A good medication review is a review of a person and of all the conditions for which we are prescribing medication. Of course, I agree with the editorial’s authors1 that such a review can sometimes reduce polypharmacy and avoidable hospital admissions. But this is true especially in frail older people with multiple comorbidities, a group where relational continuity is particularly important. Shared decision making about medication often involves relatives and other carers, and agreeing to reduce dosages or stop medications invariably requires more than one conversation. As well as covering the standard medication-specific agenda, the conversation involves inviting the patient and their family to discuss the everyday burden of taking medication, and it needs to establish the patient’s goals for their health care, particularly where medications are being taken to reduce the likelihood of future harm, rather than to mitigate or ward off symptoms.
The clinician needs not only 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. They also need a trusting relationship with the patient and their family, ideally a pre-existing relationship and necessarily one that can be continued into the future, because stopping one’s usual medication is frightening. So, I think that, at least for frail older people, ‘medication reviews’ are one element of GP work that should not be systematically delegated to a clinical pharmacist, and certainly not to a newly qualified one, however well they have done during their ‘18 months of training’. Perhaps one good use of proactive frailty identification2 could be to ensure that those identified are offered a review consultation with a GP or an experienced nurse practitioner involved in the patient’s ongoing care. The DES should be amended to cover ‘a minimum consultation duration of 30 minutes’ with this senior clinician, as well as at least one follow-up appointment.
- © British Journal of General Practice 2021
