Abstract

Background Structured Medication Reviews (SMRs) were introduced into primary care in England for patients living with multiple long-term conditions (MLTCs), polypharmacy, increased frailty, in care homes or at risk of medicines-related harm. SMRs aim to optimise the therapeutic potential of medication and reduce medicine-related harms through holistic reviews.

Aim To explore the day-to-day work being undertaken with, and by, clinical pharmacists to implement, embed and integrate SMRs into practice, and consider how to optimise SMRs.

Design and setting Qualitative one-to-one interviews with clinical pharmacists undertaking SMRs and SMR service leaders/managers (SMR leads) in England between February 2023 and November 2024.

Method Participants were recruited as part of a wider evaluation of the roll-out of SMRs in England. Interview topic guides and qualitative data analysis were informed by Normalization Process Theory (NPT).

Results Eighteen clinical pharmacists and five SMR leads participated. Participants reported often having to explain the purpose of SMRs and clinical pharmacists’ roles to patients, partly due to patients not being informed about SMRs. Participants valued SMRs and expressed that trust-building and tailored consultations were important for optimising medications. Integration varied due to high workload, inconsistent leadership support, inadequate administrative/pharmacist technician resource and lack of training. However, participants described SMRs as valuable for identifying and addressing unmet needs and supporting holistic, person-centred care across MLTC pathways.

Conclusion The findings demonstrate the need for improved information on SMRs for patients and primary care teams, adequate and appropriate resource allocation, and enhanced support for consultation skills training to optimise medicines use.

How this fits in

- SMRs were formally introduced to primary care in 2020 to address the challenges of managing polypharmacy in an ageing population with increasing patient complexity and MLTCs.

- SMRs were introduced alongside the expansion of clinical pharmacist roles in General Practice as a comprehensive, person-centred review of all a patient’s medicines.

- This qualitative evaluation examines the day-to-day work of implementing and embedding SMRs, highlighting challenges to implementation and integration.

- Our findings reveal challenges to the sustainability of SMRs and identify opportunities for optimisation, including addressing pharmacists’ training needs and resource allocation for administrative and pharmacy technician support.

Competing Interest Statement

GYHL is a Consultant and speaker for BMS/Pfizer, Boehringer Ingelheim, Daiichi-Sankyo, Anthos (No fees are received personally). FDRH acknowledges support as Director of the NIHR Applied Research Collaboration (ARC) Oxford Thames Valley, and Theme Lead of the NIHR OUH BRC. FDRH has also received occasional fees or expenses for speaking or consultancy from AZ, BI, Bayer, BMS/Pfizer, and Novartis not related to this research.

Funding Statement

This work was funded by the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) Multiple Long-term Conditions Cross-ARC collaboration. JPS received funding from the Wellcome Trust/Royal Society via a Sir Henry Dale Fellowship (ref: 211182/Z/18/Z), and now receives funding via an NIHR Advanced Fellowship (NIHR303621). RM, KT, RKB, CR & PB received funding from the National Institute of Health and Care Research (NIHR) Applied Research Collaboration (ARC) Oxford and Thames Valley at Oxford Health NHS Foundation Trust. KK is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration East Midlands (ARC EM), NIHR Global Research Centre for Multiple Long Term Conditions, NIHR Cross NIHR Collaboration for Multiple Long Term Conditions, NIHR Leicester Biomedical Research Centre (BRC) and the British Heart Foundation (BHF) Centre of Excellence. AES is supported by a Wellcome Trust funded School of Primary Care Doctoral Training Fellowship. AC is funded by a National Institute for Health and Care Research (NIHR) Research Professorship award and supported by the NIHR Applied Research Collaboration Yorkshire & Humber, the NIHR Leeds Biomedical Research Centre, and Health Data Research UK, an initiative funded by UK Research and Innovation Councils, NIHR and the UK devolved administrations and leading medical research charities. The views expressed are those of the authors and not necessarily those of the NIHR, the NHS or the Department of Health and Social Care. For the purpose of Open Access, the author has applied a CC BY public copyright licence to any Author Accepted Manuscript version arising from this submission.

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

This study received NHS Research Ethics Committee and Health Research Authority approval (reference 22/SC/0373).

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

Yes

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

Yes

I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

Yes

Data Availability

All data produced in the present study are available upon reasonable request to the authors

List of abbreviationsADEsAdverse drug eventsCPPECentre for Pharmacy Postgraduate EducationDESDirected Enhanced ServiceICBsIntegrated Care BoardsIIFImpact and Investment FundGPGeneral PractitionerMLTCsMultiple long-term conditionsNHSNational Health ServiceNPTNormalization Process TheoryNHSNational Health ServiceNIHRNational Institute for Health ResearchOSCAROptimising StruCtured medicAtion Reviews evaluationPCNPrimary Care NetworkSMRsStructured Medication Reviews