Tasked with bringing down the prescriptions by 66 per cent, the Dementia and Prescribing Antipsychotic Project in London found that GPs and pharmacists were successful when they worked together, writes Lelly Oboh
Every year 180,000 antipsychotic prescriptions are written for dementia patients in England, causing an estimated 1,800 additional deaths and 1,620 cerebrovascular adverse events, according to the Banerjee report in 2009.
Following recommendations made in the report, the care services minister called for a 66 per cent reduction in antipsychotic prescribing for behavioural and psychological symptoms in dementia (BPSD).
‘An estimated 1,800 additional deaths and 1,620 adverse events are caused by antipsychotic prescriptions’
In response, the clinically led Dementia and Prescribing Antipsychotic Project was set up by NHS London in 2011 to support 31 London primary care organisations to achieve the target.
The project team consisted of six GP cluster leads, one pharmacist lead and a project manager.
This article reveals the process that led to the reduction and shares learning about what works using examples from successful primary care organisations - mainly Bromley, Richmond, Wandsworth, Bexley and Croydon.
It also highlights the valuable contributions made by the lead pharmacist and medicines management teams to drive the process, including using existing networks and systems as levers to overcome barriers.
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Identifying and tackling the primary problem
GPs prescribe most of the antipsychotics for BPSD in primary care via repeat prescribing, although they are often initiated by prescribers outside primary care.
Hence GPs are reluctant to discontinue prescribing in spite of the associated risks and evidence that many patients will have no worsening of symptoms when discontinued.
The project team identified some actual and perceived barriers to this reduction. They include:
- difficulties identifying patients with dementia on GP systems, especially coding;
- insufficient information about the target symptoms being treated, anticipated outcomes, monitoring and discontinuation criteria;
- lack of specialist knowledge to safely withdraw antipsychotics initiated by specialists;
- lack of primary care focused protocols to ensure safe and effective reduction;
- misunderstanding of the “real” risks of harm versus the perceived risks of stopping antipsychotics such as withdrawal symptoms and the burden on carers;
- not enough “real time” knowledge about the actual symptoms the patient is experiencing or their response to therapy. Many reviews rely on secondhand information from carers, with little or no patient dialogue;
- ambiguity about what constitutes “severe distress” to warrant prescribing antipsychotics in line with National Institute for Health and Care Excellence guidance;
- poor availability and access to non-pharmacological options to manage BPSD; and
- pressure from carers and fear of litigation.
A pronged approach
With this in mind, the team proposed a two pronged approach for primary care organisations:
- Undertake an audit and reduction exercise; and
- Identify local experts to provide clinical support to GPs and champions to facilitate collaborative working between primary, acute and mental health teams.
The project pharmacist led the development of the primary care audit and a step by step reduction exercise tool.
Key prescribing messages and other practical resources, such as templates for letters and monitoring charts, were also developed.
Generally, primary care organisations followed these steps, although some aspects of the delivery varied at local level:
- Developed strategies to raise awareness of the problem, engage with and educate GPs – for example, newsletters, discussions at quality, prescribing and medicines management committees, as well as educational and learning events. Events were led by local champions - such as the medicines management team pharmacist, a GP with a special interest or a consultant - in collaboration with the project team. GPs valued sessions that focused on the practicalities of reducing antipsychotics, the opportunity to network and gain information about local services available to manage dementia patients.
- Practices undertook the audit to obtain baseline data and identify patients for review or reduction. Local incentives were offered to encourage GP participation and those with a high care home or ageing population were targeted to receive extra support.
- Practices conducted the reduction exercise by reviewing the continuing need for antipsychotics and subsequently discontinuing, reducing or referring as appropriate. Primary care organisations and specialists developed local solutions to support GPs to make decisions and assist the referral of complex or difficult cases.
- Primary care organisations developed a post-audit action plan to sustain ongoing clinician engagement.
How they reached success
Solutions included educational events, commissioning for quality and innovation targets, joint reviews, dedicated hotlines and emails for GPs to access timely advice and expedite referrals to specialists.
The feedback from the five organisations indicated that linking the work to the quality and outcomes framework targets and prescribing incentive schemes kept the issue high on the agenda and encouraged GP participation.
One organisation noted that practices in one cluster that did not address antipsychotics as part of QOF showed little reductions compared with clusters that did.
Access to London wide primary care specific resources for the audit and reduction exercise was mentioned as an enabler.
The project team identified a clinical lead or senior prescribing adviser in the medicines management team as a key contact. They offered leadership and peer support to high prescribing primary care organisations by attending local forums with local commissioners and specialists.
‘Pharmacists were conduits for sharing best practice ideas and effective strategies’
When requested, the project pharmacist delivered training to the teams, met to interpret post-audit data in the context of the locality and discuss a post-audit plan.
Existing good relationships and effective partnerships between GPs and their teams contributed largely to success at various stages.
Successful organisations had pharmacists linked to clusters of GP practices. The pharmacists were conduits for sharing best practice ideas and effective strategies.
Some pharmacist worked with care homes to identify patients, undertake medication reviews, provide therapeutic advice and act as coordinators of care between patients, carers and clinicians to facilitate a safe reduction process.
Also, advanced level pharmacists worked within multidisciplinary teams reviewing antipsychotics and managing withdrawals.
One Croydon pharmacist said: “Forty per cent of antipsychotics were stopped by asking care homes the right questions, using antecedent behaviour consequence charts and keeping eye on benzodiazepines.”
The majority of the teams’ pharmacists did not provide direct patient care but had an overall role to proactively support the practices through the audit and reduction exercise process.
They also worked closely with acute and mental health trust colleagues to develop robust processes to identify and review antipsychotics regularly in line with guidance.
Senior pharmacists had local intelligence about the demography and historical factors that impact on prescribing patterns and were able to engage with and influence local opinion leaders across primary and secondary care to support the agenda.
The results and benefits
The table summarises the results from five primary care organisations. A significant number of patients were not eligible for reduction or withdrawal due to psychiatric illness or “reported” severe distress or harm to self and others.
|The reduction of antipsychotic prescriptions in numbers|
|Borough||Number of participating practices||Number of dementia patients prescribed antipsychotics and % of total dementia patients||Antipsychotic prescriptions initiated in secondary care||Patients identified as eligible* to stop or have prescription reduced in line with NICE guidance||Number of patient prescriptions stopped or reduced||% of prescriptions stopped and reduction of total eligible|
|Bexley||28 of 28||123 (11%)||92||52||31||60%|
|Bromley||47 of 47||155 (10%)||124||30||23||77%|
|Croydon||38 of 62||151 (14%)||53||54||35||65%|
|Richmond||30 of 31||105 (11%)||61||35||19||54%|
|Wandsworth||24 of 45||191 (39%)||86||46||22||48%|
* Excludes patients with recorded psychiatric illness, those with severe distress or at risk of harm to themselves or others
The project raised awareness of the risks of antipsychotics in BPSD, identified local barriers and helped the development of simple solutions to improve care.
Post-audit, primary care organisations developed systems for ensuring ongoing review such as setting up standard EMIS searches, creating templates to identify and review patients within 3-6 months, conducting computer “pop up” reminders every 12 weeks and improving coding.
‘GPs have a better relationship with psychogeriatricians and feel more supported’
Feedback indicates that GPs have a better relationship with psychogeriatricians, feel more supported and find it easier to discuss “tricky” cases, monitor treatment and adjust doses.
Re-audit data showed a reduction in antipsychotic prescribing by high prescribing practices compared with the previous year.
Prescribing antipsychotics in BPSD is inappropriate in two-thirds of patients and leads to significant morbidity and mortality.
They are often initiated by other prescribers and hence GPs are reluctant to make changes.
This project demonstrated that with the right support, GPs can reduce inappropriate prescribing by using standardised, structured tools tailored for primary care settings and obtaining timely clinical input from specialists to support decision making.
‘Pharmacists have systems to drive large scale prescribing changes in primary care’
The high exclusions may reflect the ambiguity of what constitutes “severe distress” and needs clarification.
Raising awareness and education through local joint learning events, as well as adequate leadership and peer support from primary care pharmacists, are essential to facilitate the process.
Targeting GPs and care homes, and working closely with the home staff can lead to early wins.
Over the last decade pharmacists have developed the skills, expertise and systems to manage and drive large scale prescribing changes in primary care.
Although pharmacist input varies, common features are: the strong links with GPs; their ability to raise awareness and clearly state the case for change; and solicit commitment and facilitate joint working with clinicians across primary and secondary care.
Lelly Oboh is a consultant pharmacist (care for older people) at Guys and St Thomas Foundation Trust and East and South East Specialist Pharmacy Services