Multimorbidity — living with two or more long-term health conditions — is now the norm rather than the exception in UK primary care. According to data from the King's Fund, approximately 26% of the adult population in England has two or more long-term conditions, rising to more than 50% among those aged 65 and over. For pharmacists, these patients represent both the greatest clinical challenge and the greatest opportunity to make a measurable difference.
The polypharmacy problem
Polypharmacy — conventionally defined as the regular use of five or more medicines — is a near-inevitable consequence of multimorbidity. Each condition has its own guideline, its own first-line treatment, and its own monitoring requirements. A patient with type 2 diabetes, hypertension and osteoarthritis might reasonably be prescribed metformin, a sulfonylurea, an ACE inhibitor, amlodipine, a statin, aspirin and regular paracetamol — seven medicines before accounting for PRN treatments or over-the-counter products.
The problem is not that these medicines are individually wrong. Each may be entirely appropriate for its condition in isolation. The problem is that guidelines are written for single conditions, and real patients have several. The cumulative effect of multiple medicines includes:
- Increased adverse drug reaction risk: the risk of an ADR rises from approximately 13% with two medicines to 82% with seven or more, according to estimates published in the British Journal of Clinical Pharmacology
- Drug-drug interactions: some combinations are predictable (e.g. NSAIDs with ACE inhibitors and diuretics — the "triple whammy" for renal function), but many interactions are subtle and cumulative
- Pill burden and adherence: each additional medicine reduces overall adherence. A patient taking seven medicines three times daily faces 21 dosing events per day
- Treatment burden: the total time, effort and cognitive load that managing a complex regimen imposes on the patient and their carers
NICE guidance on managing multimorbidity
NICE guideline NG56 (Multimorbidity: Clinical Assessment and Management) provides a framework for addressing polypharmacy in the context of multimorbidity. Key recommendations include:
- Identify patients at risk: those taking ten or more regular medicines, those with frailty, and those experiencing frequent falls, ADRs or hospital admissions should be prioritised for review
- Establish goals of care: what matters most to the patient? Symptom control, independence, longevity? The answer shapes which medicines to prioritise and which to consider stopping
- Consider stopping medicines: for every medicine, ask whether the benefit still outweighs the risk in the context of the patient's overall condition and prognosis
- Simplify regimens: switch to once-daily formulations where possible, combine treatments (e.g. fixed-dose combination antihypertensives) and align dosing times
The pharmacist's role in simplification
Community and clinical pharmacists are well positioned to lead medicines optimisation for patients with multimorbidity. Several routine pharmacy touchpoints provide natural opportunities:
Structured Medication Reviews (SMRs)
The SMR, introduced as part of the NHS community pharmacy contractual framework, is the most formal mechanism for pharmacist-led medicines review. During an SMR, the pharmacist reviews the patient's entire medicines list, identifies potential problems and makes recommendations to the prescriber.
For multimorbid patients, the SMR should go beyond checking each medicine individually and consider the regimen as a whole:
| Question | What it addresses |
|---|---|
| Is this medicine still clinically needed? | Disease progression, symptom resolution, changed prognosis |
| Is this the simplest effective regimen? | Unnecessary complexity, avoidable dosing frequency |
| Are any medicines interacting harmfully? | Drug-drug and drug-disease interactions |
| Is the patient actually taking all of these? | Adherence barriers, stockpiling, selective non-adherence |
| What does the patient want from their treatment? | Patient priorities may not align with guideline-driven optimisation |
Repeat dispensing patterns
Pharmacists who manage electronic repeat dispensing (eRD) can spot patterns that suggest problems: medicines consistently returned unused, items requested early (suggesting confusion about dosing) or prescriptions that have accumulated without review. These patterns are strong prompts for an SMR or a conversation with the GP.
The hospital-to-home transition
Hospital discharge is a high-risk moment for patients with multimorbidity. New medicines are started, old medicines may be stopped or changed, and the discharge letter may not reach the GP before the patient arrives at the pharmacy. The community pharmacist who dispenses the first post-discharge prescription is often the first healthcare professional to reconcile the hospital changes with the patient's pre-existing regimen.
Practical simplification strategies
| Strategy | Example |
|---|---|
| Switch to once-daily formulations | Amlodipine 10mg OD instead of nifedipine 20mg BD |
| Use fixed-dose combinations | Perindopril/amlodipine instead of separate tablets |
| Align dosing times | Move all once-daily medicines to a single time point |
| Stop medicines that are no longer needed | Proton pump inhibitor started in hospital for stress ulcer prophylaxis but continued indefinitely |
| Substitute safer alternatives | Paracetamol instead of NSAID in a patient also on an ACE inhibitor and diuretic |
| Use compliance aids where appropriate | Dosette boxes for patients who cannot manage multiple bottles |
Where to explore further
Pharmacists can use PharmSee's job search to explore medicines optimisation and clinical pharmacist roles across the NHS. The pharmacy search tool shows dispensing volumes by area, which can serve as a proxy for polypharmacy burden. Salary data provides benchmarks for clinical pharmacist roles with a medicines management focus.
Caveats
Medicines optimisation decisions are clinical judgements that must be made in the context of individual patient circumstances. The ADR risk figures cited are estimates from published research and may vary by population. NICE NG56 provides a framework, not a protocol — pharmacists and prescribers must exercise judgement in applying its recommendations. The King's Fund multimorbidity prevalence figure is based on GP practice data and may undercount conditions that are undiagnosed or managed outside primary care.
Sources
- NICE NG56: Multimorbidity — Clinical Assessment and Management (2016)
- The King's Fund: Long-term Conditions and Multi-morbidity (2024)
- Duerden M et al., "Polypharmacy and medicines optimisation", King's Fund (2013)
- NHS England: Network Contract DES — Structured Medication Reviews
- PharmSee vacancy database, 1,715 active roles as at 15 April 2026