Deb Gompertz is a Complex Care GP and Clinical Lead in South Somerset. In the last year she has been undertaking a Population Health Fellowship focusing on person centered care, proactive care, and collaborative working as well as changing practices with environmental impact. She Tweets at @DebGompertz.
A new model of care asking a simple screening question during routine home visits by community staff provides the potential for massive reduction in medicines waste. This has subsequent environmental and cost saving benefits, along with improved individualised patient care.
What was the problem?
The role of the Complex Care GP in South Somerset is to perform holistic assessments of patients’ needs within their homes.
These patients include people who have recently been discharged from hospital, had frequent admissions to hospital and/or are involved with multiple services.
During our assessments, we identified a large number of patients not adhering to their medication as prescribed and subsequent wastage of large amounts of medication. This was only apparent from asking to see their medication, and would not have been identified otherwise.
In our first pilot we identified 40 patients not adhering to their prescribed medication regime, this accounted for 1 in 4 of people assessed.
Viewing medication is not part of the normal medication review, however if we perform this simple task we identify a cohort of the population that are at increased risk from adverse events from erratically taking medication, poor optimisation of long term conditions, and missed diagnosis (e.g. dementia).
This will also reduce medicines waste and save resources for the NHS. Currently medicines account for 25% of CO2 emissions within the NHS in England each year, and £300 million pounds is wasted on medicines that are thrown away or stockpiled.
What was the solution?
The solution was a simple screening question asked on routine visits by community staff:
“Show me your meds, please?”
The staff reported after simply viewing patient’s medications, if they had any concerns that the medications were not being taken properly. This included the complex care team, health coaches, district nurses, community physios, adult social care etc.
This information was then fed back to primary care and the patients were discussed in huddles (Multidisciplinary meetings) to decide which staff member was most appropriate to follow up the patient. Follow up could range from a phone call to a comprehensive assessment aligned to patient goals. The Primary Care Network (PCN) pharmacist, pharmacy technician, complex care team (which includes GP, nurse and support worker) and primary care team have all had a role.
What were the challenges?
There needs to be a sensitivity to the psychological impact of removing or stopping medication in case people feel their medical care is being withdrawn.
There is a potential challenge of increased clinical workload, which was addressed by the enthusiastic involvement of our PCN pharmacist and pharmacy technician who have been invaluable in helping with assessments and also liaising with community pharmacists around communication and altering medication regimes.
Two potential methods of addressing the workload involved in this impactful intervention in this group are to:
- Fund extra pharmacy support required through financial savings (initial impact assessment has suggested this would significantly exceed the costs).
- Reallocate resources away from an emphasis on routine, high volume but low impact medication reviews.
What were the results/impact?
The first pilot over a 3-month period identified 40 patients not adhering to their medication as prescribed.
1049 individual months of unused prescription items were identified.
Wasted medication was valued at £10866.
It is estimated that every pound spent on pharmaceuticals generates greenhouse gas emissions of 0.1558kg CO2 per pound (£), representing avoidable CO2 emissions of 1693 Kg.
39 medications were stopped providing predicted cost saving over the next 12 months of £3529 and 549 Kg CO2 emissions prevented.
Medication regimes were simplified in more than 50% of cases.
Social prescribing was initiated in 30% of cases.
New cognitive impairment was identified in 35% of cases.
What were the learning points?
It is necessary to physically look at people’s medication at home to identify non-adherence for some patients.
This screening question can be performed on routine visits by community staff and could be extended to carers and relatives.
It is important to recognise that poor adherence to medication is an indicator to screen for dementia.
The medication review should not be considered an isolated intervention but rather one piece of the jigsaw of a holistic patient assessment.
This simple screening question can save resources for the NHS, has a positive impact for the environment, and can reduce risk to patients from taking medication incorrectly.
The success of the project has come from good communication with community teams who share the same ethos around person centred care.
This study has demonstrated the positive impact for patients, the environment and the NHS from asking a simple screening question by community staff on routine visits.
This is a small descriptive study and scaled up this could have an enormous impact on wellbeing for patients and the environment.
Want to know more?
For more information about this project, please contact:
Dr Deb Gompertz
Clinical Lead for Complex Care South Somerset
Population Health Fellow HEE
deborah [dot] gompertz [at] ydh [dot] nhs [dot] uk