The multiple benefits (intended and unintended) of a QI project on controlled drug prescribing

Case study compiled by Dr Amy Hilton, GP Partner, Bridge Road Medical Centre, South Sefton. Health Innovation North West Coast supported Dr Hilton in her work.

Summary

Bridge Road Medical Centre, South Sefton, is a GP practice in one of the most deprived areas of South Sefton. Most of the practice catchment area is in the top 20 per cent most deprived areas in England. The practice’s list is nearly 8,000. There was a requirement to act on the high levels of controlled drug prescribing, and with a culture change and slow, steady work, the practice was able to significantly reduce prescriptions of controlled drugs, specifically anxiolytics and hypnotics.

Background

In 2023, prescribing data for the practice showed it had the highest level of controlled drug (CD) prescribing in Cheshire and Merseyside – above 500 ADQs (average daily quantities) per 100 patients, and this was identified as a problem by GP partners. Following a Never Event (a Tramadol overdose) a review identified several Tramadol prescriptions issued very closely together. The astounding prescribing data, combined with the sad passing of a patient due to overdose of a controlled drug, were a catalyst for change at the practice.

SMART aim for Quality Improvement

The project embraced a SMART approach to the project: Specific, Measurable, Achievable, Relevant, Timebound

Specific: achieve a reduction in the practice’s controlled drug prescribing.

Measurable: compare prescribing data, monitor whether there is a reduction.

Achievable: start by targeting those patients on the highest doses (>120mg morphine equivalent (ME)/24h).

Relevant: make changes to address both prescribing statistics and patient safety.

Timebound: review every 3-6 months with every medicines management review meeting when new figures are available.

Methodology

Multi-modal methodology was applied for optimum improvement. The first step was to obtain buy-in from the practice team. GPs are not a homogenous group, so it was necessary to hold several education sessions and discussions with all members of the practice team. This included GPs, GP registrars, the nursing team, and the reception and admin staff.  Sessions focused on potential benefits of changes: improved data, less harm to patients, improved prescribing budget, positive impact on workload in terms of appointments and prescribing, and greater health economy – fewer adverse drug reactions (ADRs) would mean fewer admissions to secondary care.

Discussions also centred on the changes to be made to practice procedures. An example is the SOP for practice reception staff dealing with CD requests, which involved highlighting to a patient if their 7, 14 or 28-day supply had been issued less than 7, 14, or 28 days ago; and flagging this to the prescribing clinician. The prescribing clinicians would then send an Accurx text to the patient explaining that the practice would no longer be issuing early scripts for safety reasons, and requests would be rejected. For those repeatedly requesting CDs early, we moved rapidly to weekly scripts – in some cases even daily. The practice team accessed the Oxford University Hospitals’ Resources for Primary Care Regarding opioids and chronic pain and Deprescribing.org’s Deprescribing Guidelines and Algorithms to inform the development of a controlled drug contract and patient-facing materials and messaging.

Summary of changes

• Development of a new practice controlled drug policy.
• New Accurx messages to be sent to patients: “Thank you for your prescription request. Your last prescription for [X] days’ worth of drug [Y] was issued on [Z date]; it is therefore not due until [A date] and as it is a controlled drug, for safety reasons will not be issued sooner. Patients persistently requesting controlled drugs early will be moved to weekly scripts for safety.”
• Patients on >120mg ME/24h were identified and a reduction plan was made, explaining that at doses >120mgME/24h there is no evidence of benefit but a lot of evidence of harm. A reduction plan would ideally be made in partnership with the patient but otherwise we would follow a plan to make a safe reduction anyway.
• Those requesting early repeatedly were put onto weekly scripts.
• All prescribing clinicians were strongly discouraged from prescribing opioids for non-acute, non-cancer pain management.
• The reception team were empowered to inform patients at the point of the request, that it would be very likely an early request would be rejected, and if it had been rejected and documented as such the team were empowered to reinforce this with the patient.
• New patients were told that the practice is zero-tolerance for controlled drug prescribing.

Results

Prescribing data is recorded quarterly and prescribing data for anxiolytics and hypnotics is shown in the graph on the right for Bridge Road Medical Centre. A decline in average daily quantities (ADQs) of anxiolytics and hypnotics can be seen from around mid-2023.

Outcomes

• We have reduced prescriptions of benzodiazepines, Z-drugs, and strong opioids for non-cancer pain.
• As patients have appreciated our whole-practice approach, less time is now spent dealing with repeated requests for the same rejected prescriptions; weekly controlled drug scripts are looked after by our practice pharmacist and issued automatically with patients under regular review. There are fewer prescription requests and ad hoc consultations with this patient group, freeing up time for clinicians and admin team alike.
• Practice colleagues identified an uptick in anticholinergic burden (ACB) scores, likely due to switching from controlled drugs – for example, from a hypnotic to amitriptyline for its sedative benefits; or opioids for non-cancer pain for those whose pain was thought to have a neuropathic element. A separate project was launched to address this when one of our GP registrars looked at patients with a high ACB score: she produced some educational materials on the potential harms and will be re-auditing prescribing following this.
• Changes to practice policies empowered reception staff to feel confident in declining repeat prescription requests when required as they knew they would have the support of the whole clinical team and practice manager, even if patients made complaints.

Lessons learnt

• Quality improvement is rarely easy or simple, however this work was particularly challenging. Persistence was key, along with full team buy-in and motivation for change.
• The quality improvement process required constant review and alteration as new elements emerged, for example the impact on ACB scores and the subsequent project undertaken by one of our registrars. Although there was some resistance to change, there was also positive feedback – many patients thanked practice colleagues for taking the lead in something they had wanted to address themselves for an exceptionally long time.
• We continue to review our prescribing data and educate new team members as they join us – our CD approach is now an integral part of the induction for new staff. We hope this continued refresher for current team members and education for the next generation of the practice team will continue to drive positive, lasting change.