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Revealed: MUR levels fall in wake of newspaper allegations

The number of MURs delivered by both independents and multiples declined by 15% in three months

NHS data shows the number of reviews delivered across England fell 15% in the three months after the Guardian article was published

The number of medicines use reviews (MURs) carried out across England dropped in the wake of newspaper allegations that some of these reviews were being conducted solely for profit, a C+D investigation has revealed.

The Guardian published an article in April claiming that managers in Boots branches were instructing staff to carry out unnecessary MURs to maximise income from the service. Boots said at the time that it did “not recognise” these claims.

An exclusive C+D data investigation has since revealed that the number of MURs delivered by both independents and multiples declined by 15% in the three months after the Guardian’s article was published, from around 302,500 in April to around 258,300 in July (see graph, below).

MURs delivered by all pharmacies in England

The number of MURs delivered by Boots’ branches in England fell by a steeper rate of 18% – from 57,000 to less than 47,000 – between April and June 2016. In March, the month before the article, the number of MURs it delivered stood at 55,275 (see graph, below).

MURs delivered by Boots branches in England

However, Boots’ MUR performance bucked national trends by bouncing back to more than 52,000 in July, the data, obtained by C+D from the NHS Business Services Authority (BSA), revealed. According to the BSA, this coincided with “approximately 70” Alliance pharmacies being recategorised as Boots branches. The data also showed the average number of MURs delivered per Boots branch went up from 25 to 27 over the course of June.

'No assessment framework' for Boots MURs

Boots declined to comment specifically on the figures.

In response to a freedom of information request, Boots general counsel Andy Thompson told C+D: “There is no framework to assess the performance of pharmacy managers that specifically relates to the delivery of MURs.”

Boots also said it reminds “both pharmacists and managers that professional judgment – and not commercial pressures – should be used to determine whether a patient receives a MUR”.

The number of MURs conducted at Boots stores has increased slightly – by 2.3% – in recent years, from 762,000 in 2013-14 to 780,000 in 2015-16, C+D’s investigation revealed.

Overall MUR trends

Lloydspharmacy, the UK’s second-largest multiple, saw its total number of MURs fall slightly from 46,297 in April to 45,160 in July, despite taking on almost 270 of Sainsbury’s pharmacies during this period, C+D’s investigation revealed.

Lloydspharmacy told C+D it encourages each of its branches to reach the target of 400 MURs a year “where eligible”. While the multiple insisted all of its MURs are “clinically appropriate”, it added: “When we are made aware of any inappropriate delivery of MURs, this is addressed.

“Our performance review framework includes progress against values, behaviours and business objectives. In addition, discussions are held regularly between each pharmacist and his or her line manager.”

How are allegations of service pressures being addressed?

The Guardian’s allegations of unnecessary MURs being conducted at Boots were based on findings from the Pharmacists’ Defence Association’s (PDA) survey into workplace pressures at the multiples.

In response to the findings, the General Pharmaceutical Council (GPhC) pledged in June to conduct a “programme of work” to “build a greater understanding of workplace pressures within [community] pharmacy and to discuss how these issues could be addressed”.

However, at its meeting on October 18, GPhC chief executive Duncan Rudkin stopped short of urging individual companies to resolve the issue, instead saying it is up to everyone in the sector to create a “corporate culture” to tackle workplace pressures. 

What do you think: should MURs be scrapped or altered? Or do you see the value in them? Join in the debate with C+D’s LinkedIn group here.

Listen to C+D’s exclusive interview with PDA chair Mark Koziol about the MUR investigation here.

What’s next for MURs?

Jonny Johal, Pharmacy Area manager/ Operations Manager

We can all agree that the very vast majority of MURs resulted in "no actions". I think the true scale of MUR abuse has yet to be delineated. I would include in this category, those patient 'consultations' that should not be recorded as MURs, those MURs that are done out of service contract terms, those MURs done without cause, those MURs that were recorded without patient knowledge or consent, and those which are simply 'invented'. I worked for a company which senior management 'encouraged' MURs in new stores which has not even been opened for 3 months, and used bullying tactics like recording locum pharmacists' MUR numbers, and not book those who don't do enough.

Soon-To-Be Ex-Pharmacist, Superintendent Pharmacist

Given that most of us on here are anonymous, why don't we name and shame these bad practices? I know for a fact that the companies monitor websites for mentions of the company name so it would get back to them.

Valentine Trodd, Community pharmacist

 I think the scale of MUR abuse has yet to be delineated.

I think this is very true. From what I've seen I think the true scale of abuse would be shocking to the general public. I don't think it's quite sunk in that this charade is costing the taxpayer over £100 million a year. I had an NHS probity visit recently to 'verify' the validity of MUR and NMS claims - it amounted to checking the number of consent forms matched the number of claims!

Gerry Diamond, Primary care pharmacist

Well if MURs are done properly, no harm in taking some time out from behind the counter to interact with patients instead of doing a technicians jobs checking or counting pills. I have twenty to twenty five appointments daily with patients as a practice pharmacist, and feel community pharmacy must get away from the sticking a label on a carton. Can't believe that community pharmacy is still existing to do this simple function. Atleast when I started out in pharmacy thirty plus years ago we made up creams, powders, mixtures and pharmacist nostrums. If you take murs and nms away then you may as well let technicians run dispensaries without a pharmacist.

asher barsoum, Locum pharmacist

I think you're missing the point. There's nothing wrong with MURs its the loss of your professional independence in choosing who and how many to do and suffering of pharmacists from management who have no ethics what so ever. If u started 30 years ago then im sure you remember what it was like to be respected as a clinician and to be independent in your judgement. Few have that luxury these days.

Chris Pharmacist, Community pharmacist

Gerry, community pharmacists are more business managers these days. Certainly not what I wanted to be but hey thats modern capitalism for you...and it pays the bills. It beats being a GPs lackey

Gerry Diamond, Primary care pharmacist


Jupo Patel, Production & Technical

You are are GPs lackey. With out their prescriptions your so called business is dead.

Amal England, Public Relations

Is it the job of pharmacy to get away from sticking labels on medicines- from a legal standpoint? Part of it is, but the major hurdle is that which is controlled by doctors and the Home Secretary- the dose, preprinted on each box or PIL for each indication, age, weight, kidney and liver function. We have to look back in history, when the pharmacist diagnosed, prescribed and dispensed. Many pharmacists do in Europe and other parts of the world. We have been pushed into dispensing as a core role.

Shaun Steren, Pharmaceutical Adviser

1) This assumes that pharmacists were giving less advice before the existence of MURs and NMS. If we take the period of say 2000 to 2004 (a period pre- MUR/NMS and post- significant extemporaneous), I don't know that pharmacists didn't give extensive advice with each prescription when appropriate. One might argue that if this is the case, then what is the issue with MURs/NMS? This would however be false reasoning. The reasoned response is why complicate and obstruct an activity that was already occurring in a more dynamic and natural way. It certainly falsifies any claims that MURs/NMS are anything innovative.

2) It assumes that the reason pharmacists accuracy check prescriptions is because of a differential between the accuracy of a pharmacist and technician. The actual reason is legal responsibility. As with OTC sales. 

3) It assumes that the current dispensing process is worth defending - it isn't. For a start, we could immediately abolish the labelling of medications, it is not done in continental Europe where its absence creates no extra problems. We could introduce barcode scanning technology which could quite easily act as primary accuracy check followed by a secondary human check. These two things would massively simplify and improve the process. This still leaves us with the rest of the dispensing process, which in most dispensaries, is utter chaos. 

The operational reality of the typical dispensary is the product of control entry and a government who doesn't know what to do with an archaic and anachronistic profession. As a consequence, innovation has been virtually absent for two decades. Community pharmacy spends its time creating the illusion of modernity, dressing up the old as new. The public might be fooled, but most community pharmacists in their own heart know the truth. A truth they hope won't be revealed until after their own retirement. 

Amal England, Public Relations

Can you extrapolate on how pharmacy is archaic and anachronistic ? Pharmacy is not like social media or a car, which can become driverless and I'm not sure the patient would want that either. Pharmacy and pharmacists play a vital and untouchable role in health. However i accept the logistics need to change and efficiencies brought in. The scope of the pharmacist is far greater than what you believe, it's just a shame the doctors have monopoly of the NHS and it's funds. You give pharmacists the money and I'm sure we could put a big dent in all of the public health concerns. But that is not what the doctors want and nor does the pharmaceutical industry.

Shaun Steren, Pharmaceutical Adviser

Extrapolate? Do you mean elaborate? Archaic and anachronistic - belonging to another time. Community pharmacy has changed incredibly slowly since the early 1990s in comparison to rest of the healthcare sector. Does that cover it? 

You don't know what I believe regarding the potential scope of community pharmacists from my statement. The statement I made was a positive statement (what is the case) and not a normative statement (what ought to be the case), which is what you are discussing. 

Amal England, Public Relations

Your second point is in general false, pharmacists are better at accuracy checking compared to technicians. I would rather see accuracy checking left to technicians nonetheless, so that pharmacists can put more time into the clinical aspect.

Jupo Patel, Production & Technical

You won't pay your bills with that model and in fact you'll be made redundant. 

Shaun Steren, Pharmaceutical Adviser

You need to read what was written. It was stated the reason why it is, not whether it ought to be. With respect to your comments:  Generally false? What does that mean? Pharmacists are better? What does better mean? Can you refer me to your evidence base? 

Amal England, Public Relations

Do you have data (randomised and comparative) that shows the absence of labelling in continental Europe, not only doesn't generate extra problems but also that there is no therapeutic benefit foregone?

Shaun Steren, Pharmaceutical Adviser

There is no study to compare community pharmacy dispensing error rates across the European Union with respect to labelling, how would you control for all the variables? However, I need no such study to make such a statement. The intervention is being made in this country, we label as an instruction to the patient, the onus is therefore on us to prove the need for such an intervention. In Germany and France, where labelling does not occur, there is no evidence for increased error rates, as per statement. 

This is not an argument of absence of evidence being evidence of absence. You cannot propose the benefit of labelling simply because that benefit cannot currently be disproved by a very specific study. It's the null hypothesis. This is more than a fair basis to challenge the need to label medication. Such a development may lead to a different conclusion, but this is the basis of innovation - testing by reasonable comparison to other known methods. 

Fourth Circle, Pharmaceutical Adviser

Of course they stopped for a couple of months, they deemed that appropriate. Now they resume with a renewed vigour in order to catch up. Silly lazy pharmacists, thought they’d got away with it. Not a chance.

MUR Sir, suit you Sir.  Is that targeted or non-targeted, Sir?

Em, Locum pharmacist

Apart from the figure in April, there's not really a massive difference compared to last year. See on their front page which shows the last couple of years. Also, correct me if I'm wrong but doesn't the MUR year start/end in April so there's always a push to get as many in as possible around then? 

Shaun Steren, Pharmaceutical Adviser

There are three words that explain why MURS are here to stay regardless of the complete lack of evidence for their cost-effectiveness and the bullying culture in which they are imposed:


Amal England, Public Relations

Shaun, have you ever done an MUR? To say there is no evidence that MURs are beneficial can be no further from the truth. You could see for yourself, just Google it. By the way this is coming from someone who was an MUR sceptic and believed that MURs would properly last a few yours and then disappear.

Shaun Steren, Pharmaceutical Adviser

I am trying to translate what your are saying, so bear with me. There is no robust evidence for the cost-effectiveness of MURs - that is a fact. If you want to make a claim for cost-effectiveness the onus is on you to prove it. Similar to your labelling point - it's the null hypothesis - not me 'googling it'. I am very familiar with the current evidence base for MURS (and NMS for that matter). So if you would like to reference a particular paper, I will be happy to work through it with you.


Amal England, Public Relations

No Shaun, we don't need any papers, why don't you get out there do MURs and NMSs for the next 12 months and then come and tell us they are ineffective. You seem to have no idea about MURs and yet you make such comments that not even Panocchio would speak.

Jupo Patel, Production & Technical

No way Shaun ! I thought it was just 2 words, PATIENT SAFETY

S Pessina, Pharmacist Director

Well if you look at it from cost saving point of view, thats a good enough reason to get rid of.  They are an anathema ( along with NMS)- end of.

Shaun Steren, Pharmaceutical Adviser

The concern for government is maintaining the illusion of taxpayer value. MURs and NMS are useful in this regard, they make it appear that pharmacists are doing more for their money. Of course, in reality pharmacists have just become incredibly efficient in obtaining patient signatures for minimal input. 

Government must been seen to be doing something. Whether that be making GPs carrying out useless tick box dementia tests or pharmacists taking clinically unjustified throats swabs, it all serves the propaganda purpose of masking incompetence. 

Amal England, Public Relations

If that is how you operate in your pharmacy, i feel sorry for your patients.

Shaun Steren, Pharmaceutical Adviser

No it is not, and I don't know that it is the way the majority of pharmacies operate. This is very much the point, what happens with services within any given pharmacy is opaque. MURs can quite legally be minimal in interaction. They can legally be dubious in content. What we can infer from numerous surveys is that many pharmacists question the effectiveness of what they are doing and reasons for doing it. Ultimately we are left with signatures on consent forms, boxes ticked, minor comments made and numbers on spreadsheets.

Meera Sharma, Community pharmacist

GPhC's handling of this corporate culture is appalling. My friends at Boots have said that the bullying tactics stopped for a while, but are now back on since the GPhC chose to take no action. I wonder why they even bother having a whistle blowing policy on their pharmacy - useless really. And yet again, no one wants to touch the big boys of pharmacy - think the media definitely need to be involved in this one. Turning a blind eye to corporate greed, think such companies should be exposed! 

S Pessina, Pharmacist Director

Meera, I suspect there is some collusion there also .  Otherwise papers would be full of this S**t.


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