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Are concerns around MUR abuse a storm in a teacup?

Almost half of C+D readers feel MURs are no longer fit for purpose and should be scrapped

Has the recent negative publicity about medicines use reviews shaken your faith in their benefits?

How much reputational damage is done by negative newspaper headlines? April’s revelations in the Guardian, which detailed the alleged abuse of medicines use reviews (MURs) encouraged by managers at Boots, have been detrimental – particularly as they were published by a national newspaper.

Some pharmacists feel that the fallout has been limited to within the profession, with no obvious impact on patients’ or GPs’ views of the service. Contractor Kit Tse describes the coverage as “fairly sensationalist”, while fellow contractor Chris Howland-Harris says the exposé was merely a “flash in the pan”.

But this belies the responses to the survey on workplace conditions conducted by the Pharmacists’ Defence Association (PDA), which formed the basis of the Guardian investigation. The newspaper’s coverage garnered more letters from its readers than any other story it has published in recent years, and this strength of feeling was shared in many of the comments on the C+D website in the days and weeks after the investigation, as well as during C+D’s Twitter chat on #MURabuse.

The truth may lie somewhere in between. While Pharmaceutical Services Negotiating Committee (PSNC) chair of service development Gary Warner says the story soon became “yesterday’s chip paper”, it’s clear that many of the issues the PDA survey flagged up do resonate: a poll of 320 C+D readers found some 45% feel MURs are no longer fit for purpose and should be scrapped.

At the very least, the waves made by the MUR scandal have prompted those at the very top to take notice – with both the General Pharmaceutical Council (GPhC) and England’s chief pharmaceutical officer Keith Ridge pledging to take action to make sure MURs are done well, while also providing value for money for patients and taxpayers. As the scrutiny that started with the Guardian story looks set to continue for some time, it has forced the profession to take a closer look at what positive MURs can do for patients.

Modern MURs

Mr Warner says that the MURs English pharmacists now conduct are “a different service than it was five years ago”. “The targeted approach means that [poor incentivising] was largely engineered out of the service,” Mr Warner says, referring to the requirement in place since 2011 that 50% – later raised to 70% – of a pharmacy’s MURs are conducted on nationally specified patient groups.

Nevertheless, Mr Tse – who is also a board member of the PharmaBBG partnership of Bexley, Bromley and Greenwich local pharmaceutical committees (LPCs) – says pharmacists in his area have taken the opportunity that the publicity about MURs has brought to “reflect on their own practices” with regards to the service.

There is another pressing reason to use the scrutiny as a prompt to reevaluate MURs, as Mr Howland-Harris points out: namely the looming cuts to pharmacy funding in England, which he says “rather focuses the mind” of pharmacists.

Threat from cuts

Numark service development manager Laura Reed agrees, adding: “We have noticed that there are more pharmacists wanting to engage with services and MURs, and they are looking for support to get up and running to deliver them – I think that is related to the cuts.”

So how can you look at your own MUR practice afresh, to ensure that it delivers benefits for your patients and value for the NHS? And how can the profession ensure that the service is fit for the future?

Back to basics

Ms Reed says Numark advises pharmacists who are reviewing their MUR offering to “start by thinking about the basics”, and reflect on what the service should and – crucially – shouldn’t be.

PSNC describes MURs as “structured adherence-centred reviews”, but Pharmacy Voice chief executive Rob Darracott recommends against getting too bogged down in the ‘structured’ part of the definition.

At the time they first emerged in April, Mr Darracott warned that the allegations of MUR abuse risked doing “significant harm” to the public’s perception of the profession, which could undermine the sector’s argument against the funding cuts. To make sure MURs show their worth, Mr Darracott says that they should be approached as a conversation – or even as an informal chat.

“At the heart of interventions between professionals and patients is a conversation between two people,” he explains. “One has some expert knowledge, and the other probably has lots of questions that need answers and has some decisions to make. It’s best treated as a conversation, not a series of questions to which you want to get answers.” Mr Warner has this tip: “The key is to listen more than talk,” he says.

However, the second part of the PSNC definition – that MURs should be “adherence-centred” – is vital, says Mr Warner. “Remember that adherence is one of the most critical aspects of an MUR,” he says.

Ms Reed encourages pharmacists to bear the following in mind when conducting these reviews: “What you’re checking is the patient’s use of their medicines and any issues with that. You’re not doing a full clinical review.”

MUR timeline

April 2005 –MURs introduced in England

October 2011 – addition of national target groups and the launch of the new medicine service (NMS)

July 2012 – changes made to the data capture requirements for MURs

September 2012 – further changes to data capture made

April 2013 – the Pharmaceutical Services (Advanced and Enhanced Services) (England) Directions are published, setting out the regulatory framework for the provision of the MUR service

April 2015 – NHS England and PSNC agree the percentage of MURs that contractors must provide to patients within target groups will increase from 50% to 70% a year

April 2016the Guardian publishes allegations that pharmacists at Boots are routinely pressurised to perform unnecessary MURs on patients to boost the multiple’s profits

April 2016 – a poll of C+D readers finds just under half believe MURs are not fit for purpose and should be scrapped

May 2016 – a former pharmacist at Lloydspharmacy is struck off for falsifying MURs

June 2016 – the GPhC announces that it will launch a “programme of work” to tackle the issues raised in media coverage of MUR abuse

October 2016 – A King’s Fund-led review on the “value” of pharmacy services is due to report back to England’s chief pharmaceutical officer Keith Ridge

Focus your efforts

Mr Darracott also advises pharmacists to start with the basics – and start small. His mantra for any service is: “Break things down into doable steps.” For MURs, that means: “Think about the groups that have been identified as cohorts for the service. Don’t try to think about all of the groups, just pick one.” Choose a condition, then spend a certain time period – say, three months – focusing on delivering quality MURs for that cohort.

If you choose this approach, then which condition should you focus on? Mr Tse advises liaising with local GPs and clinical commissioning groups (CCGs) to identify their priorities. Failing that, Mr Darracott and Mr Warner agree that respiratory patients, particularly those using inhalers, are as good
as guaranteed to benefit from an MUR. 

“We know people don’t know how to use [inhalers] properly. There’s lots of advice available, so you can refresh your knowledge,” says Mr Darracott.

Mr Warner adds: “We have seen time and time again how vital for patient care every respiratory MUR that’s done with an inhaler check is, and what a massive difference they can make.”

No need to overthink it

Outside of your chosen focus, or as you develop – and therefore widen – the delivery of your service, you will conduct MURs on other patients. But there’s no need to obsess over whether you are recruiting the ‘right’ ones.

If you are following the service specification, you will naturally end up delivering MURs to the patients who need them most, Mr Howland-Harris argues. “I [would] actually find it harder to do MURs of poor quality because just to get those people in the room is harder,” he says.

Similarly, there’s no need to get too hung up on whether you will reach 70% of patients in the target groups, because they are designed so that this happens naturally, Mr Warner says: “Most, if not all, community pharmacies achieve the 70% rate because these are the people that need it most.”

No matter which patient it is, once you’ve got them in your consultation room for a MUR, you need to make sure you deal with the individual in front of you. Mr Darracott warns that pharmacists, and other healthcare professions, can be guilty of “turning everything into some sort of checklist”.

“Person-centred care is where professionals and patients have conversations about health – not interviews and, almost, not consultations,” he adds.

Mr Warner agrees: “The study of the new medicine service [by University of Nottingham researchers in 2014] highlighted that we have fallen into the same trap as doctors, of being too didactic in our approach. Allowing people to express their concerns, reassuring them, and being able to explain and explore further are all key to getting the benefits out of an MUR.”

“The biggest change that pharmacists can make is reflecting on how they deliver to patients and move towards a holistic approach – rather than doing it by rote,” Mr Warner adds. Pharmacists must tailor their advice – and make a judgement on how much information about medicines is appropriate to give each patient. “The vast majority of people welcome and see the provision of information as being important and improving their care. [But] there are pieces of information that people don’t want to know,” he says, adding: “Always ask before you tell.”

Fit for the future

Every pharmacist can follow these steps to improve their individual practice, but is the service as a whole fit for purpose? Yes, say Mr Darracott and Mr Warner – they believe the underlying principle remains valid and viable – but there are several things that need to be done to secure MURs’ progression and future.

There have been few studies of the effectiveness of MURs, but a 2011 review concluded MURs focused on a specific disease were most likely to result in clinical outcomes.

Mr Darracott is personally convinced of the value of MURs, but feels the profession needs to focus on showing that they work. “We spend a lot of time counting [MURs], we spend time worrying about them, but we don’t look at the outcomes,” he says.

Mr Howland-Harris agrees, but says “it won’t necessarily be easy” to tie MUR payments to outcomes, and not activities – one of the suggestions for improving their reputation offered by respondents to the C+D poll.

And evaluation would need IT systems that capture data in real-time to avoid creating an unnecessary paperwork burden, says Mr Darracott. The service would also need better integration alongside other services, such as those focused on long-term conditions and collaboration with general practice.

But with the right development, MURs could deliver more, says Mr Warner, who suggests hospital discharge as a potential area where pharmacy is already starting to see significant engagement. Discharge MURs will take up “the bulk” of targeted MURs “within a few years”, he predicts. And he believes MURs will continue to play a vital part in patient care. “It’s one of the few services in the patient journey when you get to ask: ‘How are you getting on with your medicines?’

How to respond to patient concerns about MUR publicity

Pharmacist: “Would you like to discuss your medicines and how you take them? We offer a service called a medicines use review.”

Patient: “I’ve heard of that, but isn’t it just a waste of NHS money?”

Following the Guardian’s negative coverage of MURs, the above scenario is not unfeasible. So how should you respond?

Acknowledge the coverage

There’s no point trying to wave the confrontation away, says contractor Chris Howland-Harris: “You have to acknowledge it – and then move on.”

Be honest

Some people have been accused of abusing the service, so don’t be afraid to say so, adds Mr Howland-Harris. “I’d be honest and say, ‘Yes, you’re right, a small number of people may have abused the service, as some people do in all situations,’ without making reference to any other organisation or professions.”

Arm yourself with information

“First of all, it’s useful to know that there’s lots of strong evidence around the benefits of MURs,” says PSNC chair of service development Gary Warner. You should prepare yourself with a few key facts about the successes of the service that you can refer to when talking to patients.

Make it personal

Move the focus away from the wider service to how a conversation will benefit that patient, advises Mr Howland-Harris. “You have to say, ‘This is about you, and I hope I can prove that article wrong because I believe there will be some benefit to us discussing your medicines’.”

Encourage dialogue

Make the patient aware that you’re interested in their feedback to improve your service, says Pharmacy Voice chief executive Rob Darracott: “You could say, ‘Why don’t you tell me at the end if you think it was helpful or not; if it wasn’t then that’s useful feedback for me’.”

How do you reassure patients about MURs?

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Angela Channing, Community pharmacist

I don't think pharmacists have a problem with the concept of MURs, it's them being used as a cash cow by many companies, and pharmacists having no autonomy to select who would most benefit. This is because everything has to have a target these days in community pharmacy. (Even though the Code of Ethics tells us not to let targets affect our professional practice!) And I also think pharmacists resent non-pharmacist managers trying to tell them when and who to pick for MURs. For example, has anyone at Lloyds been investigated regarding the pressure put onto the woman who was struck off for making them up? Also, if she wasn't going to benefit financially, why on earth would she do that????! We all know the answer, because she, and others in the past, in the same position, have been under enormous pressure, which is then denied. Until the GPhC, investigate this AND do something about it, then these problems will continue. 

Boom Shakalaka, Locum pharmacist

Well said - non-pharmacist branch managers are the scourge of modern pharmacy in general. It's my policy as the responsible pharmacist, without whom the pharmacy would not be permitted to open, to ignore  these demanding bottom lickers  where appropriate and do the job at hand in a professional manner.

Leon The Apothecary, Student

I agree with Angela. Providing knowledge to patients in the form of an MUR will nearly always be of some benefit to a patient. It is perhaps the way it is financed that is an issue. The pressure stems from a company pressuring to achieve the 400 MUR limit. It is a significant amount of income, so it is hardly surprising that it is pushed so tenaciously. What would be a superior system?

Clive Hodgson, Community pharmacist

Absolutely correct Angela.The major concern with MURs is hardly touched upon in the above article. As we all know it is simply that many employee Pharmacists are being pressurised or even bullied into performing MURs purely for the financial benefit of their employers with the large Corporates being the worst offenders. The Guardian expose did reveal a lot of unpleasant truths. Defensive articles after, by the likes of Pharmacy Voice, again never address this issue presumably because they (PV) represent those Corporates to whom MURs are valued only for the revenue they generate.

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