Medicines optimisation in primary care became a formal discipline in 2013, when the Royal Pharmaceutical Society set out a four-principle framework that has guided the work ever since. The language was new at the time, but the underlying ideas were not. The framework redirected clinical attention from the medicine to the patient taking it and asked primary care teams to build that approach into routine prescribing.
More than a decade on, the four guiding principles still define how clinical pharmacy support is structured within GP practices and PCNs. NICE guideline NG5, issued in 2015, gave the principles formal clinical standing, and they now form the reference framework most clinical pharmacists, GPs and practice teams work from when designing medicines-related services. They also correspond closely to the day-to-day work of ARRS-funded pharmacy roles.
Key takeaways
- The RPS framework sets out four principles that continue to guide medicines optimisation work in primary care.
- NICE NG5 turned those principles into formal clinical guidance in 2015.
- Each principle maps to specific operational work, from shared decision-making to deprescribing.
- Clinical pharmacists in PCNs deliver against all four principles through their routine clinical work.
- The DHSC’s National Overprescribing Review reinforced the practical urgency of these objectives.
Why the Principles Still Matter
The case for getting medicines optimisation right has only grown sharper since 2013. The Department of Health and Social Care’s National Overprescribing Review found that 8.4 million people in England take five or more medicines on a regular basis, and that around 10% of items dispensed in primary care are not clinically needed. Adverse drug events cost the NHS around £400 million a year, while avoidable medication errors add another £98.5 million, with primary care prescribing responsible for around a third of harmful errors.
These are not problems any single intervention can resolve, which is why the framework treats medicines optimisation as four connected disciplines rather than a sequential checklist.
Principle One: Aim to Understand the Patient’s Experience
The first principle asks clinicians to take the patient’s experience of their medicines seriously, which includes whether they are taking each medicine as prescribed, what side effects they notice, what they believe each one does for them, and whether they can manage the regimen alongside their daily routine.
In practice this requires structured conversation rather than interrogation. A patient who has quietly stopped taking a statin because of muscle aches will not always raise that at a routine appointment, but a clinical pharmacist conducting a structured medication review with twenty or thirty minutes of dedicated time can surface the problem, document it and act on it. Shared decision-making is built into this principle, and patients who understand the rationale for each medicine they take are typically more consistent with adherence and report side effects sooner. They also respond more openly to deprescribing recommendations, an important factor in PCN deprescribing programmes.
Principle Two: Evidence-Based Choice of Medicines
The second principle covers the prescribing decision itself. Every medicine added to a patient’s regimen should rest on current evidence, follow NICE guidance and the local formulary, and stand up to a check against the existing medicines list for interactions and duplications.
This is also where prescribing cascades come to light. Common examples include a diuretic prescribed for ankle swelling caused by a calcium channel blocker, a proton pump inhibitor prescribed for indigestion caused by an NSAID, or an antidepressant added without consideration of an existing tricyclic. In each case the prescriber missed an opportunity to deprescribe the medicine causing the problem rather than add a new one. The framework therefore treats evidence-based prescribing as ongoing rather than a one-off event, which is why structured medication reviews carry as much weight as the original prescription.
Principle Three: Ensure Medicines Use Is as Safe as Possible
The third principle covers safety in routine practice, where monitoring, interaction checking and deprescribing function as continuous activities rather than appointment-bound events. Patients on high-risk medicines such as anticoagulants, lithium, methotrexate and certain immunosuppressants require recall systems that flag overdue blood tests before another prescription is issued. Patients on ten or more regular medicines are significantly more likely to be admitted to hospital with a drug-related problem, and that risk rises with each additional medicine.
PCN clinical pharmacists typically take operational responsibility for this work, which usually includes:
- Running system searches for patients overdue for high-risk medication monitoring.
- Auditing high-risk prescribing across member practices for trends and outliers.
- Coordinating practice responses to MHRA drug safety alerts.
- Leading deprescribing work to remove medicines no longer benefiting the patient.
Pharmacy technicians support the underlying repeat prescribing workflow, which is where many safety problems originate before they reach a prescriber for review.
Principle Four: Make Medicines Optimisation Part of Routine Practice
What the principle requires
The fourth principle deals with structure. Medicines optimisation cannot rest on individual goodwill or one-off projects, and the framework specifies that it must be built into routine workflow if it is to produce lasting change. That requires defined responsibilities, agreed protocols, clinical supervision arrangements, and the data infrastructure needed to show whether the work is having a measurable effect on prescribing quality and patient outcomes.
What it looks like in a PCN
In a PCN this typically means protected time for SMRs, named clinical leads for medicines safety, regular audit cycles tied to risk areas such as high-risk medication monitoring and polypharmacy in older adults, and clear escalation routes between pharmacy team members and prescribers. It also requires treating medicines optimisation as a clinical activity that warrants ongoing investment, rather than as a finite improvement project with a closing date.
How the Principles Translate to PCN Workforce Planning
The four principles correspond directly to the day-to-day work of ARRS-funded pharmacy roles. Clinical pharmacists deliver against principles one and three through SMRs and high-risk medication monitoring, while principle two depends on prescribers, including independent-prescribing pharmacists, working within evidence-based pathways and the local formulary. Principle four belongs to the network itself, expressed through workforce plans, clinical supervision arrangements and the operational integration of pharmacy roles into practice teams.
Networks that map their pharmacy workforce to these principles tend to use their ARRS allocation more effectively than those treating it as a generic recruitment fund, because the workforce plan reflects clinical need rather than headcount. Working with a specialist provider can help PCNs build pharmacy roles around all four principles from the outset, rather than retrofitting the framework when gaps appear.
