Addressing Overprescribing in Frail Older People living in care homes (2025)

Rachael Thornton and Sabah Khan, Primary Care Place Division, The Dudley Group NHS Foundation Trust

Project summary

Polypharmacy is a significant and complex issue and is acknowledged widely as being a growing problem particularly in our older population living in care homes. If we consider the physiological, metabolic and lifestyle changes that occur because of ageing, frailty and co-morbidities the risk of adverse effects from medicines increases substantially.

In 2023, in the Black Country, the total average monthly spend for an inpatient stay for a frail patient was £17.81million per month creating a substantial financial burden to the NHS but also families and social care. There is a well evidenced relationship between problematic polypharmacy and adverse reactions leading to hospital admissions.

Locally and nationally, we are aware of the ever-increasing pressure in Primary Care due to unprecedented demand from patients, this is in part due to our growing ageing populations. In addition to managing the on the day demand in primary care there is now an ask to also undergo transformation and deliver care differently so that patient requiring complex care are appropriately supported as they age.

Primary care needs to start to work differently, and the traditional appointment/clinic system may not be the best way to manage our complex older patients. Our Place has facilitated the development of a specialist primary care pharmacist team for older people to work outside the traditional constraints of GP practice which allows us to work autonomously, and as independent prescribers, we are able to complete any interventions directly, complete the patient journey whilst also being embedded into the MDT team at the GP practice. In this way we can address some of the known system and provider barriers to focusing on this workstream, creating welcome additional resource for primary care whilst addressing local and system priorities.

It's currently a small team comprising of two experienced independent prescribing pharmacists, (equivalent to 1WTE) but we adopted an approach to target patients living in care homes for review based on potential risk of harm from medication identified through bespoke searches embedded in the prescribing system. Structured medication reviews were then completed but more importantly detailed outcomes were recorded so we have been able to demonstrate the benefit and impact of having this service to supplement the daily work in primary care and also at system level. Notwithstanding the current financial pressures in the NHS, by being able to demonstrate the benefits of this approach, it complements the ideology that complex care for our older patients may be best provided through the development of specialist clinicians working in ‘frailty hubs’.

Through a population health targeted approach to SMRs, based on hospital admissions avoidance, we completed 554 SMR’s specifically in care homes, saving the equivalent number of GP appointments resulting in a workforce saving of approx. £20,000 p.a. Direct annualised cost savings from medication stopped and/or reduced was calculated to £70,410 p.a. In addition to this the harms reduction from completed interventions projected to a potential 961 hospital admissions avoided equating to a potential saving of £4,742,535.00.

This represents an excellent return on investment of 138 to 1.