With news that some pharmacists are being pressurised to perform more medicines use reviews, the RPSGB’s Professional Services Directorate examines the use of targets in delivering the service.

Pharmacists will recognise that MURs - part of the pharmacy contract in England and Wales - are an important type of concordance review, which delivers great value to patients.

MURs can help to solve significant problems the patient may be facing and are also an important professional service that takes pharmacists a step further to developing a more clinical service. It is important that as a profession we embrace the increased clinical role that will not only benefit patients but also integrate us further into the multidisciplinary primary care team.

Despite a slow start and some concerns having been expressed about the quality of some initial MURs, there are now encouraging signs that pharmacists are actively engaged in providing this important service. Pharmacists should be looking at the content of the services they deliver to patients, and seeking to adopt best practice.

Counterbalancing this, the Society recognises there has recently been much debate about MURs and the pressure that some pharmacists face from employers to reach targets. 

While there are important and legitimate drivers to increase the number of MURs, there are also reports some pharmacists feel the approach taken by their employers to reach specific volume targets amounts to 'harassing techniques' and 'corporate bullying'. Pharmacists must not be pressurised to achieve targets, especially if they feel the achievement of the targets would compromise patient care.

The role of targets 

Targets and incentives for providing a professional service are used throughout healthcare in hospitals and primary care. For example, the GP contract has a large number of incentives built in as QOF points. There are also a number of prescribing targets such as the proportion of generic prescribing, whereby GPs are given comparative feedback on their prescribing by pharmaceutical advisers with PACT data to compare their prescribing habits, and this helps GPs to compare their practice with their peers.

Targets and incentives are helpful in that they can demonstrate clearly to staff the priorities of a company and encourage them to undertake new roles. In some areas, targets have been found to drive up standards. We also know that some pharmacists view targets and incentives as a significant motivating factor in their role.

While targets can be set, it is however important they do not replace an individual's professional judgement and autonomy in deciding when, for example, an MUR might be appropriate.¹ It is up to the individual pharmacist to decide which patients receive this service, although local PCOs or GPs may recommend specific groups of patients that may be appropriate for targeting.

The provision of MURs does form part of the community pharmacy contract and therefore there is an obligation on NHS pharmacy contractors to provide this service to patients. As a pharmacist you should not refuse to undertake MURs unless there are valid reasons such as workload pressures or a negative impact on patient safety.

If, however, a pharmacist has been set targets they believe are unachievable they should in the first instance raise their concerns with their line manager. If you don't report your concerns, it is difficult for the person in a position of authority to respond to them. There should be a two-way communication between the pharmacist and employer to discuss any concerns that either may have. Reconfiguration or prioritisation of work flow, alternative or additional staffing or other ways of working could be considered as part of this.

Target-setting

When setting targets, employers must take care to ensure these do not have unintended consequences:

• MURs should not be conducted on patients who do not need them, simply to reach targets. The Society believes that the value of the MUR to the patient must be maintained.
•  If a pharmacist is undertaking an MUR, it may impact on their ability to provide other professional services, which may have a negative effect on patients and staff. 

Thus, if targets are to be set, it is important that they take account of the complexities of the situation, and also take account of the wider services and workload of the pharmacy.

Targets should be agreed with the pharmacist concerned to ensure they are achievable and will not compromise patient care in other areas. As with any new service, it may also be difficult to judge the impact on other services until experience has been gained; targets may therefore need to be adjusted in light of experience.

Supporting pharmacists

The Society recognises and welcomes the time and finance that has been invested by pharmacy owners in supporting pharmacists to undertake MURs and other new services.

Pharmacists may require support in terms of how to conduct an MUR effectively and efficiently, how to find time to conduct MURs, in targeting patients who would benefit from an MUR, and in effective delegation of certain tasks to other staff. The Society's English and Welsh pharmacy boards will be working with other professional organisations to address a number of these issues.

The care of patients is a pharmacist's first concern² and patient safety must not be compromised in an attempt to reach MUR targets. Employers and pharmacists have to recognise that undertaking MURs is likely to result in an increased workload, and therefore the staffing structure of the pharmacy may need to change to take account of this.³

As the role of the pharmacist evolves to having a more clinical focus, it is important to remember that times of change can be stressful for individuals. Employers should be alert to signs of stress, and support pharmacists through the period of change.

Responsibility for safety

Pharmacists have a duty of care to their patients. This is recognised in law and in the Code of Ethics. Pharmacists must be able to raise concerns about patient safety, and should be empowered to take action where they have concerns about the safety of a pharmacy. Employers have a duty to ensure that staff who raise genuine concerns are appropriately supported and protected.

Support from the Society

The Society is currently developing an MUR multidisciplinary audit tool that will demonstrate the benefit and quality of MURs. The audit aims to help pharmacists measure the quality of the MURs undertaken; it is planned for this to be available from spring 2009. The audit toolkit will help to demonstrate the benefit of MURs and in so doing help commissioners to understand them.

If you have concerns about any breaches of the requirements of the Code of Ethics, you can contact the legal and ethical advisory service (email: leadvice@rpsgb.org or tel: 0207 572 2308), or you can make a formal complaint to the Society's fitness to practise and legal affairs directorate.

The Listening Friends Scheme also offers a free listening service to pharmacists suffering from stress. The scheme is supported financially by the Benevolent Fund and, although it was set up by the Society, it operates wholly independently. Help can be obtained anonymously. To access the scheme, any pharmacist should initially telephone the automatic answering service on 0207 572 2242.

References
1. Principle 2.2 of the Code of Ethics for Pharmacists and Pharmacy Technicians
2. Principle 1 of the Code of Ethics for Pharmacists and Pharmacy Technicians
3. Standard 2.3 of the professional standards and guidance for pharmacists and pharmacy technicians in positions of authority.