Structured Medication Review Storylines: an interpretive policy analysis of medicines optimisation policy in primary care.

Problem

Problematic polypharmacy, usually defined as the use of 10 or more medications, is growing worldwide, particularly in older populations. The risks of polypharmacy to individual patients are well documented: medicine errors, adverse drug reactions, falls, frailty, hospital admission, increased hospital stay and premature death. Wider societal harms of polypharmacy include the environmental and financial impacts of medicine waste through unnecessary prescribing or unused medicines. In England, health policy hinges around the potential of medication reviews to alleviate harms from polypharmacy. General practice is tasked with tackling problematic polypharmacy through medicines management and the delivery of Structured Medication Reviews (SMR). Deprescribing, or stopping medicines, in medication reviews is challenging and evidence on the effectiveness of medication reviews as an intervention is limited. Gaps remain regarding policy addressing polypharmacy and how policy narratives become implementable actions.

Approach

This study is underpinned by Interpretive Policy Analysis (IPA) which seeks to understand how a policy is understood, interpreted and enacted by a range of actors. IPA will guide data collection and analysis on how medicine optimisation policy is conceptualised, developed and implemented. A corpus of 15 national policy documents spanning 10 years (2013-2023) were analysed using discourse analysis, metaphor analysis, and identifying ‘emblematic issues’. We conducted in-depth interviews with 12 key stakeholders responsible for the production, writing, rewriting and implementation of the SMR and medicines optimisation policy. Respondents were drawn from national NHS organisations, professional bodies (RCGP, RPS), and local integrated care boards and primary care networks) to further identify policy storylines and narratives. Analysis sought to: situate the policy of SMR within its recent historical context; identify key drivers for the policy; and elicit storylines inherent within the policy.

Findings

This is a work in progress and data collection and analysis is ongoing. Storylines as a type of narrative allow actors to draw upon various categories or issues to give meaning to complex social problems. Storylines inform and lead to action. In the case of the SMRs, problematic polypharmacy and overprescribing storylines within the policy focused on: increasing medicines safety by reducing the number of people who are overprescribed medication; promoting prescribing decisions that are patient-centred; introducing a new profession to the primary care workforce, reducing financial costs of prescribing to the NHS, and helping the NHS meet its carbon reduction commitments. This leads to the question – how well can the SMR be the solution to these wide-ranging and complex problems?

Consequences

As well as contributing to policy analysis and furthering understanding of how policy actions are made, this work will provide context to a linked study investigating the implementation of SMRs on the ground using video-reflexive ethnography.