Medicines provide considerable benefit for many patients, but overprescribing of medicines that people do not need or want, or where harms outweigh potential benefits, is estimated to account for at least 10% of all medicines prescribed in the NHS. Older people often take multiple medications, which can cause harmful side effects, including falls, cognitive decline and loss of independence. The risk of harm from multiple medications also increases with frailty. Care home residents and older people from ethnic minority groups are more likely to take multiple medications and to be living with severe frailty.

In 2021 the NHS in England introduced routine structured medication reviews (SMRs) for older people with severe frailty and care home residents to try and reduce unnecessary medication use. Delivered through shared decision making and with a focus on deprescribing, SMRs are a comprehensive clinical review of a patient’s medicines. However there are concerns that the training pharmacists receive may not prepare them for the diverse needs of older people with frailty. There are also concerns that some people with severe frailty, for example from ethnic minority groups or people living in deprived areas, and care home residents may not be getting these reviews. This can cause health inequalities.

Aims & Objectives

To improve quality and accessibility of SMRs to reduce overprescribing for older people with severe frailty living in the community and care home residents, informed by intersectional characteristics and experiences.


  1. To use routinely available, linked health and care datasets that include ethnically diverse populations in areas of high socioeconomic deprivation to analyse how SMRs for community dwelling older people with severe frailty and care home residents are being delivered in NHS
    care, taking account of intersectional characteristics.
  2. To investigate how exposure to high-risk medications (e.g. anticholinergic medications) and related health and social care outcomes are influenced by intersectional characteristics using routinely available, linked data?
  3. To understand how the structures and processes employed to implement and deliver SMRs, including translation of pharmacist training into practice, shapes access and engagement for diverse groups of older people with severe frailty regardless of living accommodation.
  4. To understand the intersectional experiences of SMRs from the perspectives of older people with severe frailty and care home residents, their families and informal carers, across different geographical locations.
  5. To work with older people, families, carers, health and social care professionals, commissioners, and policymakers to co-design resources to improve the quality and accessibility of Structured Medication Reviews for diverse groups of older people with severe frailty and care home residents, tailored to different settings, building on generated knowledge.


Work Package 1: We will use routinely available, linked data from Clinical Practice Research Datalink (CPRD) Aurum and Gold, and Connected Bradford to investigate inequities and inequalities in delivery and outcomes of SMRs for our target groups.

Work Package 2: We will use a case study approach, building on WP1 findings to support identification of intersectional subgroups. Drawing on process tracing techniques, we will map structural/process elements in SMR implementation and delivery to examine how these shape access and engagement. We will study, using interviews and observations, how diverse groups of older people with severe frailty and care home residents experience SMRs, including contextual factors that influence their experience and outcomes.

Work Package 3: Building on models of co-production, we will conduct a series of workshops and coproduction meetings to address our final research question. This approach will ensure the iterative development and piloting of a targeted training package for pharmacists and detailed guidance for commissioners that is grounded in lived experience to ensure equitable access to and engagement with SMRs for diverse groups of older people with frailty.

Partners & Collaborators

Clegg A, Abuzour A, Alldred A, Best K, Hawkins R, Lawton R, Mistry M,  Pirmohamed M, Smith H, Spilsbury K, Todd O, Walker L, Walters K, West R,
Zaman H.



University of Leeds, University of Liverpool, University of Bradford, University College London, NHS West Yorkshire ICB


01/01/2024 – 31/12/2026

Funding agency

This study is independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research (HSDR) Programme NIHR153660. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health and Care Research or the Department of Health.

Further information

For further information contact Professor Andrew Clegg