Structured medication reviews and the primary care network multidisciplinary approach

Case study summary

The Structured Medication Review (SMR) and Medicines Optimisation service comes into effect from October 2020 as part of the PCN Contract Directed Enhanced Service (DES).

Nipa Patel has over 20 years’ experience of working in community pharmacy, general practice and clinical commissioning groups (CCGS). This case study describes how care is being delivered in SASSE2 PCN, as well as how SMRs are already being implemented.

Key benefits and outcomes of the SMR programme

  • Better care for patients by identifying medicines that can be stopped, dosages and/or frequency changed or where new medicines are needed.
  • Could avoid admission to hospital through unnecessary medicines related harm.
  • Reduces overprescribing of medicines and waste.
  • Integration of pharmacy within wider multi-disciplinary healthcare teams (including community and hospital pharmacy) and improved access to healthcare and outcomes for patients.
  • All PCNs should implement the programme in a way that maximises its potential to reduce health inequalities.

What the organisation is doing

Nipa started working for SASSE2 PCN and Ashford and St Peter’s Hospitals NHS Foundation Trust as a Senior PCN Clinical Pharmacist in April 2020. Her role sees her split her time between the GP practices and the acute trust. SASSE2 PCN covers approximately 39,000 patients across five practices.

From the beginning, the PCN team has been very receptive and included Nipa in their meetings from January 2020, prior to her taking up the role. The PCN Clinical Director Dr Amit Vasistha, and GPs, have encouraged Nipa to share her skillset and put forward ideas for new developments and improved patient care, many of which have been adopted by the PCN.

“Most practices in the network had no experience of having a clinical pharmacist working with them but have seen the positive benefits to patients and practice staff and are now keen to receive my input.” says Nipa.

To meet the demand for clinical pharmacy support within the PCN and embed the new ways of working outlined in the service specifications this year, two further full-time pharmacists are being recruited, funded by the Additional Roles Reimbursement Scheme. Along with Nipa, they will provide the focal point for delivering the DES plans, including the SMRs and care home support, in the PCN.

Due to the national challenges during COVID-19, Nipa is currently conducting SMRs via phone or video with patients and hopes to move to face-to-face consultations in the future. By assessing prescribing data whilst carrying out her SMRs, she is targeting patients with the highest risk to find out what is important to the patient about their care and then providing appreciated and tailored advice. For example, if a patient is seeking advice to reduce the number of medicines they take, Nipa will discuss the benefits and risks of each medicine and then agree any changes with the patient to ensure they are genuinely involved in decisions about their care.

One of the priority areas of work in the PCN is respiratory issues. Using SMRs, Nipa has been addressing the overuse of SABA inhalers, looking into the causes and discussing asthma action plans with patients, as well as looking at changing to low carbon inhalers. She also plans to review high dose ICS inhalers, as the number being prescribed by the PCN is above the CCG average.

Lifestyle advice is part of a SMR and Nipa has been helping diabetic patients improve their understanding of their condition and advising them on how to best control their diabetes. The SMRs also highlight any patients who have not received diabetic eye checks and ensure they are referred onto appropriate screening services.

Some of the SMRs have highlighted patients needing non-medical input and Nipa has recommended them for onward referral to the social prescriber in the PCN to support their practical and emotional needs. This helps to reduce some of the workload for GPs and is much more appropriate for the patient.

Her role working across the acute trust and the PCN will help with the discharge of patients from hospital care into the community.

“Soon I will spend part of my working week at the local acute trust supporting projects such as improving the linkages between primary and secondary care and discussing any common queries from GP practices with secondary care colleagues.” says Nipa.

Results and outcomes

The Clinical pharmacy support provided to GPs by the PCN is helping to build resilience and create a sustainable long-term model for delivery of services within practices. Nipa has been using SMRs to focus on the medicines patients are being prescribed and linking this to information about which patients are being admitted to hospital, so she can target her support to those patients who need it most.

“A key focus for me as a clinical pharmacist is to address any health inequalities in the PCN area, using prescribing data to see how each practice is doing and address variation. I am already sharing examples of best practice within the PCN, so we can raise the standard of care for all our patients.” explains Nipa.

Nipa spends time working with her multidisciplinary team colleagues such as GPs, nurses and practice staff to improve prescribing and use of medicines.

“The multi-disciplinary approach in the PCN also means we offer a greater range of community-based services to patients shared across the five practices, including access to social prescribers and mental health assessments with a community psychiatrist.”

Nipa has also developed close links with community pharmacy colleagues, setting up a regular communication process and working closely on introducing initiatives such as electronic repeat dispensing and the electronic prescription service phase 4.

Take away tips

  • Learn how GPs operate and how they are all individual and different. Share best practice among general practice teams.
  • Invest time in building genuine, long-lasting relationships with local practices, community pharmacies and other healthcare and community service professionals, including secondary care, taking time to understand their perspectives and issues.
  • Set up a network across the wider pharmacy team in the PCN to communicate regularly and share ideas and solve problems.
  • Be prepared to explain the role of the clinical pharmacist to other colleagues within a PCN and the value you can add.
  • Get to know your local population and identify their clinical needs. Set achievable goals where pharmacy can make a difference.

For more information please contact Nipa Patel MFRPSII, ACP Diploma: