Interviews were conducted with 23 participants, 18 of whom were clinical pharmacists (or senior clinical pharmacists) and five were ‘SMR leads’ (see Table 1). Participants were from seven different NHS England regions and interviews lasted between 26 and 65 min (average 37 min). Informed by NPT, the themes identified are summarised in Box 2.
Cognitive participation
Professional identity and role alignment
Those interviewed were confident in the role of clinical pharmacists to appropriately and thoroughly review multiple medications in-depth across several conditions. Some described how they were able to pick up on different and additional details to GPs, and many had extensive experience in relevant clinical specialities, such as frailty:
‘But yeah, I mean, it, it’s stuff that we, we do all the time, isn’t it. As pharmacists we talk about medicines. It’s sort of our bread and butter, really.’ (PHR 01, qualified 7 years, SMRs 3.5 years, IP)
Interviewees also spoke of holistic SMRs as useful touchpoints for pharmacists to engage with and manage MLTCs:
‘... you’re saying, asthma is this part … come back next week and we’ll do your diabetes … it feels like we’re chopping a person up into their little conditions. Whereas … their health is a holistic thing.’ (PHR 01, qualified 7 years, SMRs 3.5 years, IP)
Organisational and peer engagement
Some interviewees described a lack of senior buy-in, resulting in inadequate resources for SMRs (for example, costing in pharmacist technicians, administrative support, or enough pharmacist time), making it difficult to see most patients who could benefit from one. One SMR lead spoke of working with the PCN clinical director and PCN board to negotiate pharmacist time allocated to SMRs:
‘We looked … [at] how many people could be eligible for an SMR in line with what the contract says … 45 000 people … across three practices … the challenge is where you start to really stratify that … also what percentage of the, the whole-time equivalent that pharmacists have … versus every other thing they do.’ (SMR lead [LDR] 03, qualified 12 years, SMRs 3 years)
Where adequate resources had been allocated, interviewees reported being able to appropriately tailor their week (for example, holding weekly SMR clinics, booking patients in, and arranging/checking blood tests). They could then focus their time better.
Many participants suggested that a lack of engagement and involvement from other clinicians was perhaps because of the lack of understanding of the purpose and value of SMRs. However, more established pharmacists described building good rapport with colleagues in their practice and improving appreciation of the length and breadth of SMRs, over time. This was especially relevant for PCN-based pharmacists who covered several practices.
Building legitimacy and patient trust
Those interviewed described how patients often appeared to view GPs as the primary, and sometimes sole, legitimate role for discussing medication decisions. When pharmacists initiated discussions around medication changes, this expectation was thought to undermine patient receptivity, requiring pharmacists to undertake additional relational work to establish legitimacy and trust:
‘Sometimes when they [patients] hear … that you’re a pharmacist and trying to make changes to their medication they sometimes aren’t really too susceptible to it because they are, “why isn’t the GP doing it and why hasn’t the GP noticed that before?”’ (PHR 07, qualified 2 years, SMRs 2 years)
Interviewees suggested that patients’ understanding of the pharmacist role and purpose of SMRs was central to cognitive participation, shaping how openly patients discussed their medications and whether they felt able or willing to consider changes to their existing medications.
Collective action
Patient identification and prioritisation for SMRs
Interviewees described undertaking SMRs with patients from DES contract priority cohorts, with some additionally targeting specific medication combinations or potentially harmful omissions (that is, instances where appropriate medicines had not been prescribed or continued, creating potential risk) outlined in the 2022/2023 IIF. Patients were commonly identified through proactive, automated searches of the practice’s electronic health records (via Ardens, Eclipse, or EMIS), with others identified opportunistically. These systems worked well when clear criteria for patient prioritisation were in place; however, after the withdrawal of IIF incentives to undertake SMRs, prioritisation became more variable. Although DES and IIF guidance provided a national framework for selection, decisions about which patients were reviewed were also shaped by local organisational capacity, pharmacist time, leadership engagement, and practice- or PCN-level strategic priorities.
Preparatory work for SMRs
Interviewees described undertaking extensive preparatory work to ‘build a picture’ before speaking to patients. This involved determining what condition(s) the patient had and understanding what was going on in their lives medically (through hospital letters, reported medication changes, blood tests, including liver function, cholesterol tests, and blood pressure readings). Also, assessment of medication prescribing patterns (such as what is taken and when requested, if at all) and inappropriate combinations. Preparatory work enabled better understanding of the complexity of the patient’s needs and history of the patient.
This preparation could take 10–20 min and aimed to optimise and focus SMR time. It was also noted that this work reduced over time as pharmacists knew the patients better (so needed less preparatory work) and patients were more prepared.
Importantly, however, blood test results were often not undertaken before an SMR, which made initiating changes during an SMR difficult or impossible, and so follow-up appointments were required to initiate, or even consider, some changes.
Modes and settings of SMRs
SMRs were undertaken in the practice, care homes or patients’ homes, or remotely. The majority were conducted remotely by telephone because of time efficiencies or lack of clinic space. Face-to-face SMRs were preferred for some patients who were older or with more complex needs (especially to assess frailty), or for patients with English-language difficulties, hearing difficulties, or when others (such as carers/family members) were involved. Face-to-face SMRs were described as better at determining whether patients understand their medications, for example, by having access to facial expressions and other non-verbal cues:
‘I would prefer a face-to-face SMR where patients come in, bring in all their medication with them ... [and] understanding of their body language, [and] whether they take their medication appropriately.’ (PHR 03, qualified 30 years, SMRs 3 years, IP)
Several participants noted that SMRs were introduced during the COVID-19 pandemic, coinciding with rapid service redesign, remote working, and significant organisational strain. This context shaped early implementation and was perceived to have ongoing implications for workload pressures and reliance on remote consultations.
SMR structure and process
After establishing the purpose of the appointment, interviewees described going through patients’ test results (if available) and medications one by one, often while following a clinical consultation guide/‘template’ (for example, a multimorbidity, self-made, or generic electronic template). Templates were used as a prompt and to initiate broader, open questions, such as to understand how medication is taken and any side effects experienced. Interviewees reported exploring social circumstances and questions or concerns about the medication or other health matters. Then coming to a shared agreement about any changes (for example, medication doses, adding, or removing medication). Where changes were agreed, these sometimes resulted in further follow-up (especially if dependent on blood tests):
‘I have my own set of questions … have you got a good routine for your medication? Any over the counter medication … we normally go through all each and every single medication. We go through their concerns first … [and] try to come to sort of shared agreement with regards to a plan … that can result in another follow-up appointment.’ (PHR 07, qualified 2 years, SMRs 2 years)
Although existing templates were useful to aid the process of SMRs, they were also described as detailed and sometimes difficult to navigate in real-time consultations, particularly for those newer to the role.
Time allocation and workload implications
SMRs were typically described as lasting at least 20 min, and often extended to 30 or 45 min or more, depending on the complexity of patients’ needs. Some also required follow-up consultation(s). The time allocated for SMRs, compared with standard GP appointments, was seen as crucial in building rapport and trust, and allowing deeper exploration of the complexity of patients’ needs. Interviewees said this time enabled patients to reflect on their medication use and to speak openly, providing more opportunity for partnership and shared decision making:
‘There was a lot of to-ing and fro-ing about how long we were gonna be allowed to do them in … so I stood my ground and still kept half an hour for an SMR plus 20 minutes follow-up [if needed] … in some areas pharmacists have ended up doing them in a lot shorter time, that doesn't give the patient as much freedom I think to actually be honest with you and kind of get that rapport built.’ (LDR 04, qualified 14 years, SMRs 3 years)
Giving patients sufficient time to express their concerns was frequently described as essential to conducting an SMR well, ensuring that patients’ perspectives were being heard and addressed.
Interprofessional relationships
Where interviewees did not have the authority or confidence to change an existing medication or start a new one (for example, not an IP or unfamiliar with a particular medication/condition), it was resolved with a GP. This relied on collaborative relationships with GPs in the practice.
Training needs and approaches
There were two sub-themes, training needs and training approaches.
In terms of training needs, interviewees appeared to be familiar and comfortable with making changes with medications that matched their own professional knowledge and experience. However, some changes were reported as being difficult, largely concerning pain and addictive medications. Any dose changes here were depicted as a slow and difficult process, requiring careful conversations, advanced consultation skills, and multiple follow-ups:
‘It’s resistance to people wanting to bring themselves off pain relief medication and … I mean refusing tablet doses to be reduced. So, despite being in their best interests, they see it differently … so it’s a question of understanding and educating them and that can be potentially problematic as well.’ (PHR 06, qualified 10 years, SMRs 3.5 years, IP)
Although pharmacists expressed that conducting SMRs aligned well with their professional role, participants identified ongoing training needs, particularly for newer clinicians, and to optimise SMRs. These included developing expertise in managing specific conditions or medicines and in engaging in difficult conversations, especially around deprescribing, which was widely described as one of the most relationally challenging aspects of SMRs.
Templates were seen as particularly helpful for less experienced pharmacists, who were less confident in conducting complex, holistic reviews. The templates functioned as a safety net to ensure important domains were not missed. However, some more experienced pharmacists described using templates more flexibly over time, adapting them to support a more conversational and patient-led approach.
Interviewees commonly highlighted training needs, often centred around building confidence and consultation skills for stopping or reducing certain medications. These were particularly around building rapport and trust with patients, encouraging open conversations, and supporting patient disclosure. Additional priorities included shared decision making, interpreting non-verbal cues, and developing knowledge and confidence in deprescribing for patients in care homes owing to deteriorating physiology and increased frailty. Mental health skills and consultation length and structure were also noted.
In terms of training approaches, interviewees described the training they had undertaken to prepare them for conducting SMRs (see Box 3). There was huge variation in the types of training described (which largely depended on the PCN or practice) as well as the time allocated to receive training.
Box 3. Training approaches described by interviewees Conducting SMRs in care homes
Care home SMRs were widely perceived as resource intensive. The complexity of patients’ cases, as many have significant cognitive impairment, along with the need to engage multiple parties (including patients, families, carers, and specialist staff), was considered challenging.
There was considerable variability in the management of SMRs in care homes. In some areas, GPs were designated to manage care home residents because of the complexities of these patients’ cases. Some PCNs assigned pharmacists to specific care homes, designated particular care homes to individual practices, or a single practice took responsibility for all care homes within the PCN.
One barrier was limited WiFi in care homes, which obstructed access to patient records. To facilitate the administration of SMRs, some care homes allocated tasks (such as logging patients’ blood pressure/weight) to night staff, to copy and paste into relevant records. Medication changes were often reported as well-managed within care home protocols, particularly when aligned with their monthly medication cycles. When pharmacists engaged with and aligned with these procedures and protocols, and were familiar with care home staff, SMRs ran more smoothly.
Reflexive monitoring
Identifying unmet patient needs and prescribing savings through SMRs
Two SMR leads described how they carried out local service evaluations or audits of their SMRs, with evidence that SMRs facilitated prescribing savings for the practice, the identification of work to help patients, and prevented hospital admissions:
‘I’ve done a bit of a like a service evaluation … it’s led to some savings, but generally it’s led to some kind of intervention … It identifies work that we could, we needed to do … quite a few of the GPs … have said ... [it’s] what they were hoping for, not that they would do less, but the things that they were missing would get picked up.’ (LDR 02, qualified 19 years, SMRs 3 years, IP)
‘When we audited our own SMRs … we were showing a [prescribing] savings of around £280 [per year] per patient … [and] if you found the same problem in ten people … every ten you've prevented one hospital admission … [but] we are quite an experienced team.’ (LDR 05, qualified 23 years, SMRs 20 years, IP)
Interviewees described how SMRs have helped pick up patient care that has previously been missed, and led to interventions that would otherwise not have occurred. For example, SMRs have supported the identification of overlooked/misattributed clinical issues, review of long-neglected medications, optimisation of symptom management, and reduced medication burden and drug interactions. Further, establishing trust, continuity, and holistic care enabled them to support patients, such as those with complex pain, through safe, gradual medication reductions.
Positioning SMRs within MLTC management pathways
Interviewees saw SMRs as an important element of MLTC management, providing a holistic and patient-centred approach to reviewing medications while addressing broader aspects of care. SMRs allowed assessment of advice previously provided and clarification on whether patients fully understood medication guidance, while agreeing on strategies moving forward. SMRs also provided an opportunity to consolidate primary and secondary care medication management plans, supporting patients to feel more informed and have clearer understanding of their medications:
‘We’ve just incorporated [SMRs] as part of our … Chronic Disease Process because that is the backbone as a pharmacy team of what we do … I think it just comes down to SMRs are really important. They are really good holistic reviews and they just support a really good prescribing process.’ (PHR 13, qualified 11 years, SMRs 3 years, IP)
