The Pharmaceutical Journal
Vol 269 No 7211 p209-210
17 August 2002

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What does medication review mean?

The National Service Framework for Older People recognises that all health care professionals, especially pharmacists, can help optimise medicine use among the elderly. However, the requirement for an annual medication review in all patients over 75 years has led to some confusion about what should be done and how. Monika Polak (on the staff of The Journal) tries to unravel what the review means for pharmacy

No one would disagree that optimising medicine use among the elderly is a worthy pursuit. As well as decreasing costs to the National Health Service, it can improve outcomes by ensuring patients do not suffer illness as a result of excessive, inappropriate or inadequate consumption of medicines.

However, in attempting to set up systems that can provide annual medication reviews for the elderly, as required by the National Service Framework for Older People, doctors and pharmacists have come up with a whole plethora of questions. What should medicines review involve — does it mean going through patients' medical records to see what is being prescribed, or should it be a more in-depth discussion with the patient about what each medicine is for and what benefit it gives them? Is a full review necessary for every patient over 75 years, or only for those on multiple medicines? And should it be done by a general practitioner, or should pharmacists take the lead?

The NSF specifies that an in-depth evaluation of all a patient's medication (prescribed and non-prescribed) should be targeted at older people who are known to be "at higher risk of medicines-related problems". It says this group is likely to include those being prescribed more than four drugs, those just discharged from hospital, those in care homes, those in whom medicines-related problems have previously been identified, those suffering an adverse change in health and those aged over 75 years. This is a huge number of people and it is no wonder that health care teams are daunted by the workload in-depth medication reviews will undoubtedly generate.

Where to begin

England's national director for older people's services, Professor Ian Philp, admits there will be workload pressures in the short term, but firmly believes it will only take three years to embed good medicines management into everyday practice. He advises primary care trusts, together with their pharmaceutical advisers, to get a clear view of the client group — frail, old people with age-related needs and polypharmacy — and then agree on a shared approach to medicines management.

Professor Philp, who is also a consultant geriatrician at Sheffield's Northern General Hospital and professor of health care for elderly people at Sheffield University, says having a feel for which drugs could be causing more harm than good is important and that pharmacists have this expertise. However, he also believes that concentrating medication review work in one sector would ignore many other health care professionals involved in an older person's care who could also contribute to medicines management. "In some areas it may be right that you train a cadre of community pharmacists to go out into the community, but in other areas that may not be possible. Who would do it would depend on what local resources there are," he says. "I see no reason why GPs, hospital doctors and nursing staff trained to a given level, should also not be able to spot these problems. Some 90 per cent of older people will see a community nurse or their GP at least once a year and a lot of those taking four or more drugs will come into contact with secondary care. What we need to do is incorporate it into normal practice."

Professor Philp hopes people will eventually break away from a rigid, age-related approach to medication review and says much could be learnt from the Australian health care system, which this year launched a medication review process for all patients, not only the elderly. However, for the present time, even existing NSF guidance is proving expensive to implement, both in terms of time and money, and Professor Philp agrees that focusing on elderly people who are most at risk is a sensible approach.

Focus on high-risk groups

East Elmbridge and Mid-Surrey PCT has opted to target those most at risk. Pharmaceutical adviser Gabrielle Clezy says: "I worked out that to do the annual review as stated in the NSF would need four full-time pharmacists — we could not afford that. You have to pick out the most vulnerable groups, such as those on multiple medicines or those recently discharged from hospital."

The PCT has employed seven primary care pharmacists on a sessional basis to implement general practice-based medication reviews. All have completed the Keele University clinical pharmacy for medicines management course. Pharmacists carry out reviews themselves, but also provide guidance for GPs and practice nurses so that they too can do them. Each review takes about 20 minutes, and a report is produced for the GP at the end of each three-and-a-half-hour session at the practice, detailing any problems or recommended changes. Ms Clezy says the initiative is costly both in financial terms and in the time and energy required by staff, but she adds: "It is money well spent. We now have a core group of skilled pharmacists, who can go back to practices and help them in other ways and the GPs are grateful for the pharmacists' input."

Although she would have preferred more community pharmacy involvement, funding was only available for a practice-based scheme and Ms Clezy admits there are advantages to this: "The programme has to be a gold standard. The only way to achieve that is to have access to medical records and involve a multidisciplinary team."

Following the Scottish example

The forerunner for many of the medication review schemes now being put in place in England began in Glasgow back in 1995. This practice-based, pharmacist-run model was targeted at patients over 65 years on four or more drugs, and it has demonstrated both cost savings and health improvements (PJ, 18 September 1999, pR7).

Suitable patients were identified from practice records and, once informed consent was obtained, were interviewed by a pharmacist. Interviews involved the patients bringing in their medicines, including over-the-counter products, and took about 15 minutes. Project lead and head of pharmacy at the Robert Gordon University in Aberdeen, Professor Clare Mackie, says: "This model has been used throughout Scotland and in many PCTs in England. The key point is that the patient is interviewed."

She adds that many Scottish projects, including the Glasgow example, are now moving on to target other specific groups of patients, such as those with hypertension and diabetes: "About 60 per cent of the medication problems we found occurred in patients with cardiovascular disease, that is why we targeted hypertension. Some people are targeting heart failure, others are targeting particular drugs, such as non-steroidal anti-inflammatory drugs."

Barking and Havering Health Authority has launched a medication review pilot based on the Glasgow experience, targeting people over 65 years who are taking four or more medicines (PJ, 16 February, p197). Professor Mackie, who is also leading this project, says: "Interviews in Glasgow have been practice-based, but we are now looking at transferring it to community pharmacists. The other big thing is making it electronic. Standard reviews are seven to eight pages long, whereas everything will be electronic in Barking and Havering."

Patient recruitment has not yet begun, but a considerable amount of time has already been invested in training pharmacists to do the reviews — about 300 hours of postgraduate education per pharmacist. Approximately half of the pharmacy contractors in the health authority are involved. Informed consent will be sought from suitable patients identified by general practices, giving pharmacists access to the patients' medical histories. Face-to-face reviews will normally take place in the pharmacy. If no private area is available an alternative venue will be found.

Pharmacists will look for any side effects or difficulties that patients have with their medication and discuss any discrepancies that arise between the medicines being taken and patients' medical profiles. They will also ask patients if they understand why they are taking each medicine.

New medicines review toolkit

Earlier this year, the government launched the Medicines Partnership programme, based at the Royal Pharmaceutical Society, with the aim of helping people maximise benefits from their medication (PJ, 26 January, p87). Its director, Joanne Shaw, says many PCTs in England are now making major strides towards implementing medication reviews, but recognises others still need more information on how to proceed.

She says help will soon be at hand through the Medicines Management Services Collaborative, organised by the National Prescribing Centre: "There are many examples of good practice, but there is a need for more practical guidance about what constitutes a review and how to deliver reviews effectively. That is why the Task Force on Medicines Partnership has joined with the NPC to develop a guide to medication review, with advice and tools for practitioner and patients."

According to Professor Alison Blenkinsopp, who is director of the pharmacy department at Keele University and co-author of the Medicines and Older People section of the NSF, the NPC's new guidance will provide a definition and ideas on how to take things forward. She agrees there has been much discussion as to what medicine reviews should involve, but says PCTs should focus on outcomes, rather than the process of reviewing patients. "I would prefer it if we started to concentrate on what we are trying to achieve," she says. "We have tried to look at different levels of medication review — we are not suggesting that everyone needs a full clinical review, because that is not feasible. In reality, different patients have different needs. A patient might be on four medicines, but they might be symptomatic treatments, such as paracetamol or antacids, rather than medicines for chronic conditions."

Professor Blenkinsopp says the role of pharmacists has now risen up the agenda considerably: "In many areas people will be asking 'Can we use community pharmacists?' and GPs are very much seeing pharmacists as key people in this process."

Director of the National Prescribing Centre, Clive Jackson, agrees. He believes medication review is linked to many other aspects of the NHS plan that involve increasing pharmacist input, such as repeat dispensing, local pharmaceutical services and medicines management services. "Medication review is potentially multidisciplinary, but pharmacists are well placed to do it. It is absolutely right that this is not the exclusive domain of pharmacists, but having said that, the unique skills that pharmacists have are particularly suitable to an effective patient review," he says.

Mr Jackson also says access to full patient records is not essential for a review to be effective: "Not everyone can have a full review or needs one. It is all about adapting the service to the needs of the patient. Hopefully the NPC's new guidance will help people to understand that and to develop a flexible service. It will include views from the patient and also examples of good practice from a range of areas."

According to Mr Jackson, results from the collaborative pilot sites have been encouraging and a report will be published along with the new guidance in October.