Exploring the implementation and integration of structured medication reviews in primary care: A qualitative evaluation using normalization process theory

Abstract Background Structured Medication Reviews (SMRs) were introduced into primary care in England for patients living with multiple long-term conditions (MLTCs), polypharmacy, increased frailty, in care homes or at risk of medicines-related harm. SMRs aim to optimise the therapeutic potential of medication and reduce medicine-related harms through holistic reviews. Aim To explore the day-to-day work being undertaken with, and by, clinical pharmacists to implement, embed and integrate SMRs into practice, and consider how to optimise SMRs. Design and setting Qualitative one-to-one interviews with clinical pharmacists undertaking SMRs and SMR service leaders/managers (SMR leads) in England between February 2023 and November 2024. Method Participants were recruited as part of a wider evaluation of the roll-out of SMRs in England. Interview topic guides and qualitative data analysis were informed by Normalization Process Theory (NPT). Results Eighteen clinical pharmacists and five SMR leads participated. Participants reported often having to explain the purpose of SMRs and clinical pharmacists’ roles to patients, partly due to patients not being informed about SMRs. Participants valued SMRs and expressed that trust-building and tailored consultations were important for optimising medications. Integration varied due to high workload, inconsistent leadership support, inadequate administrative/pharmacist technician resource and lack of training. However, participants described SMRs as valuable for identifying and addressing unmet needs and supporting holistic, person-centred care across MLTC pathways. Conclusion The findings demonstrate the need for improved information on SMRs for patients and primary care teams, adequate and appropriate resource allocation, and enhanced support for consultation skills training to optimise medicines use. How this fits in - SMRs were formally introduced to primary care in 2020 to address the challenges of managing polypharmacy in an ageing population with increasing patient complexity and MLTCs. - SMRs were introduced alongside the expansion of clinical pharmacist roles in General Practice as a comprehensive, person-centred review of all a patient’s medicines. - This qualitative evaluation examines the day-to-day work of implementing and embedding SMRs, highlighting challenges to implementation and integration. - Our findings reveal challenges to the sustainability of SMRs and identify opportunities for optimisation, including addressing pharmacists’ training needs and resource allocation for administrative and pharmacy technician support.