for potential adverse drug reactions (ADRs) and take steps to reduce the risk of harm, this should include the identification and reporting of suspected ADRs using the Yellow Card Scheme 
• Pharmacists in care homes ensure they have undertaken training to carry out holistic, structured medication reviews and use evidence-based tools to support high quality medication reviews
• Pharmacists in care homes have undertaken ongoing training to ensure that their consultation skills are such that they enable high quality person-centred discussions about medicines
• Community pharmacists supporting care homes work in collaboration with pharmacists working in the care home (where they are in place) to ensure that these recommendations are addressed and agree roles and responsibilities.

• Pharmacy Technicians in all care settings contribute to reducing the impact of taking multiple medicines and the pill burden on people and particularly for vulnerable groups such as older people
• Pharmacy Technicians, in all care settings, undertake ongoing training to ensure that their consultation skills enable high quality person-centred discussions about medicines; that they can carry out holistic, structured medication reviews and use evidence-based tools to support high quality medication reviews and that they highlight any issues or concerns raised with the most appropriate person (e.g. pharmacist, prescriber, multidisciplinary team)
• Pharmacy Technicians undertaken medication reviews in all care settings, where possible, within the pharmacy and multidisciplinary team and with the input of people using medicines, as well as carers if the situation allows
• Pharmacy Technicians have an understanding of the side effects of medicines, recommended doses and best time to take a medicine for optimum effect and are alert to identifying persons taking multiple medicines, especially those who may not be managing the challenges of taking complex regimens or multiple medicines and highlight these people to their pharmacist or prescriber.
• Pharmacy Technicians in all care settings manage the supply and storage of appropriately prescribed medicines reducing medicines wastage and associated cost savings and engage with people to increase medicines adherence to potentially reduce admissions to hospital caused by poor adherence
• Pharmacy Technicians in all settings are alert to potential adverse drug reactions (ADRs) and take steps to reduce the risk of harm, this should include highlighting any issues identified with the most appropriate person and ensuring the reporting of suspected ADRs using the Yellow Card Scheme.

• Nurses in all care settings are aware of the impact of taking multiple medicines on people under their care and particularly for vulnerable groups such as older people
• Nurses are alert to identifying persons taking multiple medicines, especially those who may not be managing the challenges of taking complex medicine regimes or multiple medicines and highlight these people to their prescriber or pharmacist for a possible medication review
• Nurses have an awareness of side effects of medicines and an understanding of the recommended doses and best time to take a medicine for optimum effect
• Nurses in all care settings, but particularly those working with vulnerable people such as older people, ensure that they are able to engage people under their care in a discussion about how they are coping with their medicines taking and highlight any issues raised with the most appropriate person (for example, their GP or prescriber).

The iSIMPATHY project from across Europe, clearly identifies that stopping medicines that are no longer required cannot be an automated, robotic task. It has stated that isolated practices to stop medicines may not be the best solution for patients and populations. Instead, it advocates an approach whereby policy makers, healthcare providers, caregivers and patient associations come together to develop best practice for managing polypharmacy particularly in older people.

The best practice advice provided in this guidance is based on this recommendation. See isimpathy.eu.

A key recommendation from work done in the EU already, is to design processes to address polypharmacy in collaboration with clinicians, policy makers, educators, commissioners and the patient.

Work done in a number of countries on polypharmacy has also highlighted the importance of a clear implementation strategy based on evidence base and effective change models. Such change models could be helpful at both the national, strategic level as well as for local projects to be successful and for change to be sustained.

Finally, policy makers and healthcare organisations should identify and review any perverse incentives built into their systems and process that may inadvertently contribute to polypharmacy.

The key audience for this guidance is the pharmacy profession. However, as polypharmacy is such a broad topic, influenced by all clinical groups involved with medicines, this document is also aimed at being relevant for all healthcare professionals and organisations involved with the care of people where medicines are likely to be used.

Whilst this guidance has been written for health and social care professionals, the central theme of the work is that if healthcare professionals fail to engage with these people and fail to make person-centred prescribing and shared decision making the norm, then the issue of polypharmacy will never be fully addressed. Therefore, the representatives of people using healthcare services involved in this work were highly valued in its development and we hope that patient groups can use this guidance to help drive the change in approach. To facilitate this, we have developed a summary aimed at the general public, and a concise guide aimed at pharmacists. 

There are many definitions of the term polypharmacy. This guidance uses the term broadly, to cover four main scenarios of where multiple medicines taking becomes problematic polypharmacy:

• The prescribing of medicines that are no longer clinically indicated or appropriate or optimised for that person
• Where the benefit of a particular medicine or medicines does not outweigh the harm
• Where the combination of multiple medicines has the potential to, or is actually causing harm to the person, and
• Where the practicalities of using the medicines prescribed to a person have become unmanageable or are causing harm or distress.

The term ’pill or treatment burden’ has been used to describe when a person is taking a number of medicines (mostly in oral form) that may be difficult to manage due to the number of tablets/capsules to be taken, the way they have to be taken, how easy they are to swallow, whether they can be taken all together and the general consequences of ordering, storing and managing a large number of medicines. However, it can also include medicines administered via other routes, for example eye drops, and any ongoing monitoring and other appointments. 

This guidance is designed to provide an initial, overarching summary of the size, scale and complexity of the issue of polypharmacy; and aims to outline the vital role that people themselves (and their carers) must play in the solutions to problematic polypharmacy. It will aim to signpost to some of the good work already being done and make recommendations to healthcare professionals and healthcare organisations who encounter polypharmacy and its consequences.

This guidance is not intended to be a clinical guideline to inform decisions about stopping medicines in specific individuals but will signpost healthcare professionals to some of the excellent resources available that do help with those decisions.

The guidance seeks to ensure that the solutions to polypharmacy are always underpinned by the principles of medicines optimisation and to ensure that the person is at the heart of any decision taken about their medicines.

This guide is intentionally aspirational. The recommendations made in this guidance may not necessarily reflect the current arrangements in healthcare but aim to set out a picture of what good systems can and should have in place and how healthcare professionals could behave in order to address the problems that can arise from polypharmacy.

There are numerous definitions of polypharmacy. The Kings Fund report defined problematic polypharmacy as being where ‘multiple medications are prescribed inappropriately, or where the intended benefit of the medication is not realised’.

This RPS guidance uses the term broadly, to cover four main scenarios of problematic polypharmacy including:

• The prescribing of medicines that are no longer clinically indicated or appropriate or optimised for that person
• Where the benefit of a particular medicine or medicines does not outweigh the harm
• Where the combination of multiple medicines has the potential to, or is actually causing harm to the person, and
• Where the practicalities of using the medicines prescribed to a person have become unmanageable or are causing harm or distress.

It is important to set out that whilst polypharmacy is often linked to concerns about older people, it is not an issue solely confined to this group. Other groups of people such as children, those with mental health problems, those from more deprived backgrounds and those with multiple morbidities are at significant risk from the problems associated with polypharmacy. Polypharmacy crosses all care settings, and all healthcare professionals should be alert to the issue of problematic polypharmacy in hospitals, community pharmacy, care homes and prisons, for example.

The World Health Organisation (WHO) has described polypharmacy as a major global problem, saying ‘Irrational use of medicines is a major problem worldwide. WHO estimates that more than half of all medicines are prescribed, dispensed or sold inappropriately, and that half of all patients fail to take them correctly. The overuse, underuse or misuse of medicines results in wastage of scarce resources and widespread health hazards’. In its 3^rd Global Health Challenge, Medication Without Harm, launched in March 2017, WHO aims to reduce severe avoidable medication-related harm by 50% globally in the next 5 years.

WHO has identified some early priority actions and asked countries and key stakeholders to make strong commitments, prioritise and take early action, and effectively manage three key areas to protect people from harm, namely:

• High-risk situations
• Polypharmacy, and
• Transitions of care.

The actions planned in this Global Challenge are based on four domains of work, one for each fundamental problem identified. These are: 

• People taking medicines and the public
• Medicines
• Healthcare professionals, and
• Systems and practices of medication. 

To support this, we have set out the guidance under three key areas:

Polypharmacy and People 

Polypharmacy and Healthcare Systems

Polypharmacy and Healthcare Professionals

A central theme of the guidance is that the solutions to polypharmacy are complex and multifaceted but will not bring about the desired change if healthcare professionals fail to engage people much more in their medicines taking. Shared decision making around which medicines are most appropriate for that individual is vital to reducing problematic polypharmacy and the potential harm from it. Holistic, structured medication reviews carried out by healthcare professionals who are competent to engage with people under their care in open and honest conversation about medicines will be key.

Prescribing multiple medicines is associated with various adverse outcomes for people receiving and taking medicines. Unplanned hospitalisation is strongly associated with the number of regular medications prescribed (“Is Polypharmacy always Hazardous? A retrospective cohort Analysis using linked health records from primary and secondary care. BJCP 77:6 1074-1082 )

As the number of medicines being prescribed to an individual person is increasing, it seems sensible to be concerned about the raised risk that taking more medicines may bring.

It was estimated that in 2015/16 nearly half of all adults in England (48%) had taken one prescribed medicine in the previous week, and three or more prescribed medicines had been taken by nearly a quarter of all adults (24%). (NHS Digital England Health Survey 2016)

In 2017, a study into the medication usage in older people, including both prescribed medicines and over the counter products, showed that there had been a dramatic increase in use over the last two decades, with a quadrupling in the number of people taking five or more medicines (from 12 to 49%). The number of people taking no medicines has reduced from 1 in 5 to 1 in 13.
(Medication usage change in older people (65+) in England over 20 years: findings from CFAS I and CFAS II ).

Prescribing data from England shows that the total number of items dispensed in 2016 was 1,104.1 million. This is an increase of 46.8% on the number of items dispensed in 2006.

The average number of annual prescription items per head of the population in 2016 was 20.0, compared to 19.8 items in the previous year and 14.8 in 2006.

In 2016, Wales dispensed 25.9 prescription items per head of population, in the same year, this compared to 20.2 in England and 19.1 in Scotland (Prescriptions dispensed in the community).

One third of over those over 75 years of age now takes at least six medicines (ref HSCIC Information centre. Prescriptions dispensed in the community, statistics for England 2004-2014) (https://digital.nhs.uk/data-and-information/publications/statistical/prescriptions-dispensed-in-the-community/prescriptions-dispensed-in-the-community-statistics-for-england-2004-2014 )

There are serious consequences of this increase for individuals; a person taking ten or more medicines is 300% more likely to be admitted to hospital (Payne RA et al. Is polypharmacy always hazardous? A retrospective cohort analysis linked to electronic health records from primary and secondary care. BJ Clin Pharmacology 2014; 77:1073-1082 ). Adverse effects of medicines account for 6.5% of hospital admissions, and the rates in the over 65 years of age varies widely in various studies, rates of over 10 and up to 20% have been seen in the over 65s. (Adverse drug reactions as cause of admission to hospital perspective analysis of 18,820 patients, Pirmohamed et al).

Better systems aimed at identifying those who are at high risk of a preventable hospital admission associated with an adverse drug reaction (namely those aged over 65 years old, those receiving more than five drugs or those starting a new high-risk drug) should be implemented in order to minimise the risks to people and the burden on the healthcare system (www.ncbi.nlm.nih.gov/pubmed/23686895).

‘However, whilst unplanned hospitalisation is strongly associated with the number of regular medications, the effect is reduced in patients with multiple conditions, in whom only the most extreme levels of polypharmacy are associated with increased admissions. Assumptions that polypharmacy is always hazardous and represents poor care should be tempered by clinical assessment of the conditions for which those drugs are being prescribed’ (Payne RA et al. Is polypharmacy always hazardous? A retrospective cohort analysis linked to electronic health records from primary and secondary care. BJ Clin Pharmacology 2014; 77:10731082 http://www.clinmed.rcpjournal.org/content/16/5/465 ).

Therefore, work aimed at reducing polypharmacy and tools aimed at identifying people at risk from problematic polypharmacy need to be more sophisticated than simply measuring the number of medicines a person takes. Initiatives and tools will need to look at the number, types and combination of medicines being taken as well the number of conditions an individual has.

Finally, an important but uncomfortable factor leading to increased polypharmacy, certainly in western cultures, is the over-medicalisation of some health problems and the failure to embrace changes in lifestyle as a key solution to many long-term health issues. This has led to a number of high profile campaigns such as Slow Medicine in Italy, Choose Wisely by the Association of Medical Royal Colleges, JAMAs Less is More, the BMJ’s Too Much Medicine and the RCGP Overdiagnosis work (Medicalisation and Overdiagnosis: What society does to medicines)

The UK population has grown by 8.4 million since 1975 (https://visual.ons.gov.uk/uk-perspectives-2016-the-changing-uk-population/), and life expectancy has grown steadily since the 1980s. The projected life expectancy in 2039 is 96 years for women and 93 years for men. However, healthy life expectancy is not increasing as steadily, meaning we live longer but spend a growing proportion of that time in poor health. 18% of the UK population is over 65 years of age and 2.4% are over 85 years. (Ref Office on National Statistics Overview of the UK population: July 2017).

The number of UK residents aged over 90 has tripled since the 1980s and in 2014, 853 of every 100,000 residents in the UK was over 90. 

‘Long-term conditions are more prevalent in older people – 58% of people over 60 years live with a long-term condition compared to 14% of those under 40 years of age.

Long-term conditions are also more prevalent in more deprived groups – people in the poorest social class have a 60% higher occurrence than those in the richest social class and 30% increased severity of disease.

People with long-term conditions now account for about 50% of all GP appointments, 64% of all outpatient appointments and over 70% of all inpatient bed days.’

( www.kingsfund.org.uk/projects/time-think-differently/trends-disease-and-disability-long-term-conditions-multi-morbidity).

So, some of the key population drivers for prescribing more and more medicines to people are very clear – an ageing population with increasing co-morbidities means an increased risk of more medicines.

However, it isn’t obvious why, in the healthcare system at the various touch points with people being prescribed multiple medicines, no one stops to say, ‘Why is this person taking 19 drugs and how are they managing that?’ To explore this further we will also highlight some of the barriers to stopping medicines. (See section 7.6)

Medication adherence is defined by the World Health Organization (WHO) ‘as the degree to which the person's behaviour corresponds with the agreed recommendations from a healthcare professional’. Poor adherence to prescribed regimes can result in serious health consequences.

Adherence is an important but often overlooked factor in polypharmacy. WHO in 2003, highlighted that 30-50% of medicines are not taken as intended (www.who.int/chp/knowledge/publications/adherence_full_report.pdf ).

Often further medicines are prescribed in response to ‘treatment failure’ rather than a check of the level of treatment adherence. This was illustrated by a recent study (BJ Clinical Pharmacology Vol 84 Issue 1 Jan 2018 18-24)  which highlighted that hypertension is only controlled in 35% of people. Those in this study were assessed for adherence to their blood pressure medicines (physicians and people under their care were unaware of adherence measurements), and 68% of the people prescribed medicines were non-adherent. Furthermore, for every one more pill prescribed, the prescribed pill was less detectable in their blood, showing reduced compliance.

Therefore, healthcare professionals should consider non-adherence to be a significant factor in treatment failure and should attempt to discuss this with the person before any further medicines are prescribed. Failure to address this may lead to more medicines being prescribed, potentially increasing the pill burden as well as increasing the risk of problematic polypharmacy, which in turn, may cause harm to the person without the underlying illness actually being treated. This approach also potentially increases the risk of medicines waste.

The World Health Organisation has said that people are not always medication-wise. They are too often made to be passive recipients of medicines and not informed or empowered to play their part in making the process of medicine prescribing safer.

To address this, both healthcare professionals and the people under their care need to come together and make treatment decisions in a shared and equal way.

NICE described shared decision making as ‘when health professionals and patients work together. This puts people at the centre of decisions about their own treatment and care’. NICE outlines the benefits as:

• ‘People receiving and delivering care can both understand what's important to the other person
• People feel supported and empowered to make informed choices and reach a shared decision about care  
• Health and social care professionals can tailor the care or treatment to the needs of the individual.’ (www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/nice-guidelines/shared-decision-making).

The Scottish Government in its Quality Strategy 2020 highlights person-centred care as one of its three Quality Ambitions.  It defines person-centred care as ’mutually beneficial partnerships between patients, their families and those delivering healthcare services which respect individual needs and values and which demonstrates compassion, continuity, clear communication and shared decision-making’ (www.gov.scot/Publications/2010/05/10102307/2).
In Wales, the 1,000 lives programme supported the implementation of shared decision making; and Cardiff has been a key site in the MAGIC Project, which is a Health Foundation programme aimed at implementing shared decision making (MAGIC stands for ‘making good decisions in collaboration’ and looked at how to embed best practice in shared decision making).

It is possible to make shared decision making part of routine practice in the NHS. See learning from the MAGIC Project www.bmj.com/content/357/bmj.j1744.full.print ) .

A more engaged approach as suggested by NICE or the work led by members of the public such as the ‘Me and My Medicines’ work or ‘My Medication Passport’ should be embraced and supported by healthcare systems.

The table below sets out a selection of shared decision tools to support the conversation with a person and/or their carer(s) to ensure that the decision to prescribe or stop a medicine is reached appropriately and with equality of influence from both the prescriber and the person under their care taking important factors in to consideration.

In addition, all those working with people to help them to use their medicines should ensure that they have reflected on their own consultation skills to enable people under their care to be open and honest about their medicines taking and about the key factors in their lives that may influence their engagement and adherence with their medicines.

Whilst this guidance clearly recommends that people taking medicines have a responsibility to share where multiple medicines taking is becoming problematic, it is recognised that some people will find this especially challenging. Examples include those with learning difficulties, cognitive impairment, drug addiction, young people and children. For these groups of people and others who may have difficulty highlighting their medication challenges, healthcare professionals and healthcare organisations should make special arrangements to facilitate the sharing of issues related to polypharmacy.

Regardless of what polypharmacy initiatives are put in place, and which tools are used, people make decisions about their medicines every day. They may choose to adhere or not, but unless a conversation is undertaken with the person about what their priorities for their health and their life are, it will be difficult to understand the context in which their medicines taking fits (or doesn’t). Therefore, polypharmacy will remain problematic until healthcare professionals and people work together to arrive at a shared decision about the priority areas of health, the agreed number of treatments and the treatment regimes and how they will be adopted.

Good Practice

All healthcare professionals should familiarise themselves with a tool or tools to help them conduct high quality, shared decision making conversations with people under their care that result in agreed outcomes.Those supporting people to take their medicines should ensure that they have reflected on their consultation skills to enable people under their care to be open and honest about their medicines taking.

The challenges faced around polypharmacy are inextricably linked to the fact that as the number of medicines prescribed increases, the risk from adverse effects increases too. Medication safety is a particular concern in key people groups, such as older people.

A study commissioned by the GMC in 2012 and carried out in general practice aimed to determine the prevalence and nature of prescribing errors in general practice. It showed that 1 in 20 prescription items has an error and 1 in 550 potentially has a serious outcome.

As over a billion items are dispensed in England each year, this equates to around 1.8 million potentially serious errors (GMC Investigating the prevalence and causes of prescribing errors in general practice)

Studies in the hospital setting show similar levels of error that are of concern. The EQUIP study showed that of 4,238 prescriptions evaluated, one or more errors were noted in 43.8% of prescriptions, with a total of 3011 errors detected. 54.1% of the errors were deemed significant, 109 (3.6%) were serious and 9 (0.30%) were potentially life threatening and the error rate was not significantly different between newly qualified doctors compared with junior, middle grade or senior doctors. 

(REF http://bmjopen.bmj.com/content/3/1/e002036)

More recently, a Secretary of State commissioned report from York, Manchester and Sheffield Universities reviewed the prevalence and economic burden of medication errors in the NHS. They estimated that 66 million potentially clinically significant errors occur in the UK each year, 71% of which occur in primary care. Prescribing in primary care accounts for 33.9% of all potentially clinically significant errors. The estimated cost of avoidable adverse drug reactions is £98.5 million per year, with 181,626 hospital bed days, 712 deaths and contributing to 1,708 deaths. It was found that the medication errors were more likely in older people, in those with multiple morbidity conditions or as a result of polypharmacy.

Adverse drug reactions (ADRs) account for 6.5% of hospital admissions and more than 70% of these ADRs are deemed avoidable (www.bmj.com/content/329/7456/15)

Over 50% of medication errors occur in four drug classes: antiplatelets, non-steroidal anti-inflammatory drugs (NSAIDs), diuretics and anticoagulants.

Key studies show that errors remain high in medicines classed as ‘high-risk’, namely antiplatelets, NSAIDs, diuretics, anticoagulants and ACE inhibitors.

Medicines most likely to be related to a hospital admission:

• Antiplatelets
• NSAIDs
• Diuretics
• Anticoagulants
• ACE inhibitors

(Howard RL et al. Which drugs cause preventable admissions to hospital? A systematic review. Br J Clin Pharmacol 2006; 63(2): 138-147. Kongkaew C et al. Risk factors for hospital

Actions to systematically address problematic polypharmacy should not only focus on the holistic review of a person and their medicines, but healthcare professionals should also be particularly alert to safety concerns when medicines from one or more of the high-risk classes are prescribed.

Good practice

Even with the best systems around medicines, medication errors can occur. GP practices and NHS organisations should routinely deploy audit tools that capture and highlight those people at high risk from medication errors. Tools such as the PINCER medication safety audit and associated pharmacist intervention (REF www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61817-5/abstract) and polypharmacy specific tools such as the Polypharmacy prescribing comparators in England or Case Finding indicators or SPARRA score (Score that considered medicines and risk of admission or readmission to hospital) in Scotland should be deployed so that organisations are aware of those people who are taking risky combinations or high-risk medicines and prioritise those people for a holistic, person centred medication review.

The potential for adverse drug reactions (ADRs) should always be considered in older people. The risk of an ADR increases with age, along with the risks associated with co-morbidity, polypharmacy, inappropriate prescribing and possible issues with the monitoring of drugs. 

(Predicting risk of adverse drug reactions in older adults. Therapeutic advances in Drug Safety 2016 Feb; 7(1): 11–22. doi:  10.1177/2042098615615472)

In addition to the four classes of high-risk medicines cited above, other medicines that should be prescribed with extreme caution in older people include (NICE: Prescribing in elderly https://bnf.nice.org.uk/guidance/prescribing-in-the-elderly ):

• Anticholinergic agents – research has suggested a link to increased mortality with the number and potency of anticholinergic agents prescribed
• Digoxin
• Sulfonylureas
• Methotrexate, and
• Antipsychotics.

The prescribing cascade has been described as ‘when a drug is prescribed, an adverse drug event occurs that is misinterpreted as a new medical condition, and a subsequent drug is prescribed to treat this drug-induced adverse event’ (REF www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)31188-1/abstract?code=lancet-site

The person is placed at risk of developing additional adverse effects relating to the addition of a potentially unnecessary medicine.

The identification and interruption of prescribing cascades is an important, actionable, and often underappreciated opportunity to improve medication safety, particularly in older people.

Drawing prescribers' attention to this disturbing sequence of events may be an important step in minimising the occurrence of preventable adverse drug events associated with suboptimal prescribing decisions (REF BMJ www.bmj.com/content/315/7115/1096?variant=full-text).

To prevent the prescribing cascade, prescribers are advised to consider:

• Whether any new signs and symptoms are as a result current drug treatment
• Before any new drug treatment is started, the need for the new drug should be re-evaluated and whether a non-drug treatment option is available, and
• If drug treatment is necessary, the lowest feasible dose of the drug should be used and if there is an alternative drug with fewer adverse effects.

Common examples of prescribing cascades include:

The prescribing of a new drug specifically to treat an adverse drug effect should be considered the choice of last resort in the care of older people. More prudent strategies include:

• Carefully re-evaluating the absolute need for the offending agent
• Using non-pharmacological treatment for managing a person's medical condition
• Reducing the dosage of the implicated drug to the lowest feasible dose that is effective in treating a person's medical condition, and
• Considering alternative drugs that might be safer in terms of the risk of adverse effects in older people.

See www.bmj.com/content/315/7115/1096

The Lancet The Prescribing Cascade revisited.

Undoubtedly, repeat prescribing systems contribute to problematic polypharmacy. The sheer volume of medicines prescribed and dispensed every month to millions of people means that high quality medication reviews cannot happen each time a medicine is repeated. A study in 2014 found that 77% of all medicines issues in primary care were repeat medicines.

The volume of prescription items dispensed in Great Britain:

• England 2016                     1,104.1 million 

• Scotland 2015/16                 102.22 million
• Wales 2016                           80.3 million

77% of this total were supplied to people on repeat prescriptions, this would indicate that around 900 million items are dispensed over the course of a year.

43% of the population were prescribed at least one repeat medicine and this rose to 75% of those aged 60 years and over.

So, a significant proportion of the population receive repeat prescriptions and this proportion increases with age. Whilst the proportion of repeat items to acute items has remained unchanged over the last two decades, the number of repeat prescription items issued has doubled. This has huge implications for general practice and community pharmacy workloads, the convenience of people taking medicines, NHS costs and risk (REF https://bmchealthservres.biomedcentral.com/articles/10.1186/1472-6963-14-76

Overburdened repeat prescribing systems are more likely to enable the supply of medicines that perhaps should not be repeated, or medicines that were intended to be prescribed for a finite duration. As a result, these remain as repeatable items long after they were due to be stopped.

Agreed guidance around what constitutes a good repeat prescribing system is available in paragraphs 55-59 of GMS Guidance Good practice in prescribing and managing medicines and devices.

www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/prescribing-and-managing-medicines-and-devices/repeat-prescribing-and-prescribing-with-repeats

However, issues related to poorly managed repeat prescribing systems especially where multiple medicines are prescribed for multiple long-term conditions remain and their contribution to problematic polypharmacy should not be overlooked.

Where available and where appropriate, the use of NHS funded repeat prescribing systems should be encouraged such as the electronic repeat dispensing service in England, the Chronic Medicines Service (CMS) in Scotland and the Repeat Dispensing service in Wales. Such services, when implemented well, can support the streamlining of multiple medicines and avoid unnecessary stockpiling and waste.

Research has repeatedly shown that patients often experience errors or unintentional changes to their medicines when they move between care providers, presenting a significant risk to patient safety ref National Patient Safety Agency and National Institute for Health and Clinical Excellence Technical safety solutions, medicines reconciliation 2007

Improving the safe transfer of information about medicines should therefore reduce the incidence of avoidable harm to patients, and this has become a priority improvement area for the NHS. It is estimated that 60% of patients have three or more changes made to their medicines during a hospital stay. The transfer of care process is associated with an increased risk of adverse effects ref Himmel W, Kochen MM, Sorns U et al Drug changes at the interface between primary and secondary care. International Journal of Clinical Pharmacology and Therapeutics 2004:42; 103-109) 30-70% of patients experience unintentional changes to their treatment, or an error is made because of a lack of communication or miscommunication. Only 10% of older patients will be discharged on the same medication that they were admitted to hospital on. Ref Mansur N Weiss A Beloosesky Y. Relationship of in hospital medication modifications of elderly patients to post discharge medication, adherence and mortality Ann Pharmacotherapy 2008; 42: 783-789) and 20% of patients have been reported to experience adverse events within three weeks of discharge, 60% of which could have been avoided Ref Hesselink G, Schoonhoven L, Barach P, Spijker A, Gademan P; Kalkman C, Liefers J, Vernoonji-Dassen M, Wollersheim H. Improving patient handovers from hospital to primary care; A systematic review. Ann Intrn Med 2012; 157: 417-28).

In order to address this issue, systems need to be in place to safely transfer information about any changes made to a person’s medicines during a stay in hospital back to their usual prescriber as well as their usual pharmacist in the community.

However, this information sharing alone will not prevent problems with multiple medicines taking. Systems need to be developed to ensure that where a person has already had a comprehensive, person-centred medication review in the community and where decisions were made about stopping medicines, that these decisions are clearly communicated to secondary care providers. This will help to ensure that medicines that have been stopped for valid reasons (clinical or pragmatic reasons including preference of the person receiving the medicine) are not restarted inadvertently and without reference to the agreement reached by the person and their prescriber.

Whilst research on the size of the issue of problematic polypharmacy is fairly abundant, literature to support the solutions to addressing this are not widespread. The evidence base to support prescribers in stopping medicines safely is small and peoples’ attitudes to medicines being stopped can be a challenge to healthcare professionals.

However, an evidence base is emerging. Importantly, studies (in the context of polypharmacy) are demonstrating that strategies for stopping medicine are not more harmful to patients than not stopping medicines and strategies for stopping medicines that have been used long-term appear safe, but mortality can be significantly reduced when patient specific intervention to stop medicines are deployed.

(Ref www.ncbi.nlm.nih.gov/pubmed/27077231)

Barriers to stopping medicines

Both healthcare professionals and people taking medicines may have concerns about stopping medicines, even when there is no clear benefit to taking it or even when there is a potential risk of harm. This may seem counter-intuitive but is widely recognised by those working to address and reduce problematic polypharmacy. An understanding of these barriers is important when planning work to reduce problematic polypharmacy.

A comprehensive review of the barriers and enablers to stopping potentially inappropriate medicines safely highlighted four themes:

• Lack of awareness of the problem
• Lack of inertia around stopping a medicine versus continuing with the medicine (this is linked lower perceptions around the risks of taking a medicine)
• Self-efficacy in regard to personal ability to alter prescribing, and
• Feasibility of altering prescribing in routine care environments given external constraints.

The first three themes are intrinsic to the prescriber (for example, beliefs, attitudes, knowledge, skills, behaviour) and the fourth is extrinsic (for example, the person, work setting, health system and cultural factors) 

(Ref: http://bmjopen.bmj.com/content/4/12/e006544).

This review concluded that there are many factors that determine prescribers’ behaviour towards continuing or discontinuing medicines. A full understanding of these barriers and enablers to changing prescribing behaviour is really important for the development of targeted interventions aimed at safely stopping potentially inappropriate medicines and reducing the risk of harm.

A further review (ref: European Journal of Hospital Pharmacy, volume 24, issue 1, January 2017) highlighted the importance of being mindful of the concerns about stopping medicines. They identified four categories of concern, these are:

• Withdrawal/adverse events
• Recurrence of the condition
• Consequences of any changes to existing drug interactions, and
• Negative impact on the person prescriber relationship.

This review states that mitigation of these factors requires a person-centred approach to stopping medicines with a structured process which includes planned medication reduction and withdrawal with appropriate follow up and monitoring.

The geriatrician, Professor Doron Garfinkle described that for all drugs, the positive risk/benefit ratio decreases or is inverted in correlation to:

• Very Old age
• Dementia
• CO-morbidity
• Frailty, and
• Limited life EXpectancy. He called this VODCOFLEX.

(Ref European Journal of Hospital Pharmacy, 2017 24; 16-20).

Garfinkel described the main obstacles to routinely stopping medicines as largely being composed of emotional and/or psychological myths, namely that there is an expectation that when people see a prescriber they expect a prescription, and that the prescriber will choose the right and appropriate medicines.

Although most clinical guidelines are not developed directly from studies conducted in older people, prescribers are afraid of the consequences and the reactions of a person or their family if they do not follow all guidance and prescribe appropriate medicines in certain conditions, regardless of the person’s situation.

However, the evidence and confidence to stop medicines, particularly in older people, is emerging. A number of countries have produced excellent evidence based resources to help prescribers to stop medicines safely. (See www.polypharmacy.scot.nhs.uk/polypharmacy-guidance-medicines-review/for-healthcare-professionals/principles  

Good practice

A Health Foundation project led by Yorkshire and Humber Academic Health Science Networks (AHSN) across 12 GP practice teams supported by Harrogate & Rural District CCG, aimed at tackling the barriers GPs face when stopping medicines in frail people. The Safer Prescribing for Frailty project achieved a 6% reduction in the average number of prescription items prescribed to people with frailty. This equated to 795 prescription items across the cohort of people in the project.

Case studies demonstrated individual and team level impact in three ways:

• Achieving changes in behaviours related to deprescribing in frailty
• System impact through the development of new stopping medicines protocols, and
• Cost savings (for example, one practice calculated a cost saving of £704 per month /£8448 per annum).

See www.yhahsn.org.uk/how-we-can-help-you/healthcare/case-studies/reducing-problematic-polypharmacy-in-frailty

In highlighting what should be done to address problematic polypharmacy, it is important to look at the good work already being done.

What is already being done?

Activities to address polypharmacy can be categorised into two key areas:

• Tools to help prescribers stop medicines safely, and
• Strategies or national polices at the population level aimed at coordinating activities to address problematic polypharmacy.

Tools to help the prescriber make an evidence-based judgement about whether a medicine is appropriate or not.

Such tools can be helpful in reminding healthcare professionals about which medicines are more likely to cause harm and helping them to prioritise areas that need to be addressed as part of a holistic person-centred medication review.

Whilst there are a number of ‘Polypharmacy tools’ routinely being used to help healthcare professionals to conduct a review of a person’s medicines (See Appendix 2), no single tool has been highlighted as the most effective and the reality is that in order to address polypharmacy, a collaboration across practice, health policy and public attitudes will be needed.

National strategies or policies

There are some emerging examples of good work that is taking effect. This guidance aims to highlight those areas of good work and outline recommendations for various stakeholders.

National strategies and policies to address polypharmacy have underlined the fact that addressing polypharmacy successfully requires a collaborative, broad and multidisciplinary approach involving specialists and generalists and where all who are involved (including people taking medicines and the public) address their responsibilities.

Among Scottish people with two medical conditions, 20.8% were receiving four to nine medicines and 10.1% were receiving 10 or more medicines.

NHS Scotland has led the way with a programme to review inappropriate polypharmacy that has been implemented nationally by developing clinical guidance and building an economic case that would ensure sustainability for healthcare managers and policy makers. A key feature has been workforce sustainability and an innovative model of pharmacists undertaking reviews with doctors. See www.polypharmacy.scot.nhs.uk

The Scottish guidance builds on the economic case, with data collected during the reviews that demonstrated that the number of medicines was decreased but also that the medicines reduced were high-risk medicines (meaning those more likely to cause admission to hospital). See Appendix D of the third edition of Polypharmacy Guidance. An EU economic tool has been developed as part of the SIMPATHY project and this is available for use to support building a business case. www.therapeutics.scot.nhs.uk/wp-content/uploads/2018/04/Polypharmacy-Guidance-2018.pdf

Good Practice

The Scottish polypharmacy guidelines were developed by policy makers working with geriatricians, pharmacists and general practitioners from both hospital and community settings and consist of a seven-step process, which includes a holistic assessment of indication, determination of effectiveness, checking of side effects, number needed to treat and a discussion with the person under their care about their medicines. The discussion begins with “What matters to you?” to encourage joint decision making and the 7 steps focusses on ensuring that the patient is able to implement the outcome of the review and to share with relevant people. A series of outcomes measures have been developed that are designed to

In summary the MDT polypharmacy reviews have contributed to changing the culture of prescribing in the frail elderly within primary care. A quality improvement bid has also been submitted by one of the practices to answer the question “Does targeting polypharmacy reviews in the frail elderly reduce admissions to hospital?

In line with its policy work ‘Achieving prudent health care’ the All Wales Medicines Strategy Group has developed guidance for prescribing and promotes the NO TEARS tool to help clinicians carry out person-centred mediation review.

(REF www.awmsg.org/docs/awmsg/medman/Polypharmacy%20-%20Guidance%20for%20Prescribing.pdf)

There are a number of recently published studies demonstrating good practice, particularly in care homes.

The Northumbria Shine Care Homes project aimed to reduce the amount of unnecessary medicines prescribed to older people in care homes and to involve both them and their families or carers in decisions about prescribing and stopping medicines. It was also designed to build evidence about ethical decision making in prescribing.

The medication reviews were conducted by clinical pharmacists, with the findings discussed by multidisciplinary teams which included care home nurses and GPs as well as the people under their care, along with their families and carers (where this was possible). Day-to-day project management was carried out by the trust’s transformation team.

Outcomes

The project led to 422 reviews carried out in 20 care homes. There were 1,346 interventions, most of which involved stopping medicines. An average of 1.7 medicines were stopped for every resident reviewed.

The main reasons for stopping medicines were 'no current indication' or 'resident requested to stop'. The work resulted in a net annualised savings of £77,703 or £184 per person reviewed.

For every £1 invested in the intervention, £2.38 could be released from the medicines budget.

This model has been spread to the Northumbria region and NHS England is looking at the model as part of its work looking at medicines in care homes.

NICE guidance on multimorbidity and polypharmacy

In 2018, NICE published a key therapeutic topic on multimorbidity and polypharmacy. The NICE guideline on multimorbidity recommends that ‘involves personalised assessment and the development of an individualised management plan. The aim should be to improve quality of life by reducing treatment burden, adverse events, and unplanned or uncoordinated care. The approach takes account of the person's individual needs, preferences for treatments, health priorities and lifestyle,’ and the NICE guideline on medicines optimisation ‘recognises that optimising a person's medicines can support the management of long-term health conditions, multimorbidity and polypharmacy’.

NICE advises that people have the right to be involved in discussions and make informed decisions about their care.

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), as well as safeguarding.

A brief overview of other countries in Europe

The SIMPATHY Project (Stimulating Innovation and Management of Polypharmacy and Adherence in the Elderly) is funded by the EU health programme. The project is being delivered by a consortium of 10 institutions from 8 countries across Europe including Scotland, Sweden and Northern Ireland.

The project suggests that whilst medication reviews are suggested as effective interventions to reduce inappropriate polypharmacy, the majority of these interventions are described in research articles but their actual implementation as national or regional policies seems limited across Europe.

In countries where programmes have been implemented, a key success criterion was the inclusion of change management strategies using Kotter’s 8 steps process. www.kotterinc.com/8-steps-process-for-leading-change

A key recommendation was to design processes with clinicians, policy makers, educators, commissioners and the patient.

An EU economic tool has been developed as part of the SIMPATHY project.

As part of the literature review, an evaluation of the polypharmacy guidance documents in use across the EU was undertaken. Only three met the AGREE II criteria. These were Scotland, Germany and the Netherlands

Canada

Polypharmacy.ca has a range of resources and tools to help clinicians conduct good medication reviews.

Work in Ontario has developed a robust process to develop evidence-based guidance and algorithms to support clinicians in stopping certain medicines. See www.open-pharmacy-research.ca/research-projects/emerging-services/deprescribing-guidelines

The Bruyere Research institute in Canada has a range of resources to help clinicians to stop certain medicines. The Canadian Deprescribing Network (CaDeN) is a network of advocates for people taking medicines, healthcare professionals, researchers and health policy leaders aimed at reducing harm by curbing prescribing of inappropriate medications by 50% by 2020 and promoting health by ensuring access to safer pharmacological or nonpharmacological therapies. See Deprescribing.org

In addition to the prescriber-focused resources, work in Canada has developed patient leaflets and community pharmacy resources to prompt conversations about why people are taking certain medicines.

Australia

Australia has a well-developed social media resource addressing polypharmacy. This embraces the person-centred approach as well as clinical resources to support stopping medicines safely.

How do we capture the size of the issue, observe variation and identify where good and poor practice exist?

NHS Scotland stated that ‘The route to identifying where polypharmacy exists, where it might be causing harm and assessing if our approaches to tackling polypharmacy have been successful in a systematic way, is dependent upon high quality data management systems that can help clinicians to identify people who are taking multiple medicines or combinations of medicines that are thought to increase the risks from harm in those people.’

England, Scotland and Wales now have polypharmacy measurement systems in place for primary care:

• NHS England - NHSBSA Polypharmacy prescribing comparators 
• NHS Scotland - SPARRA Polypharmacy indicator 
• NHS Wales – National Prescribing Indicators 

Those involved in working to address polypharmacy should ensure that they are familiar with these tools and how they can be deployed locally to ensure that people at risk from problematic polypharmacy are identified and reviewed.

It is arguably difficult to measure the impact of initiatives aimed at reducing problematic polypharmacy. However, high quality polypharmacy prescribing data (particularly measured over time) used in combination with data showing hospital admissions or harm to people caused by taking medicines could be utilised in combination to identify where initiatives to address polypharmacy have been successful or not and how they could be improved.

Quality improvement methodology should form the basis for ensuring that initiatives are deployed carefully and successfully with results attributable to change and then sustainable in the longer term.  See www.health.org.uk/publication/quality-improvement-made-simple

Data based on geographic location can also help to inform health systems how well they are tackling polypharmacy collectively. Data sources should be shared within a health economy and should prompt discussions and questions.

The SIMPATHY Project clearly highlights that countries with the most well developed and successful polypharmacy strategies have brought health and social care professionals, policy makers and patients together to understand the issues and to developed strategies to address the problems.

At a more localised level, Polypharmacy Communities of Practice offer the opportunity of a system-wide forum to bring together relevant healthcare professionals and patients to address this difficult issue. These Polypharmacy Communities of Practice offer the opportunity to enable those working on polypharmacy to share their challenges, share solutions, share tools and resources and ultimately allow a multidisciplinary approach (which includes the public voice) to design care pathways so that people are better supported to use their medicines. These new pathways can support person-centred, holistic medication reviews carried out with people who are at high risk of problems from polypharmacy and enable the outcomes of such reviews to be shared across health and social care sectors to avoid duplication of effort or inadvertent undoing of actions agreed with the person. 

(CCGs, STPs, Health Boards, ICS and Trusts) to ask in order to self-assess their approach to polypharmacy

• How well do we work together as a system to address polypharmacy?
• Do we have, at very senior or board level, clearly identified leaders responsible for reviewing the issue of polypharmacy at organisational level and accountable for delivering a strategy aimed at addressing problematic polypharmacy?
• Do our pathways include all those who might be able to identify and address problematic polypharmacy, for example, community pharmacy, community nursing, physiotherapy?
• Do our pathways enable referral to clinicians with the appropriate skills and expertise to carry our holistic, person-centred medication reviews, for example GPs, clinical pharmacists, community care of the older person consultants and clinical pharmacologists?
• Do individual healthcare professionals have the support they need to carry out person-centred holistic polypharmacy medication reviews and escalation processes if needed?
• How are we engaging with people under our care to discuss the issues of problematic polypharmacy and what we are doing to address this?
• Do our staff (especially prescribers) have access to good quality resources that accurately set out the efficacy of medicines, for example NHS Scotland NNTs?

Whilst healthcare professionals are reliant on good health systems to enable them to work well with people under their care and identify those at risk of problematic polypharmacy; ultimately at some point a medication review will be conducted in order to assess what the medicines are being used for, how well treatment goals are being achieved, including looking at any issues and concerns that people taking medicines may have. How well these reviews are carried out is dependent upon the individual healthcare professional, the person and the quality of the interaction between them. How well the professional and patient know each other, linked to the frequency of their interactions may also be an important factor for success. 

There are numerous support tools for good medication review. Both NICE and NHS Scotland have set out the components of a structured medication review.

(REF www.nice.org.uk/guidance/qs120/chapter/quality-statement-6-structured-medication-review)

www.polypharmacy.scot.nhs.uk/7-steps

The GMC (independent regulator of the of the medical profession makes clear in its guidance Good Practice in Prescribing and Managing Medicines and Devices

that doctors are expected to make prescribing decisions based on the needs of the individual patient and reach agreement about any proposed treatment with the patients giving them all the relevant information they want or need in a way that they understand.

Many of the medication review tools share common principles such as:

• Seeking the person’s (and/or their carer’s) perspective of their medicines and how they will take them
• Identification of the aims of the drug therapy (from a clinical perspective and from the person’s perspective)
• Assessment of whether the medicines are essential or not
• Assessment of the person’s level of adherence to the medicines
• Assessment of the effectiveness (both clinical and cost effectiveness) of the medicines
• Assessment of the safety of the medicines, and                  
• Decision and actions regarding stopping or continuing the medicines.

Yet, despite these tools and guidance, people remain concerned about the way that decisions are taken about their medicines.

Often, individuals may not be clear about the purpose of a medication review. Organisations such as Age UK provide people with some useful guidance such as: 

www.ageuk.org.uk/brandpartnerglobal/walthamforestvpp/documents/medication-faq.pdf  

The work led by people in Leeds, ‘Me and My Medicines’, advises a medication communication charter to help the prescriber and person under their care to be clear about the role of medication review. See Appendix 5

If we conduct medication reviews in line with best practice, then people should feel the following:

• That when they leave the consultation they know what they are taking the medicines for
• If they have any further questions, they know where to go to for help
• That they have been listened to and their concerns have been heard and addressed, and
• That if they have further concerns about side effects or how to take the medicines properly that they can raise them.

Focus should be (rightly) on person-centred medication review as a vital part of tackling polypharmacy. However, one area about prescribing that can be overlooked is how we start medicines. Often people are given little or no information about the medicines that are being prescribed and little attention is given to setting out clearly for the person the likely length of the course of the treatment. In some cases, medicines prescribed for long-term conditions will be prescribed with a recommendation to the person that the medicine will need to be ‘taken for life’. Whilst this may be true for a small number of medicines, for example insulin, often medicines for long-term conditions will be changed over time and possibly stopped as the person ages or their condition changes. Therefore, prescribers ought to set the expectation at the outset that medicines will be frequently reviewed and may be stopped if they are no longer appropriate. This should help people to understand when decisions are being discussed about stopping medicines that the rationale is driven by medication safety and appropriateness rather than cost savings.

The decision to move a medicine to be a ‘repeat medicine’ is a critical decision. Once a medicine is able to be obtained on a ‘repeat prescription’, the risk of it not being reviewed or being continued after it is still clinically appropriate may be increased. The risk of repeat medicines and their contribution to problematic polypharmacy can often be overlooked.

Whilst systematically targeted, holistic, person-centred medication reviews conducted in line with best practice guidance should be considered to be the best way for all healthcare organisations as a whole to tackle problematic polypharmacy, opportunities will arise for individuals and organisations to take immediate action which will support the efforts to address polypharmacy in an individual person.

Triggers for such actions could be proactive or reactive:

Proactive triggers include:

• Individuals identified as taking more than 10 or more medicines
• A change in the evidence base for a particular medicine
• A person’s annual medicines review
• Individuals identified taking a high-risk medicine or a risky combination of medicines
• The decision to make a medicine a ‘repeat medicine’, and
• The addition of a medicine to a number of medicines already being prescribed.

Reactive triggers include:

• An unplanned admission to hospital and the associated discharge back into the community setting
• A sudden crisis, such as a change in family situation
• A serious incident (may be linked to medication directly or indirectly, for example a fall)
• A request for medicines to be managed via a Monitored Dosage System
• The diagnosis of a “life limiting” condition, and
• The addition of a medicine to a number of medicines already being prescribed.

Good practice

Healthcare professionals will deploy a range of tools to aid them in identifying people at risk from harm from polypharmacy. These will include audit type or data tools to highlight individual people at risk of problematic polypharmacy as well as opportunities for healthcare professionals to respond to triggers for a polypharmacy medication review.

There are a number of areas that will need further development in order that problematic polypharmacy is able to be tackled successfully.

These include:

• Risk stratification tools to help healthcare professionals to identify people at an increased risk of problematic polypharmacy
• Better collaboration between health and social care sectors to identify and resolve polypharmacy
• Greater interoperability of IT systems which identify those taking multiple medicines or flag those that have had a medications review where medicines have been stopped, so that other healthcare professionals do not inadvertently re-start medicines that have been agreed as no longer needed
• Better utilisation of digital tools to help with polypharmacy: apps and support services are being developed and used already but a greater systematic deployment of tools to help the conversations between prescriber and person under their care would be particularly helpful
• Better guidance around safer systems for repeat prescribing
• Holistic, person-centred medication review embedded in education and training for all healthcare professionals, including medicines efficacy
• Education and training to help healthcare professionals and all those conducting polypharmacy reviews to understand the barriers to stopping medicines safely
• A change in culture for people in Great Britain from a passive role receiving medicines that are prescribed for them towards a more engaged partnership where decisions about medicines are agreed between the person and their healthcare professional
• The impact of polypharmacy on special groups of people, for example children, those in prison and those in deprived areas, and
• Guidance on how to conduct shared decision making with certain patient groups such as those with cognitive impairment.

There are numerous questions and research gaps in the arena of polypharmacy, but the most significant include:

• Evidence based tools to help healthcare professionals be more confident to stop medicines safely
• What constitutes a high-quality medication review consultation?
• By whom and where is the best place for holistic, structured medication reviews to occur to have the greatest impact?
• Will greater use of genomics reduce the unnecessary prescribing of medicines that won’t work?
• How are healthcare professionals supported to work across disciplines and sectors to address polypharmacy?
• How do we best engage with people to reduce problematic polypharmacy?
• What should our workforce look like to address problematic polypharmacy well?
• Evaluation of the impact of initiatives to address problematic polypharmacy especially those in the community pharmacy and general practice setting
• What technologies support clinicians to make evidence-based decisions to address problematic polypharmacy, and
• What technologies help patients to share their concerns about multiple medicines and the impact that taking them is having?

The Polypharmacy steering group were asked to outline their hopes for the impact of this guidance. Suggestions included:

• Higher education institutions recognising the size and scale of polypharmacy and building topics relating to polypharmacy (including the best practice recommendation made here) into core curricula for health and socials care professionals
• Commissioning organisations addressing the issue of polypharmacy and beginning to build the solutions and good practice recommendations made here into their service plans
• Health and social care organisations reflecting on this guidance and addressing the issue of polypharmacy in their strategic plans
• Regulators recognising their role in holding educators, health providers and individual professionals to account for addressing the problems associated with polypharmacy and including the assessment of shared decision making and consultation skills
• Continuing professional development (CPD) plans and revalidation submissions to reflect the issues raised here including shared decision making and person-centred, holistic medication reviews and individual practitioners are able to reflect on their current practice and cite how they have addressed any knowledge gaps, and
• The public narrative around medicines beginning to shift away from assuming a medicine is the answer to every problem towards an expectation of a more holistic approach from their clinicians to reach the right solution for them as an individual.

The Polypharmacy steering group were hopeful that many of the benefits outlined in the table below were being demonstrably realised in five years’ time.

The group hoped to see progress in four key areas:

• Clear progress at national and local level to achieve a situation where person-centred, holistic medication reviews were the norm and built into care pathways across health and social care
• That measures (metrics, key performance indicators and national indicators) were in place and routinely used by policy makers, commissioners and individual organisations and practitioners to benchmark practice and measure the impact of change programmes to identify patients at risk from and address the causes of problematic polypharmacy
• That research was in place and reporting on some of the key issues related to polypharmacy where we have a paucity of evidence to drive good practice (See page X Research gaps), and
• Finally, that we have moved away from reactive processes to deal with those already experiencing problems with polypharmacy to a more proactive approach that identifies people earlier in their health journey to ensure that they are never prescribed more medicines than they are able to manage and are not prescribed medicines that not or are no longer clinically appropriate for them.

There are significant benefits if problematic polypharmacy can be addressed. If done correctly, this will achieve the behaviour change needed to ensure shared decision making as the norm and adopt the best practice recommended in this guidance. There are potentially significant gains to be made. These include:

The expectation is that organisations will review how problematic polypharmacy is addressed for people under their care in line with the recommendations made in this document. In order that this issue is effectively tackled, stakeholders from a range of backgrounds and disciplines (including policy makers, managers, health and social care practitioners and people taking medicines) will need to come together and each play their part.

Polypharmacy is not an issue that can be resolved quickly or simply, or by organisations or individuals working in isolation. It will require a multi-faceted, multi-sector collaborative approach.

However, many of the actions driven by healthcare professionals or organisations will not deliver the desired impact if there is failure to engage with people under their care. Open and honest discussions about medicines and the burden and consequences of taking multiple medicines should be addressed in consultations with people.

It is hoped that:

• Individual healthcare professionals will consider and act upon their responsibilities to people who are taking multiple medicines
• All healthcare professionals will reflect on this guidance and think about how their practice could be improved to reduce the risk from harm from problematic polypharmacy
• This work will provide a platform for all healthcare professionals to recognise that this is a major issue for people and that the systems by which medicines are prescribed, dispensed, administered and advised about may need to change
• People will, over time, be better supported to have meaningful conversations with their healthcare professionals about their medicines
• All healthcare organisations will support initiatives to help people to have shared decision making conversations about their medicines
• Holistic, shared decision making conversations become part of routine practice
• Healthcare organisations will support efforts to rigorously and meaningfully measure the size and impact of polypharmacy on both individuals and healthcare systems
• Policy makers remove perverse incentives in the current healthcare system that drive up polypharmacy and may inadvertently be increasing harm, and
• Regulators build this guidance into their inspections of all healthcare organisations.

 The standards have been updated based on the RPS process for the development of standards and guidance. 

NHS Scotland 7 Steps

The NHS in Scotland has described the 7 steps to good medication review. 

The following 7-Steps are intended as a guide to structure the review process

N.B. No list can be comprehensive and the reviewer’s clinical judgement and experience continues to be essential in tailoring the advice given to the needs of an individual patient and to identify other additional medication related problems.

Step 1: (Aim) What matters to the patient?

• Identify aims and objectives of drug therapy by asking the patient what matters to you?
• Explain any key information such as laboratory markers
• Establish treatment objectives with the patient through shared decision making

Step 2: (Need) Identify essential drug therapy.

• Separate the list of medicines which the patient is taking
• Ensure the patient understands the importance of essential drug therapy
• All medication whether herbal, prescribed or traditional remedies should be included

Step 3: (Need) Does the patient take unnecessary drug therapy?

• For the remaining drugs, it should be verified that each has a function in achieving the therapeutic goals or outcomes that matter most to the patient
• Review preventative treatment to ensure the patient is able to continue taking medicine for required time to gain benefit (Drug Efficacy (NNT) table).
• Can lifestyle changes replace any unnecessary drug therapy?

Step 4: (Effectiveness) Are therapeutic objectives being achieved?

• Check treatment choice is the most effective to achieve intended outcomes
• If this is not the case, the possibility of patient non-adherence should be investigated as a potential explanation. Otherwise, the need for dose titration may also be considered. 50% of patients taking four or more medicines don’t take them as prescribed (Medication Adherence: WHO Cares?).

Step 5: (Safety) Is the patient at risk of ADRs or suffers actual ADRs?

• The presence of ADRs can sometimes be identified from laboratory data (e.g. hypokalaemia from diuretic use)
• The patient may report such symptoms (including drug-drug and drug-disease interactions, but also the patient’s ability to self-medicate)
• Ask the patient specific questions (for example, about the presence of anticholinergic symptoms, dizziness or drowsiness). If patient is experiencing ADRs, use Yellow Card Reporting

Step 6: (Efficiency) Is drug therapy cost-effective? 

• Opportunities for cost minimisation should be explored, but changing drugs for cost reasons should only be considered if effectiveness, safety or adherence would not be comprised
• Ensure prescribing is in line with current formulary recommendations

Step 7: (Patient-centred) Is the patient willing and able to take drug therapy as intended?

• Does the patient understand the outcome of the review?
• Ensure drug therapy is tailored to patient preferences
• Agree and communicate plan with patient and/or welfare proxy
• Even if adult lacks capacity, adults with Incapacity Act still requires that the adult’s views are sought. Ensure “Adults with Incapacity Documentation” in place

NICE Guidance on mediation review

NICE Guidance recommend structured medication review for people taking multiple medicines. 

They advise, during a structured medication review, to consider:

• The person's, and their family members or carers where appropriate, views and understanding about their medicines
• The person's, and their family members' or carers' where appropriate, concerns, questions or problems with the medicines
• All prescribed, over-the-counter and complementary medicines that the person is taking or using, and what these are for
• How safe the medicines are, how well they work for the person, how appropriate they are, and whether their use is in line with national guidance
• Whether the person has had or has any risk factors for developing adverse drug reactions (report ADRs in line with the Yellow Card Scheme), and
• Any monitoring that is needed.

See also their guidance on shared decision making and care plans.

Royal College of General Practitioners

The RCGP recommends a range of tools to help identify those people at risk from harm from medicines. These include trigger tools, prescribing safety indicators (such as those used in the PINCER study) 

Centre for Pharmacy Postgraduate Education

The CPPE in its polypharmacy distance learning support recommended a person-centred approach based on the work of the Specialist Pharmacy Service. The steps in this are similar to the 7 steps in Scotland in that it asks pharmacist to assess the person’s overall goals, identify medicines with potential risks, asses the risks and agree actions (such as stopping a medicines) and communicate these actions with all relevant parties.

In addition, the CPPE provide an extensive range of consultation skills for pharmacy practice. 

• PREVENT TOOL
• STOPP/START tool
• De Beers (login required)
• NO TEARS 
• NHS Specialist Pharmacy Service patient-centred polypharmacy process
• All Wales Medicines Stragey group
• Consultation skills for Pharmacy Practice
• Developing a measure of polypharmacy appropriateness in primary care: systematic review and expert consensus study

Royal College of General Practitioners

A free e-learning resource on Multimorbidity and Polypharmacy to help you think differently about multimorbidity and polypharmacy. There are three modules covering topics of Polypharmacy, multimorbidity, treatment burden, and medication review. Learners can log in (or register for a free e-learning account) here and can access the course here.

‘Appropriate polypharmacy is prescribing for an individual for complex conditions or for multiple conditions in circumstances where medicines use has been optimised and the medicines are prescribed according to best evidence. The overall intent for the combination of medicines prescribed should be to maintain good quality of life, improve longevity and minimise harm from drugs.

Problematic polypharmacy is where multiple medications are prescribed inappropriately, or where the intended benefit of the medication is not realised. The reasons why prescribing may be problematic may be that the treatments are not evidence based, or the risk of harm from treatments is likely to outweigh benefit, or where one or more of the following apply:

1. The drug combination is hazardous because of interactions       
2. The overall demands of medicine-taking, or ‘pill burden’, are unacceptable to the patient
3. These demands make it difficult to achieve clinically useful medication adherence (reducing the ‘pill burden’ to the most essential medicines is likely to be more beneficial)
4. Medicines are being prescribed to treat the side-effects of other medicines where alternative solutions are available to reduce the number of medicines prescribed.’

(REF: Polypharmacy and medicines optimisation: Making it safe and sound page 1)

• NHS BSA Polypharmacy prescribing Comparators (England)
• NHS Scotland - Polypharmacy
• NHS Wales - Polypharmacy

Me and My Medicines

My Medication Passport

NICE Guidance (REF: www.nice.org.uk/about/nice-communities/public-involvement/your-care) outlines:

It is your right to be involved in making choices about your care. People often find they are happier with their care, and more likely to stick with any treatments or care plans, when they make decisions jointly with their health or care professional.

To make a decision, you need to know what your options are and what might happen if you don’t want any treatment or care. Your health or care professionals should explain what might work for you – some options may not be suitable.

You need to have information about the pros and cons of the options. This must be easy for you to understand.

Your health and care professionals need to know what matters to you – no two people are the same and they should listen carefully to your views and concerns.

You and your health or care professionals need time to talk through what you want to get out of any treatments or care and any worries or questions you have.

Patients Know best 

A patient controlled online medical record system used by some hospitals and NHS trusts in England and Wales. www.patientsknowbest.com/case-studies

Adapted from: Patient-centred management of polypharmacy: a process for practice

•  HSCIC, Prescriptions dispensed in the community, England 2003-13, July 2014 (https://digital.nhs.uk/data-and-information/publications/statistical/prescriptions-dispensed-in-the-community/prescriptions-dispensed-in-the-community-statistics-for-england-2003-2013 )
•  http://content.digital.nhs.uk/catalogue/PUB20664/pres-disp-com-eng-2005-15-rep.pdf
• HSCIC Information centre. Prescriptions dispensed in the community, statistics for England 2004-2014 https://digital.nhs.uk/data-and-information/publications/statistical/prescriptions-dispensed-in-the-community/prescriptions-dispensed-in-the-community-statistics-for-england-2004-2014
• Payne RA et al. Is polypharmacy always hazardous? A retrospective cohort analysis linked to electronic health records form primary and secondary care. BJClin Pharmacology 2014;77:1073-1082: https://bpspubs.onlinelibrary.wiley.com/doi/full/10.1111/bcp.12292
• NHS Choices, Prescriptions '1 in 20 has an error', 2012 (http://www.nhs.uk/news/2012/05may/Pages/gmc-medication-prescribing-errors-report.aspx)
• University of Nottingham, Prescribing Safety and Overview of PINCER, September 2014 https://www.nottingham.ac.uk/primis/tools-audits/tools-audits/pincer/pincer.aspx (https://www.nottingham.ac.uk/primis/documents/pptsforum2014/prescribingsafetypincertonyaverysarahrodgers.pdf
• http://www.amjmed.com/article/S0002-9343(17)30253-X/fulltext
• https://bmcfampract.biomedcentral.com/articles/10.1186/s12875-017-0642-0
• Improve drug compliance | The BMJ 
• http://www.telegraph.co.uk/science/2016/07/05/pill-organisers-causing-dangerous-overdoses-in-elderly1/
• http://deprescribing.org/resources/deprescribing-patient-decision-aids/

If you have any comments on this guidance or suggestions as to how the guidance can be further developed please contact the Professional Support team at [email protected].

Steering Group

Clare Howard - Steering group chair, lead author and consultant to the RPS

RPS Team

Rakhee Amin

Rakesh Bhundia

Yogeeta Bhupal

Rachel Quinlan

Wing Tang

Ruth Wakeman (until March 2018)