Early implementation of the structured medication review in England: a qualitative study

BACKGROUND: NHS England has introduced a new structured medication review (SMR) service within primary care networks (PCNs) forming during the COVID-19 pandemic. Policy drivers are addressing problematic polypharmacy, reducing avoidable hospitalisations, and delivering better value from medicines spending. This study explores early implementation of the SMR from the perspective of the primary care clinical pharmacist workforce. AIM: To identify factors affecting the early implementation of the SMR service. DESIGN AND SETTING: Qualitative interview study in general practice between September 2020 and June 2021. METHOD: Two semi-structured interviews were carried out with each of 10 newly appointed pharmacists (20 in total) in 10 PCNs in Northern England; and one interview was carried out with 10 pharmacists already established in GP practices in 10 other PCNs across England. Audiorecordings were transcribed verbatim and a modified framework method supported a constructionist thematic analysis. RESULTS: SMRs were not yet a PCN priority and SMR implementation was largely delegated to individual pharmacists; those already in general practice appearing to be more ready for implementation. New pharmacists were on the primary care education pathway and drew on pre-existing practice frames, habits, and heuristics. Those lacking patient-facing expertise sought template-driven, institution-centred practice. Consequently, SMR practices reverted to prior medication review practices, compromising the distinct purposes of the new service. CONCLUSION: Early SMR implementation did not match the vision for patients presented in policy of an invited, holistic, shared decision-making opportunity offered by well-trained pharmacists. There is an important opportunity cost of SMR implementation without prior adequate skills development, testing, and refining.