In September 2021, the Department of Health and Social Care (DHSC) published findings from its National Overprescribing Review (NOR) led by the Chief Pharmaceutical Officer, detailing the extent of overprescribing in the NHS. The report, Good for you, good for us, good for everybody, set out a series of recommendations to help tackle overprescribing, particularly in primary care. It included a call for further research to understand the links between overprescribing and deprivation, ethnicity, age and inequalities and the impact these have on the health of the population.
Overprescribing is where people are given medicines they don’t need or want, or where harms outweigh the benefits of use and it is estimated that at least 10% of the current volume of medicines in England may be overprescribed, equivalent to around 110 million items a year. Overprescribing is not a new problem and occurs in every health system in the world representing a significant waste. Tackling overprescribing has the potential to bring savings, not only in medicines prescribing but also in improving patient safety, preventing avoidable admissions and use of other services, as well as helping health systems to become more sustainable such as helping the NHS fulfil its commitment to becoming carbon net zero. Tackling overprescribing also contributes to the NHS priority to reduce antibiotic resistance through overprescribing of antibiotics.
Pertinent to this call are the findings in the NOR that suggest the consequences of overprescribing may be greater among certain populations. For example, rates of polypharmacy (taking multiple medicines) were found to increase with deprivation, with those taking two or more medicines 2.8-times greater in the most-deprived compared with the least-deprived areas of England. Recent NICE guidelines also asked for more research on the impact of social distress, low income and other factors on risk of dependence on prescribed medicines like opioids.
People with multiple long-term conditions (MLTC) may be more greatly affected due to taking multiple medicines, increasing the likelihood of experiencing adverse drug reactions (ADRs) as are older people who are more likely to be taking multiple medicines due to comorbidities. A higher than average proportion of people who identify as Asian/Asian British are on eight or more medicines. While the NOR doesn’t indicate if and how much of the differences in polypharmacy is problematic, it highlights that these differences exist between populations which is concerning and warrants further investigation.
Areas of interest
The NOR calls for research to understand the links between overprescribing, deprivation, ethnicity, age and inequalities and the impact these have on the health of the population and how this can be addressed. The NIHR Health and Social Care Delivery Research (HSDR) Programme is inviting applications to address this research need.
Any research focused on the broad area of overprescribing and inequalities, in relation to the remit of the HSDR programme (organisation and quality of services), is welcome. This might focus on particular at-risk groups, as well as looking at the intersection of disadvantage, for instance, older people from minority ethnic groups living in deprived communities. It may also focus on times, or points, of vulnerability, such as, transition from hospital to community or in the last year of life. Areas of interest are broad, including the evaluation of interventions to review and manage multiple medicines, outreach services, shared decision-making schemes and new staff roles.
Applications addressing other research recommendations set out in the NOR, or related to overprescribing more generally, can be submitted through the researcher-led workstreams of any of the NIHR programmes.
Relevant NIHR studies
An example of some related studies the HSDR Programme has funded in this area include:
- Evaluation of prescribing interventions with hard to reach groups
- Managing medicines for patients with serious illness being cared for at home
- How, when and why do STOPP/START criteria based interventions improve medicines management for older people: a realist synthesis
- Alternatives to prescribing
- Medicines optimisation in care homes
- Improving Medicines use in People with Polypharmacy in Primary Care (IMPPP)
- Cluster randomised trial to improve antibiotic prescribing in primary care: individualised knowledge support during consultation for general practitioners and patients
- Safety of reducing antibiotic prescribing in primary care. New evidence from electronic health records
- Does better quality of primary care influence admissions and health outcomes for people with serious mental illness (SMI)? A linked patient-level analysis of the full patient care pathway
- Accessing medicines at end-of-life: a multi-stakeholder, mixed method evaluation of service provision
We recommend prospective applicants refer to the NIHR funding and awards website to ensure that they do not duplicate the existing evidence base or overlap with ongoing research funded by the NIHR, as well as by other funders. A list of further research NIHR has funded in this area can be made available upon request, please contact; firstname.lastname@example.org.
Equality, diversity and inclusion
The NIHR is committed to actively and openly supporting and promoting equality, diversity and inclusion (EDI). All NIHR applications need to demonstrate that they have met the requirements of the Equality Act (2010) by embedding EDI throughout their research proposal, ensuring that there is no discrimination across the following domains:
- race (including colour, nationality, ethnic or national origin)
- religion or belief
- sex; sexual orientation
- gender reassignment
- being married or in a civil partnership
- being pregnant or on maternity leave.
Applicants are expected to pay attention to populations that have been underserved, to conduct research in locations where the need is greatest, and to promote the inclusion of diverse participants.
The HSDR Programme supports applied research with the aim of improving both health and social care services across the nation and is open to any appropriate methodology to answer the proposed research question; this must be fully explained and justified. In order to enhance the success of a proposal, a clear theory of change and pathway to impact, with links into the NHS and social care services delivery process, is suggested. It is useful to consider in the research study design how outcomes could be scaled up to maximise impact and value for money across the NHS and social care services – the focus is on applied research with tangible impacts that improve the quality, accessibility and organisation of health and social care services. This includes stakeholder engagement and the development of processes, tools and guidelines to strengthen workforce capacity. Further general information is available about the HSDR Programme can be found here.
Research proposals should be co-produced with national organisations, professional bodies, health and social care service professionals, and service users. Links with health and social care planners and professional bodies are required to ensure impact and scaling up of research findings to benefit the wider health and social care system.
The COVID-19 pandemic is having a significant impact across the health and social care system. As this research may be conducted during the COVID-19 response and recovery period, applicants should consider how the impact of the COVID-19 response and recovery may affect the deliverability of their research.