Professor Nina Barnett, Consultant Pharmacist for Older People, Medicines Use and Safety Team, NHS Specialist Pharmacy Service
As clinicians we think of polypharmacy as patients being prescribed too many medicines, some of which are at best redundant and at worst cause patient harm. It is easy for us to take a clinician-centred, negative view of the prescribing of multiple medicines because of our awareness of the risks associated with polypharmacy, but I want challenge this thinking and reframe our view of polypharmacy, so we think about it from a patient perspective.
We might assume that patients don’t want to take lots of medicines and for some patients this might be right. However, others might think about medicine taking as a route to better health and the more they take the more good they believe it is doing them. So if we as clinicians invite patients for a polypharmacy review and we imply that they could be taking too many medicines, we might risk them losing faith in our ability to manage prescribing or fear that we are undertaking a cost cutting exercise by reducing their medicines.
Working in partnership with GPs, we, as pharmacists, have a golden opportunity to change the shared understanding of polypharmacy for patients and clinicians. For patients, we can highlight how prescribing medication is, rather than an event, an ongoing process. We can highlight that change is both inevitable and often desirable. Medications that were once appropriate for a patient may no longer be necessary and because the process is fluid, new medications may now be required. Working together with patients, pharmacists can move towards medicines optimisation through discovering what patients want from their medicines, discovering which ones they feel are beneficial and which ones are of concern to them. Add to that our knowledge of the risk and benefits of medicines and we start to create a patient-centred process for managing polypharmacy.
Pharmacists, working with doctors in GP practices, can expand the meaning of polypharmacy and medication review to reflect the collaborative process for identifying and managing polypharmacy in the context of medicines optimisation. This might include deprescribing or additional prescribing and can be supported by tools such as STOPP/START or some of the many local iterations which support its use in practice.
The use of an evidence base to optimise medicines is not new, however I suggest the concept of starting with the patient’s view of what medication they feel needs to be reviewed in a polypharmacy setting may be new to some. While we are used to eliciting the patient’s view in a consultation, it is usually in response to our suggestions of what medication we think needs to be reviewed because the consultation is driven by our need to review medicines in an evidence based way. This is our chance to work with our GP colleagues to address polypharmacy by first focusing on the patient’s polypharmacy agenda and then working with the patient to consider the evidence based agenda. These two agendas can then be brought together in a priority list of which medicines to address first, balancing clinical need with patient concern. In this way, we address the issue of polypharmacy as an ongoing, collaborative endeavour, supporting patients to get the best health outcome from medicines they choose to take.
Prof Barnett is speaking at “The Challenge of Polypharmacy: From Rhetoric to Reality” on April 20, an event being held jointly by the RPS and the Royal College of GPs. To book your ticket go to the RPS website.