How to… deliver the medication review service

GP partner and PCN co-CD Dr Rupa Joshi offers tips on meeting this year’s structured medication reviews and medicines optimisation service requirements

The structured medication reviews and medicines optimisation service began last October and continues under the Network Contract DES for 2021/22.¹ 

As we increase our focus on implementing the Network DES activities, what can PCNs do to ensure they meet the updated requirements effectively? 

1 Be creative with workforce funding

Most PCNs now have pharmacists on their teams, with the help of Additional Roles Reimbursement Scheme (ARRS) funding. A senior clinical pharmacist or clinical pharmacist with the support of a suitably trained pharmacy technician can deliver the structured medication review (SMR) requirements. However, remember that any prescribing clinician can complete SMRs, with oversight from a senior pharmacist if needed. Note also there is a new banding 8a option for clinical pharmacists in this year’s ARRS.²

2 Consider employing an extra pharmacist

Clinical pharmacists and pharmacy technicians are already working extremely hard delivering the daily demands of general practice. PCNs may benefit from employing an additional pharmacist to ensure they can deliver the service, as well as meet the increasing demands in primary care. This may be particularly beneficial for PCNs with, for example, a large number of care-home residents or elderly complex patients.   

3 Use both proactive and reactive ways to identify patients

Patients who must be prioritised for SMRs are those: 

• In care homes. 
• On 10 or more medications; on medicines commonly associated with medication errors; with severe frailty and isolated or housebound, or with recent hospital admissions or falls; and using one or more of opioids, gabapentinoids, benzodiazepines and z-drugs.

Patients may be identified proactively by simple searches for numbers of medications, via the GP IT system, or by the use of tools such as PINCER, the electronic frailty index and the Integrated Populations Analytic tool.^3,4,5

Make sure you can also include patients reactively, based on clinical need, for example via MDT meetings or PCN team referrals, or following abnormal biochemistry or rationalisation in end-of-life care. 

4 Set realistic SMR goals

The number of SMRs offered depends on your capacity to deliver. Collaboration between CCGs and PCNs to set an achievable target is essential. Each SMR should take between 20-45 minutes, depending on complexity. We consulted our CCG medicines management lead, who recommended we aim to complete one or two SMRs per session initially, giving time to embed the process, with capacity to be reviewed in April 2022. 

5 Offer a tailored approach

Patients on long-term opioids and gabapentinoids can be difficult to engage. They are often concerned their medications will be stopped or reduced. This is where your wider workforce can be crucial to delivering an effective review. We have found using a personalised approach, via a group consultation, beneficial. Psychological approaches such as coaching techniques and teaching the biopsychosocial model can help, and be delivered by social prescribing link workers and health and wellbeing coaches. There are also useful reading resources, and
if appropriate patients can be referred to discuss psychological causes with their GP or mental health practitioners or pain psychologists.⁶

6 Make use of local and national frameworks

It will really help reduce your PCN workload if you can align activities with local and national quality incentives. In my region we have CCG initiatives to identify high-risk patients for medicines optimisation and new medicines reviews. The NHS Long Term Plan also sets out aims for medicines optimisation, while the national antimicrobial action plan and Stopping over-medication of people with a learning disability, autism or both (STOMP) initiatives also overlap.^7,8,9  It is important to share lessons learned here among PCNs, CCGs and integrated care systems (ICSs). 

7 Forge bonds with community pharmacy

Your community pharmacy colleagues can offer vital support here, in particular with the new medicines reviews. We already have a PCN lead community pharmacist who works with community pharmacy colleagues and can identify patients who may benefit from this service, which supports patients with adherence to newly prescribed medications such as for asthma, COPD, type 2 diabetes and hypertension, and newly prescribed anticoagulants.

Dr Rupa Joshi is a GP partner in West Berkshire, co-clinical director of Wokingham North PCN and NHS Confederation PCN board member

For more contract guidance as well as practice business and financial advice, visit pulse-intelligence.co.uk

References

1. NHS England. Network contract Directed Enhanced Service. Contract specification 2021/22 – PCN requirements and entitlements. Leeds: NHSE, 2021.
2. NHS England. Network contract Directed Enhanced Service. Contract specification 2021/22 – PCN requirements and entitlements. Part 7. Additional Roles Reimbursement Scheme. Leeds: NHSE, 2021. p 33.
3. University of Nottingham School of Medicine. PINCER 2020.
4. NHS England. Electronic Frailty Index.
5. South Central and West NHS. Insights population analytics and risk stratification tool
6. Ravindran D. The pain-free mindset: 7 steps to taking control and overcoming chronic pain. London: Vermilion, 2021.
7. NHS England. Medicines optimisation.
8. Department of Health and Social Care. Tackling antimicrobial resistance 2019 to 2024: the UK’s 5-year national action plan. London: DHSC, 2019.
9. NHS England. Stopping over-medication of people with learning disability, autism or both (STOMP): Professional resources.