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Where next for MURs: redesign, refine or scrap?

Many pharmacists say MURs benefit patient care, but could be improved
Many pharmacists say MURs benefit patient care, but could be improved

With the future of medicines use reviews (MURs) on the agenda in ongoing pharmacy funding negotiations, C+D asks pharmacists how they would like the service to change

MURs may have been introduced in 2005 to boost patients’ medicine compliance, but many pharmacists think that while they offer value to patients, there is room for improvement.

In 2016, academics concluded that MURs had no evidence for cost-effectiveness and there was significant variability in delivery. The review, led by Professor David Wright from the University of East Anglia, questioned their viability, against a backdrop of mounting pressures on pharmacists and lack of support for the service from GPs.

Professor Wright told C+D that he believed problems with MURs resulted from the speed of the service’s implementation, such as insufficient testing. Training and assessment was “variable” and many GPs were “dissatisfied” with the information they were receiving from pharmacists, he said.

In December 2016, the NHS England-commissioned 'Murray' review, which Professor Wright’s findings fed into, recommended a redesign of the service that included “ongoing monitoring and regular follow-up with patients”. The report concluded that “ultimately MURs should evolve into full clinical medication reviews, utilising independent prescribing as part of the care pathway”.

While NHS England never formally responded to the review, in March this year the Pharmaceutical Services Negotiating Committee (PSNC) pledged to talk about the future of the MUR service as part of its contract negotiations, which began in April. It hopes “that any substantive changes to the community pharmacy contractual framework will be agreed in time to be implemented from October”.

What value do MURs have for patients?

Many pharmacists think MURs benefit patient care. Paras Shah (pictured below), lead pharmacist for the London Victoria branch of Green Light Pharmacy, and the group’s business and development lead, says they present a rare opportunity for patients to talk in-depth about their medication and health.

“When patients have a review with a nurse or doctor, it can be quite limited,” he says. “But with the MUR patients [can] have 15-25 minutes to consider why they take their medicines and have a holistic conversation about their health in general.”

Saghir Ahmed, head of operations and development for pharmacy chain Imaan Healthcare, also says patients benefit from the service. “Issues are identified, resolved or escalated” during MURs, he says. “Patients are reassured that they are getting the best from their medicines.”

However, Mr Shah says a key challenge for MURs is convincing patients of this value.

“Patients are familiar with being reviewed by a doctor or nurse, so it is difficult for them to understand the MUR,” he says. “We need to get across to patients that this is an opportunity for them that they might not have in the doctor’s surgery.”

Locum difficulties

The benefits of the service are not always as apparent to locum pharmacists. One locum called Sanjai, who doesn’t want to reveal his surname, says that during MURs “most patients learn something, [with] the elderly in particular finding them useful”.

But Sanjai has found that some “patients are still not overly keen on the service and would rather be reviewed at the doctor's. As a locum, it’s harder as we are often unfamiliar with the patients, who would rather be reviewed by the resident pharmacist”.

He feels pharmacy teams can be “pressurised” into providing the service in order to achieve maximum remuneration, even if patients have had a similar review at their surgery. Add to this not having enough staff support, pressure to please managers and insufficient time, and it can make the service a real challenge, he says.

Pressure to perform

Sanjai is not the first to highlight pressures on staff to perform MURs. The Pharmacists’ Defence Association head of policy Alima Batchelor (pictured below) says pharmacists have contacted the organisation claiming they have been criticised for failing to perform the expected number of MURs, with “inappropriate pressure” placed upon them.

“We hear anecdotally of locums who have been told they will not be hired again unless they complete the required number of MURs per day, irrespective of how busy the pharmacy is or how inappropriate the patients may be,” she says.

“MURs were ostensibly introduced to better utilise pharmacist skills and improve patient care, not to boost profits,” she adds.

Insufficient staffing levels

The PDA believes that insufficient staffing levels in the sector make it difficult for MURs to be carried out correctly, Ms Batchelor says.

“When staffing levels are such that pharmacists and their dispensary teams are hard pressed to cope with the expectations placed upon them, the provision of services such as MURs will invariably be adversely affected,” she says. She would like to see “better regulation of staffing levels”.

RPS: Scrap the cap

Another key factor is the annual cap of 400 paid MURs per pharmacy. PSNC’s interim funding arrangement has limited the number of MURs contractors can deliver over six months (from April 1 to September 30) to 200, potentially leaving opportunity for change after this period.

Royal Pharmaceutical Society (RPS) English pharmacy board chair Sandra Gidley (pictured above) says she would like to see the cap lifted and for the reviews to “become more outcome-led, so their impact is even greater on patient care and safety”. The RPS has discussed with PSNC how community pharmacy “is likely to evolve from a supply role to a more clinical, patient-facing role”, Ms Gidley says.

One fifth (19%) of pharmacists and pharmacy staff who responded to a C+D poll agreed with Ms Gidley, voting to remove the annual cap. However, 61% said they would rather scrap the MUR service completely.

Result

Should the cap of the number of paid medicines use reviews be amended?
Yes, it should be removed
19%
Yes, it should be raised
9%
Yes, it should be lowered
5%
No, it should remain at 400 a year
6%
The service should be stopped entirely
61%
Total votes: 112

Satyan Kotecha, superintendent pharmacist at K&K Healthcare, believes that pharmacies should have the freedom to set their own MUR targets. His pharmacies dispense a “high volume” of medicines, he says. “If I see more people, that means I should be able to do more MURs in proportion.”

Learning from GP consultations

Mr Kotecha says feedback from patients on MURs had been “phenomenal” but he would like them to be better adapted “to specific disease areas”. At least 70% of MURs in a year must be carried out on patients in one or more of four target groups, including those with respiratory or cardiovascular disease. But Mr Kotecha reckons MURs should build on GP consultation models.

“If you think about how GPs do consultations, they use models [which] allow them to elicit all the right information in a very short space of time. Pharmacists could learn a lot from [GP] consultations,” he says, pointing to the Centre for Pharmacy Postgraduate Education module on the subject.

“As pharmacists we have the opportunity to see a patient for two or three hours a year, but it would be useful if we were able to do more frequent interventions spread out over a period of time, rather than just a snapshot once a year, or when there’s a problem.”

Create an integrated service

Mr Kotecha says GPs are unconvinced of the value of MURs, as they carry out similar reviews themselves. One way to increase understanding would be for pharmacies and GPs to improve their communication of medication review results, he says.

“The issue is we’re not plugged into the system,” says Mr Kotecha (pictured below). “Wouldn’t it be great if there was a unified system where everything about the patient sat and everybody who provided healthcare for that patient could access it?”

Mr Kotecha believes MURs could become “slightly more clinical” if pharmacists were able to view more of patients' records, such as blood test results.

Mr Shah agrees that greater access to patient information is needed to improve MURs. “We only report back to GPs via email or fax if there is an issue with medication, but I would like to see full access to patient records, so we can feed back to GPs anything which could benefit patient care.”

The RPS's Ms Gidley agrees: “To make [MURs] work successfully with our GP colleagues, the information must be transferred electronically from the pharmacy to the GP practice.”

MURs can be vital to patients and provide a much-needed source of revenue for pharmacies, but clearly work is needed to improve them. They could benefit from better integration with GPs and rethinking the annual cap of 400, while preserving the quality time with patients that they create. If the current funding negotiations take these issues into account, perhaps pharmacy will get a MUR service that everyone can support.

26 Comments
Question: 
How would you like MURs to change?

Andrew Paxton, Community pharmacist

of course, that doesn't mean that it'll be agreed

Andrew Paxton, Community pharmacist

You can request a raise in the cap any time

Andrew Paxton, Community pharmacist

When I worked in Cumbria, we could do MURS one month (Respiratory only!) and do a follow up a month later to check that  the instructions had been  remembered.

Benie I, Locum pharmacist

I'd love to see what happens if the cap is scrapped. Do you reckon we might see a multiple to be the first to deliver  400 MURs in a single day of trading  ? Set a reasonable  target of  500,000 MURs for a finacial year?

Community Pharmacist, Community pharmacist

We need a proportional target starting at 400 depending on script volume which is a good indicator of the number of patients a pharmacy serves i.,e a % of total patients .It's grossly unfair that all pharmacies have the same maximum set as all vary in the number of patients seen so 400 in a very quiet pharmacy is virtually all yet in a busy one it is a drop in the ocean so many patients miss out.Same scenario when payback is made to Pharmacy when DHSS deducts too much from the agreed global sum.Repayment should be proportional to the number of prescriptions/patients served ...Not divided equally to all as the level of contribution to pharmaceutical services varies from pharmacy to pharmacy....More work ,more reward...Surely that's fair ???

Beta Blocker, Primary care pharmacist

Yes, I bet we'd see silly targets like that! Even the low volume pharmacies, i.e the ones that do 2000-4000 items a months would be expected to increase the volume of MURs, year on year.

Community Pharmacist, Community pharmacist

'Care has to be available face to face ' as the health Minister said.MURs are a great face to face interaction that patients reallly appreciate as they are ' on the clock' when they see their over worked GP.MURs I have performed many MURs that have enlightened patients and gave them an opportunity to discuss other issues at the same time.Our GPs operate a 'one appointment - one issue policy' in an effort to meet the time restraints applied by the NHS.Pharmacies should use MURs wisely and not chase 'targets'.Unfortunately multiples apply bullying tactics (come on the PDA!!)to pressurise employees, including pharmacists.This unprofessional approach just enhances profits or subsidises the Head Office,Regional,Area 'team' to help their'blue sky' thinking meetings.The pharmacists/staff  rarely see any benefit even though they provide the service under time pressures or else face career hiatus or job loss as they are branded as 'not Proactive' on some aspiring middle managers' report sheet.I also suspect that 'abandoning MURs' is mostly spin and scaremongering...'Ok then' is the reply from the powers that be followed by ' if you want to keep MURs...we want more for the fees we pay '. This is a classic 'Service Creep' scenario - more work less/same money.MURs are good if performed correctly and for the right reasons.....Ask a Pharmacist who is allowed free speech/thought then collate the replies .

Jim D, Community pharmacist

25 minutes for an MUR?? I don't think so. What's happening regarding supervision during this time?

Community Pharmacist, Community pharmacist

GPhC should enforce adequate pharmacist levels to allow for supervision as well as the latest Health authority driven and usually underfunded service...More Services=More Pharmacists ...Simples

A B, Community pharmacist

You are right but there is about a 0.001% chance of this happening

K B locum, Locum pharmacist

The people who really need MURs are the elderly housebound who have their medicines delivered and are hardly ever seen by health care professionals. This is the group we should be concentrating on.

 

 

Andrew Paxton, Community pharmacist

But NHS England will not approve home MURs

will cockburn, Community pharmacist

GPs and Pharmacists work in businesses. Their income and their    jobs depend on that business. Locums seem to think there is some imagined land that provides them with a professional platform on which to work with no pressure to deliver. GPs have a great deal of pressure to deliver. Primary Care pharmacists feel pressure to deliver (or their job is too easy) and Practice Pharmacists will gradually feel pressure to deliver (for a salary of 25% less than everyone else’s). There is no hallowed ground.. Be professional, deliver your services to the best of your ability and take advantage of the opportunities and recognition allowed pharmacists when compared to the profession of 20 years ago).

Community Pharmacist, Community pharmacist

....And don't undersell your skills and qualifications..to a government that can find millions to bribe other politicians in order to stay in power, but nothing new for your skills and additional work..Refuse to work for peanuts and being treated like a cheap monkey or face the consequences...lack of appreciation and remuneration  which is where we are today thanks to the ...We can do it (free) brigade .

Sue Per, Locum pharmacist

Professor wright's, G.P.'s views and that of 61% of those pharmacits who voted, to scrap the service, is overwhelming evidence that MUR's add very little to positive outcomes. The views of the RPS and this editorial would be to the contrary, as they would speak for those who bankroll their very existence through subscriptions!!.The service is a cash cow for the contractors, who are more interested in filling their coffers, than the benefit accrued to the patients.Scrap It, plus all other service which are  capable for being consumer fed, rather than consumer led.A serious concern is the Minor Ailment Service, and to avoid or mitigate abuse, a fee of say £2.00 should be introduced per consultation, regardless of age, payable by the recepient of the service!!  

Robert Rees, Manager

Community pharmacists only add value to the dispensing process by spending time with patients. The only way that is monitored is via MURs or NMS. If you don’t do them you can’t complain when all repeat  prescriptions are sent to P2U

Community Pharmacist, Community pharmacist

I sincerely hope you are not involved with PSNC or any other body who battle for our remuneration ...£2 professional  fee !!! Try getting that past the GP,Nurse,Dentist,Optician let alone Solicitor,Accountant etc etc .......We must stop underselling our profession....I dispare at some peoples Naivity....Or let's just do it for free and the powers that be will be our friends and I can put it on my CPD.....It's laughable....the powers that be are our paymasters and try to get max for min pay ..they then justify their job/pension.4pm finish,weekends off by telling their superiors/accountants ' Look what I've suckered them into doing this time  ....Wake up and smell the coffee pharmacists - you are too accomodating and continue give yourselves away.

SP Ph, Community pharmacist

Yes, I do realise that this money has to be restored elsewhere

And do you know where would this money be restored? What if this money is re-routed to another service INVOLVING a PHARMACIST, don't you think there will still be pressure?? 

Community Pharmacist, Community pharmacist

Or even if the money is rerouted to bribe Northern Irelands MPs to keep the current government in power....

Sue Per, Locum pharmacist

I think most pharmacits can put up with the pressure, but what is not acceptable, is the bullying, harrasment, exploitation,  undermining of professional independence and authority!!. If the contrat is volume/item led, there is no reason why the pharmacist cannot be rewarded accordingly, instead of being stretched to the maximum for the contractor / management to extract to the Max!!.

Scrap all volume led services which can be fed to the consumers.

 

Community Pharmacist, Community pharmacist

'I think most pharmacits can put up with the pressure' ....based on what evidence ??? Get real

N O, Pharmaceutical Adviser

I hope you understand that, just like how a contractor is the Pharmacist's paymaster - the NHS/ Gov is the paymaster of the contractor. Your point is valid that the Pharmacists should be paid well for all the efforts they put in. But, at the same time the contractors needs to be paid well too so that they can pass it on down the line.

Just to refresh your memory. When the funding was at its peak, no 100hr pharmacies or internet pharmacies and low number of Pharmacists available, the pay was very very good. As the time passed by, number of pharmacies and Pharmacists increased but the Cat M kicked in. Then the funding started dropping, hence the pay and staffing levels dropped proportionately. Locums did not want to move from the centres (like LOndon, Manchester, Birmingham etc) where due to over supply the rate kept on falling. Even today, there are areas like the South West of England where the Locums get paid as much as £25/hr for routine shifts and the staffing + work ethics are very high (don't know much about the multiples), but not many locums available.

So, the learning here is 1) unless the funding gets better at the contractor level don't expect dramatic change in the staffing or rates. 2) As the demand and supply rule always rules, be ready to move out of the comfort zone if you want to get a good pay and a better work environment.

SP Ph, Community pharmacist

"Scrap all volume led services"

So basically, close all community pharmacies and encourage Amazon style pharmacies, is that what you are suggesting? Because, if there are no services provided through a Pharmacy (which are properly funded), then patients would just sign up with internet based Pharmacies for their medicines and look to the GPs and Hospitals for all other health problems. With no footfall, no one would be interested in keeping their business open. Is this agreeable to you? 

David Moore, Locum pharmacist

What is essential is that the payment must be withdrawn to stop the pharmacy companies pressuring pharmacists into carrying out unnecessary MURs. (Yes, I do realise that this money has to be restored elsewhere.)

Community Pharmacist, Community pharmacist

Just pay the fee direct to the pharmacists ....Team leaders,branch managers,District managers ,cluster ManagersArea managers,Regional managers,business Development Managers, Head Office  and the rest of the 'hanger on brigade' that feed off our profession will very rapidly lose interest....

Leon The Apothecary, Student

I actually think that is a really good idea. Give it to the pharmacist who does the question; rather then the owner of the building it is conducted in, because one can work without the other, and I don't think I need to explain which one.

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