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Barriers to de-prescribing

Considering the "4 P" barriers to de-prescribing (Permission, Prioritisation, Professional Skills and Confidence and Performance Management).
De-prescribing can help to reduce the burden and iatrogenic harm caused by inappropriate polypharmacy. Medicines optimisation looks at the value which medicines deliver, making sure they are clinically-effective and cost-effective. However, an expert generalists’ role goes beyond this, asking how does medicalisation of illness, including use of medication, help or hinder health for daily living. The goal is to tailor medication use to the needs and circumstances of the individual. What is considered “effective” for one person may not be the same for another. Tailored prescribing is based on a whole person assessment and negotiation of need, drawing on our roles as generalist gatekeepers. It helps us to avoid inappropriate medicalisation of illness and potentially problematic polypharmacy.
Tailored prescribing decisions may need us to offer ‘beyond protocol’ decisions about the potential value or harm of medicines. So what barriers might we face when approaching tailored de-prescribing? During weeks 1 and 2, we discussed the concept of the 4 Ps. First permission Should we tailor prescribing? Is it safe? Acceptable? Effective? Second prioritisation Whose role is tailored de-prescribing? Where would it fit in with everything else? Third professional skills and confidence Do I have the skills to work beyond protocol care? How do I gain and use these skills? Then fourth, performance management How do I know if I’ve done tailored prescribing well? What can I expect to see if I’ve done it properly?
Considering these 4 Ps, through the next part of this course, we’ll discuss the merits of tailored prescribing and the requirement for this to be prioritised. We’ll consider how application of tools such as the SAGE framework can support you when going beyond safe prescribing guidelines and reflect on how you can evaluate the effectiveness of your own tailored prescribing.

In this video, Dr Annabelle Machin will discuss the barriers to tailored de-prescribing we can face in our daily practice. In the following steps we will then consider safe management of beyond guidelines prescribing, supported by tools such as the SAGE Consultation Model.

Video reference

Reeve J, Britten N, Byng R, Fleming J, Heaton J, Krska J. Identifying enablers and barriers to individually tailored prescribing: a survey of healthcare professionals in the UK. BMC Fam Pract. 2018; 19 (17). DOI:

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