Community pharmacists say the following true story is sadly too familiar these days: a High Street chemist is handed a new prescription by a regular customer already taking a gamut of medications prescribed by his GP.
The new prescription is for Parkinson’s disease. The pharmacist wonders at the man’s misfortune: already this patient is on so many drugs for his various symptoms that he’s recently also been put on one called prochlorperazine (brand name Stemetil) just to deal with the dizziness and nausea that the multiple medications cause as a side-effect.
And now, on top of everything else, the patient has developed Parkinson’s — and has a new prescription for a drug with its own serious potential side-effects, including nausea (again), confusion and an uncontrollable drive to gamble, have sex or pursue hobbies obsessively (the drugs interfere with the brain’s chemical reward systems).
But something at the back of the pharmacist’s mind begins to nag at him about prochlorperazine, so he double-checks the medicine’s list of warnings.
This reveals that, in some patients, the drug can cause Parkinson’s-like symptoms as a side-effect, such as a shuffling walk. (The drug may block the action of the chemical dopamine in the brain, and with Parkinson’s itself, the brain steadily loses its ability to produce dopamine, which is key to the co-ordination of movement.)
Many prescribed medicines can be harmful as well as helpful. This is especially true when people are taking multiple drugs that may interact badly, or overburden patients’ bodies (file image)
So rather than dispensing this latest prescription, the pharmacist rang the patient’s GP surgery.
‘The prescriber agreed to review the patient,’ the pharmacist told Good Health, ‘and the patient didn’t end up on the anti-Parkinson’s medicines.’ Instead, his GP took him off prochlorperazine and his Parkinson’s-type symptoms resolved.
The pharmacist asked Good Health to withhold his name because he wants to maintain a good relationship with his local prescriber.
But his professional organisation, the Association of Independent Multiple Pharmacies (AIMP), said that this story is typical of an increasing nationwide problem: patients being prescribed an ever-lengthening list of drugs, or ‘polypharmacy’.
And while pharmacists themselves can act as a safeguard against the dangers of polypharmacy, their ability to vet whether prescriptions are always appropriate is being severely hampered by the large-scale closure of pharmacies — some 540 in 2023 alone — triggered by soaring overheads and frozen incomes.
The fact is, many prescribed medicines can be harmful as well as helpful. This is especially true when people are taking multiple drugs that may interact badly, or overburden patients’ bodies.
A 2022 study by Newcastle University concluded that each additional drug prescribed to a patient was associated with a 3 per cent increased risk of mortality.
And as a report published by NHS England (NHSE) in July 2023 concluded, it is not unusual for patients, particularly older people, to be taking ten or more prescribed medications, which could mean a 30 per cent increased risk of dying based solely on the number of medications the patient takes, not their actual condition.
Polypharmacy is often caused by patients seeing hospital doctors or new GPs who are not aware of the other medications that they are on already, explains Fin McCaul, managing director of Prestwich Pharmacy in Manchester, and a committee member of the High Street chemists’ negotiating body, Community Pharmacy England (CPE).
‘The problem can also happen when a patient’s GP substitutes one of their drugs for another, but the old one does not get deleted from their prescription list — so they end up taking both,’ he says.
Dr Leyla Hannbeck, chief executive of AIMP, blames the rise in polypharmacy on cuts in NHS services which mean that medical practitioners don’t have the time to see patients as individuals, but rather a series of illnesses that need medicating.
‘This leads to extra medication being ‘bolted on’ to manage symptoms as they arise,’ she says. ‘This is particularly true when patients move between primary care to hospitals, and back — and leads to them being on increasingly complex drug regimens.’
The Government itself acknowledges that at least 10 per cent of drug prescriptions are unnecessary. Its National Overprescribing Review report, published in 2021, said that stopping these unnecessary prescriptions ‘would be equivalent to a reduction of around 110 million items a year’.
Medications prescribed in the community cost the NHS in England £10.4 billion in 2022/23, according to the Dispensing Doctors’ Association.
If that was cut by 10 per cent, it would save nearly £1.5 billion, without counting the costs in human misery saved by reducing hospitalisations. A spokesman for NHSE told Good Health that efforts to cut unnecessary prescriptions are ongoing.
They pointed to this year’s NHSE medicines ‘optimisation strategy’, which recommends that local NHS commissioning authorities consider ‘addressing problematic polypharmacy’ as a new project.
In fact, the NHS has been setting policies to cut polypharmacy for more than two decades. However, excessive prescription levels seem not to have changed, and the Dispensing Doctors’ Association’s prescribing figures look much as they did three years ago.
Why does the problem remain so intractable?
Dr Victoria Tzortziou Brown, the Royal College of General Practitioners’ vice chair for external affairs, told Good Health that GPs are highly trained experts both in prescribing and ‘de-prescribing’, but are facing unprecedented demands and shrinking resources.
‘GPs are seeing a higher number of patients with multiple conditions needing complex treatment plans, part of which will involve careful consideration of how their medications will interact, to minimise the potential risk of adverse side-effects,’ she says.
‘This makes it vital for GPs to have sufficient time for patient consultations. But general practice is buckling under the strain of workforce shortages at the same time as demand is rising.’
Community chemists understand the severe strain that GPs face. However, they see other causes for overprescribing which the pharmacists themselves could tackle — if they were allowed to.
They say that, bizarrely, although community pharmacists are the professionals who physically provide medicines, see patients most frequently and are expert in drugs and their interactions, under the current system they are not meant to ‘de-prescribe’ drugs if a patient is being prescribed them unnecessarily.
Under a system that the NHS introduced in 2020, GP surgeries are instead paid to conduct structured medicine reviews (SMRs) with those patients who are at risk from polypharmacy.
At these reviews, which may be conducted yearly or at different intervals depending on the doctor’s discretion, a GP or other primary care professional is expected to go through the patient’s medicines with them to discuss whether they are necessary, safe and effective.
Although community pharmacists are the professionals who physically provide medicines, see patients most frequently and are expert in drugs and their interactions, under the current system they are not meant to ‘de-prescribe’ drugs (file image)
But as for how extensive or useful these new SMRs are, no one seems to know. An Oxford University study is under way into what effects (if any) SMRs have had on prescribing since their introduction, with initial findings expected in the second half of 2024.
However, it seems that accessing these GP surgeries’ SMR services may at the very least be slow and difficult, given the fact that NHSE figures in July show that 1.3 million patients a month wait four weeks to see a family doctor.
Jay Badenhorst, vice chair of the National Pharmacy Association, told Good Health that ‘people have to make do with the limited number of SMR appointments offered by doctors’ surgeries’.
In countries such as Sweden, the Netherlands, Spain, Canada, Japan and Australia, community pharmacists already have the power to de-prescribe.
A review in the British Journal of Clinical Pharmacology in 2021 of 24 studies, covering more than 4,000 patients in these countries, concluded that this approach does work effectively.
So why not in the UK? In September, two highly respected health policy charities, the King’s Fund and the Nuffield Trust, published a report recommending the NHS pay community pharmacists to conduct medication reviews.
Fin McCaul believes any such system is being held back by an unspoken government policy to fund GPs in preference to community pharmacists.
‘But enabling community pharmacists to review patients’ medicines and de-prescribe unnecessary ones is not only the right thing for the patient, it can also save serious sums of money if it prevents them from being harmed and needing hospitalisation.’
Instead, as Jay Badenhorst says: ‘NHS funding cuts mean that the number of community pharmacies continues to go down, with hundreds of closures each year.’
Meanwhile, ever more patients end up on ever more drugs.
