Tackling problematic polypharmacy in Surrey Heartlands

Find out how Health Innovation Network accredited polypharmacy trainers have helped transform practice in Surrey Heartlands.

The problem of polypharmacy

As we live longer, the number of health issues and medicines we take in our old age is increasing. Not only is this tricky for patients and carers to manage, but taking ten or more medications can increase the chance of hospital admissions. Polypharmacy adds preventable cost to the healthcare system and diminishes quality of care for the patient.

One of the aims of  The Health Innovation Network Polypharmacy Programme is to help clinicians feel more confident in understanding and addressing the complex issues of stopping inappropriate medicines safely.

It does this using evidence-based Polypharmacy Action Learning Sets. These aim to help GPs, pharmacists and other healthcare professionals, who undertake prescribing, medication reviews and de-prescribing on a regular basis, to understand the complex issues surrounding stopping inappropriate medicines safely.

Helping healthcare professionals in Kent, Surrey and Sussex identify at-risk patients and have better conversations around medicines

Over the course of the three-year national programme, which launched in 2022, Health Innovation Kent Surrey Sussex supported a number of clinicians to train as polypharmacy trainers, so they could not only improve their own practice, but also deliver training locally.

They first completed three half-day Action Learning Set sessions as delegates, before joining the future cohorts as facilitators. Their training involved leading breakout groups and designing and presenting quality improvement posters focused on a specific area of problematic polypharmacy in their own clinical setting.

Q&A with two of the Surrey Heartlands trainers

As a specialist frailty GP at the Bedser Hub in Woking, Dr Priti Kadoo commonly encounters long medication lists and the challenges of polypharmacy.

Pain specialist pharmacist Kim Ridout’s experience as both an emergency department and GP pharmacist gives her a cross-setting perspective on polypharmacy.

Why did you want to become a polypharmacy Action Learning Sets trainer?

Priti – Identifying problematic polypharmacy is a key part of a frailty GP’s role, but there is no specific training on it. We see a lot of falls in older adults due to postural hypotension, and often the patients have a long list of medications that have had limited  holistic reviews.

Reducing medications that can increase the risk of falls has the potential to prevent the fall itself and subsequent injury – such as fractures, head injury. It can even reduce the fear of falling, which is beneficial. I believe you get a lot of “bang for your buck” by having the confidence to address this.

Reviewing polypharmacy is one of the five M’s (Medications) of Geriatrics, however the action learning set training also discusses another – ‘what Matters most’ when we engage in shared decision making. This is a key part of the process.

In addition to side effects like falls, the logistics of taking multiple medicines a day puts a huge burden on patients and carers. Time is a real challenge for practice GPs. You focus on the patient’s immediate problem and don’t always have time to look at the full medication list.

Kim – If you ask patients if they want to take fewer meds, they’ll almost universally say yes. But ironically, clinicians worry it will be a battle. The Action Learning Sets and subsequent training are all about helping to support the conversations and change this mindset.

Priti – It’s a confidence thing as you’re challenging a past decision: the renal specialist has one opinion, the cardiologist has another, and the hospital addresses acute issues  etc…but you’ve got the patient in front of you and know what they’ve been experiencing and their views on their symptoms and their medications.

Did you learn anything surprising from attending and running polypharmacy training sessions?

Priti – Polypharmacy is everyone’s problem, and the training showed the value of having multiple disciplines in one room. A lot of medicines are prescribed in secondary care, so we need the insight of people like hospital specialists.

Training works when it’s not just about telling you things; it’s about getting you to think through discussion and practical tasks. Part of the accreditation was to make a poster. I did mine on proton pump inhibitors, and Kim on anticholinergic burden. The process made me rethink my approach to one of our most commonly prescribed medicines.

Kim –Becoming a trainer taught me the importance of being relatable and finding shared problems through discussion, whether with a patient or other health professionals. A GP might look at things in a different way to a pharmacist, but we’re both passionate about reaching the same goal.

Priti – The confidence of the experts who trained us was inspiring. They presented the latest data and papers with an enthusiasm that rubbed off. You can get focused on your day-to-day work, and in a challenging environment, it was good to have support and encouragement from Health Innovation Kent Surrey Sussex to think about how we can benefit the wider network.

How did the experience of becoming a polypharmacy trainer change your own practice?

Kim – Before, I had a list of specific medicines that would ring alarm bells for a frail older patient. Now, I understand that a wide range of medicines can increase the risk of hospitalisation or mortality. I’m more critical of the simple stuff: is a patient on Aspirin because they are at risk of heart attack, or were they put on it ten years ago for a reason that’s now unclear and it’s been continued without review?

I now work in chronic non-cancer pain. Patients in this group traditionally have a very fixed view on their medications and have often developed a dependency on them. Having the skills and materials, like the Health Innovation Network Structured Medication Review Resources to talk to patients is really valuable.

Priti – It has given me a new focus on medication lists. I count the number of medications a patient is on. If it’s over ten, I’ll highlight them for a detailed review with our hub pharmacist and also introduce the idea of polypharmacy to the patients I also use codes such as eligible for polypharmacy review and shared decision making.

How has your training benefited other clinicians in your network?

Priti – We’ve both presented at and chaired our local polypharmacy Community of Practice on more than one occasion. We’ve been able to tailor the knowledge from the national sessions to the needs of our local area and share the knowledge with non-prescribers who weren’t eligible for the national ALS.

Kim – My current role involves supporting people who work in general practice, like new prescribers, pharmacists or newly qualified GPs. I can now facilitate groups and give them tools to support them with structured medicine reviews.

What about your patients?

Kim – Anecdotally, in my General Practice role, I saw an elderly lady with dementia who had experienced around six episodes of care. Her GP and I stopped all her medicines after a review. For the first time in years, she started saying her husband’s and son’s names. Medicine was also one less thing for her husband and carer to think about.

Priti – Patients and carers are surprised when I’m the one to bring up a structured medicine review. They might have been privately questioning whether they should be on a particular medicine and are relieved that I’m the one to raise it.

How would you like to see awareness of polypharmacy develop in the future?

Kim – I’d really like to see people get engaged across the spectrum of primary and secondary care and different specialities and sectors. More than ever, I appreciate that you need input from different people to make a system-wide difference.

Priti – I agree. Even people who’ve had quite a lot of experience in polypharmacy will get something out of the Action Learning Sets, as they drive mindset change as much as learning. It would definitely be beneficial to continue delivering local sessions in this area to highlight all issues around polypharmacy for the benefit of both clinicians and more importantly he patients to reduce the potential harms that exist.

Polypharmacy resources

Polypharmacy programme

Resources to support Structured Medication Reviews

Medicines optimisation programme