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Organisation develops an integrated team of pharmacists to enhance identification and management of suboptimal prescribing, resulting in over 5000 patients receiving an intervention


    • Around £300 million per year of medicines are wasted in primary care
    • At least 6% of emergency re-admissions are caused by avoidable adverse reactions to medicines
    • Reduce admissions to hospital caused by polypharmacy and poor medicines management
    • Enhance the quality of prescribing and improve patient safety


    • Recruited a central pharmacy team to optimise medicines management
    • Trained central team on clinical management protocols/targets
    • Used the EZ Analytics dashboard to identify non optimised patients
    • Pharmacists reviewed and optimised patients, using telephone as the primary medium
    • Patients requiring face-to-face intervention had a care plan written into the clinical notes and were recalled for an appointment with a local clinician


    • Over 5000 patients received an intervention, improving safety, optimisation and value for money
    • Resulted in diabetes plans being completed for more than 3000 patients
    • 40% to 47% Diabetic Triple target improvement from across the organisation
    • 63% reduction in Amlodipine/ Simvastatin 40mg combination
    • 71% improvement on Warfarin with appropriate international normalized ratio monitoring


 AT Medics provides General Practice services to over 240,000 patients. This project was instigated upon the realisation that there was a considerable gap between guidance/best practice and their practical application.

The scale of the issue was identified using our innovative BI tool (EZ Analytics), across multiple medicine safety and medicine optimisation categories A central pharmacy team was recruited and trained to take on the challenge of providing an at scale intervention to enhance and optimise medicines management and improve the quality of prescribing and prescribing safety.

A team of 6 clinical pharmacists led by a GP Director, analysed data produced by our automated BI tool to identify patients with sub optimal medicines management. Patient records were reviewed and those suitable for a remote intervention by telephone were managed accordingly and followed up at appropriate intervals to ensure medicine adherence and monitoring.

Those who needed local face-to-face intervention had a care plan written into the clinical notes and were recalled for an appointment with a local clinician (usually a pharmacist). The outcomes were that over the period of the project, over 5000 patients received an intervention, which improved safety, optimisation, quality of prescribing and value for money.


There are numerous challenges related medicines optimisation which have been well documented in journals and national guidelines. For example, over half a million-medication incidents were reported to the NPSA between 2005 and 2010. In primary care around £300 million per year of medicines are wasted.

At least 6% of emergency re-admissions are caused by avoidable adverse reactions to medicines. This projects aim was to improve patient outcomes by ensuring medicines concordance and optimisation against National guidelines, leading to better outcomes.

For example BP/Hba1c/Lipids for diabetic patients. Patients were counselled in depth and their ideas and concerns explored to ensure that there was an aligned approach between clinician and patient. We knew that our GP workforce may not always have the time to be able to do this during a 10 minute consultation. We also wanted to create wider financial efficiencies by reducing unnecessary medicines thus reducing wastage.

Additionally we aimed to ensure patients received the correct monitoring for their medication to reduce admissions to hospital caused by polypharmacy and poor medicines management. We identified patients using our analytics tool and then invited them for review or made the initial intervention by telephone followed by review.


A selection of outcomes are below:

• Diabetes plans completed for 3000+ patients.

• Diabetic Triple target improvement from 40% to 47% across the organisation

• 63% reduction Amlodipine/ Simvastatin 40mg combination

• 53% reduction in Asthmatics on Betablockers

• 43% reduction Asthmatics on LABA and no ICS

• 26% improvement in DMARD monitoring

• 64% improvement in complete Lithium monitoring

• 71% improvement on Warfarin with appropriate INR monitoring

• 43% reduction in patient on long term repeat NSAIDS

• 57% increase in patients with Asthma issued a spacer

The outcomes were achieved through a multi-pronged approach.

1) The central team were intensively trained to ensure clarity on clinical management protocols, targets.

2) The EZ Analytics dashboard was used to identify non optimised patients. Pharmacists reviewed and optimised patients, using telephone as the primary medium.

Where the pharmacist felt telephone monitoring was inappropriate, a plan was recorded in the notes and the patient invited for a face to face review at their surgery.

The main difficulty we experienced was in being able to contact patients. Like many areas of London, our list turnover is 20% and having a transient population can make follow ups difficult.Language barriers can create issues as well were overcome using telephone translation services.


The central pharmacist team worked closely with colleagues within our practices with continual sharing of problems and learning. The use of our BI dashboard has been fundamental to spread performance information across all of our practices. To this end it was vital that we had the support of our central BI team to regularly process and organise the data in a visually useful way.

The fact that we have been able to replicate the improvements across some of our newly acquired sites provides evidence that the model can facilitate rapid clinical improvements in previously underperforming General Practice. While this centralised approach has been focussed on the needs of AT Medics we believe that this package of QI and learning resource provides a clear template for federations, super partnerships and alliances across the UK.

We recognised a gap existed in primary care for an ongoing modular learning set that facilitated development in General Practice specific areas. The package comprises a combination of tools including web based sessions, face to face all day events and direct observation in practice. By learning together, the central and practice based pharmacy team are able to share in the knowledge acquisition and performance improvements collectively.


Patient perspective: As a result of more frequent in depth personalised follow up our patients feel that they are receiving an enhanced level of care and attention. They have often commented how pleased they are that we are taking the time to proactively address their health issues without the need to physically attend a practice.

Clinical outcomes: There has been a step change improvement in the identification and management of suboptimal prescribing. We anticipate that as this sustained and built upon there will be a reduction morbidity and mortality from medicines related harm.

Practice value: The recruitment and retention of doctors has been enhanced as some of this workload has been reduced. In addition the team has built confidence into the system that there is a systematic process to review medicines safety at scale. This additional layer provides huge reassurance to our clinical teams.

Financial value: The model outlined above has proved its sustainability in terms of improved clinical outcomes, patient experience and general resilience. It costs just £2000/ year for an average sized practice. Financial benefits to the Health system are more difficult to quantify but the available research would indicate a reduction of medicines related admissions.


Our stakeholders were host practice clinical teams which included GP, Practice nurses, Practice pharmacists and admin staff. At the commencement of the project, we set up face to face engagement meetings via host practice clinical meetings and admin meetings which led to the setting up of a slack channel with regular updates on work being done, progress and future work streams.

In practice clinical staff bought into the project very quickly as they recognised that they were hard pushed to deal with a huge structural issue like medicines optimisation whilst providing business as usual service provision. They were also aware of prescribing issues being present for a long period of time but not being able to deal with them during routine appointments.

There was close co-ordination as patients that needed to be brought back in for further GP or local face to face review needed a clear plan in the notes so that there was a clear communication plan with all the clinical members involved in the patients care. Administration teams were engaged to ensure that where patients had been identified but contact was not possible, they held the responsibility for ensuring the patients were contacted and offered appointments.

Key individuals

Dr Hasnain Abbasi