GP view: Are MURs and the NMS cost-effective?
GP Toni Hazell is a fan of the new medicines service (NMS) but has found that medicine use reviews (MURs) can add to her workload
The NMS looks to be going the way of MURs – taken away from community pharmacists and made part of the job of “clinical” pharmacists working for a primary care network (PCN). Is this change a good thing?
I suppose there are two sides to this discussion. Are MURs and the NMS useful for patients, and are they cost-effective? It would seem obvious that for patients, going over medications with a healthcare professional would be useful, and surveys suggest that patients like them.
Similarly, I have often used the NMS stamp that I have in my drawer to indicate to the pharmacy that this is a new medicine. I’ve told the patient that the pharmacist will get the inhaler and spacer out of the box to demonstrate its use, which seems a much more sensible way to do it than my terrible drawing on a scrap of paper. With medicine shortages sometimes meaning a change of brand for critical medicines such as adrenaline auto-injectors, it is vital that patients know how to use what they are given. I am a fan of the NMS system.
To be honest, I’m less sure about MURs. I’ve only ever had a few letters from pharmacists following up on an MUR, so I may not be seeing a representative sample. However, in the ones I have seen, the MUR has duplicated what we have already told the patient. In some cases, they generate unnecessary work and anxiety.
I suspect that the value of an MUR depends on the experience of the individual pharmacist and maybe how well they know the patient, rather than having a set outcome. It may be that the change in MURs last October, targeting only high-risk and recently discharged patients will make them more useful.
Patients like MURs, but with the NHS is on its knees we must deliver what is needed. We may not have the capacity to provide things that are wanted but not unnecessary, which brings me on to cost-effectiveness. At first glance, it is hard to see how one MUR, for which pharmacists are reimbursed £28, can be cost-effective, compared to the £120 or so that GPs are funded to see the patient as many times as they need for a whole year.
Admittedly, things are never that simple. The NHS payment system means that patients who never visit their GP subsidise those who are in the practice all the time. I am fully aware that the pharmacy global sum has been cut in recent years, and that pharmacy is under the same financial strains that affect GPs.
I’m not confident that NMS or MURs are cost-effective, although work with some specific groups such as patients with asthma has been positive. I can understand that some of the benefits may be difficult to quantify. If the patient has fewer adverse effects than they would have done otherwise, that is both clinically and financially a good thing.
So, is moving MURs and the NMS into the remit of PCN pharmacists a good thing? I can feel the splinters in the seat of my jeans as I sit firmly on the fence on this one.
The role of the PCN pharmacist is yet to be fully worked out. No doubt there will be some who are amazingly competent and whose medicines reviews add significant benefit to the patient, in a very cost-effective way.
There will be others whose efforts only add to the workload of GPs. Possibly the worst outcome would be if this loss of income destabilises pharmacies in the way that loss of flu jab income has destabilised some GPs. We can all agree that pharmacies and GPs having to close their doors is never a good thing.
Toni Hazell is a GP based in a practice in London