Ministers have pledged to ‘take action’ on overprescribing after an official review concluded that 10% of medicines dispensed in primary care in England were ‘unnecessary’.
The Government commissioned review, published yesterday (22 September), found that 15% of people are now taking five or more medicines a day, with one in five hospital admissions among over-65s caused by adverse effects of medicines.
In the review Dr Keith Ridge, outgoing Chief Pharmaceutical Officer for England, made a number of recommendations to address overprescribing — all of which Ministers have accepted.
Dr Ridge referred to an aim within the NHS Long Term Plan to increase the number of pharmacists and pharmacy technicians. To fill these additional roles ‘without any dilution of quality,’ Dr Ridge said the healthcare system as a whole ‘will need to expand the provision of training and development, including upgrading existing skills’.
These additional pharmacy staff will be able to ‘provide comprehensive reviews of the medication regimes for the most vulnerable patients through Structured Medication Reviews,’ Dr Ridge explained.
Dr Ridge recommended that the Department of Health and Social Care (DHSC) should work alongside the General Pharmaceutical Council (GPhC) and other stakeholders to ‘support the safe and rapid implementation of the pharmacist initial education and training reforms, including allowing for more extensive clinical placements’.
He also said the GPhC should develop a similar programme for pharmacy technicians.
The review was commissioned in 2018, after NHS figures showed a 5% year-on-year growth in spending on medicines from £13 billion in 2010/11 to £18.2 billion in 2017/18.
Dr Ridge’s recommendations in the review include:
● changes to improve patient records;
● routinely recording clinical indications at the point of prescribing;
● improving handovers between primary and secondary care;
● expanding structured medication reviews (SMRs) carried out by PCNs;
● developing a national toolkit and deliver training to help general practices improve the consistency of repeat prescribing processes; and
● cultural changes to reduce a reliance on medicines while increasing the use of social prescribing and other evidence-based alternatives to medicines.
Dr Ridge also said that NICE and professional bodies should include ‘recommendations for reviewing and discontinuing medicines where appropriate’ in their guidelines and that the MHRA should use ‘post-marketing surveillance’ to ‘support deprescribing’.
The review discusses ‘deprescribing’ based on improved evidence base for ‘safely withdrawing inappropriate medication, with clinical guidance to be updated to ‘support more patient-centred care’.
The DHSC also intends to develop ‘interventions’ to ‘reduce waste’, as part of the NHS’s net zero carbon emissions.
It also intends to commission more research investigating the reasons why overprescribing is ‘more likely to affect older people, people from ethnic minority communities and people with disabilities’.
The recommendations additionally include providing ‘clear information’ on the NHS website for patients about medications, and establishing ‘a platform for patients to be able to provide information about the effectiveness and the adverse effects of their medicines’.
The proposals will be overseen by a new National Clinical Director for Prescribing who will lead a three-year programme, including research and training to help enable effective prescribing.
Pharmacy sector responses
Responding to the review, health minister Syed Kamall said: ‘This vital review is a significant step forward which will benefit patients across the country, and we will help ensure busy primary care teams are supported with improved systems and resources.
‘Whether it’s helping to change a culture of demand for medicines that are not needed, providing better alternatives and preventing ill-health in the first place, we will take a range of steps to act on this review.’
Thorrun Govind, Chair of the Royal Pharmaceutical Society (RPS) in England, welcomed the review and said pharmacists would be ‘eager’ to help tackle overprescribing across the country.
‘As science advances and people live with complex and multiple conditions, they are prescribed an increasing number of medicines. For too long the healthcare system has focused on the positive effects of adding medicines to a prescription, rather than acknowledging that this can also increase the risk of side effects and interactions between medicines, leading to poor health and costly unnecessary admissions to hospital.
‘We need to focus on putting shared decision making between the prescriber and patient at the heart of prescribing, and look at the individual needs and circumstances of each person.
‘This report explores many of the issues that pharmacists have been highlighting for a long time and gives a range of solutions. Pharmacists across the country will be eager to play an active role, working alongside the patients and communities they serve, to reduce the harm that medicines can cause when over prescribed,’ he said.
Leyla Hannbeck, chief executive of the Association of Independent Multiple Pharmacies (AIMp),said: ‘The review into prescribing is welcomed and should be embraced by the [pharmacy] profession.
‘However, the answer is more complex than just addressing process. Education, social responsibility, personal accountability and sweeping national cultural changes are necessary. Community pharmacy should be centre stage to these reforms.’
She added: ‘Any changes are likely to impact on the sector and concentrate disproportionately on cost and will thus have a complex and uneven impact on the network. It is therefore crucial that the sector is engaged with in this journey and be a key influencer in driving the patients’ and public’s expectations.’
Duncan Rudkin, Chief Executive of the General Pharmaceutical Council (GPhC), also welcomed the review, commenting: ‘As this review highlights, pharmacists are increasingly taking on greater responsibilities for helping to make sure that patients get the most appropriate treatment for their needs, including through working as independent prescribers.’.
He added: ‘We are working with stakeholders to introduce major changes to the initial education and training of pharmacists so that in the future all pharmacists joining our register will be independent prescribers from the point of registration. We will also shortly begin a consultation that proposes changes to enable more pharmacists already on our register to begin training as independent prescriber at an earlier stage.
‘The report also highlights that there will be further demand for pharmacy technicians with the skills and knowledge to help deliver the report’s recommendations. We will work with key stakeholders to consider how the education and training of pharmacy technicians need to develop to meet this demand and the future needs of patients and the public.’