The Polypharmacy Challenge Blog
Polypharmacy perspectives: the challenge for pharmacy
Nina Barnett, in the last of our perspectives series, sets out how pharmacists need to use their communication skills to enter into dialogue with patients if we are to address the polypharmacy challenge.
The pharmacy profession has entered a new arena: a renewed focus on talking to people about their medicines. However, there is fundamental shift in these conversations: Pharmacists are moving from asking ‘What do I, as a pharmacist, need to tell you, my patient?’ to ‘What do you need to know about your medicines?’ and ‘What do I need to know about you?’ In other words, we are putting the patient's wants and needs before discussing what the pharmacist thinks the patient needs to know.
Until recently, pharmacy was a profession of process; including manufacturing, dispensing and safe use of medicines. Pharmacists are experts in managing safe processes; formulation of medicines is the origin of our practice. This takes us back to the time when a pharmacist’s role, following a diagnosis made by a doctor, was to safely compound medicines according to specific formulas. The patient-facing aspect of the role was to explain to the patient how to safely use and take the medicines. However, since the advent of the NHS and the growth of pharmaceutical manufacturing companies, the pharmacist’s role changed to a more supply-orientated role. The development of a patient-facing clinical role over the last 25 years has meant that communication skills between pharmacists and other health professionals, and pharmacist and patients, are now central to effective pharmacy practice.
Prescribing by health professionals now focuses on evidence-based prescribing guidelines in the UK. However, we know that drug trials often don’t provide the evidence we need to treat older people and those with multiple, complex conditions. More importantly, we need to recognise that, in addition to health professionals wanting to give patients information about medicines, patients often know a lot about what they take. People have their own ideas about medicines and how they want their medicines to fit into their lives. These factors need to be taken into account in all consultations about medicines. This can only be achieved with a two way dialogue between patients and health professionals, which will often involve more listening than speaking on the part of the health professional.
So what do pharmacists need to do to embed person-centred medicine reviews into their practice?
My suggestion is that pharmacists need to move from thinking about the medicine first to focusing on what the patient in front of them wants from their life, in relation to health improvement and how medicines contribute to or prevent them from reaching their goals. It is much more relevant for a patient with exercise-induced asthma to talk about being able to take their dog for an early morning walk without ending up wheezing, than to talk about 'reducing asthma symptoms' or 'increasing peak flow rates'.
In terms of the role pharmacists can play in addressing polypharmacy, both Medicines Use Reviews (MUR) and New Medicines Service (NMS) consultations are an ideal opportunity to address the use of multiple medicines. In order to maximise the person-centredness of these consultations, the questions suggested in the MUR and NMS guidance can be re-phrased as open-ended questions that encourage people to talk about what has changed, how their medicines fit into their life, and how are they managing with the medicines.
For example, by asking, ‘What’s changed since you’ve taken your medicines?’ rather than, ‘Have you had any side effects?’ a patient may tell us about the cough that has come on since they started taking an ACE inhibitor for high blood pressure, a link they may not make themselves; why would anyone think that a medicine to treat blood pressure could bring on a cough? Asking about side effects through a closed question may not elicit this information.
Rather than asking, ‘Have you taken your tablets?’, a broader question such as ‘How many doses have you missed in the past week?’ can reveal more because it assumes that, at some point, we will all forget to, or choose not to, take our medicines. It is therefore much less judgmental and normalises missing doses, making it easier for the patient to tell us that a dose has been missed. This type of question can build rapport with patients and help to reveal why they haven’t taken their tablets which may in turn reveal attitudes such as, ‘I don’t like taking my tablets because I don’t want to be reminded that I’m sick.’
While health professionals are good at starting medicines, using evidence-based guidelines, there are very few guidelines around stopping medicines which makes deprescribing inherently more difficult. Perhaps conversations about starting a medicine (prescribing conversations) should also be conversations about how long the medicine may be needed for and when it might be stopped, in other words deprescribing conversations. This brings in the concept of deprescribing at the start of a course of treatment and links it with prescribing from the outset. This requires a change in practice for all health professionals who prescribe. We are all taught how to prescribe but how many of us learn to deprescribe? And what are we taught about helping patients with stopping medicines, ensuring they feel safe stopping a medicine and that they can come back to us if symptoms recur? We must be careful to maintain equality in a prescribing and deprescribing relationship, so that both are seen as a continuous process of working together towards optimising the patient's health through medicines.
So I encourage all pharmacists and other health professionals who work with medicines to consider how they can engage in dialogue with patients to understand medicines in the context of patients’ lives and goals for health. These conversations with patients will support effective deprescribing to minimise inappropriate polypharmacy.
Nina Barnett is a Professor and Consultant Pharmacist for older people, London North West Hospitals NHS Trust & NHS Specialist Pharmacy Services. She is currently a visiting professor at King’s College London. Nina pioneered the use of coaching in pharmacy to optimise patient adherence and, with colleagues, has designed a patient centred process for managing polypharmacy.