'I reviewed services for NHS England. Here's how MURs should change'

Professor Wright: I am fully aware of the pressure to deliver MURs

Professor David Wright wrote an influential evidence review on pharmacy services. Now he explains why MURs should be revised.

When I reviewed the literature to inform the ['Murray'] review on behalf of NHS England, I developed a clear personal view as to what a revised medicines use review (MUR) service should look like, and how this could be implemented and developed.

However, I have no insight into what [NHS England] intends to happen following the review.

I was a practising community pharmacist for over 20 years – I only gave this up last year due to work and family commitments – and I undertook my last MUR in the summer of 2016. So I am fully aware of the pressure to deliver MURs, and the barriers to doing so when the work environment is not ideally configured.

As a health services researcher, I have also developed a better understanding of how new services should be developed and introduced to maximise effectiveness, safety, acceptability and equity in service provision. This informs my view of what a revised MUR should look like, and how a new service should be implemented to prevent the problems initially encountered with the original MUR [service].

Shift from medicines supply to management

MURs were introduced to shift community pharmacy's reliance on income from medicines supply to improving medicines management. A service had to be introduced quickly which did not require extensive retraining, was likely to be well received by patients, and was seen to improve patient outcomes.

A single consultation to improve medicines adherence was the obvious solution. Its legacy today is the almost ubiquitous appearance of consultation rooms in community pharmacies, and perhaps an increasing recognition by the general public of the pharmacist’s expertise in medicines.

My personal view is that the problems identified in the literature at the point of MUR introduction largely resulted from the speed of their implementation, and insufficient engagement with stakeholders – the actual providers and recipients of the service – in the process.

There was no meaningful testing and development process, and the training and assessment associated with it was variable with respect to its content and implementation. The initial delivery of MURs was therefore unsurprisingly variable, and GPs reported dissatisfaction with some of the information they were receiving.

Disparity remains

While the service was well received by patients, it had a number of significant teething problems, not all of which have been ironed out with time. As MUR provision has increased and equity in access to the service for patients has improved, disparities still remain between the provision by different community pharmacies.

Furthermore, while the current funding model encourages service provision, it does not consider quality or outcomes. This is in contrast to current thinking regarding how such services should be commissioned.

In my opinion, two fundamental problems with MURs suggest that they require revision:

  • Reviews of MUR service provision have identified that they can overlap with the services already routinely provided within GP practices. Unless we work in a more integrated manner, this could be seen as an inefficient use of resources.
  • A relatively recent Cochrane review of one-off patient consultations similar to MURs reported that although medicines reviews "appear promising" and patient satisfaction is likely to be enhanced, there is limited evidence for benefit beyond that.

I would argue from personal experience that patients do benefit from MURs beyond patient satisfaction. But the question for the NHS is whether the money currently being spent on MURs could be better used to deliver greater patient outcomes.

What would a revised MUR look like?

During my review of the literature, I identified a number of studies that demonstrated positive clinical outcomes and cost-effectiveness from pharmacists providing multiple consultations of a similar nature to MURs, to patients identified as requiring support to optimise their medicines.

So what do I believe a revised MUR should look like? The answer is a service that:

  • supports medication adherence
  • reviews patients' therapy, and
  • monitors their progress.

This redesigned service should be provided to patients with chronic disease, who have been referred by their GP and through the repeat dispensing scheme.

The frequency and duration of consultations would be dependent on a patient's needs, which would be determined by the clinical outcomes they are being monitored for. There would need to be close communication with a patient's GP practice to ensure that there was no unnecessary duplication of effort.

Assuming that the current funding envelope remains constant, this would not result in 400 patients being managed each year, but a number much smaller than this, to reflect the additional workload per patient.

Funding to incentivise outcomes

The funding [for revamped MURs] should also be redesigned to incentivise outcomes, rather than service delivery. It would reflect an increase in the proportion of patients within a target range (for example, the proportion of patients on blood pressure medication whose blood pressure is within the desired range). The pharmacy target would align with GPs' quality and outcomes framework (QOF), to encourage integrated working with GPs.

However, the obvious barriers to this model of care are:

But without direct communication with practices to enable patient identification, access to records, or effective regular communication with the patient’s GP, delivery of such a service would be difficult.

I would, therefore, expect significant engagement with practising community pharmacists, patients and GPs, to identify barriers and enablers to service implementation. Training should also be carefully considered to maximise safety and provide reassurance regarding quality.

Testing before wider rollout

The provisional service should be feasibility tested on a small scale to test its acceptability, piloted to confirm that the service is likely to be effectively delivered on a larger scale, and then rolled out nationally – with plans for a service evaluation to provide evidence for its effectiveness and cost-effectiveness.

Once a new service is successfully introduced, it would be reasonable to expand the service to involve more complex patient groups, introduce new diagnostic tests, and enable community pharmacists to independently prescribe. This would allow more autonomous management of therapy.

The process of training community pharmacists to become independent prescribers, with local GPs as the designated medical practitioner, would also overcome some of the identified barriers [between GPs and pharmacists] and is therefore worth considering. What's more, training community pharmacists as independent prescribers may provide an opportunity to expedite the [medicines review] process and enhance service provision.

In summary, any revision to the current MUR requires extensive stakeholder engagement, careful consideration of the funding model, and iterative testing to ensure that the final service is likely to be safe, effective, acceptable and equitable.

David Wright is professor of pharmacy practice at the University of East Anglia

Keywords: 
17 Comments

janet maynard, Community pharmacist

At least it sounds as if you know what you are talking about! Since MURs I do far less clinicla stuff than i used to!

Honest Pharmacist, Community pharmacist

Just a suggestion...but why don't they just scrap the MUR service in the community pharmacy setting, and let it be a role that only the practice pharmacists carry out within the GP surgeries?

That will remove the pressure that community pharmacists face from the multiples, who we all know are the ONLY ones who actually benefit from MURs, and the pharmacists within the GP surgeries can liaise with the GP's to ensure that they only carry out MURs on the patients that really need them.

I might be stating the obvious, but i think this simple solution would be the answer to many community pharmacy problems and work place pressures. It would also be a way to get the Multiples to 'back off' and stop bullying us into providing this unnecessary service which is a complete waste of money to the tax payer.

 

 

Leroy Jackson, Community pharmacist

Need changes to ; "current legislation regarding supervision, limiting the pharmacist’s time away from the dispensary"

Yeah.....nice try.

And to the point of informing patients of the cost of MURs - why not.....lets also cost them up the price of a Gp appointment, QOF points and not to mention the cash they get for just having a patient on their list each year. Value for money????

 

Imran Wahid, Community pharmacist

I definitely agree that MURs need to be redesigned and better integrated into the wider healthcare team and recording systems, but thats the case for pharmacy in general. Integrated IT systems should bbe embedded within each locality beyond the capabilities of ordering and receiving prescriptions electronically.
But the comments on MURs being a waste of time and having to declare how much you are paid for them bemuses me. Its like a GP saying they should tell a patient how much they get paid on top of their salary for controlling BP or offering smoking cessation advice or giving a flu jab etc. It is irrelevant. What is more relevant that internally the NHS reviews the value of all services not just with the current witch hunt of pharmacy and that professionals are recording everything to demonstrate the value of the services they provide.
Lastly, to those who say there is no demand from patients or that the murs they have done were useless, it sounds more of a reflection of the relationship and expectation your patients have in you. You create the demand by educating you patients and engaging them in positive health behaviours. In my experience over the years I have found an ever increasing demand for consultations such as MURs because the patients are more engaged in improving their health and want to get the best out of their medicines and health interventions. In fact most leave saying 'you are better than my GP'.

Valentine Trodd, Community pharmacist

I think a few key points mentioned stand out about MURs and bear repeating...

* patients have no idea they cost the taxpayer £28 - it should be mandatory to inform the patient of this

* there is absolutely no demand from customers whatsoever for them - customers ask for services they find beneficial e.g. needle exchange, blister packs, delivery, etc. I've NEVER had a customer say they heard about the great new service the NHS is offering called MUR and NMS, please can I have one?

* I have yet to see any convincing unbiased research to say they provide any benefit to the patient - probably because it doesn't exist... how would you even measure it?

Marcus Jones, Student

100% Agree the general public need to know the cost of these services, and im 100% certain they will choose not to have them. 

As a pharmacist, I’m happy to answer the customs questions when i have time and i see this as my job and part of providing high quality services. So when people come to me with questions they are free, and more beneficial, since they are being asked by the patient.

But wasting so much more on poorly targeted patients, with no real outcome or benefit is wasting vital money that could be used else where.

Maybe the NHS should trail providing information on the cost of the service and see if people would still want one?  

How many full time nurses could we employ with this money? 

 

C A, Community pharmacist

So you have never had a patient come to you with boxes of tablets and ask to talk to you about them? or

You have never had someone come in with a discharge sheet confused about what the hospital wanted them to do? or

You have never had someone come in and say the doctor gave me this - what is it/what is it for?

I have had all of the above happen, with reasonably regularity, and whilst the patients aren't mentioning the services by name, I'm sure you can guess which apply!

Valentine Trodd, Community pharmacist

Answering patients questions and helping them out is called 'being a pharmacist' - it's something most of us do as a matter of course and is what we signed up for. You know you can answer questions without dragging the patient in for a MUR and relieving the taxpayer of £28.

Locum Pharmacist, Locum pharmacist

With regards to the above scenarios, it is not like pharmacists will refuse to help them if they don't sign the MUR form. We would counsel them regardless.

Ilove Pharmacy, Non Pharmacist Branch Manager

Next time tell them before you proceed it will cost £28. Depending on your locality you'll either get a brick in the face or they'll be out the door quick sharp.

Marcus Jones, Student

from the MUR's i have carried out, and the MUR notes i have reviewed from other pharmacist, i can say with certainty they are a waste of tax payers money, provide little or no benefit to the patient, and would probably better managed and carried out by the patients GP who a ) has a relationship with the clients b) Knows their full medical history. 

Also note 9/10 MUR’s completed by other pharmacists I have seen have no notes, just yes or no, when a patient has stipulated they have had some sort of reaction to the drugs, there have been no notes for the GP to follow up on, what a waste of time and £28 down the toilet

I also believe the public should be educated and told it costs the NHS £28 each time a review is conducted, and on the way out they should register whether it they believe it was a good use of their tax money or should be used elsewhere.

I am quite confident 99% of patients would say it should be spent elsewhere.

Please get grip, don’t turn pharmacists (unless you are going to change the whole profession and training provided) into doctors and nurses, each has their place.

Jonny Johal, Pharmacy Area manager/ Operations Manager

This is a perfect example of a profession lost and confused about its role ... an attempt to prove a pharmacist's worth without even consulting the recipients (the patients). What is he talking about? Turning pharmacists into the adherence police or forcibly imparting unwanted knowledge which patients can get from Google? But sorry, poor medicines compliance/adherance etc is and should remain a patient choice, and not illegal. As a consumer of health, I have always refused to participate in MURs.

There is no demand in the market place for MURs of any form, and there is no evidence that any patients have been harmed by the lack of MUR!

Ilove Pharmacy, Non Pharmacist Branch Manager

Careful now, Boots ahem C&D will delete your post.

Boland Rowland, Locum pharmacist

Excellent article. Unlike most community pharmacy articles, it is obvious the author has actually worked in the real world of community pharmacy (20 years) and it is reflected in the pragmatic approach to a very obvious (from the dispensary floor) problem with the current MUR service. It is also refreshing to see a focus on patient outcomes and integration with GPs.

Meera Sharma, Community pharmacist

Very good article, balanced and fair.

JOHN MUNDAY, Locum pharmacist

Brilliant piece of writing which had opened my eyes to a new way. I really think this is the way to go.

Barry Pharmacist, Community pharmacist

There are some excellent idea in this. Congratulation and thanks for sharing. The current situation is appalling frankly in terms of workload pressure and having the service linked to RDs is a great idea. 

Job of the week

Relief Pharmacists
Various locaction in the South West
Competitve + Relocate fee + mileage
Normal datacapture modal