Structured Medication Reviews in England

RPS Position Statement

Key Point Summary

• There is a strong evidence base for the clinical and economic impact of pharmacists conducting Structured Medication Reviews (SMRs) in primary care
• Pharmacists are well placed to support appropriate medication use in collaboration with patients and to reduce the potential for harm from problematic polypharmacy
• NHS England has provided investment in training and recruiting pharmacists to work in Primary Care Networks (PCN) to support the delivery of SMRs
• The Royal Pharmaceutical Society is concerned that the focus of the pharmacy workforce in Primary Care is moving away from the delivery of SMRs in practice
• The Royal Pharmaceutical Society would welcome more transparency around SMR uptake and delivery at a PCN and ICS level, to ensure the pharmacy workforce is supported and empowered to deliver this important medicines optimisation service for patients.

Background

In 2022/23 there were 1.18 billion prescribed medicines dispensed in the community in England, with this number increasing every yearⁱ. Complexity of patient care is increasing with an ageing population and more people living longer with multiple health conditions and taking multiple medicines. A third of people aged 65 or older take five or more regular medications, described as polypharmacyⁱⁱ. There are over one million people who receive ten or more regular medicines, and almost half of these are aged 75 and overⁱⁱⁱ.

Polypharmacy can become problematic and cause a significant, but avoidable, harm to patientsiv. It can result in the use of medicines that are no longer clinically indicated, appropriate or optimised for that person or where the benefit of a particular medicine or medicines does not outweigh the harm. A recent study has shown that 16.5% of unplanned hospital admissions are related to adverse drug reactions, with polypharmacy and comorbidity as key contributory factors^v.

One suggested approach to address problematic polypharmacy has been to use structured medication reviews (SMR). The NHS Long Term Plan (2019) set out the ambition of clinical pharmacists working in primary care networks (PCN)^vi. All clinical pharmacists were required to undertake additional clinical training and work to deliver appropriate structured medication reviews, improve medicine safety, support care homes, and run practice clinics.  

What is an SMR?

An SMR has been defined by NICE as a structured, holistic, and personalised review of an individual who is at risk of harm or medicines-related problems because of their current medicine regimen^vii.

The research literature shows that structured medication reviews are best delivered by a multidisciplinary approach coupled with shared-decision making, involving patients, to identify and manage or stop inappropriate medications^viii,ix,x,xi.

Pharmacists have the underpinning knowledge of medications and the skills to support this. A recent realist review of person-centred medication review and deprescribing in older people highlighted the role that pharmacists can play in supporting continuity of care and the development of trust that is often needed to support successful deprescribing^xii,xiii.

The role of pharmacists was further recognised in the Chief Medical Officers 2023 report: “As leaders in medicines optimisation, they reduce the risk of polypharmacy and support the safe and effective use of medicines to enable the best possible outcomes” ^xiv.

What are the contractual requirements?

SMRs were introduced as part of the 2020/21 Network Contract Direct Enhanced Service (DES) specification for PCNs. PCNs began offering SMRs to key, priority groups of patients from October 2020. These included: patients living in care homes; those with complex and problematic polypharmacy taking ten or more medicines; patients with severe frailty at risk of hospital admission and/or falls; patients at risk of harm due to medication errors; and patients prescribed potentially addictive medicines such as opioids, gabapentinoids, benzodiazepines and z-drugs.

The National Over-Prescribing Review (2021) made a clear recommendation (Recommendation 8) for NHS England to further expand the use of SMRs in PCNs to benefit patients at risk of overprescribing, with resources to support practice teams. It recommended that appointments be long enough to allow for shared decision-making – typically at least 30 minutes – and social prescribing link workers should be trained to help support patients after a SMR^xv.

Financial incentivisation

Alongside the DES, the Investment and Impact Fund (IIF) was introduced as an income stream for PCNs. In 2020/21 the IIF included a series of indicators focussed on improved prescribing to reduce medicines-related harm. In 2022/23 further indicators were introduced increasing the total value of the IIF scheme to £223 million. This included 9 SMR indicators to reward PCNs for high rates of SMR delivery for the primary target patient cohorts.

In 2023/24 the IIF scheme was reduced from 36 indicators to five and in 2024/25 the number of IIF indicators reduced further from five to two.

However, the expectation for the delivery of SMRs continues in the associated guidance and remains part of the Network Contract DES^xvi.

Building the Workforce to Deliver SMRs

Expanding the number of pharmacists working within primary care has been a key pillar of this strategy by providing a workforce to deliver SMRs.  As a result, PCNs were required to maximise the capacity of the clinical pharmacists employed within the PCN to be able to deliver SMRs. Individuals had to be qualified as a prescriber or enrolled on a current training pathway.  A total of 5,675 learners have completed a pathway delivered by the Centre for Pharmacy Postgraduate Education (CPPE) since 2016^xvii.

PCNs have been able to claim funding for pharmacists under the Additional Roles Reimbursement Scheme (ARRS)^xviii, which, since its introduction in 2019 as part of a five-year GP contract, has provided an incentive to increase the number of pharmacists working directly with General Practice. Between 2019/2020 and 2021/2022 the ARRS scheme allocated £387m to fund pharmacists in General Practice^xix.

Between September 2021 and December 2023, the number of FTE pharmacists working in primary care increased by 24.5% to 6,874, and there are now 707 advanced pharmacist practitioners working in this sector. Of these, about 5,000 were funded through ARRS routes. The number of pharmacy technicians working with pharmacy teams has also increased by 40.4% to 2,292^xx.

Delivery of SMRs

NHS England publishes monthly data capturing the type and number of appointments on GP practice and PCN appointment systems. In September 2021, 0.6% of appointments (of a total 29 million) were coded as SMR, on average, across England. In December 2023, this increased slightly to 0.9% of a total 26 million appointments that month^xxi.

The data are limited to the activity coded, which relies on individual user input, and may not represent all work happening or the quality of the SMR, nor the complexity or specific patient groups.

A recent analysis of medication reviews which extracted data from primary care records, identified nine individual SNOMED codes being used for medication reviews. The most used code was “medication review done” (59.5%), whilst SMR only accounted for 3.6% of consultations^xxii. There is therefore much more work to be done to improve the accuracy of reporting of SMR activity.

Evidence and impact of pharmacist-led medication reviews on patient care

Implementing Stimulating Innovation in the Management of Polypharmacy and Adherence Through the Years (iSIMPATHY) was a three-and-a-half-year European Union funded project and managed by the Special EU Programme Body in Northern Ireland, Scotland and the Republic of Ireland^xxiii. The project aims were to ensure the most sustainable use of medicines for patients by training pharmacists and other healthcare professionals to deliver person-centred medicines reviews and embedding a shared decision-making approach to managing polypharmacy.  

Over 6,400 patients were reviewed, with an average age of 72 and diagnoses of six long-term conditions.  The project pharmacists made an average of 11 interventions per review which included patient education, medicines reconciliation, medication changes and monitoring. 78% were graded clinically significant interventions (Eadon grading). In an economic analysis, there were 8.1 avoidable inpatient bed-days per 100 reviews and 0.9 avoidable adverse drug reaction admissions per 100 reviews.  The study also demonstrated cost-effectiveness^xxiv.

Patient feedback was collected via Patient Reported Outcome Measures (PROMs) questionnaires. 86% of the respondents reported not having had a previous medicines review. Benefits noted included improved understanding of their medicines, reduced side effects and 95% said all or most of their views and concerns were considered.

In a more recent realist review and synthesis, 28 papers were analysed (including ten randomised controlled trials) involving people aged 65 years and older who lived at home.  The project team found that deprescribing is most successful when pharmacists lead structured medication reviews, in collaboration with GPs and other healthcare professionalsxi.

Structured medication reviews are also essential in a care home setting. Evidence from the Shine project, funded by the Health Foundation, demonstrated that a medication review service in care homes helped to reduce inappropriate polypharmacy. Across 20 care homes, 422 patients were reviewed and 70.6% had at least one medicine stopped with 704 medicines being stopped overall. This represented 19.5% of the medicines originally prescribed (3602 medicines)^xxv.

Opportunities

Pharmacists and wider pharmacy teams have an essential role to play in supporting patients with to get the most from their medicines. As the initial education and training of the pharmacy profession is changing, there will be an increase in the number of pharmacist prescribers, as well as an increase in the number of advanced practitioners. With adequate focus there is an opportunity for this emerging workforce to prioritise the care delivery of patients with long-term conditions and those at risk of harm from multiple medicines.

The Chief Medical Officer’s Report Health in an ageing Society (2023) also highlights the key role pharmacists have in the care of older adults, to reduce the risk of polypharmacy and support safe and effective use of medicines^xii. Community pharmacists are also an important regular point of contact for patients with long-term conditions and may work in collaboration with their PCN colleagues.

The RPS is concerned that the focus of the pharmacy workforce in Primary Care is moving away from the delivery of these important medication reviews.

The 2024/25 Network Contract DES asks PCNs to detail the measures they will take to improve medicines optimisation including SMRs. Whilst we welcome the inclusion of high-risk patient cohorts in the accompanying guidance, we are concerned that this is non-contractual and may be missed or de-prioritised by hard working practices.

The impact of SMRs on improving patients' understanding of medicines and safety, reducing unnecessary prescribing and health care costs is understood. Gathering further evidence to quantify the impact on patient outcomes should not be a barrier to the continued delivery and expansion of SMRs in primary care.

We believe it is essential for patients that there remains a continued focus on the delivery of Structure Medication Reviews (SMRs) by pharmacy teams within Primary Care Networks.  

Recommendations

Against this background, the RPS recommends that:

• Primary Care Networks must recognise that medicines optimisation and SMRs, remain a part of the core PCN contract and they are accountable for their delivery. PCN Pharmacy teams should be enabled to prioritise SMR activity in the highest risk patients
• SMR uptake and delivery should be monitored and reviewed regularly at ICS and PCN level. This activity and monitoring should particularly focus on the patient cohorts highlighted in the guidance published alongside the Network Contract DES (for example, those in care homes, those taking ten or more medicines, or those taking specific higher-risk medications)
• Efforts should be made to improve the quality and accuracy of the coding and structure of SMRs to support benchmarking and evaluation possibly via local Population Health Management Dashboards
• Further patient outcome orientated research should be funded to measure and evaluate the value of SMRs in England.