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Room for Review: Foreword

Professor Marshall Marinker
The hazards of prescribing and taking inappropriate medicines have been long recognised. They include the secondary morbidity from unnecessary or inappropriate medicines, from wrong doses, incompatibilities, and confusion from the multiplicity of medicines prescribed, particularly in the treatment of older people. For these reasons the importance of reconsidering the patient's medication has always been implicit in any concept of good practice. What is new in medication review is the requirement that this should now be carried out in the NHS in an explicit and systematic way. The guide describes this as a "structured, critical examination of a patient's medicines".
Clearly it will be necessary for reviews to be evidence-based, in line with many NHS initiatives that seek to bring the best information from research to the care of patients. This will be necessary but it will not be sufficient. The guide specifies that whenever some change to the prescription is proposed, in line with other NHS initiatives like Medicines Partnership, such change is to be implemented by "reaching an agreement with the patient". Therefore, no less crucial than the evidence from clinical and pharmacological research, reviewers will also need evidence about the diagnoses, about the medicines that the patient is actually taking, about the patient's capacity and motivation to take the medicines, and about the patient's priorities and beliefs about medicine taking.
Two theoretical concerns about the scope of medication review require to be addressed here. The first refers to the danger of isolating consideration of prescribing and medicine taking from the whole clinical picture and process. The guide makes clear that there should be no such danger. Reviews of scripts in the absence of the medical record, or of the record in the absence of the patient, are described here as screens for significant prescribing error, and are to trigger a full medication review which must involve consideration of the relevant clinical information contained in the medical record, and can only be effective with the active participation of the patient.
The second concern refers to an apparent conflict between the two linked goals of medication review to prescribe according to best evidence from scientific research, and to be mindful of the precepts of patient autonomy. Scientific evidence and patient autonomy are relative not absolute values. Studies of the performance of medicines refer to their performance in research populations. They can only suggest the most sensible starting point in considering what best to prescribe. The evidence cannot predict what will best suit any one individual patient. The patient is someone in a relationship with a health professional. Just as the citizen can expect to enjoy only such autonomy as is consonant with living in a society, so the patient can expect only such autonomy as is consonant with engagement in health care.
The theoretical conflict between these values will in practice be resolved by the exercise of professional judgement which must always go beyond the evidence, and by the development of a co-operative style of communication, what is described as concordance, between professional and patient.
There will always be trade offs, but one principle seems imperative. In order to come to an understanding with the patient about the medicines that will help, and about the need for co-operation, it is essential that the patient and the professional actually meet to discuss any substantial variations suggested by the review to the previous medication. For medication review to make a real difference, such discussion must be sensitive and responsive to the patient's particular situation, reasoning and concerns. If we are able to achieve this, the full implementation of medication review should transform both the quality of prescribing and the benefit to patients.
Marshall Marinker

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