Structured Medicine Reviews (SMRs) are an evidence-based and comprehensive review of a patient’s medication, taking into consideration all aspects of their health. In a structured medication review clinicians and patients work as equal partners to understand the balance between the benefits and risks of and alternatives of taking medicines. The shared decision-making conversation being led by the patient’s individual needs, preferences and circumstances.
Problematic polypharmacy is where, for an individual taking multiple medicines, the potential for harm outweighs any benefits from the medicines and/or they do not fully understand the implications of the medication regime they are taking. This includes:
- medicines that are no longer clinically indicated or appropriate or optimised for that person
- combination of multiple medicines has the potential to, or is actually causing harm to the person
- practicalities of using the medicines become unmanageable or are causing harm or distress.
SMRs have benefits to people taking multiple medicines:
- improved experience and quality of care through being involved in the decision-making process and having a better understanding of the medicines they take
- less risk of harm from medicines (e.g. adverse drug events, side effects, hospitalisation or addiction)
- better value for local health systems (e.g. reduced medicine waste).
Role for primary care networks
Across England, general practices are working together with community, mental health, social care, pharmacy, hospital and voluntary services in their local areas in primary care networks (PCNs). Professionals are working together to support patients with structured medication reviews as one of the PCN service requirements which commenced during 2020/21.
Undertaking a SMR
From October 2020, all PCNs are required to identify patients who would benefit from a SMR, specifically those:
- in care homes;
- with complex and problematic polypharmacy, specifically those on 10 or more medications;
- on medicines commonly associated with medication errors;
- with severe frailty, who are particularly isolated or housebound or who have had recent hospital admissions and/or falls;
- using potentially addictive pain management medication.
The number of patients to be offered a SMR will depend upon the PCN’s clinical pharmacist capacity. Further information on the expectations of PCNs and more detailed clinical guidance, for example from the Royal Pharmaceutical Society and NHS Scotland can be found in the Network Contract DES SMR guidance.
Key components of a SMR
- Shared decision-making principles should underpin the conversation
- Personalised approach – tailored to the patient
- Safety – consider the balance of benefit and risk of current treatment and starting new medicines
- Effectiveness – all medication must be effective, except where explicitly permitted in guidelines on low priority prescribing.
Working in partnership across a PCN
It is expected that clinical pharmacists working in primary care will lead on and undertake SMRs across PCNs. Given the complexity of some of the cases, a multidisciplinary approach will be essential across the wider PCN team (e.g. a GP and/or social prescribing link worker) supporting the SMR process and follow up. PCN teams should be working with NHS acute, community and mental health trusts and experts (e.g. consultant geriatricians, behavioural therapists and specialist pharmacists) to support their SMRs. For specific conditions where new medicines are started (e.g. asthma, COPD, type 2 diabetes, hypertension and those started on blood thinning medicines), community pharmacists can follow up patients using the new medicines service.
Wider Medicines Optimisation
The NHS Long Term Plan sets out the aims for medicines optimisation to reduce inappropriate prescribing, including:
- medicines that can cause dependency
- higher-carbon inhalers; and
- nationally identified medicines of low priority.
To help achieve these outcomes longer-term, alongside SMRs, PCNs must actively work with their clinical commissioning group (CCG) and at integrated care system (ICS)/sustainability and transformation partnerships (STP) level, to share expertise and lessons learned: for example, to integrate national-level programmes, such as the AMR action plan and STOMP (stopping over medication of people with a learning disability, autism or both with psychotropic medicines) set out in the NHS Long Term Plan, into their local implementation of SMRs, medicines optimisation and related work. Open data, e.g. OpenPrescribing, can further support this work.
Example of PCNs delivering SMRs
- This case study describes how care is being delivered in Staines, Ashford, Stanwell, Sunbury and Egham PCN, as well as how SMRs are already being implemented.
If you have any questions about SMRs, contact the team at firstname.lastname@example.org