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GP view: Are MURs and the NMS cost-effective?

"In some cases, MURs have generated unnecessary work and anxiety"

GP Toni Hazell is a fan of the new medicines service (NMS) but has found that medicine use reviews (MURs) can add to her workload

The NMS looks to be going the way of MURs – taken away from community pharmacists and made part of the job of “clinical” pharmacists working for a primary care network (PCN). Is this change a good thing?

I suppose there are two sides to this discussion. Are MURs and the NMS useful for patients, and are they cost-effective? It would seem obvious that for patients, going over medications with a healthcare professional would be useful, and surveys suggest that patients like them.

Similarly, I have often used the NMS stamp that I have in my drawer to indicate to the pharmacy that this is a new medicine. I’ve told the patient that the pharmacist will get the inhaler and spacer out of the box to demonstrate its use, which seems a much more sensible way to do it than my terrible drawing on a scrap of paper. With medicine shortages sometimes meaning a change of brand for critical medicines such as adrenaline auto-injectors, it is vital that patients know how to use what they are given. I am a fan of the NMS system.

To be honest, I’m less sure about MURs. I’ve only ever had a few letters from pharmacists following up on an MUR, so I may not be seeing a representative sample. However, in the ones I have seen, the MUR has duplicated what we have already told the patient. In some cases, they generate unnecessary work and anxiety.

I suspect that the value of an MUR depends on the experience of the individual pharmacist and maybe how well they know the patient, rather than having a set outcome. It may be that the change in MURs last October, targeting only high-risk and recently discharged patients will make them more useful.

Patients like MURs, but with the NHS is on its knees we must deliver what is needed. We may not have the capacity to provide things that are wanted but not unnecessary, which brings me on to cost-effectiveness. At first glance, it is hard to see how one MUR, for which pharmacists are reimbursed £28, can be cost-effective, compared to the £120 or so that GPs are funded to see the patient as many times as they need for a whole year.

Admittedly, things are never that simple. The NHS payment system means that patients who never visit their GP subsidise those who are in the practice all the time. I am fully aware that the pharmacy global sum has been cut in recent years, and that pharmacy is under the same financial strains that affect GPs.

I’m not confident that NMS or MURs are cost-effective, although work with some specific groups such as patients with asthma has been positive. I can understand that some of the benefits may be difficult to quantify. If the patient has fewer adverse effects than they would have done otherwise, that is both clinically and financially a good thing.

So, is moving MURs and the NMS into the remit of PCN pharmacists a good thing? I can feel the splinters in the seat of my jeans as I sit firmly on the fence on this one.

The role of the PCN pharmacist is yet to be fully worked out. No doubt there will be some who are amazingly competent and whose medicines reviews add significant benefit to the patient, in a very cost-effective way.

There will be others whose efforts only add to the workload of GPs. Possibly the worst outcome would be if this loss of income destabilises pharmacies in the way that loss of flu jab income has destabilised some GPs. We can all agree that pharmacies and GPs having to close their doors is never a good thing.

Toni Hazell is a GP based in a practice in London

7 Comments

Amjad Khan, Senior Management

Those who believe MURs are a total loss of money in community pharmacy are sadly not thinking with an open mind or just not competent enough to deliver them.

I was really saddened to the loss of MURs. I never number crunched them. I just targeted my high population of diabetic patients in my community. The money I believe I saved in return to the NHS was, I believe, phenomenonal. Aswell as the clinical benefit to the patients.

I would regularly write to GPs, after integrating fasting blood glucose tests, or home measured BP readings, reinforced patients understanding of signs and symptoms of uncontrolled diabetes, and lifestyle improvements. And writing to GPs recommending changes in drug regimens, or just quick not on findings and I did see many changes from the GP too, we had an improved relationship.

All this on average in a 20min clinical consultation, plus often follow up and paperwork, the £28 per MUR was excellent value for money for the NHS.

Michael Mustoe, Community pharmacist

Any clinically focused conversation with a patient should be positive and cost effective.
Waste is in the hundreds of millions, difficulty in using some prescribed medicines is not uncommon, confusion over medicines regimes is very common, over-prescribing is far too prevalent, and quality lifestyle education is sorely needed.
Conclusion - ALL pharmacists could be doing alot more in these areas, and should be paid for their contribution. Just because the current system is flawed, doesn't mean that everything is wrong, but that change is needed to build on experience and satisfy future needs
Pharmacists are key to the successful delivery of a clinically and cost effective NHS
They just need to be used more intelligently and extensively

Benie I, Locum pharmacist

MURs and NMS. Targets/tools with which to abuse pharmacists, discipline and eventually dismiss them. 

Jenny Etches, Community pharmacist

I concur that the most useful of all the MURS I've done over the years are for asthma patients. Time taken over inhaler and spacer technique has never been wasted. But a lot of MURs have left me feeling slightly fraudulent although I've usually increased patient trust and know a bit more about the patient, usually not clinically though. 

ABC DEF, Primary care pharmacist

Mur and Nms are merely seen as "targets" in the eyes of pharmacy upper management with pitful benefits to patients. It's all about money not treatment outcomes. They only care about the £28 but not at all what benefits patients are getting out of it. 90%+ of them are a total waste of time and just a tick box exercise. I've even seen shameless colleagues doing it just over the counter and ask one or two questions and ask patients to sign the consent form, merely taken 10 seconds. Patients also don't want to have a chat anyway as they just want to pick up their meds and go and don't want to be "ambushed by 'pretend doctors' saying they are too fat" according to some this morning or evening journalists.

Joan Richardson, Locum pharmacist

I carried out quite a number of MUR's and generally found it very hard to tick one of the boxes at the end about the expected benefit to the patient.  If they didn't have any side effects than I was not helping them manage them.  If they were taking their medication, or told me that they were, then their compliance was not going to be improved.  If they knew what the medicines were for then I wasn't explaining their condition. 

I did have one success and that was by an intervention MUR whan a conversation at the counter told me that a patient was not using their eye drops correctly.  However one out of many left me feeling despondant as I was spending all this time on MUR's with no benefit to patients.

They were introduced to give us back the funding that had been taken away and as an attempt to quantify what pharmacists do on a daily basis via a brief conversation at the counter.  While patients may well be willing to have a brief discussion at the counter, moved into the consultation room if necessary for privacy, they are far less willing to be sat in the consultation room for a MUR.

Alexander The Great, Community pharmacist

MURs are total waste of money. They took the money out of our OWN pharmacy funding pot and then "gave it back to us" to provide this service and then to take it away from us again. Its a total funding shambles once again. NMS, we did this anyway, without getting paid for it, they are paying us to make a paperwork trail.

All us "normal" pharmacist want, is enough funding to cover staff costs (decent wages for EVERYONE - and an NHS pension would be a dream), overheads covered and a little more so we can afford to refurbish once every 10years. None of this providing more clinical services malarky - customers dont want that!

 

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