GP partner and PCN Co-Clinical Director Dr Rupa Joshi offers tips on meeting this year’s service requirements
The structured medication reviews and medicines optimisation service began last October and continues under the Network Contract DES for 2021/22.1 In this year’s service specification the structured medication review (SMR) requirements have been extended, to include any patients using one or more of opioids, gabapentinoids, benzodiazepines and z-drugs.
As we increase our focus on implementing the Network DES activities, what can PCNs do to ensure they meet the updated requirements effectively? Here are my top tips for delivering a successful and efficient service this year.
1. Be creative with workforce funding
Most PCNs have now deployed pharmacists into 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 SMR requirements. However, remember that any prescribing clinician can complete SMRs, which could be done with oversight from a senior pharmacist if needed. Note also there is a new band 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 providing an additional resource to help 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:
Patients may be identified proactively by simple searches, such as for numbers of medications, via the GP IT system, or by the use of tools such as PINCER, Eclipse or the electronic frailty index (eFI).3-5
Make sure you can also include patients reactively, based on clinical need, for example via MDT meetings or PCN team referrals, self-referral or abnormal biochemistry, following acute illness or rationalisation in end of life care. For patients in care homes, agree a framework for communication whether by telephone, email or video consultations and prioritise patients both reactively, as above, and through risk stratification tools such as the eFI, QCovid and the Integrated Populations Analytic (IPA) tool.6-7
4. Set realistic SMR targets
The number of SMRs offered is dependent upon 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 upon complexity, and patients should be prioritised according to clinical need for initial, follow-up and reactive SMRs. We consulted our CCG medicines management lead, who recommended we aim to complete one or two SMRs per session initially, allowing time for pharmacists to embed and refine processes, with capacity to be reviewed in April 2022.
5. Offer a tailored approach where needed
Patients on long-term opioids and gabapentinoids can be difficult to engage. They are often concerned their medications will be stopped or reduced when they receive an invitation to discuss their medicines. 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, has been 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 approaches to pain, such as dealing with adverse childhood experiences with their GP or mental health practitioners or pain psychologists.8
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 review; we use the PINCER tool to fulfil some of our local prescribing quality scheme goals, which can be extended to fulfil the SMR requirements.
The NHS Long Term Planalso sets out aims for medicines optimisation to reduce inappropriate prescribing of antimicrobials, medicines that cause dependency, high-carbon inhalers and low priority medications, while the national antimicrobial action plan and STOMP (Stopping over medication of people with a learning disability, autism or both) initiatives also overlap.9-11 It is important to share lessons learned here among PCNs, CCGs and ICSs.
7. Forge bonds with community pharmacy
Your community pharmacy colleagues can offer vital support with this service, in particular the new medicines review aspect. We are lucky to already have a PCN lead community pharmacist, who works with community pharmacy colleagues and is able to identify patients who may benefit from a full clinical review of their medications. The service supports patients with adherence to newly prescribed medications such as for asthma, COPD, type 2 diabetes and hypertension, and newly prescribed anticoagulants.
Tools for identifying patients for SMR
There are many evidence-based tools to help us with identification and prioritisation of patients for the SMRs.We have found the GP IT system valuable for identifying our care home patients, those with over 10 medications, and those on specific medications. The eFI has helped to prioritise our most frail and vulnerable patients and the IPA tool those most likely to contact GP and secondary care.5,7 Others include the PINCER and the NHS BSA Polypharmacy Comparator tool.3,12
We have also found the NHS Scotland 7 Steps Medication Review offers a good framework:
1. Aim – What matters to the patient?
2. Need – Identify essential drug therapy.
3. Need – Is the patient taking unnecessary drug therapy?
4. Effectiveness – Are therapeutic objectives being achieved?
5. Safety – Is the patient at risk of ADRs or suffers actual ADRs?
6. Efficiency – Is drug therapy cost-effective?
7. Patient-Centred – Is the patient willing and able to take drug therapy as intended?
Dr Rupa Joshi is a GP partner in West Berkshire, Co-Clinical Director of Wokingham North PCN and NHS Confederation PCN Network board member
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