Reading through the new primary care network (PCN) DES for 2023/24, I can’t help but feel sorrow and mourn the disincentivising of the humble SMR.
Undoubtedly, we need to improve patient access into primary care and the latest PCN DES and investment and impact fund (IIF) will certainly facilitate and incentivise this.
However, I can’t help being sad that we’ve lost an important conduit for managing long-term conditions and engaging with our more vulnerable patients.
Read more: What will the push for access in the new GP contract mean for pharmacists?
The 2022/2023 PCN DES had a specific domain for prescribing, with an emphasis on SMRs.
These were divided into three categories and the points-based system actively incentivised practices within a PCN to all row together for a common purpose, utilising clinical pharmacists and technicians to deliver SMRs for patient benefit.
Over the last three years in my role as a PCN pharmacist, I’ve completed hundreds of SMRs. Without exception, all the housebound patients were appreciative of the contact and care afforded through these consultations.
Read more: PCNs: Golden opportunity or just a pain in the ARRS for community pharmacy?
I was often welcomed with, "Thank you for ringing, it’s nice to feel you’re looking after us."
Many of the older patients, who were stoic and frail, used SMR conversations to mention medicine-related issues that otherwise would have been left unattended.
I would often be told, "I don’t want to bother you as I know how busy you all are."
I regularly found that these consultations would end with a classic telephone 'door handle conversation': "Just before you go I must ask you about..."
Read more: New GP contract marks 'another blow for primary care', says PSNC
These consultations would often throw up medicine safety issues, such as a post myocardial infarction (MI) patient still taking aspirin and ticagrelor 18 months after their emergency, or a frail, 58kg 82-year-old still on apixaban 5mg twice daily.
They might also throw up a medicine safety issue related to a patient with heartburn taking aspirin and clopidogrel but no proton pump inhibitor (PPI), or a direct oral anticoagulant (DOAC) patient who bleeds and bruises very easily and occasionally has haematuria too.
Admittedly, during 2022 and 2023, many SMRs were booked to achieve the IIF threshold. However, in doing so they provided a first-rate platform to have an in-depth review of a patient and their medication, and in doing so really understand the patients or carers’ ideas, concerns and expectations.
The SMR platform allowed many Making Every Contact Count interventions.
Read more: Structured medication reviews mark a huge success for PCN pharmacy
This included annual bloods for angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB). These were proactively booked to save patients ringing reception in response to a text or letter.
It also ensured patient adherence with a shared decision making agenda and patients were offered and booked in for pneumonia, shingles or flu vaccinations.
In addition, it included numerous lifestyle opportunities to discuss diet, smoking cessation, weight loss and exercise and reminders about inhaler techniques – particularly if a patient had recently switched to a dry powdered inhaler (DPI) – and oral hygiene for an inhaled corticosteroid (ICS) user.
We know good practice is for all patients on repeat medications to have regular medication reviews, and various medicines have associated monitoring requirements such as ACEi and ARB annual renal function.
Read more: ‘Chaos’: GPs to ‘signpost’ patients to pharmacies from tomorrow
Nevertheless, I strongly believe that fewer reviews will be delivered by removing the financial incentive and measurement system while eradicating the focus on SMRs.
Ultimately, this could result in our frail and housebound patients receiving less care and attention than they truly deserve.
Chris Grahame is a senior clinical pharmacist, independent prescriber and a Centre for Pharmacy Postgraduate Education (CPPE) pathway mentor
