An overview of the specification outlined in draft proposals published by NHS England
Under this specification, NHS England proposes that PCNs identify people who would benefit most from receiving a structured medication review (SMR), using automated clinical tools such as PINCER and Eclipse Live.
PCNS are also expected to have processes in place to refer patients for SMR reactively.
NHS England identify the following groups as being most
likely to benefit:
- All patients in care homes as per the Enhanced
Health in Care Home specification;
- Patients with complex and problematic
polypharmacy, specifically those on 10 or more medications;
- Patients who are being prescribed medicines that
are commonly and consistently associated with medication errors;
- Patients with multiple long-term conditions
and/or multiple comorbidities – in particular respiratory disease and
cardiovascular disease;
- Housebound, isolated patients and those with
frailty – particularly patients who have had recent admissions to hospital
and/or falls;
- Patients who have received a comprehensive
geriatric assessment as per the anticipatory care requirements;
- Patients with severe frailty; and
- Patients prescribed high numbers of addictive
pain management medication.
PCNs must ensure that only appropriately trained
clinicians should undertake SMRs. These professionals will need to have a
prescribing qualification and advanced assessment and history taking skills –
or be enrolled in a current training pathway to develop these skills – and must
be able to take a holistic view of a patient’s medication. This could include:
- Clinical Pharmacists
- GPs
- Advanced Nurse Practitioners
The service requirements
From April 2020, practices working as part of PCNs will:
- Identify a clinical lead who will be responsible
across the PCN for the delivery of the service requirements in this section.
- Run locally-defined processes at least twice
yearly, on a six-monthly basis, to identify the patients within the
practice-registered population that require SMRs. This must include consideration
of patients within the cohorts described in paragraph
- Develop local processes for reactive SMR
referrals, adhering to published guidance;
- Provide written communication to patients
invited for an SMR, detailing the process and intention of the appointment;
- Offer SMRs to 100% of identified patients,
except in exceptional circumstances where the commissioner agrees that proven
capacity constraints (where the PCN had demonstrated all reasonable attempts to
ensure capacity had been undertaken) would justify a lower proportion of
identified patients to be offered a SMR;
- Undertake SMRs and follow-up consultations in
line with detailed guidance. CCGs will review variation in the numbers of SMRs
undertaken, which will inform the potential development of a standardised
requirement in future years;
- Use appropriate clinical decision-making tools
to support the delivery of SMRs, examples of which will be provided through
guidance;
- Clearly record all SMRs within GPIT systems, as
well as using appropriate clinical codes to signify the reasons for an SMR;
- Develop local PCN action plans to reduce
inappropriate prescribing of (a) antimicrobial medicines, (b) medicines which
can cause dependency, and (c) nationally identified medicines of low priority.
This plan will react to guidance specifying how the PCN will deliver against
the guidance;
- Work with community pharmacies locally to ensure
alignment with delivery of both the New Medicines Service (to support adherence
to newly-prescribed medicines) and developing medicines reconciliation services
(to support effective transfers of care between hospital and community);
- Ensure delivery of SMRs and medication
optimisation aligns to the work of medicines optimisation teams within CCGs
local to the PCN.
Metrics to assess PCN performance in delivery of service:
1. The number of individual SMR episodes undertaken, including:
- The number of SMR processes undertaken (number
of individual patients given one or more SMR appointment)
- The number of SMR follow-up appointments
2. Outcome measurement to monitor impact of SMR
3. Prescribing rate of nationally identified medicines of
low value that should not be routinely prescribed
4. Prescribing rate of low carbon inhalers
5. Prescribing rate of medicines that can cause
dependency
6. Prescribing rate of antimicrobial medication
The document also notes that ‘reducing unwarranted prescribing spend’ is likely to be one early focus of the Investment and Impact Fund (additional funding stream for PCNs that make accelerated progress with the specification), with progress expected to be measured against baseline levels of performance in 2019/20.
You can access the full draft specification document here.
