Dr Simon Hendricks, clinical strategy lead at FDB (First Databank), is excited by the recent attention from Whitehall to improving NHS prescribing. He asks what progress is already being made, what needs to happen next, and where technology can play a role.
Political will for better and safer prescribing in the NHS has fast gained momentum in recent months. With prescribing featuring prominently in the NHS Long Term Plan published in January 2019, a subsequent plan and vision from the government into antimicrobial resistance, as well as a dedicated review into over-prescribing being ordered by health and social care secretary Matt Hancock just before Christmas, now is a time for action.
It’s not surprising prescribing is receiving such attention. It represents a huge opportunity for reducing harm; avoidable adverse drug reactions cost the NHS £98.5 million and lead to more than 700 deaths a year. More effective prescribing can help improve patient outcomes, and support the NHS on its mission to get the most from the £16 billion it spends each year on medicines.
So, what needs to happen to help reduce over-prescribing? What must the review, led by NHS England’s chief pharmaceutical officer Dr Keith Ridge, address? And, as the review itself is exploring, how can digital technology play a role in supporting national ambitions?
Over-prescribing – where is the action so far?
A good deal of work is already underway to tackle over-prescribing. Across the two thirds of clinical commissioning groups (CCGs) in England that work with FDB, technology is being used at the point of care to support more effective prescribing practice.
As GPs, pharmacists and other healthcare professionals prescribe, thousands are now making increasingly effective use of decision support directly through their practice’s clinical system. Messages alert prescribers with guidance on NHS national or local policies, clinical best practice, or patient contraindications. This is helping professionals make prescribing choices, but also supporting important national imperatives around cost avoidance and patient safety.
For example, messages are helping to reduce the issuing of medicines with low clinical effectiveness, by alerting unsuspecting prescribers to this information. In the same way, GPs are being prompted with suggestions in their IT system around appropriate use of antimicrobials. And technology is helping professionals to identify situations where long-term treatments, like oral nutritional supplements or antiplatelet therapy, might not be appropriate.
These are just a few examples, but importantly, GPs are acting on the guidance provided; by extension lessening the over-prescribing burden.
In fact, CCGs are already using technology in this way to alert thousands of GPs to a great many medication choices that might contribute to the over-prescribing challenge, not only drawing on national guidelines, but also implementing messaging alerts around locally developed drug policy. And it’s worth noting from an NHS finance perspective, that in 2018, practices across England reached £100m of savings by doing this.
But a lot more could be done with technology to change prescribing behaviours, and to help address problematic polypharmacy, the challenge of non-reviewed repeat prescriptions and other issues now in the focus of the Ridge review.
Empowering the practice pharmacist
National action is also taking place beyond the point of care, centred around an emerging role. The NHS Long Term plan emphasised howclinical pharmacists are now a key part of the general practice team – working alongside GPs and nurses to get the best outcomes for patients from medicines. Primary care networks are soon expected to use funding to substantially expand the number of clinical pharmacists.
Empowered with the right technology, these individuals can make a huge difference in tackling the complex medicines burden faced by many patients, especially those with chronic conditions. And this could have a big impact on over-prescribing for the NHS.
Already, the ‘Pharmacist-led Information Technology Intervention for Medication Errors’, or PINCER, project, is reportedly set for national rollout. With expectations around reducing hospital admissions and other clinical benefits, this project analyses patient data to help pharmacists in the practice identify patients who might be at risks from medicines they have been prescribed, with staff then creating an action plan for that patient.
But technology could be used to do more than just identify patients. It could inform the action plan and advise the pharmacist on the best course of action for their target cohorts and the individual patients they have identified for proactive intervention.
Informed, patient-specific medication review is key
Tailoring decisions to the needs of individual patients is vital. Take the case of problematic polypharmacy, which sees patients taking multiple medicines unnecessarily.
Finding patients on 15-20 drugs, for example, is relatively easy. The tricky bit is creating an effective plan of attack for deprescribing based on clinical best practice, national and local drug policy, and patient context. Conversations with the patient and with the wider multi-disciplinary team will undoubtedly be key in reviewing medications and, where appropriate, starting the deprescribing process.
But conversations and care coordination would be better informed if the practice pharmacist could use technology to assist with patient-specific guidance, in a similar way to decision support already benefiting GPs at the point of initial prescribing. This can also help coordinate and track the ongoing, complex medicines-related interactions between the patients and the clinicians involved in their care.
And, for that to work really well, guidance needs to evolve so that it reflects the latest thinking and also the developing needs of the individual. If you have a patient on a proton pump inhibitor for 10 years, how do you take them off it safely? Do you stop it? Do you reduce the dose gradually? If so, by how much, at what rate? Those sorts of deprescribing events have limited guidance on how to perform them safely.
The more clinical guidance and best practice that exists, and is made readily available to the pharmacist prescribers, in the context of other patient information, then the more informed their decisions will be around medicines optimisation, and around medicines safety – with the potential for improving outcomes and the reducing the overall cost to the wider health economy.
Technology has a big role to play here. I’ve seen first-hand how it can positively influence prescribing decisions when medication is initiated. But we now have the potential to do more for patients who need urgent medication review, and for whom subsequent decisions will make a difference to their wellbeing.