Polypharmacy Action Learning Set celebrates 1000th delegate

Lesley Bull, a South London GP and our 1000^th delegate chats to Lois-Hooper Ainsworth, Programme Coordinator on the National Polypharmacy Programme, about why she registered for the Health Innovation Network Polypharmacy Action Learning Set, what she got out of it and why other GPs should attend.

So, Lesley, could you tell me why you chose to register for the Polypharmacy Action Learning Sets?

I attended the British Geriatric Society Conference in November last year and colleagues who run the course were presenting there – it just seemed common sense. I don’t think we have enough of that.  We just do what we always do when prescribing and often we’re not thinking hard enough about each individual decision. I look after a big elderly population; I’ve been the lead GP for a care home for some time and I’m the clinical lead for frailty in my area. Therefore, I have a big interest in looking after frail people as best we can. Obviously, they are in the main the group deprescribing is targeted at, so I registered as it seemed a practically useful approach to developing practise.

What did you gain from attending the course?

Enthusiasm was one of the big things. It gave me permission and motivation to do some of the slightly more in-depth and difficult things such as starting a conversation with patients about the potential risks of starting some medicines. I learnt things I didn’t know – embarrassingly, I’ve been a GP for seven years and a doctor for 13; you get into the habit of ‘X’ is the treatment for ‘Y’ without necessarily thinking through or discussing in detail some of the potential downsides of taking medication. So that’s one thing I think that’s definitely developed my practise in terms of thinking twice before I start drugs.

Also, when I’m processing monthly prescriptions for my care home residents, I now have a much lower threshold for trial without ‘X’,’Y’ or ‘Z’ drug. I’ve been routinely reducing the dose of Proton Pump Inhibitors (PPIs) that people have been on for a long time, discussing with families, patients and care home staff, saying ‘if we’re not sure the medicines are doing any good, maybe we could try without it and see?’ So, for those frail people, that has made a big difference. I’ve seen improvements, particularly in unsteadiness and cognition.

The quote from the course ‘guidelines, not tram lines’ is brilliant and I’m really encouraging other colleagues to think about polypharmacy and guidelines more.  We are a training practice and I have GP trainees coming through – it’s really important that they start their careers with more confidence to use common sense in their own judgement rather than blindly follow what NICE says – for example, what is clinically appropriate for a 50 year old may actually be harmful for the patient in front of you who is 85.

The course has given me more confidence to stand my ground. Confidence to individualise treatment, to step outside what might be standard practise. Before the course I was having these ideas, quite isolated with potentially the fear of criticism. Now I’ve got this learning and resources behind me that I didn’t have before, plus the group of respected clinicians saying this is a good thing to do. This is not going against guidelines, actually, this is eminently justifiable. It’s not just ‘okay’ to stop unnecessary medicines – it’s the ‘we should’ be doing it. I can now comfortably justify these decisions, knowing I’m not the only one doing it – in fact I’m the 1000^th!

How have patients responded when you suggest stopping or reducing their medication?

The Polypharmacy ALS provides tools to support a more nuanced conversation with patients about proposed treatments or ongoing treatments, to make a decision together with the patient rather than in opposition. Sometimes that doesn’t work out because some patients just want you to decide for them, which is fine. But it was encouraging to be reminded to approach the conversation from the patient’s point of view, rather than the NICE guidelines point of view.

When I say to people ‘actually, you could probably do without this medicine’ they mostly say, ‘oh, yes please’,. Of course, I’ve had a few patients who were a bit more tentative. But that’s okay.

Would you recommend the course to other GPs?

I absolutely would recommend GPs do it and I think particularly GPs looking after older people in bigger groups and GPs responsible for a care home, for example.Sometimes, in a busy practice a lot of suggestions for improving practice feel quite time consuming and unwieldy, and so we don’t always get a chance to do them. It’s not all about massive medication reviews and convincing people to stop things that they’ve been taking for years. Some of it is very simple. Saying to patients there are risks associated with this, as well as benefits, that I think we should start this as a trial and deliberately review it in a few months rather than just put it on repeat and forget about it. The Polypharmacy ALS should appeal to GPs because there is huge benefit to be gained both for the patients and actually in terms of workload. The fewer unnecessary repeat prescriptions we’re authorising every month, the less work we have to do from a very pragmatic point of view.

These are relatively easy interventions that we already know how to do. I think sometimes we just need more evidence to back us up. That’s another great thing about the course – the wealth of resources. Pretty much any decision needed I can now point at a respected, evidence-based source that says this is a good thing to do and provides a good reason to do it. It’s really useful for putting things like national guidance into context for a particular person or group.

From the name, some GPs may think the Polypharmacy ALS is just another training course but it’s so more advanced than that. It’s a discussion about practice, with colleagues who want to do better.  Everyone brings their experience and vulnerability, saying ‘I’m not sure about’ or ‘this is something that I’ve done in the past’ in small group facilitated discussions about whether that was the right or wrong decision or what we could do differently next time. On day three, there is an expert forum that includes Geriatricians and is incredibly useful. As GPs we don’t get enough opportunities to have frank conversations with clinicians from other disciplines. Also, being in a group with pharmacists and colleagues from other professions who prescribe, and understanding the differences in our practise better is really valuable.

Are there any specific medications that following the course, stand out as particular ones to focus on?

We have a lot of people whose bisphosphonates haven’t been reviewed and stopped, or reviewed with a view to stopping, despite the fact they’ve been on the treatment a long time. It’s something I do ad hoc, but it would be beneficial to just do the whole practice in one go. You know, the searches exist. It’s fairly easy to do and most people are quite happy to get off them to be honest, because they have side effects and they’re a bit of a pain to take.

PPIs are another one. We have so many PPI prescriptions and, again, lots of people stay on PPIs long term where they probably don’t need to. I talk to patients when I start them now, saying take this every day for four weeks and then reduce the frequency and see how you go. You might need to just take it for a week or two, or here or there if your symptoms recur. Or you might just need to take it twice a week instead of every day.  That will reduce the potential risk associated with long term use for older people and also post-menopausal women, particularly for the risk of osteoporosis.

Also Selective Serotonin Reuptake Inhibitors (SSRIs). There is the belief with SSRIs that if it isn’t broken, don’t fix it, but perhaps people and practitioners don’t realise the side effects of long-term use. I’ve started to invite people for review to have those conversations. Some people are more comfortable staying on them and that’s fine, but I think we’re not talking about it enough.

A big issue is anticholinergic burden in old people and also hypertension. Antihypertensives are probably the most commonly prescribed group of drugs. It’s not that helpful when you have a patient who’s over 80 and actually their blood pressure just doesn’t respond in the same way as a younger person. I’d really like to target patients that have conflicting drugs. This is something I would love to have the time to set aside and really do with our older population. Too many things!

You can hear more from Lesley in this video interview. 

Lesley is a GP and Speciality Doctor, Greenwich & Bexley Community Hospice.  Lesley has an Extended Role in Palliative Medicine, and the Clinical & Care Professional Lead for Frailty in Bexley. She has clinical roles in traditional General Practice, care homes and community palliative care, and her frailty role focuses on commissioning of services by the CCG Primary Care Team and Local Authority.

Register your interest to join our next series of Action Learning Sets in 2025 here