GP Contract Enhanced Services Primary Care Networks

The Structured Medication Review and Medicines Optimisation service: a summary

The Structured Medication Review (SMR) and Medicines Optimisation service comes into effect from October 2020 as part of the PCN Contract Directed Enhanced Service (DES).

NHS England says the SMR programme:

  • Provides better care for patients by identifying medicines that can be stopped, dosages and/or frequency changed or where new medicines are needed.
  • Could avoid admission to hospital through unnecessary medicines related harm.
  • Reduces overprescribing of medicines and waste.
  • Supports integration of pharmacy within wider multi-disciplinary healthcare teams (including community and hospital pharmacy) and improved access to healthcare and outcomes for patients.

All PCNs are encouraged to implement the programme ‘in a way that maximises its potential to reduce health inequalities’.

Service requirements

From the 1 October 2020, a PCN is required to:

1. Use appropriate tools to identify and prioritise patients who would benefit from a structured medication review (SMR). This must include patients: i) in care homes; ii) with complex and problematic polypharmacy, specifically those on 10 or more medications; iii) on medicines commonly associated with medication errors; iv) with severe frailty, who are particularly isolated or housebound patients, or who have had recent hospital admissions and/or falls; and v) using potentially addictive pain management medication.

2. Deliver as many SMRs as possible to these patients, according to the local clinical pharmacist capacity. The PCN must demonstrate reasonable ongoing efforts to maximise that capacity.

3. Explain the benefits of SMRs and what to expect from them when inviting patients.

4. Ensure only appropriately trained clinicians working within their sphere of competence undertake SMRs. Professionals undertaking SMRs must have a prescribing qualification and advanced assessment and history taking skills, or be enrolled in a current training pathway to develop this qualification and skills.

5. Clearly record all SMRs within GP IT systems.

6. Actively work with the CCG to optimise the quality of local prescribing of: i) antimicrobial medicines; ii) medicines which can cause dependency; iii) metered dose inhalers, where a lower carbon device may be appropriate; and iv) nationally identified medicines of low priority.

7. Work with community pharmacies to connect patients appropriately to the New Medicines Service which supports adherence to newly prescribed medicines.

8. Observe the NHS England and NHS Improvement guidance on Structured Medication Reviews and Medicines Optimisation.

How will performance be monitored?

Prescription of high-carbon inhalers and medicines of low priority will be displayed in the Network Dashboard.

Metrics on prescribing quality for anti-microbials and drugs that potentially cause dependency, as well as a wider patient outcome measurement, are in development – to be informed by implementation of Public Health England’s (PHE) report into prescribed medicines. In the meantime, the Network Dashboard will link to existing data on prescribing rates of relevant drugs hosted by the BSA and Open Prescribing.

Further detail is contained in the standalone guidance document for the SMR and Medicines Optimisation.

NHS England case study: Senior PCN Clinical pharmacist


Nipa Patel started working for SASSE2 PCN and Ashford and St Peter’s Hospitals NHS Foundation Trust as a Senior PCN Clinical Pharmacist in April 2020.

Her role sees her split her time between the GP practices and the acute trust.

SASSE2 PCN covers approximately 39,000 patients across five practices.

The PCN team includes Nipa in their meetings has encouraged Nipa to share her skillset and put forward ideas for new developments and improved patient care.

Two further full-time pharmacists are being recruited, funded by the Additional Roles Reimbursement Scheme. The pharmacists will provide the focal point for delivering the DES plans, including the SMRs and care home support, in the PCN.

How the SMRs are run

Due to the national challenges during COVID-19, SMRs are currently done via phone or video with patients, with plans to move to face-to-face consultations in the future.

By assessing prescribing data whilst carrying out SMRs, the pharmacist targets patients with the highest risk to find out what is important to the patient about their care and then provides tailored advice. For example, if a patient is seeking advice to reduce the number of medicines they take, Nipa will discuss the benefits and risks of each medicine and then agree any changes with the patient to ensure they are genuinely involved in decisions about their care.

Some therapeutic areas on which SMRs are focused include:

  • Respiratory issues. Using SMRs, the pharmacist is addressing the overuse of SABA inhalers, looking into the causes and discussing asthma action plans with patients, as well as looking at changing to low carbon inhalers. She also plans to review high-dose ICS inhalers, as the number being prescribed by the PCN is above the CCG average.
  • Lifestyle advice is part of a SMR. The pharmacist helps diabetic patients improve their understanding of their condition and advises them on how to best control their diabetes. The SMRs also highlight any patients who have not received diabetic eye checks and ensure they are referred onto appropriate screening services.

Some of the SMRs have also highlighted patients needing non-medical support, for which the pharmacist provides onward referral to the social prescriber in the PCN to support their practical and emotional needs. This helps to reduce some of the workload for GPs and is more appropriate for the patient.

Results and outcomes

The pharmacist support is helping to build resilience and create a sustainable long-term model for delivery of services within practices. SMRs are used to focus on the medicines patients are being prescribed and linked to patient hospital admissions, so support to those patients who need it most.

Nipa says: ‘The multi-disciplinary approach in the PCN also means we offer a greater range of community-based services to patients shared across the five practices, including access to social prescribers and mental health assessments with a community psychiatrist.’

She has also developed close links with community pharmacy colleagues, setting up a regular communication process and working closely on introducing initiatives such as electronic repeat dispensing and the electronic prescription service phase 4.

Tips for success

  • GPs all individual and different. Share best practice among general practice teams.
  • Invest time in building genuine, long-lasting relationships with local practices, community pharmacies and other healthcare and community service professionals, including secondary care, taking time to understand their perspectives and issues.
  • Set up a network across the wider pharmacy team in the PCN to communicate regularly and share ideas and solve problems.
  • Be prepared to explain the role of the clinical pharmacist to other colleagues within a PCN and the value they can add.
  • Get to know your local population and identify their clinical needs. Set achievable goals where pharmacy can make a difference.
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