A structured medication review starts with one question for every medicine on the list: what is it for? When each repeat prescription already carries a clinical indication, the answer is on the list before the review begins.
What is a structured medication review?
A structured medication review (SMR) is a full clinical review of a patient’s medicines with the patient, looking at how well each one works for them, whether it is still needed and how they are getting on with it. Since October 2020, primary care networks in England have offered SMRs under the Network Contract Directed Enhanced Service. The 2020 specification asked them to put first:
- people living in care homes;
- people with learning disabilities;
- people on complex and problematic polypharmacy, especially those prescribed ten or more medicines;
- people taking medicines commonly linked to medication errors and harm.
These are the same people clinical indications were designed to help. As Dr Masters put it on the About page, many elderly people are on over ten different medications, and it is easy for them to become confused about what each medicine is for.
How does an indication on every repeat prescription help?
- The reason is already recorded. Many drugs have several uses: atenolol may be prescribed “to lower blood pressure”, “to prevent palpitations”, “to prevent angina” or “to prevent heart attacks”. The indication says which, so the reviewer does not have to work it out from the notes (FAQ 5).
- The list becomes a summary of the patient’s problems. FAQ 7 describes a list of indications linked to repeat prescriptions as “a rudimentary active patient summary list”.
- A medicine whose reason has gone is easier to spot. When the reason is written beside the drug, the GP and pharmacist can ask whether it still applies.
- The patient can join in. The patient’s labels carry the same words, so they come to the review knowing why they take each medicine. Patients at Highfield Surgery said: “It enables me to be in control of my own health.”
- GP and pharmacist start from the same place. Dr Masters wrote of the 2006 medicines use reviews that indications helped “as the pharmacist and patient already understand the need for the medication” (FAQ 16). The same holds when a practice pharmacist and GP review medicines together.
Can the review be used to add indications?
Yes. Highfield Surgery added indications as each repeat request came in, and a review is another natural moment, because the reason for each medicine is being checked anyway. Keep each indication short, ideally three or four words, and take the wording from a list such as the Sample Directory, checking each phrase before you use it. Ask before adding an indication that may be sensitive; a patient who would rather not have one can have “patient preference no indication” instead.
Is there evidence that it helps?
Not yet measured. No study has looked at whether indications make structured medication reviews quicker or better, and Dr Masters’ own work calls for prospective studies with controls. See what is known and what is not.
Where can I find out more?
Getting started with clinical indications sets out the first steps for a practice, and clinical indications for pharmacists and medicines optimisation teams covers medication reviews and rolling out across practices.