Harnessing behavioural science to tackle overprescribing
By Debi Bhattacharya, Professor of Behavioural Medicine, University of Leicester / CHARMER Co-Chief Investigator
In October 2022, I delivered a talk at the Westminster Health Forum about how we can harness behavioural science to tackle overprescribing in the NHS. Here’s a summary of the key messages from the talk:
1. Overprescribing should be addressed during a hospital admission
The NHS National Overprescribing Review Report quite rightly focuses on primary care as this is where the majority of prescribing occurs. Yet 99.8% of patients and carers want doctors to initiate deprescribing discussions in hospital.
Currently half of older people are prescribed a medicine with a safety risk. The CHARMER team’s previous research found that these medicines are rarely stopped; less than 1% of hospital admission medication is proactively deprescribed. The CHARMER programme aims to develop and test a behaviour change intervention for hospital doctors and pharmacists to encourage proactive deprescribing.
2. Key stakeholders need to be involved in the development of deprescribing interventions
Existing deprescribing interventions have demonstrated marginal increases in deprescribing activity that are not sustained beyond the trial period. This can be partly attributed to how these interventions are developed and designed.
The CHARMER team’s previous research with geriatricians and pharmacists working with older adults identified what things help and what things hinder them from proactively deprescribing medicines in hospital. The team also worked with them to identify and decide on what strategies would help to address these things and support proactive deprescribing. These strategies are called ‘Behaviour Change Techniques’ and are the active ingredients that are responsible for bringing about change. In other words, the CHARMER intervention has been designed in collaboration with the people who will deliver and receive the intervention.
3. Deprescribing interventions need to be supported by behaviour change theory
While stakeholder engagement is essential for achieving behaviour change, purely focussing on what people think they need to deliver the change often fails to address all barriers and enablers. Staff commonly cite the need for extra resource as the solution. However, given extra resource such as time and workforce, staff will often increase existing activities with which they are familiar and have a known pathway of recognition rather than undertake the desired new behaviour. Another commonly delivered ‘solution’ to effect a change in practice is education and training. Whilst having the required knowledge and skills is clearly essential, behaviour change is rarely achieved by addressing only these barriers/enablers.
Asking staff what help they think they need places the onus on them to correctly identify their barriers and enablers to undertaking the desired behaviour and then select the most appropriate solutions. The field of behavioural science has offered a scientific approach to garner more meaningful input from stakeholders to shape the development of strategies (or Behaviour Change Techniques) to support implementation of a new behaviour. In CHARMER, we have worked with geriatricians and pharmacists to select and design strategies that are likely to be acceptable to everyone, affordable for NHS organisations and that will not introduce inequity.
Combining research evidence, behaviour change theory and collaborative design methods increases the likelihood that deprescribing activity resulting from the CHARMER intervention will be sustained beyond the trial period.