Less is more: the struggle to prioritise structured medication reviews

“There was very much a conversation of, ‘we’re not being incentivised to prioritise structured medication reviews (SMRs), so pharmacists can be tasked with doing transfer of care and discharges’,” explains a primary care network (PCN) pharmacist based in south east England, who has requested not to be named to avoid repercussions from their employer.

SMRs were introduced to primary care teams in England in October 2020 (see Box), with priority given to high-risk patients, which includes people diagnosed with frailty or living in care homes, people with complex polypharmacy or taking medicines commonly associated with medication errors, and anyone using potentially addictive pain management medicines^​1​.

However, after NHS England removed financial incentives for PCNs to carry out SMRs from the Impact and Investment Fund (IIF) in April 2023, pharmacists have been told to deprioritise SMRs. 

The PCN pharmacist we spoke to explains that financial struggles within general practice, compounded by challenges with GP recruitment, mean that GP pharmacists are having to take on more duties, leaving management of chronic medicines to take a back seat.

“The number of [SMR] clinic slots went down to quite a lot less [following removal of the financial incentive]. Our operations managers will say, ‘We don’t need to do SMRs because we’ve got this backlog of [clinic] letters that you need to see’,” the PCN pharmacist explains. 

“It got to the point where the nine to five, Monday to Friday, 90% of the time, pharmacists were given other day-to-day tasks, which were plenty to keep us going.” 

In March 2024, NHS England data on appointments in general practice, an experimental dataset that comes from the appointments system, indicated an increase in SMR appointments from 2.5 million in 2022/2023 to 2.9 million in 2023/2024 (up to and including February 2024)^​2​.

However, according to Tony Avery, national clinical director for prescribing in England, there is no single authoritative source of data on the total number of SMRs conducted.

Speaking at the Clinical Pharmacy Congress (CPC) in London on 11 May 2024, Avery presented Network Contract Directed Enhanced Service (DES) data — which come from clinical codes within the patient record in the GP system —suggesting the total number of SMRs carried out in primary care across England has decreased from 2.7 million in 2022/2023 to 2.0 million in 2023/2024^​3​. 

According to NHS England, the discrepancy between the two datasets could be attributed to several reasons, including incorrect clinical coding, incorrect categorisation of appointments and variation in practice participation.

Among the priority cohorts outlined by the IIF, DES data indicate the proportion of patients who received an SMR has also significantly dropped in 2023/2024 from the previous year, with a 27 percentage point decline in patients at risk of harm owing to medication errors (see Figure)^​3​.

Clare Howard, clinical lead for the Health Innovation Network (HIN) polypharmacy programme, says the reduction in the proportion of patients in priority groups receiving SMRs is “very concerning” particularly in those “practices that are more in financial straits”.

“In the PCN DES, it very clearly says, ‘these are the patients that the pharmacists should be seeing’ — that has not changed. 

“[But] now that the financial incentive is gone: there are some practices that have taken that as a signal, [to say] ‘we don’t need to do these anymore. You don’t need half an hour, we’ll give you 12 minutes if you want to see some of these patients, but what we really want you to do is some other stuff’. That’s problematic because these patients — they’re high risk of going into hospital,” she adds.

Brendon Jiang, senior clinical pharmacist for North Oxfordshire Rural Alliance PCN, shares Howard’s concerns, describing it as a “real missed opportunity” to improve patient outcomes.

“SMRs have always been a core requirement of the PCN DES and delivery naturally lies within the skillset of pharmacists as experts in medicines.

“When SMRs were incentivised, there was a huge focus on delivery. Without that ‘financial carrot’, the focus has drifted to other areas and that is reflected in fewer recorded numbers.

“The concern is that the difference between the delivery last year and the delivery this year will translate into missed opportunities for helping patients to stay out of hospital,” states Jiang.

The PCN pharmacist says that, although they are “not a massive fan” of the financial drivers, “it does seem to be how things get prioritised”. 

Evidence for structured medication reviews 

One way of “selling” SMRs to PCN directors would be via data that show the benefits, says the PCN pharmacist. “Not just case-by-case examples — we need the numbers and the data to show that SMRs really benefit our patients,” they add.

However, Matthew Boyd, professor of medicines safety at University of Nottingham, points out that the impact of SMRs on an individual patient level is “incredibly hard to measure”.

“SMRs have different value depending on the patient, the disease, the medicines [and] the complexities. 

“It would be like saying, compare the success of cardiology versus thoracic surgery — it’s chalk and cheese. So sometimes, it’s not necessarily appropriate to make those comparisons,” he adds.

However, Boyd explains that SMRs have a population benefit.

“[For example], antihypertensives: if you improve adherence over the whole population, you will gain population-level benefit. You may not see a direct translation into things like hospital admissions, but you might see changes in quality-of-life measurements.

“This might not be directly health-related costs, but might be health and social care related costs, [such as] reduced sickness days … or reduced falls,” says Boyd.

There are studies that show the impact of polypharmacy on the NHS. According to an observational study of 1,187 hospital admissions conducted in England, published by The BMJ in June 2022, adverse drug reactions (ADRs) accounted for 16.5% of total admissions, 40.4% of which were classified as ‘avoidable’ or ‘possibly avoidable’^​6​. Those with an ADR were on average taking more medicines than those without an ADR (10.5 vs 7.8; P<0.01).

Researchers concluded that ADR admissions projected an annual cost of £2.21bn to the NHS in England and advised that “reducing inappropriate polypharmacy should be a major aim for preventing ADRs”.

In January 2017, a retrospective analysis of 422 care home residents across 20 care homes in north east England found that SMRs can reduce the number of medicines taken by around 19.5%^​7​. 

The benefits of SMRs are further supported by the ‘Implementing Stimulating Innovation in the Management of Polypharmacy and Adherence Through the Years’ (iSIMPATHY) evaluation report, which was published in December 2023^​8​.

The 3.5-year, EU-funded project involved delivery of pharmacist-led medication reviews to 6,481 patients across Northern Ireland, Scotland and the Republic of Ireland. 

An analysis of economic costs determined that — on average — 100 polypharmacy reviews resulted in £13,100 in direct savings associated with medicines changes, £6,600 in indirect savings from reduced ADR-related hospital admissions (inpatient costs), and a 7.4 ‘quality-adjusted life year’ gain, totalling an average of £168,000 in avoided medical costs. 

The report also revealed large improvements in patients’ understanding of their medicines, with more than 90% of patients reporting post review that they fully understood their medicines and associated risk, compared with 16% before their review. The number of ADRs reported by patients also reduced from 64% to 38% post-review.

Speaking at the CPC, Avery acknowledged the “real benefits” of the iSYMPATHY project and said that everyone should be “promoting this incredibly important intervention for patients”.

However, he added: “One of the key challenges for us is often confidence. A lot of this work [is] off-piste — there’s not a protocol to tell you exactly what to do in each different situation and I think giving us [the GPs and pharmacists] some of the confidence to help make those decisions is important.”

Improving delivery 

Training pharmacists on how to conduct effective SMRs is part of HIN’s polypharmacy programme, which was launched across England in April 2022. Led by Howard, the programme is aimed at addressing problematic polypharmacy by upskilling the primary care workforce and improving patients’ understanding of their medicines.

The programme is made up of three pillars — population health management, education and training, and public behaviour change — and includes a series of national webinars, action learning sets and masterclasses to support GPs, pharmacists and other healthcare professionals.

 “We’ve trained over 1,000, GPs and pharmacists in the last five years [since the pilot in 2018],” she says. 

“We bring geriatricians into the training… I spend a lot of my time with people working in PCNs, talking to them about how to do really good SMRs, to really think about what’s important to older, frail patients where medicines may no longer be the answer, [and] may be causing harm.”

Another way to improve delivery of SMRs is to ensure that patients understand their value. The third pillar of HIN’s polypharmacy programme is focused on increasing public understanding of polypharmacy and encourages patients to open up about their medicines, through campaigns such as ‘Me + My Medicines’ and ‘Are Your Medicines Working For You?’.

Since the national roll-out of pillar 3 of the programme in September 2023, the Me + My Medicines campaign documents and leaflets are now available to patients in 12 different languages — Arabic, Bengali, Chinese Cantonese, Chinese Mandarin, Gujarati, English, Polish, Punjabi Gurmukhi, Punjabi Shahmukhi, Romanian, Somalian and Urdu — with each including a QR code that leads to an audio version of the document in their chosen language as well as ‘easy read’ versions for those with learning disabilities.

Lawrence Brad, former NHS GP partner, says an important part of the campaign is patients’ understanding of what SMRs are.

“There’s always been this slight problem: the brand. Do patients understand what an SMR is, and what on earth are they being called in for?” he asks. 

Once the understanding is there, “it allows you to push a bit more on an open door, rather than patients being a bit resistant or suspicious about it,” Brad explains. 

“[For] any clinician when any patient presents with a clinical complaint, if they’ve not had anybody look at the load of polypharmacy, you’re immediately starting on the backfoot.

“We’re just in that transition where patients are beginning to get the hang of what this is and why it’s useful,” he adds.

On 23 July 2024, the Royal Pharmaceutical Society (RPS) expressed concern that the primary care workforce is moving away from the delivery of SMRs in practice and published a position statement and set of recommendations to address this. 

The recommendations state that PCNs “must recognise that medicines optimisation and SMRs remain a part of the core PCN contract and they are accountable for their delivery”, adding that “PCN pharmacy teams should be enabled to prioritise SMR activity in the highest risk patients”. 

The position statement also calls for further efforts to improve accurate coding of SMRs and further patient-outcome-orientated research to measure and evaluate the value of SMRs in England. 

Jiang, who is vice-chair of the RPS English Pharmacy Board, explains that the RPS has seen an increase in patient safety issues that could have been mitigated had the patients had an SMR.

He adds: “This is a good time to try and influence or change practice ahead of the new contract discussions for April 2025.

“Polypharmacy can potentially cause significant harm and it is vital that pharmacists can maximise their role in helping patients to get the most from their medicines and reducing avoidable hospital admissions.”

While an uptick in SMR numbers is unlikely to be seen overnight, the message about their importance for mitigating inappropriate polypharmacy is beginning to gain momentum. 

Avery emphasised this point during his presentation at the CPC: “Tackling polypharmacy is an important challenge for us and — from my perspective — SMRs are the key way in which we can deliver that.”