THE SCALE OF THE CHALLENGE
Polypharmacy, usually defined as the ongoing use of ≥4 medicines by one person, presents one of the most pressing primary care challenges of our time. This simple definition conceals much of the complexity that the concept evokes in the mind of the GP. Polypharmacy is not a new challenge for general practice, but the scale and complexity of the challenge is increasing. One Scottish study showed that about 20% of adults are dispensed ≥5 drugs (this has doubled since 1995) and about 6% of adults are dispensed ≥10 drugs (this has tripled since 1995).1 The use of 10 drugs is regarded as a pragmatic indicator of ‘high risk’ prescribing and we should all be concerned by the rising prevalence of this phenomenon, especially in the context that 10% of hospital admissions among older adults are attributed to adverse drug reactions. Polypharmacy is costly to the NHS, wasteful (50% of medicines prescribed for long-term conditions are not used), and prone to error. According to the PRACtICe study,2 errors arise in 5% of prescription items in general practice. Although these are mostly errors of mild to moderate severity, one in 550 of these errors has the potential to cause severe harm. Given the scale of prescribing it is clearly an important area in which to improve care.
FACTORS DRIVING POLYPHARMACY
There are many factors driving polypharmacy. At best polypharmacy may be a necessary response to shifting demographics and a rising, ageing population of patients with multimorbidities; above the age of 65 years multimorbidity is the norm. At worst, polypharmacy is an example of medical overactivity and iatrogenic harm. It arises in the context of a market-driven approach to health, focused on disease-specific, measurable standards, incentives, and an insatiable desire to eliminate …