Last year's white paper demanded MURs be rebuilt around quality instead of quantity. Chris Chapman asks how the service might be developed.

One year ago, the DH threw down the gauntlet on MURs. The pharmacy white paper warned the service was becoming a numbers game, with the effectiveness of MURs lost under a payment system dictated by volume.

The document promised reforms that would deliver rewards for MUR quality, not simply for quantity.But this lofty pledge raises more questions than answers. How do you assess quality and who gets to judge whether an MUR has been a hit or miss?

Twelve months on and the sector awaits the answers with baited breath.MURs as they stand can be beneficial, according to supporters. The problem with the service remains that it is not being focused toward the right patients, says Dr Lisa Silver, a GP in Oxfordshire.

She says: “We need to get away from recommending to the GP for them to do something that’s really obvious. I know that sounds trite, but the MURs I’ve had back, what was written down didn’t seem to be valuable.

“What we need to do is have close discussion with LMCs, LPCs and PCTs about the specific patients who will be taken aside and their medicines gone through.”

Closer collaboration between pharmacists and GPs will be essential to upping the quality of future MURs agrees Kevin Western, a pharmacist in Essex.

He says: “At the moment the amount of feedback GPs give pharmacists from MURs is very limited. The best way to get a quality MUR system is for the two professions to sit down and chew it over.”

The result of these discussions could be a more targeted approach, tailoring MURs to tackle a specific condition. For example, asthma use review for areas where the condition is particularly prevalent.

However, not all parties are in favour of a more channelled MUR mark II.

Pharmacist David Smith, who won C+D’s MUR Champion of the Year award in 2008, says: “You’re going to get the same amount of problems and quality with each different patient group. Each particular group has its own specifics and you’re going to get the same sort of balance of quality ones, and ones where you don’t find much out.”

Limiting MURs to specific conditions or patients with a certain number of items is also potentially damaging, Mr Smith points out. A patient on two inhalers may need an MUR as badly as a patient prescribed six or seven drugs, he says.

The only way to assess the quality of an MUR is from its outcomes, Mr Smith says. “I would say the number of action points from the MUR [measures quality]. I tried to audit mine, and the only way I could do it was the number of action points I was coming up with.”

Mr Smith’s audit also raises a final question: who will determine quality? A quantitative measure is hard and fast; the number of patients on whom you carry out MURs is indisputable. Quality, however, is subjective. It needs an appointed assessor.

One of those looking to provide the answers is Alastair Buxton, head of NHS services at PSNC. The contract negotiator alongside NHS Employers has been tasked with drawing up a blueprint for a new look quality driven MUR.

That document has been presented to health ministers in line with white paper recommendations. However, neither organisation was willing to go public with their MUR proposals just now.

What is obvious is that future MURs will be built on a funding system linked to outcomes. And it’s likely to be the PCT who gets the final say on whether your MUR has been a success, Mr Buxton suggests.

He says. “When you look at the [white paper] action points it talks about PCTs. So you can infer some groups that would want to ensure themselves of quality.”

The full PSNC/NHS Employers proposals are still under discussion, Mr Buxton reveals. The recommendations will theme on “targeting and improving the usefulness” of MURs, he adds.

“It’s about ensuring there is perceived value attached to each MUR. Clearly, numbers of MURs are being done, but what we want to ensure is the best value is achieved from each individual MUR.”

Ultimately, experts suggest, the future of MUR assessment lies out of the hands of pharmacists, both in settling the quality measure conundrum and in assessing the success of individual MURs.

Targeting specific patient groups, determined by discussion with the PCT and GPs to focus on local needs, seems to be a strong candidate for the revised national MUR model.

But while targeting will increase quality, it will never measure it. And a measure of action points generated in an MUR discussion will only provide a glimpse of the reality hidden behind the statistics.

It’s hard to see the assessment of MURs moving away from a quantity measure. It may be that quality just needs a better definition.