The structured medication review (SMR) is one of the most clinically useful things a practice or primary care network can do, and one of the easiest to let slip when clinical time is short. A good SMR catches the patient on eight medicines who only needs four, the frail older person whose blood pressure target has quietly become unsafe, and the inhaler that has not worked properly in years. The challenge is rarely whether SMRs matter. It is finding the trained clinical time, the governance and the consistency to deliver them at scale.
This guide explains what a structured medication review actually is, the NICE-aligned method behind it, how to decide which patients to prioritise, and how managed structured medication review support helps PCNs deliver reviews safely without adding another person for the practice to look after.
What is a structured medication review?
A structured medication review is a planned, comprehensive and clinical review of a patient’s medicines, carried out in partnership with the patient. It is not a quick reauthorisation of a repeat prescription. The SMR looks at the whole picture: every medicine the patient takes, whether each one is still doing its job, whether any are causing harm, what the patient actually wants from their treatment, and whether the regimen can be made simpler and safer.
SMRs were formalised as a core part of primary care through the Network Contract DES, with PCNs expected to identify and review the patients who stand to benefit most. The aim is to move medicines reviews away from a transactional, prescription-by-prescription habit and towards a considered clinical conversation that improves outcomes and reduces avoidable harm.
An SMR sits alongside other medicines work such as clinical medication reviews, high-risk drug monitoring and wider medicines optimisation. Together these form the backbone of safe prescribing across a practice population.
The NICE-aligned method behind a good SMR
A structured medication review is shaped by NICE guidance on medicines optimisation (NG5) and on multimorbidity (NG56), along with the principles of shared decision making. The structure is what makes it reliable. A consistent method supports a thorough assessment while allowing for individual clinical needs and patient preferences.
In practice, a well-run SMR works through the following stages.
- Preparation. The clinician reviews the full record before the appointment: diagnoses, blood results, monitoring history, recent admissions, allergies and the complete medication list, including anything bought over the counter.
- Identifying problems. The review screens for the things that cause real harm: drug interactions, anticholinergic burden, medicines lacking a clear indication, dosing that no longer suits renal function or age, and gaps in monitoring for high-risk drugs.
- The patient conversation. The SMR is a two-way discussion. What matters to the patient, how they actually take their medicines, what side effects they live with, and which treatments they would happily stop all shape the outcome.
- Shared decisions. Changes are agreed with the patient rather than imposed. This includes deprescribing where a medicine no longer offers benefit, and optimising doses where it does.
- Action and follow-up. Every change is recorded clearly, communicated to the patient, and given a follow-up plan so nothing is left unmonitored.
Done this way, the SMR tends to reduce pill burden, cut waste and improve adherence, picking up safety issues before they become admissions. It also generates clean, coded records that support QOF reporting.
How to prioritise patients for SMRs
No practice has the capacity to review everyone at once, and not everyone needs a full SMR. The skill is in targeting the patients where a review changes the most. NHS guidance points clearly towards prioritising people at higher risk of medicines-related harm.
Sensible priority groups include:
- People in care homes, who are often on the longest and most complex regimens.
- People with polypharmacy, particularly those on ten or more medicines or on problematic combinations.
- People taking high-risk drugs such as anticoagulants, methotrexate, lithium, DMARDs and NSAIDs.
- People with severe frailty, chronic kidney disease, or multiple long-term conditions.
- People recently discharged from hospital, where medicines often change and reconciliation is incomplete.
- People with addiction risks, including those on dependence-forming medicines.
Searches across EMIS, SystmOne, Vision or Medicus can surface these cohorts quickly, but the searches need to be designed and refined by someone who understands both the clinical risk and the coding. Getting the prioritisation right is what turns a pile of reviews into measurable improvement in patient safety.
Why SMRs are hard to deliver consistently
Most practices and PCNs already know they should be doing more SMRs. The barriers are practical. A thorough review takes time and a clinician confident enough to deprescribe. Pharmacist recruitment is difficult, induction is slow, and clinical pharmacy roles can sit unfilled for months. When a reviewer leaves, the work stalls and the backlog rebuilds. Quality also drifts when there is no shared method and no oversight of the decisions being made.
There is also the question of who carries the clinical risk. An SMR involves real prescribing decisions on real patients. Practices need confidence that those decisions are made to a defined standard, documented properly and backed by clinical governance.
How managed structured medication review support works
This is where a managed service differs from a staffing model. Rather than the practice recruiting, inducting and supervising another individual, structured medication review support is delivered as a complete, governed clinical service. Virtual Pharmacist runs SMRs remotely inside the practice’s own clinical system, whether that is EMIS, SystmOne, Vision or Medicus. Our pharmacists are professionally accountable for their own clinical decisions and any prescriptions they sign. Virtual Pharmacist is accountable for the service we deliver, including its clinical governance, supervision and quality assurance. The commissioning practice or organisation retains its own clinical and regulatory responsibilities.
In practical terms that means:
- Reviews are carried out by GPhC-registered pharmacists working to a consistent, NICE-aligned method, supported where appropriate by pharmacy technicians for the searches, data and administrative groundwork.
- Work happens within the practice’s records, so coding, follow-up and reporting all sit in the right place for QOF reporting.
- Quality is checked. Decisions are reviewed against an agreed standard rather than left to vary by individual.
- The information governance is already in place, including NHS Data Security and Protection Toolkit compliance, Cyber Essentials, HSCN, ICO registration and data sharing agreements.
- The practice is not left managing another person. The service is delivered and owned end to end.
For a PCN, this model scales SMR delivery across multiple practices without each one solving the same recruitment and governance problem separately. It can run alongside broader PCN management support and wider NHS support, and at ICB level it complements medicines management priorities across a system.
What good SMR support should give you
When you assess any structured medication review support, look past the headcount and ask about outcomes and assurance. A strong service should give you a clear method you can see, GPhC-registered clinicians delivering it, strong clinical governance and data security, coded records that feed your reporting, and a provider that is accountable for the service it delivers, alongside the practice’s own responsibilities and agreed escalation arrangements. That combination is what lets a practice or PCN deliver SMRs at the volume the contract expects while keeping patients safe.
Frequently asked questions
What is the difference between a structured medication review and a medication review?
A structured medication review is a deeper, planned clinical review that looks at the whole patient and their full medicines list in partnership with them, following a defined NICE-aligned method. The depth and format of other medication reviews depend on their purpose and the patient’s needs. A records-only check or repeat authorisation is not, by itself, a patient-centred SMR.
Who can carry out a structured medication review?
SMRs are clinical reviews and should be carried out by a suitably trained prescriber or clinical pharmacist with the right competencies, including the confidence to deprescribe. Pharmacy technicians can support the process by running searches, preparing data and handling administrative work, with the clinical decisions made by the pharmacist.
Which patients should be prioritised for an SMR?
Prioritise patients at highest risk of medicines-related harm. That typically means care home residents, people on ten or more medicines, those taking high-risk drugs such as anticoagulants or methotrexate, people with frailty or chronic kidney disease, recently discharged patients, and those at risk of dependence on certain medicines.
Can SMRs be delivered remotely?
Yes. SMRs can be delivered remotely by pharmacists working securely inside the practice’s own EMIS, SystmOne, Vision or Medicus system, with the patient conversation held by phone or video where appropriate. Remote delivery keeps coding, follow-up and reporting in the right place while the governance and data security sit with the provider.
How does managed SMR support protect the practice?
A managed service means the provider is accountable for the service it delivers, including its clinical governance, supervision and quality assurance. It works to a consistent standard and brings its own information governance stack. The practice gains the clinical output without taking on the recruitment, supervision and risk of managing another individual.
If your practice or PCN wants to deliver structured medication reviews safely and at scale, Virtual Pharmacist can help. We deliver SMRs as a fully managed, remote clinical service inside your own clinical systems, and we are accountable for that service, including its clinical governance, supervision and quality assurance. Contact Virtual Pharmacist to discuss what your practice or network needs.
