The medication review project tested out using structured reviews of medication for care home residents in Northumbria. The approach helped to significantly reduce unnecessary prescribing and improved people’s quality of life. Dr Wasim Baqir is a clinical pharmacist at Northumbria Healthcare NHS Foundation Trust and led the work to develop the new review framework. We spoke to him about the inspiration for the project and what he learned along the way.
‘I remember working with a patient, Ethel, in a care home. She had end-stage dementia and was very agitated,’ says Wasim.
‘When reviewing her medication, we found that she was taking a lot of drugs, including strong antipsychotic medication to manage her agitation and long term preventive medications that were no longer useful. The preventive medications were stopped. She became much less agitated, and, with the support of colleagues from old-age psychiatry, almost all the other medications were stopped as well. We can’t know for sure, but it’s possible that some of the preventive medications were causing side-effects, and Ethel’s agitation was a way of communicating that she was in distress, or in pain.’
The memory of the effect that medication review had on Ethel’s quality of life has stayed with Wasim, demonstrating the power that a more structured approach to medication review could have on many other people’s lives.
Finding the right approach
Wasim and his colleagues wanted to find a way of getting the best balance of treatment for people in care homes – in particular, discontinuing unnecessary drugs.
There is lots of research on inappropriate prescribing in older people and various tools to help (including STOPP-START), but Wasim says they can be difficult to use in practice.
In the end the approach they tested involved getting people together to discuss treatment and make decisions. Where possible, the group included the care home resident, a family member, a nurse from the care home, a GP and a pharmacist. A team of clinical pharmacists were involved in the project, to conduct the medication reviews. A key part of Wasim’s role was getting care homes and GPs on board.
The care homes were enthusiastic about their residents having detailed medication reviews. Working with GPs was a bit more challenging.
‘We were naïve in thinking we could come up with a model and apply it across the whole health economy. Every practice was different,’ Wasim says. To overcome this, the team came up with several different ways of involving GPs, so that GPs could be part of every review.
A central part of the medication review approach was empowering residents to be involved in decisions about their treatment and care, but meaningful involvement was sometimes challenging. Overcoming difficulties encouraged the team to think creatively – rather than assuming that someone with advanced dementia couldn’t be involved in decisions, the team looked at working with family members and advocates.
Another early challenge, Wasim says, was ‘coming up with a process to reassure ourselves that the interventions we were making were safe’. There was nervousness that stopping medications might result in more hospital admissions, or have other safety issues, so the team was very vigilant in collecting data and reviewing the impact of their decisions.
‘We didn’t want to send people into hospital and that didn’t happen,’ Wasim says. ‘We found a statistical reduction in hospital admissions – people were actually less likely to go into hospital after having one of our interventions.’
The secrets of success
Getting the right team together was important. The team included health professionals or managers from GP practices and care homes, experts in psychiatry, Age UK, and the executive management team.
Wasim believes that the communications strategy was also crucial. The team visited every care home and GP practice involved in the project. Publishing and sharing early data also helped. People from all over the country – and as far afield as Canada – got in touch to share ideas.
Wasim has some words of advice for anyone starting an improvement project. ‘Take a step back, don’t jump in, speak to people, and listen.’ In particular, he says, listen to the nay-sayers. ‘If people tell you “this will never happen”, really listen to what their concerns are – because once you’ve tackled those, everything else will be easier.’
And if it is a success? ‘At the end of it, don’t be shy. Do a bit of celebration, go for awards, it’s really good to get it out there if it’s a good idea. And whatever happens, ensure you publish your learning.’