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'No evidence MURs are clinical or cost effective'

Professor David Wright: MUR targets have increased pressure on pharmacists

An evidence review commissioned to inform the Murray report into pharmacy services has suggested commissioners learn from the failings of medicines use reviews (MURs).

While the service was introduced in 2005 to improve medicines adherence, and revised in 2015 to ensure a greater proportion of reviews are delivered to target groups, “there is currently no evidence for the clinical or cost-effectiveness of MURs”, the review’s author suggested last month (December 14).

The review – which was completed before the funding cuts were implemented on December 1, 2016 – states that the implementation of MURs was “unstandardised from the outset, resulting in significant variability in delivery”, and has led to inequity in access to MUR provision across England.

The review's author David Wright, professor of pharmacy practice at the University of East Anglia, pointed to the fact that independents are less likely to offer MURs.

MURs are expected to be delivered “in addition to” the essential services pharmacies already provide, which has resulted in increased workload and pressure on pharmacy staff, he said.

With a lack of evidence of the cost and patient benefits, “national funding of the MUR service requires review”, Professor Wright concluded.

Influence on future service provision

The Murray report, which Professor Wright’s review helped to inform, stopped short of calling for MURs to be scrapped altogether. Instead, it recommended to NHS England last month that the service be "redesigned" to include "ongoing monitoring and regular follow-up with patients".

Professor Wright said: “The problems found with MURs largely derived from training, service introduction and service targeting.”

These problems would have been identified if the service had been “appropriately feasibility-tested with a view to service refinement”, he added. 

"[The issues with MURs] need to be carefully considered and addressed within any newly commissioned community pharmacy services," he concluded in the report.

GPs don't see value in MURs

The potential benefits of MURs are also not being maximised because of a lack of support from GPs, Professor Wright said.

While patients have been broadly positive regarding MUR provision, GPs have been “less so”, with many reporting an “unnecessary duplication” of workload and pharmacists making clinical recommendations beyond the original remit of an MUR.

“Negative perceptions regarding the value of MURs by GPs may result in non-implementation of recommendations, which further reduces their cost-effectiveness," Professor Wright said.

While giving pharmacists access to the summary care record might help reduce some of the duplicated work, “it will not remedy the lack of collaboration between the two professions”, he warned.

This is the second of C+D’s three-part analysis of Mr Wright’s evidence review. You can read the first article here and look out for the third article later this week.

Readers have been discussing the future of MURs on C+D's LinkedIn group. Share your views by joining the discussion here 

What would improve current MUR provision?

sanjai sankar, Locum pharmacist

I strongly believe the intention of MURs when they were first conceived was a good one. On roll out day back in 2005, if NHS England or the designers of the format had included a clause along the lines of: "The conducting of MURS rely solely at the discretion of the Responsible Pharmacist only"....Any evidence of coercion by employers will result in an investigation into the business practices of that instituion"....A clause like this may have prevented the bullying some Pharmacists felt ( and there are loads lets be honest) at the hands of certain employers...multiple and independents alike...

Valentine Trodd, Community pharmacist

Boots et al. probably vetoed that clause.

Jupo Patel, Production & Technical

Dead right Sanjai. The problem is the likes of Boots would have been involved in the design and their lawyers would never have allowed such clause.

Valentine Trodd, Community pharmacist

'No evidence MURs are clinical or cost effective'

Editor, shouldn't it be 'clinically' cost effective?

Gerry Diamond, Primary care pharmacist

What ever anyon's opinion on MURs, what is clear is that they are controversial and possibly on balance do not deliver positive outcomes in terms of educating the patient, optimising medication, monitoring adherence and they are difficulties in delivering the service by community pharmacies. That said, in my view they need to be scrapped and another service implemented that does deliver tangibe benefits to patients and enhances clinical cost effective outcomes for the NHS, while addressing the delivery issues raised by practitioners.

Tom Kennedy, Pharmacy Area manager/ Operations Manager

"redesigned" to include "ongoing monitoring and regular follow-up with patients",  so basically the same targets with much more work involved.  Looks like these lazy pharmacists are going to have to spend a little less time texting and playing on Tinder.

Arun Bains, Community pharmacist

Managers like you are directly to blame for the reduction of job satisfaction in pharmacy.

Valentine Trodd, Community pharmacist

Click bait...

Jupo Patel, Production & Technical

An area manager. Your honour I rest my case.

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

And as an area manager you can get off your mobile phone as well....

Jupo Patel, Production & Technical

Strange, A pharmacist told me this as soon as they were launched but said the 28 quid would be handy.

Valentine Trodd, Community pharmacist

How many more reviews and reports will it take before the NHS believe what pharmacists have been telling them for years?

Farm Assistant, Community pharmacist

Nearly everyone knows MURs are a waste of time because their quality is directly related to the pressure that pharmacists are placed under to do them. If we had loads of spare time and were adequately staffed it might be a different picture. As for NMS I have found them to be a real benefit because the lack of information that GPs give patients can sometimes be staggering. One example I had was someone being presribed metformin daily but not told what time of the day to take it. The other point is that all NMSs are automatically selected unlike all the one item and useless MURs we all do just to make up the numbers.

Meera Sharma, Community pharmacist

Yet another report that is saying what most pharmacists have been saying for a number of years - is this report going to be used sensibly and scrap this service? Or are we going to keep having even more articles and reports stating the obvious for the umpteenth time??! Its getting tedious!

Valentine Trodd, Community pharmacist

Sooner or later common sense will prevail among those in power and they'll finally realise how they have been lead up the garden path regarding MURs & NMS. It's coming slowly but surely... until then all of us at the coal face must struggle on with this inane waste of taxpayers money. But I think the real damage has already been done - the irreparable damage to the 'profession' and the relationship between contractors and employee pharmacists/locums.

Clive Hodgson, Community pharmacist

Absolutely correct. The MUR and NMS “services” have indeed caused much damage in Community because of their very poor designs and especially in that they can be set as numerical targets purely for the revenue they generate 

Is anyone aware of anything else that has proved so polarising and divisive?

T. Pharm., Community pharmacist

Scrap em. Advice should be free

Tom Kennedy, Pharmacy Area manager/ Operations Manager

'No evidence MURs are clinical or cost effective', £28 for conning confused and elderly patients into signing a form is nothing, I'm sure there are worse scams going on in the world. Go mither someone else Professor Wright, leave the multiples to carry out their business in peace.

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

And leave the area managers free to bully their managers into an early grave.....

T. Pharm., Community pharmacist

I'm sure there are worse scams going on in the world but seeing as this is a Pharmacy thread, regarding a Pharmacy article, the comment/point your making has no context.

Valentine Trodd, Community pharmacist

Pharmacy is not as virtuous a 'profession' as we'd all like to think. I's got it's fair share of fraud, as an occasional look at the NHS Counter Fraud website and our own great GPhC Regulate rag will testify - the only difference being that company directors, bankers, etc. seem to get away scot free whilst the pharmacist, if caught, will be publically hung, drawn and quartered!

Boom Shakalaka, Locum pharmacist

MUR = MEDICINES USE REVIEW ie a review of how and when a patient is using his/her medicines. It is not a clinical review. They are good value for £28. If the powers that be wish to pay us to carry out Clinical Use Reviews then by all means introduce the training and up the ante accordingly. In my view a fee of £70 per CUR would cover the degree of expertise involved and be money better spent by the NHS. This money can easily be found by, for instance, abolishing the facility some companies deploy in extortionately increasing the cost of branded generics and/or incorporating stricter controls on pricing in the manufacture and distribution of Specials.

David Moore, Locum pharmacist

Unfortunately, the multiples would only see the £70, and increase the pressure to do more. 

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

The pressure would be exactly 2.5 times greater.

Kevin Western, Community pharmacist

Done even reasonably well, MURs ar a win win for the Profession, patients, the NHS and Contractors.

They demonstrate to patients that you, the Pharmacist care about them and that you know a lot more about their medicines than their Gp and Nurse.they promote contact between Pharmacist ad patient, and help ensure that medicines are being taken reasonably well.They raise revenue to pay for staff including Pharmacists.

To say they are a waste of time is ludicrous. If you want to spend your time ticking boxes and filling bottles, be my guest and if you feel that doing the same function over the counter ( wait till IG REALLY bites...) for nothing is sensible then I suspect your future is limited. 

I understand that the pressure to do them can be counterproductive but most of my patients welcome them - even 3rd,4th xth time round in some cases.

In reply to the article above, there are no clinical outcomes, because the service IS NOT meant to be a clinical service! though where the line is drawn is anyone's guess. 

The outcomes were always going to be intangible to a large extent and the resistance of GPs has made it even more un-measurable.

I have lost count of the number of people that I have correcte  asthma techniques for and corrected the use of other medicines. The service works for patients - try it!

Shaun Steren, Pharmaceutical Adviser

Mr Western , I can distill the meaning of your post to a few words - twenty eight pounds.

Please, can we now remove pharmacy schools from the science department and ask if humanities will accept us. This is getting too embarrassing to bear. 

Kevin Western, Community pharmacist

Shaun - have you ever done an MUR? if you have have you never managed to find a patient who isnt taking their medicine correctly? If either answer is no then i suspect you are being deliberately provocative and if the answer to the second is no then you may need to review your technique...

Shaun Steren, Pharmaceutical Adviser

Do you understand the terms opportunity cost and experimental control? If you do, can you explain to me how your post can be considered valid? If you don't (which is my suspicion) then you are evidence of the validity of my own post. 

As an aside, do you understand (again my suspicion is you don't) how provocative your posts are to those pharmacists who work for multiples and for those whom scientific truth is fundamental to their practice as a pharmacist?

Kevin Western, Community pharmacist

"£28 pounds" isnt provocative? - since i'm not paid that, yet see the service as a definite plus both for my standing with my patients and their health outcomes, and incidentally my job satisfaction, i couldnt give a stuff about opportunity cost and experimental control, though I note you havent replied that you actually carry out the service, or if you do, actually help your patients....

Shaun Steren, Pharmaceutical Adviser

'I couldnt give a stuff about opportunity cost and experimental control' 

and with this I rest my case. Only community pharmacy could harbour somebody who could utter such a statement with such pride. I have observed much ignorance towards matters of science on this website, but you certainly push those boundaries. I would suggest you ought to be embarrassed by your statement, but in your world I imagine subtly and complexity in thought is rarely an issue. 

I have worked for decades in community pharmacy and I still practice to this day. So, of course, I have carried out many MURs. Somehow, I don't think you will quite understand what I mean, when I say, this is not relevant. 


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