Medicines Safety: Reducing harm from psychotropics
Whole-system approach reducing harm from psychotropics in people with learning disabilities
in 2025-26
Identified success and gaps in service provision through 14 insight sessions with system stakeholders and surveying over 30 social care providers
Involved and engaged service users and support workers and integrated insights from people with lived experience
The challenge
Psychotropic medications can often have side effects and may negatively affect a person’s quality of life. They should only be used when there is a clear clinical indication.
NHS England has estimated that the possible avoidable harms from psychotropic use are significant. For every three people with a learning disability and behaviour that challenges who are prescribed an antipsychotic for more than three months, one will develop a movement disorder that would not have occurred if all three had been supported without antipsychotics.
For every two people prescribed any psychotropic medication, one will experience side effects that significantly reduce their quality of life – effects that could have been avoided through non-drug support.
Behaviour that challenges is not a diagnosis. It describes a range of behaviours some people with a learning disability may display when they are distressed or when their needs are not being met.
Where possible, psychotropic medicines should be avoided for behaviour that challenges or distressed behaviour. When medication is needed, it should be prescribed at the lowest effective dose, reviewed regularly, and stopped as soon as appropriate.
The solution
In 2025-26 the Medicines Safety Improvement Programme focused on reducing harm from psychotropics used to manage behaviour that challenges in people with a learning disability, and on supporting systems to establish personalised, non-pharmacological support tailored to individual needs.
The key principles of this programme include the importance of proactive care planning and shared decision-making with patients, carers, and advocates. Management should incorporate holistic, non-pharmacological approaches to reduce overprescribing and the avoidable harm associated with these medications.
It is essential to work across the whole system to enable joined-up, person-centred care. This includes improving access to the right support across an individual’s entire care pathway. One of the ongoing challenges is balancing short- and long-term health needs, especially when concerns about destabilisation are combined with limited access to non-pharmacological support such as sensory integration or lifestyle-based interventions.
Our work in partnership
Health Innovation South West is one of 15 health innovation networks working in partnership with Integrated Care Systems across England to implement this programme.
We are supporting a systems approach to this work, bringing together NHS providers, social care, the voluntary sector and people with lived experience across our region, supporting local teams and identifying opportunities to scale what works. Our shared aim is to improve safety, reduce harm, and ensure people receive the right support at the right time.
In 2025-26, through a process of in-depth system mapping with key system stakeholders in Devon and Cornwall, we gathered and collated information on the levels of care provided to people with a learning disability who may be prescribed psychotropic medications off label. We assessed the challenges and opportunities in both general and specialist learning disability services.
Our impact
In 2025-26, we:
- Held 30 insight sessions with key system stakeholders across Devon and Cornwall to identify where services are working well, and where there are gaps in provision
- Surveyed over 30 social care professionals to identify where services are working well, and where there are gaps in provision
- Ensured patient and public involvement and engagement by holding safe, structured conversations with service users and support workers to gather insights on lived experience. These focused on people’s direct experience of taking psychotropic medications (and other medications)
- Identified emerging themes, gaps in care provision, and opportunities for development across the South West through system mapping.
All insights were reviewed to identify emerging themes, gaps in care and areas for development.
- Eight overarching themes were identified, including workforce, service and system integration, medicines reviews, lived experience, education / training, quality assurance, and resourcing.
- Challenges highlighted included variation in medication reviews and Annual Health Checks, high thresholds for accessing specialist care, a need for improved advocacy in care planning, a lack of clarity around medication changes, limited community alternatives, and financial and capacity pressures, alongside a changing commissioning landscape.
- A number of opportunities identified suggest areas for development. These include: improvements in shared care arrangements between primary and secondary care for anti-psychotic prescribing, harnessing peer networks for learning disability staff in primary care, the opportunity to improve the signposting to specialist support via existing education and training, and updated referral and information sharing processes in specialist community services.
What’s next?
Work is now underway to develop a whole system action plan for 2026-27.
Key area of focus will be on improving knowledge around psychotropic medication reviews and prescribing (for both professionals and service users), establishing clear processes for primary and secondary care colleagues to oversee a patient’s care, and increasing knowledge and awareness around holistic approaches to support an individual’s behavioural needs.
