Structured medication reviews: progress since 2020 and opportunities for improvement

Structured medication review (SMR) is a service delivered by clinical pharmacists in primary care networks (PCNs) to replace a previous scheme, the medicine use review (MUR), conducted by community pharmacists but not considered cost-effective.^1,2 Despite nearly 4 years since SMRs were introduced, their uptake, quality, and impact remain unclear. This editorial explores the experiences and challenges pharmacists in England face as they implement SMRs, drawing on collective insights from a small group of GP pharmacists in Greater Manchester and Cambridgeshire. We also propose strategies to enhance SMR uptake and effectiveness, offering a pathway to better medication management and patient outcomes.

Structured medication review service

The SMR service was launched in October 2020 as an intervention to tackle the increasing polypharmacy, inappropriate prescribing, and medication-related deaths in the UK.^3,4 The NHS Long Term Plan considers SMRs to be crucial to optimise medication use in primary care, aimed at reducing inappropriate prescribing and enhancing patient care.⁵ With the increasing ageing population, multimorbidity and polypharmacy have become significant challenges, driving up health and social care costs.^6,7 While polypharmacy is sometimes necessary for managing multimorbidity, it requires regular review to ensure treatment effectiveness and safety.

Since the launch of the SMR policy, changes have been made, particularly regarding target populations and the required number of SMRs each PCN must deliver. The service now targets six specific groups:

1. residents in care homes;

2. individuals with learning disabilities;

3. those experiencing complex and problematic polypharmacy, especially those on ten or more medications;

4. patients on medicines commonly associated with medication errors;

5. individuals with severe frailty; and

6. patients using highly addictive medications, such as opioids, gabapentinoids, benzodiazepines, and Z-drugs.⁸

Initially, each PCN was tasked with delivering a set number of SMRs based on pharmacist capacity.⁹ Approaches varied, with some in Salford considering proportions, while others did not address the target. Competing priorities and unclear guidance on which patient groups to prioritise led to limited focus on SMRs. In April 2023, this requirement was removed, along with the associated incentive payments from NHS England’s Investment and Impact Fund.¹⁰ While this eased pressure on pharmacists, allowing for more thorough SMRs, it might pose a challenge. The removal of the target seemed to have an immediate impact: the Network Integrated Practice Pharmacy team in Salford (NIPPS), covering five PCNs, completed 6268 SMRs in 2023/2024, down by 918 from the previous year, despite no change in staffing levels (Bartlett J, unpublished data, 2024). This reduction could be due to some patients missing timely SMRs or a focus on prioritising more complex cases. Further research is imperative to understand the positive and negative impact of the policy change.

Resources for implementation

Pharmacist expertise

Pharmacists’ capability to conduct SMRs varies significantly based on their training, experience, and confidence. SMRs are in-depth reviews that involve shared decision-making conversations with patients, particularly when negotiating with them and reaching an agreement to taper down or discontinue medications. Confidence plays a critical role in these conversations. Currently, the Health Innovation Network’s national polypharmacy programme regularly supports healthcare professionals in identifying at-risk patients and improving conversations about medications.¹¹

With the removal of mandatory SMR targets for PCNs, pharmacist motivation has become crucial. Pharmacists’ confidence, prior experience, and understanding of SMRs’ benefits significantly influence their willingness to dedicate time and effort to these reviews. Additionally, the longer pharmacists work in the same practice, the stronger their relationships with patients become. This results in better communication and increases the chances of successful medication adjustments.¹²

Practice environment

Pharmacists’ capacity to perform SMRs also depends on the workload and working environment. Conducting SMRs requires careful review of medical profiles, identification of potential medication issues, and building patient trust to facilitate medication changes. The recommended minimum time for an SMR is 30 minutes,¹³ but this may be impractical given pharmacists’ workloads, especially in understaffed PCNs. Excessive administrative duties further reduce the time pharmacists can commit to SMRs. Local policy variations also impact capacity; for instance, Salford, with its better staffing as it prioritises regional funding to support the NIPPS team,¹⁴ allows pharmacists more time to complete SMRs compared to other regions.

Practice leads also play a crucial role in SMR implementation. While guidance allows PCN pharmacists who have completed or are enrolled in accredited pathways to conduct SMRs, some practice leads restrict SMRs to independent prescribers only, limiting the number of reviews. Some require SMRs to be completed in 10–15 minutes, which is contrary to best practice and places additional pressure on pharmacists, negatively impacting SMR implementation and hampering the quality (based on authors’ experience).

Incentive introduction

Introducing incentives, such as additional payments to practices, could improve SMR uptake. Unlike the previous MUR scheme, SMR delivery currently lacks compensation. Some local areas have developed initiatives to prioritise specific schemes. Take Salford Standard, a local guidance released by the Salford Locality Team of the NHS Greater Manchester integrated care board, as an example, it offers extra payments for high-risk reviews (not necessarily an SMR) for patients with cardiovascular diseases and diabetes in 2024/2025 in Greater Manchester.

Facilitators of service efficiency

Effective strategy

Pharmacists use various strategies to manage and deliver SMRs effectively. Experienced pharmacists typically conduct an average of four SMRs per day to ensure patients receive timely assessments. Due to the limited time allocated to SMRs (that is, 30 minutes for each), they balance time between complex (approximately 45 minutes) and simple cases (approximately 15 minutes) to allow more time spent on complex cases to meet daily targets (based on authors’ experience). This efficiency is mainly due to their experience and familiarity with patient interactions. In contrast, new or less experienced pharmacists often struggle with SMRs due to their reliance on template-driven behaviours, which can undermine the personalised approach needed for effective SMRs.¹⁵ Furthermore, experienced pharmacists tend to schedule follow-up appointments with the same patients, which allows patients to digest information and enable more meaningful medication adjustments. This ongoing engagement is essential for optimising medication use and improving patient outcomes rather than merely completing reviews.

Digital tools

The tools to facilitate SMRs vary across regions and PCNs. Practices use various systems such as EMIS, Vision, and SystmOne, each of which is compatible with specific tools that can vary by region. These tools help pharmacists prioritise patients for SMRs based on criteria like frailty or medication use, but no clear guidance exists on which are the most effective. Efficient use of tools requires advanced knowledge and experience, creating challenges for less experienced pharmacists. For instance, Salford has integrated Ardens and Salford Standards across all practices. Still, the setup is inconsistent in other regions. Such variability in tools and systems can result in inconsistent SMR uptake and quality. Less experienced pharmacists, in particular, need additional support to deliver SMRs and ensure consistently high service quality.

Reflections on current policy and strategy

In summary, there is a significant gap in evidence on SMR uptake and effectiveness, with pharmacists reporting inconsistencies in implementation. This points out the need for targeted research and action to enhance both the uptake and quality of these reviews, ultimately leading to better patient outcomes. To address these challenges, several steps can be taken:

1. Introduce financial incentives for SMR completion. This could motivate practices to allow more ring-fenced time dedicated to SMR services, ensuring more patients receive timely and necessary medication assessments.

2. Develop a digital risk stratification tool. This could help pharmacists to identify patients with a high risk of medication-related harm by integrating existing resources and indicators (for example, anticoagulants and addictive medications). The tool would provide clear guidance, particularly benefiting less experienced pharmacists, and help standardise SMR services across areas. With the support of this tool, pharmacists could focus on medication assessments, and develop their confidence and skills in efficiently deprescribing where appropriate.

3. Establish quality control indicators. This would ensure SMRs are conducted with high quality to benefit patients truly, not just in quantity.

4. Enhance SMR training, focusing on regular medication optimisation, patient communication, practice collaboration, confidence building, and deprescribing skills.

Improvements in policy, tools, and training will enable pharmacists to provide high-quality SMRs and personalised care, contributing to better patient outcomes.

Provenance

Commissioned; externally peer reviewed.

Competing interests

The authors have declared no competing interests.