Targeted holistic review of patients’ medicines is well overdue

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The authors are right that the evidence base for the long-term benefits of structured medication reviews (SMRs) is not particularly strong.¹ However, with the publication of the Department of Health and Social Care (DHSC) ‘overprescribing’ report² any primary care clinician or patient/advocate will tell you that there is much to do to support people to optimise treatments. Why? Because in our time-poor, overstretched NHS, with an ever-increasing number of ‘single organologists’ who invariably just add medicines, never subtracting, therefore multiplying the problems, the dedicated time for a real holistic consultation to find out what matters to a person about their medicines and health/wellbeing should not just be welcomed, but cherished.

Poor adherence to medicines and adverse drug reactions, let alone full-blown problematic polypharmacy, are rife.³ The general overestimation of the benefits of medicines and an underappreciation of their risks, coupled with imprecise systems for maintaining accurate medicines records across care sectors, also contribute to unnecessary follow-up clinician appointments and medicines waste.

Dr Louisa Polak⁴ is also right that clinicians performing SMRs need to be ‘competent to interpret evidence-based guidance, but also confident enough to disregard it where they and the patient agree that following it does not serve the patient’s agenda’ and that relational continuity can be particularly important. However, as an experienced clinical pharmacist, who regularly teaches GPs about polypharmacy/deprescribing, I would disagree that clinical pharmacists, the new medicines experts in primary care, cannot perform these SMRs. Yes, some less experienced may need additional training and more GP input to perform SMRs in complex patients with multimorbidity. But then many experienced GPs, who have excellent relationships with patients, also lack the confidence to stop medicines and arguably have more appropriate primary care clinical roles that only they can best perform.

I suggest that Primary Care Networks hone their plans to risk stratify which patients are most in need of an SMR, agree how many clinicians have the competency and time to provide them, then set up the maximum appointment sessions they have the capacity to provide and crack on! Our patients will thank us.

Competing interests

Department of Health and Social Care, Good for You, Good for Us, Good for Everybody: A Plan to Reduce Overprescribing, 2021, short-life working group member. NHSE/I Network Contract Direct Enhanced Service SMRs, 2019/2020, short-life working group member.