Early Implementation of the Structured Medication Review in England

Abstract

Background: The National Health Service in England (NHSE) has introduced a new Structured Medication Review (SMR) service within forming Primary Care Networks (PCNs) during the COVID-19 pandemic. Policy drivers are addressing problematic polypharmacy, reducing avoidable hospitalisations and delivering better value from medicines spending. This paper explores early implementation of the SMR from the perspective of the primary care clinical pharmacist workforce. Aim: To identify factors affecting the early implementation of the SMR service. Design and setting: Qualitative interview study in general practice September 2020 to June 2021. Method: Two semi-structured interviews were carried out with 10 newly appointed pharmacists in 10 PCNs in Northern England; and one with 10 pharmacists already established in GP practices in 10 other PCNs across England. Audio-recordings were transcribed verbatim and a modified framework method supported a constructionist thematic analysis. Results: SMRs were not yet a PCN priority and SMR implementation was largely delegated to individual pharmacists, with those already in general practice appearing more ready for this. New pharmacists were on the primary care education pathway and drew on pre-existing practice frames, habits and heuristics. Those lacking in patient-facing expertise sought template driven, institution-centred, practice. Consequently, SMR practices reverted to prior medication review practices, compromising the distinct purposes of the new service. Conclusion: Early SMR implementation did not match the vision for patients presented in policy of an invited, holistic, shared-decision-making opportunity offered by well-trained pharmacists. There is an important opportunity cost of SMR implementation without prior adequate skills development, testing and refining.