• A framework for medication review in care homes has improved safety and involved patients and their families in prescribing decisions.
  • The work has successfully reduced unnecessary prescribing, demonstrating cost savings of around £184 per patient and releasing valuable nursing time.
  • ‘Our analysis showed that for every £1 invested in the review process, £2.38 could be released from the medicines budget’, says Dr Wasim Baqir. ‘But the bit I’m most proud of is managing to give patients a voice.’ 

Medication can be a cause of harm

It is common for older people living in care homes to take a large number of medicines every day. These medications can do much to ease symptoms and help preserve the person’s quality of life.

However in care homes, medicines are often prescribed without regular review and it’s harder for residents to have a say over what medication they are taking. This can mean medicines are sometimes prescribed when they are no longer needed, leading to unnecessary wastage and potential risks for patients’ safety.

A framework for review and shared decision making

Funded by the Health Foundation’s Shine 2012 programme, Northumbria Healthcare NHS Foundation Trust set out to design a framework for medication review that would question the appropriateness of medicines being prescribed to patients in care homes.

‘We wanted to make a point of involving patients and their family in prescribing decisions, while also building evidence about ethical decision making in prescribing’, explains Dr Wasim Baqir, Research and Development Pharmacist, who worked on the project.

Clinical pharmacists undertook structured reviews in 20 care homes across North Tyneside, using primary care, care home and secondary care notes. Their findings were then discussed by a multidisciplinary team including the pharmacist and a care home nurse, with input from the resident and/or their family or advocate. Where possible GPs also attended these meetings, however as different GP practices offer varying levels of support to care homes, the project tested four different models of GP involvement.

‘The gold standard was to have the GP present at the meeting. It costs more but in everyone’s view it was worth paying extra for as it led to a more thorough discussion’, explains Wasim.

Empowering patients

The team’s premise was to assume that each patient had the capacity to be involved in shared decision making, and then to bring in family or carers if that wasn’t the case.

Patients and their families generally welcomed this opportunity to be involved in decisions about prescribing. In the end:

  • 16% were able to make their own decisions
  • 39% had family members represent them at the review meeting
  • 40% had family members who were invited to attend the review but either didn’t want to be involved, or couldn’t attend as they lived too far away. In these cases detailed information was sent in the post with the option for families to question any intervention proposed by the team
  • only 5% of residents had no family or significant friends able to represent them. In these cases advocates were invited to oversee any decisions.

‘I remember one lady, on being told it was up to her whether she wanted to stop a particular medication she didn’t like, actually punching the air with joy. She was so pleased to have been given a say in her own treatment. That kind of informed non-compliance to medication (not taking medicines because you choose not to) can be rare in a care home, where it’s a lot harder to refuse medication, so the process was really empowering’, says Wasim.

Proud of quality and cost outcomes

The review process helped to reduce unnecessary prescribing across care homes, reducing the risk of harm caused by medicines. In total, reviews were carried out for 422 residents, resulting in 1,346 interventions, the majority of which involved stopping medicines.

These interventions helped to reduce the overall yearly medicines budget by nearly £78k across the project, equivalent to £184 per person reviewed. By reducing the number of medicines staff administer, the project also released around an hour of care home nursing time per day.

Sharing and spreading the work

The project has demonstrated the economic benefits of structured medication reviews, while also demonstrating the possibilities and benefits of involving older residents in shared decision making. The review methodology has now been embedded into the specification for all care homes in North Tyneside, and the team believe a similar approach could be adopted nationally to improve prescribing for older people. They are currently exploring the potential for further work in association with the Royal Pharmaceutical Society.

‘Our analysis showed that for every £1 invested in the review process, £2.38 could be released from the medicines budget’, says Wasim. ‘There is now a huge opportunity for the NHS to optimise the medicines review process and expand this approach to all older patients, including people living in sheltered housing or in their own homes.

‘But the bit I’m most proud of is managing to give patients a voice – we’ve developed a process that really puts patients at the heart of the review process. Patient involvement must be seen as part of standard review practice. Not just the cherry on the cake, but an integral part of the cake itself.’

Further reading