Bringing pharmacy commissioning under integrated care boards (ICBs) next month could bring an opportunity for a more coordinated approach to medicines optimisation, Ellen Rule, deputy CEO and director of strategy and transformation, NHS Gloucestershire ICB has said.

Historically, local deprescribing strategies had not been very responsive, she said, and while there was a programme in place to address the harms and waste caused by overprescribing, this approach was often ‘siloed’ without communication between primary and secondary care, as well as between primary care and community pharmacists.

‘We often lack the infrastructure to take a really coordinated approach to structured medicines reviews and reviewing the whole approach that we're offering to our patients,’ she said at a Westminster Health Forum on the next steps for pharmacy in healthcare delivery in England on Tuesday.

But she said that there was an opportunity to change this and ‘take a coordinated view moving forwards’ when ICBs take on responsibility for pharmaceutical services from next month.

Ms Rule highlighted the potential for community pharmacists to take a more integrated and ambitious role in medicines management and deprescribing, especially with the workforce increasing its number of independent prescribers.

‘We have the opportunity to give them a greater stake in our system, greater input into decision making, and to take the opportunity that community pharmacy can offer us to take a whole pathway approach in the best interests of our patients, freeing up capacity in other parts of the system like primary care and secondary care,’ she said.

Ms Rule also said that NHS medicines pathways often focused on treatment escalation, rather than de-escalation, adding that in this context, it was ‘no wonder’ that pharmacists found deprescribing challenging.

‘Constrained financial environments’

Ms Rule also said that medicines optimisation teams often have to balance pressure to save money alongside improving outcomes for patients.

Ms Rule said that integrated care boards (ICBs) are ‘regularly’ in a position where they have overspent against the medicines budget, and that medicines optimisations teams often operate within ‘constrained financial environments’.

‘There's a lot of focus in terms of improving outcomes, but also realising savings,’ she said, which she described as ‘really challenging’.

She warned: ‘If we take just quite a simplistic view to cutting costs, we may actually result in an increase in morbidity and poor patient outcomes, if we're not patient-centric in how we approach these challenges.’

A 2021 government-commissioned review found that 15% of people were taking five or more medicines a day, with one in five hospital admissions among over-65s caused by adverse effects of medicines.

The review was commissioned after NHS figures showed a 5% year-on-year growth in spending on medicines.

In addition to addressing polypharmacy and overprescribing, Ms Rule said that pharmacy teams needed to engage more with patients to find out what they wanted.

For example, she said that healthcare teams often assume that patients will make certain choices around medicines, such as wanting access closer to home, but asked: ‘do we actually know what patients think unless we involve them in the decision making?’

She questioned whether patients were actually able to give informed consent to being prescribed 10 medicines with complex side effects, all within a short – often less than ten minutes – GP consultation.

She also drew attention to the success of patient-centric programmes around opioid deprescribing.

‘No proper incentives’ for deprescribing

Nigel Clarke, former co-chair of the UK Commission on Pharmacy Professional Leadership and former chair of the General Pharmaceutical Council, called for an urgent review of the community pharmacy contract in order to support deprescribing.

He said that the current contract, with its focus on drugs reimbursement and dispensing fees, does not financially incentivise deprescribing.

He said: ‘There is no doubt in my mind that a review of how community pharmacy is funded is urgently needed. It's based on the wrong kinds of things. If it's simply volume prescribing, then you've got no proper incentives that medicine has been used well, and that is a fundamentally important characteristic of pharmacy skill set.’