Medication review and adherence

• Ensure you can confidently identify and discuss any medicine-related issue, such as potential side effects, incorrect dosing schedules or device technique.
• You could obtain information from the patient medication record (PMR), prescription repeat ordering slip, hospital patient notes (including bedside data), prescription charts, test results, GP notes, etc.

• Identify any gaps in your knowledge and sign up for any training you may need to competently conduct the review. For example:
  • Clinical and medicines knowledge
  • Shared decision making
  • Any contractual requirements

We have various guides to support you, including prescribing, assessment skills, history-taking skills and consultation skills.

• Speak to your team and make sure you have support (in terms of a chaperone, admin, capacity to deliver the service, help raise awareness, etc.) and provide training if appropriate.

• Reviews should be conducted in an area where you and the person can speak without being overheard by others (e.g. in a dedicated consultation area or room).
• On wards, you could minimise other staff members or other patients/visitors overhearing the discussion (e.g. by drawing the curtains around the bed, conducting the review during non-visiting hours, etc.).
• If you want to conduct the medicine review at the person’s home or offsite, refer to local policies or your local health organisation/health board for information. 
• Risk assess the suitability of the room/area and ensure it has appropriate facilities and is regularly cleaned and disinfected.

• Access appropriate clinical reference materials in the consultation room/area – you can also access e-books such as the Renal Drug Handbook via our e-library.
• Have access to a computer/tablet device and the internet for filling in forms, accessing electronic records or resources online such as clinical guidelines, SPCs, local guidelines and prescribing formularies.
• Use support tools under further information to help your medicine review.

• Ensure you have a robust appointment system in place and train the pharmacy team in how to use this.
• Schedule reviews at suitable times via an appointment system.
• Ensure you have a process for dealing with late arrivals and no shows.
• Ensure you have a process for dealing with staff absence and when you cannot provide the service – contact people booked in for the service to reschedule.
• A diary (paper or electronic forms) showing the times and dates of when medicine reviews can be conducted by the pharmacist.
• You could also contact people by phone, SMS or email to confirm appointments and provide pre-appointment information (where possible).

• Have SOPs in place for how the medicine review service operates and ensure that all pharmacists and staff involved in providing the service read it.
• Keep the SOPs easily accessible, regularly reviewed and up to date.
• You could add assessment of adherence to existing pharmacy SOPs (e.g. dispensing process, delivery of pharmacy services and medicine taking).

• Use relevant support materials (such as dummy inhalers, patient leaflets, etc.) during the review, which will make the review more effective.
• Obtain equipment from a reputable source and store according to manufacturer’s recommendations.

• Provide information (written is preferable) about the review, either at the time when the review is arranged or during the review itself. Information could include the purpose of the review, what to expect, who it will be with, approximately how long it takes, any preparation needed and the possible outcome of the review.
• Encourage the person to bring to the review (if pre-booked) a list of questions about their medicines and a list of prescribed and non-prescribed medicines they are taking (alternatively, ask them to bring their medicines with them if you want to check their technique, e.g., their inhaler). Encourage them to bring in any patient-held records (e.g. insulin passport, warfarin books, steroid cards).
• You may also want to suggest the person bring a pen and paper to write down what was discussed for their own reference.
• There should be a complaints procedure available in your pharmacy and people using the service should be advised of this should they want to make a complaint or raise a concern.

You may need to consider developing written literature that can be given to people with the above and any other relevant information or use websites and posters.

Consider the following to help support your consultation: 

• Introductions – Introduce yourself: state your name and role (‘hello my name is…’), smile, make eye contact and ask, ‘is it OK to talk about your medicines?’ 
• Confirm the person’s ID – If appropriate, especially in circumstances where they are not known to you.
• Set the scene – Explain to the person and/or their carer the purpose, structure and expectations of the review.
  • Are any reasonable adjustments or other requirements needed, e.g., hearing loop, chaperone or translator (where appropriate)?
• Consent – You should obtain the person’s consent to conduct a review (written consent is preferable).
  • This should include consent (if appropriate) to share details of the review with the person’s GP or wider healthcare team.
  • Consider the person’s capacity to consent and contribute to the see the GPhC’s guidance for pharmacy professionals.
  • Where relevant, consider discussing the content and wording used on the consent form with legal advisors (i.e. business indemnity insurance providers, local health organisations/health boards, trust advisors, etc.).
• Chaperone – All people should be given the option of having a chaperone with them at the review (for further information see the GPhC Guidance for pharmacy professionals). The chaperone can aid with communication issues, act as a prompt to ask more questions, etc.
• Safeguarding children and young adults – Where children may also benefit from a review, and it’s appropriate, the child is competent and has the capacity to give consent, consider discussing their treatment with them. You should be aware of local child protection policies and guidelines (see our safeguarding guide on protecting children and young people). If it is not appropriate to conduct the review with the child, you may want to consider doing the review with their parent(s) or guardian.
• Communication – Communicate any advice or counselling given in a clear and structured way. Consider the health literacy of the person and be satisfied the person has understood the information correctly. Clarify vague responses with further questioning or by using other sources of information.

The following questions may help you gather relevant information and medication history:

• Ask the person how they are getting on with their medicines.
• Ask the person what they know and understand about each of their medicines and the conditions they are used for (indication) to identity the aims of drug therapy (from a clinical and the person’s perspective) and to assess whether the medicines are essential or not.
• For each medicine, check the dose is correct and ask how they take it. Compare this with how its prescribed.
• Ask if they want to take the medicine or want to continue taking it to seek the person’s (and/or their carer’s) perspective of their medicines and how they take them.
• Ask the person if the medicine is working to assess effectiveness (both clinical and cost effectiveness) of the medicines.
• Check they need the medicine and if they are on the right medicine (using updated clinical and prescribing guidelines) to support decisions and actions regarding stopping or continuing the medicines.
• Ask about any general or specific concerns they have (such as side effects/adverse effects or dependence).
• Ask the person and check about recent and required monitoring and relevant clinical examinations, e.g., bloods tests, annual reviews, blood pressure, weight and screening for risks (e.g., Q Risk or PHQ9). These may be needed to calculate dose.
• Check for contraindications.
• Check interactions (including with non-prescribed medicines).
• Ask about any other medicines they are taking/using, e.g., including prescribed, OTC, herbal, complementary, vitamins, dietary supplements, recreational drugs, alcohol, tobacco, etc.) in case they are of clinical relevance, and to check interactions.
• Check use of any medical devices supplied. You may find our guide on medical devices useful.
• Check effect on ability to drive – for example, if it causes drowsiness.

The following pointers can help you get an accurate picture of how the person is using their medicine and issues relating to non-adherence. To assess the person’s level of adherence to the medicines it may be useful to:

• Ask about adherence and clarify possible causes of non-adherence.
• Explain why you are asking about their medicines adherence, e.g., a substantial break in their treatment may result in adverse effects, a deterioration of their condition.
• Ask about their medicine-taking habits.
• Ask the person if they have missed any doses recently in a way that does not assign blame, e.g., have you been able to take your medicines regularly as directed?
• Ask whether they think they still need the medicine.

If a person is non-adherent, discuss with them possible reasons why this may be – perhaps it conflicts with their beliefs or their reluctance to take charge of their medicine regime is compounded by ill-informed concerns (intentional non-adherence).

Remember intentional and unintentional reasons for non-adherence may overlap. For example, a person who does not think their medicine is necessary may be more likely to forget it. In this instance, simply providing reminders might not be as effective as providing a clear rationale for treatment in addition to reminders.

It is important to offer all people the opportunity to be involved in decision making about their medicines and to identify what level of involvement the person is comfortable with.

To increase their involvement:

• Listen to the person to clearly identify what they hope the treatment will achieve.
• Do not make assumptions about the person’s preferences about treatment if they appear non-committal about their options.
• Support people to make decisions based on likely benefits and risks rather than misconceptions.
• Bear in mind that people have the right to decide not to take a medicine as long as they have capacity and have been given the information to make an informed decision. If the person decides not to take or to stop taking a medicine, and in your view this could be harmful, you may want to make a record of the decision and the information you provided on risks and benefits.
• Use coaching and motivational interviewing techniques to make the person accountable for their own goals.
• Create a plan together on decisions and actions regarding continuing, starting or stopping medicines.
• Follow up with people after the review as appropriate, e.g., by phone or face to face. 
• Encourage people and, where appropriate, support their families and carers to keep an up-to-date list of prescription and non-prescription medicines, allergies or adverse reactions.

Interventions should only be used to overcome practical problems if there is a specific need.

Side effects

Where a person raises concerns about possible side effects or has already experienced side effects with their medicines, it may be worth discussing how best these side effects could be managed in practical terms, particularly if there is a possibility that these could develop into long-term effects. Where side effects cannot be managed practically, consider options such as adjusting the dosage, switching to another medicine, or changing the timing of medicines. These options should be discussed with the person’s prescriber where appropriate. Liaising with other healthcare professionals involved in the person’s care requires patient consent.

Complex medicines regimes

Suggest people record their medicine-taking, encourage them to monitor their condition, or simplify the dosing regimen using alternative packaging or compliance aids (see the multi-compartment compliance aids guide for more information). 

Check if there is an opportunity for deprescribing or medicines optimisation (see our guide on polypharmacy for more information). 

Lack of understanding of their condition

Recommending peer support groups or national organisations whose focus relates directly to the person’s condition may be worthwhile where the person is keen to learn more from individuals affected by the same illness and/or who follow a similar medicine regime.

People may need more support to help them use their medicines more effectively. This may mean providing further information or making changes to their medicine regime.

Address any specific concerns, bearing in mind that people may wish to minimise their medicines and discuss:

• The aims of treatment
• What will happen if they don’t take the medicine
• Non-pharmacological alternatives
• Reducing or stopping long-term medicines
• Fitting medicines into their routine
• Choosing between medicines
• Provide patient information leaflets (PILs) and signpost them to useful websites (e.g., www.nhs.uk)

• Summarise discussions. 
• Safety net. 
• Ask the person to recap what they understood and the actions they agreed upon.
• Agree a plan of action and date for a follow-up.
• Ask if they have any questions.
• Offer contact details if the person has further questions after the review is over.

• Provide people with information on how to get in touch with a pharmacist if they have any questions after the review.
• Ensure you follow-up on any changes made during the review and to review the impact of the change and whether there is a need for another review.
• Within a hospital you may consider communicating any follow-up requirements in the care plan, patient medical notes or discharge summary/transfer of care documents.
• You may find it appropriate to conduct reviews on people who have previously had one to ensure that any actions agreed by the person or other healthcare colleagues have been made, if they have had a significant change in their medicine, dose changes, suffering side effects from new/existing medicines, etc.
• As an audit trail any follow up actions or communications should be recorded, i.e., in the PMR, patient medical notes, etc.

• People’s experience of using their medicines and their need for adherence support may change over time and should be reviewed regularly at agreed intervals. 
• People should be offered repeat reviews to help them optimise their medicines use, especially where their condition requires long-term treatment, or they are taking multiple medicines. You should continue to consider interventions to increase adherence as appropriate. 

What to record and where

• Make sure there’s a robust system in place to capture information that must be recorded as part of the review (on paper or electronically). This includes if you are delivering the service at an alternative location.
• Records could be captured in the person’s PMR, patient notes and records (using correct codes), hospital medical notes, discharge summary/transfer of care documents and care plans where relevant.
• You may want to keep records of discussions, changes in treatment and advice you’ve provided people for audit purposes and to support future reviews (during or after the review).
• In community pharmacy, there may be contractual requirements to record details of the medicines reviews, interventions and outcomes. For further information see the Community Pharmacy England, Community Pharmacy Scotland or Community Pharmacy Wales websites as appropriate.
• The following may help you in writing a template when conducting the review, providing prompts on what questions to ask and information to record (note: this is not an exhaustive list, you may consider it appropriate to record other details):
  • Patient details (e.g., name, address, date of birth, NHS/CHI number, etc.)
  • GP/doctor details (e.g., name of GP practice/doctor, address of surgery/hospital, etc.)
  • Medicines the person is currently taking (both prescribed and not prescribed)
  • Comments or discussion on taking the medicine, side effects, the person’s understanding of the medicine/treatment, etc.
  • Medicine/treatment-related issues and any action points discussed in the review (i.e., recommendations to improve treatment, discussion for pharmacist to have with GP) and follow-up information (such as monitoring, when to follow up, next review etc.)
  • Additional lifestyle advice provided
  • Referral to other healthcare professionals

Further details and support of what to record and document can be found in our clinical documentation guide.

Retention period of reviews

• Keep a record of the review (on paper or electronically) for as long as appropriate, e.g., as reference for any follow ups and audit purposes and securely, i.e., in line with the service requirements and/or indemnity insurance provider requirements.
• You may want to consider supplying a copy of the record made or notes to the person for their information.

People may be under the care of more than one healthcare professional at a time. Therefore:

• Information, recommended changes or concerns (including red flags) that arise during the review should be communicated to the person and any other healthcare providers involved in their care. 
• If you need to discuss anything with the GP or share details of the review with other healthcare professionals, you will need to obtain consent (preferably written consent) and ensure no breach in patient confidentiality.
• To maintain an audit trail, any communication should be recorded, i.e., in the PMR, patient medical notes, etc. 

On transfer between services (for example, discharge from hospital) give the person and subsequent healthcare or other providers a written report containing:

• The person’s diagnosis
• A list of all medicines the person should be taking
• Clear identification of any new medicines that were started
• Clear identification of any medicines that were stopped with reasons
• Clear information on which medicines should be continued after transfer and for how long
• Any known adverse reactions and allergies
• Any potential difficulties with adherence and any actions taken (e.g., provision of a multi-compartment medicines system)

NICE defines a structured medication review as ‘a critical examination of a person’s medicines with the objective of reaching an agreement with the person about treatment, optimising the impact of medicines, minimising the number of medication related problems and reducing waste’. See NICE. Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes 2015 | NG5. [Accessed 4 September 2020].

A structured medication review (SMR) (England only) is a holistic and personalised review of an individual at risk of medicines-related harms (e.g. those in care homes, with problematic polypharmacy, severe frailty, isolated or housebound, recent falls or hospital admissions or on medicines associated with errors). When conducting SMRs you need to consider shared decision-making, personalising the review and the safety and effectiveness of medicines prescribed as well as providing advice, signposting and making appropriate referrals.  

Medicines adherence focuses on the person’s behaviour in taking their medicines.

The World Health Organisation (WHO) defines adherence as; ‘the extent to which a person’s behaviour – taking medication, following a diet and/or executing lifestyle changes – corresponds with agreed recommendations from a healthcare provider’.

Non-adherence falls into two categories:

• Intentional – where that person decides not to follow the treatment recommendations.
• Unintentional – where the person wants to follow the treatment recommendations but faces practical problems.

Concordance describes the process whereby the clinician and person collaboratively design a treatment regimen.

• Counselling patients on the use of medicines.
• Multi-compartment compliance aids.
• Clinical documentation.
• Medicines reconciliation and medication history.
• Polypharmacy: getting our medicines right.
• Medicines optimisation.
• Antimicrobial stewardship.
• Repeat prescribing toolkit – developed with the RCGP, to improve the safety and efficiency of repeat prescribing and reduce medicines waste.

Community Pharmacy Contractual Medication Review services

Specific requirements for each of the services can be viewed on the links provided.

• England – Community Pharmacy England. 
• Scotland – Community Pharmacy Scotland.
• Wales – Community Pharmacy Wales.

Adapted resources to give to patients, families and care providers ​​

• Resources to support patients having a Structured Medication Review – The Health Innovation Network​ has patient information materials in different community languages to support and prepare people who have been invited for a medication review with their GP, pharmacist or other healthcare professional.​ Easy read materials on this site​ include:
  • Patient invitation letter – easy read.​​
  • Safely stopping medication – easy read.​​
  • Me and my medicines charter – easy read​​.

Examples of medication review tools and checklists

• Medichec AntiCholinergic Burden (ACB) tool.
• NHS Scotland Polypharmacy Guidance – Medicines review – seven steps.
• NHS England Toolkit for general practice in supporting older people living with frailty – Appendix 5 STOPP START Medication Review Tool.
• BMJ Using the NO TEARS tool for medication review – 19 August 2004.
• NHS England Structured medication reviews and medicines optimisation (SMR) – 17 September 2020.
• Pharmaceutical Journal How to prepare for and contribute to a consultant’s ward – 1 February 2010.
• Royal College of Physicians’ (RCP) medicines safety checklist – to ensure people have the information they need about their medicines at hospital discharge.
• Specialist Pharmacy Service Using resources to support medication review.
• Specialist Pharmacy Service Understanding when a check adds value to medication processes – resource to help you understand what a check is (not referring to a clinical check), the principles of an effective check and factors to consider if introducing an independent second check to a medication process.
• NICE Medicines Adherence: Involving patients in decisions about prescribed medicines and supporting adherence – 28 January 2009.
• NICE Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes – 4 March 2015.
• Health innovation network The mechanics of tackling overprescribing and problematic polypharmacy – aimed at helping primary care organisations and integrated care boards (ICBs) understand and address problematic polypharmacy, providing practical, evidence-based strategies to help organisations and healthcare professionals help to reduce overprescribing, improve patient outcomes and improve the quality of SMRs.

Frailty

• NHS England Frailty resources.

Inhalers

• NHS England Improving health outcomes for respiratory patients while reducing carbon emissions.
• Asthma+Lung UK How to use your inhaler – videos.
• NICE Asthma inhalers and climate change (patient decision aid).

NHS Futures (free, but requires registration)

• Community of Practice Pilot Report outlines key recommendations in relation to the role local health systems and all pharmacy teams in the use of medication reviews to reduce over-medication of people with a learning disability.
• STOMP and STAMP – Futures highlights and develops good practice relating to the most appropriate use of medication in people with a learning disability and autistic people, including links to training webinars, resources, reports and access to a community of practice to ask questions and share good practice.
• This workspace is free to access with a suitable email via NHS Futures.