In July of last year, I started a new post with Greater Manchester West Mental Health Foundation NHS Trust. The post is part funded by Trafford Clinical Commissioning Group. At around this time, NHS England launched a ‘Call to action’ regarding the inappropriate use of psychotropic medicines for challenging behaviour in people with learning disabilities. So – this instantly became my first project for the CCG.
My predecessor had worked on the use of antipsychotics in dementia, and demonstrated (on the whole) appropriate use. My piece of work had many parallels. But there were lots of unknowns. How many patients within the CCG population had learning disabilities? Of these people, how many were prescribed psychotropic medicines? And then of these people, how many had challenging behaviour, for which they had a psychotropic medicine prescribed? In order to answer these questions, we decided to pilot scoping work within the five biggest GP practices.
My starting point was to take a proposal for this work to the Greater Manchester Medicines Management Group. This was done for a number of reasons, such as to give them oversight of the work I was doing, and to potentially act as a point of contact for other CCG’s if they decided to embark upon a similar piece of work.
I made some interesting discoveries. With the help of my CCG medicines management colleagues, I was able to search EMIS and identify the cohort of patients I was interested in. By reviewing the EMIS records of these patients, I was able to make recommendations about the prescribing of their psychotropic medicines. Some examples of these were:
1. Discontinuing procyclidine (indicated for side effects associated with antipsychotics) as the depot antipsychotic had been stopped several months previously.
2. A plan to discontinue an antipsychotic, antidepressant and antiepileptic, in a stepwise manner, which had all been prescribed for challenging behaviour. The patient had moved into the area several years ago on this combination of medicines. At the initial learning disabilities outpatient appointment, the Consultant had recommended stopping these medicines in the future if the patient continued to present as settled. And the same was said in the outpatient letter from the following year. And the next. And so on. But the medicines had never been reduced!
In total, I have accessed the records of 284 patients, and found 36 who had been prescribed psychotropic medicines for challenging behaviour. An in-depth medication review of these patients resulted in 83 recommendations to the prescriber – either GP or Learning Disabilities Consultant, dependent upon whose care the patient was under. Interestingly, 20 of those recommendations were ‘no action’ indicating the therapy was appropriate. It is my intention to follow up these 36 patients in a few months, to see how many of my recommendations have been followed.
This work is not without its limitations. I’m acutely aware that my recommendations are only as good as the information contained within EMIS, on which they are based. Further, the process can be time consuming, but this has got better as my familiarity with EMIS has improved.
In conclusion, I feel this project has been extremely worthwhile and I’m delighted to be a part of it.
Steve Buckley is speaking at the King’s Fund event ‘Commissioning person-centred care for vulnerable groups: what role does pharmacy play?’ on February 24th on addressing inappropriate use of psychotropic medicines in people with learning disabilities.