Early implementation of structured medication reviews (SMRs) by pharmacists working in general practice is being undermined by a lack of skills and supervision, researchers have concluded.
A series of interviews with 20 pharmacists — 10 newly appointed primary care network (PCN) pharmacists and 10 pharmacists already established in general practice — found that SMRs were not yet a priority and were largely delegated to individual pharmacists to implement in busy GP practices.
Responses showed that, as a result, most of the newly appointed pharmacists said they relied on their previous experience, including what the researchers called “the target driven incentives of corporate community pharmacy”, meaning activity was being put before improving patient outcomes.
PCNs had been expected to start offering SMRs through their pharmacy teams from April 2020, but their introduction was delayed until October 2020 owing to the COVID-19 pandemic. The reviews are intended to address problematic polypharmacy and reduce avoidable hospital admissions.
However, the researchers, who reported their findings in the British Journal of General Practice on 20 April 2022, concluded that the current roll out was setting “unhelpful precedents”. They added: “Early SMR implementation did not therefore match the ideal for patients presented in policy documents of an invited, holistic, shared-decision-making opportunity offered by prescribing pharmacists, experienced in history taking.”
The researchers also found that the purpose of the SMR service risked being undermined by clinical pharmacists having to be reactive to the needs of individual practices as they grappled with workforce and pandemic pressures.
“At this early stage of implementation, SMR practice outside care homes appears to have largely developed by fulfilling a variety of routine medicines tasks in response to backlogs,” the researchers said.
They called on GPs implementing pharmacist-run SMRs to clarify the “distinct purposes” for their practice population and recognise that pharmacists will require additional supervision to develop the skills needed.
Graham Stretch, chief pharmacist at Argyle Health Group and clinical director at Brentworth PCN, said the problem was that pharmacists were being required to deliver a service for which they have not yet been fully trained.
“Pharmacists absolutely want to be doing this and we should absolutely be training our pharmacists to do this but it is too much too soon,” he said.
“This is a relatively immature workforce. And there has also been a lot of misunderstanding about what an SMR is and I don’t think we have done a good job of communicating how it differs from a medication review,” he added.
The skills needed to carry out an SMR in complex patients require a lot of experience, supervision has been variable and there are not enough senior pharmacists to help mentor and train those coming through, he said.
“The difficulty is, if you don’t deliver the SMR with the required rigour, the output will be inferior. We are being set up to fail because we don’t yet have the workforce.”