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The Locum: Why MURs are both life-saving and worthless

"The announcement that MURs will only be funded for the first half of the year is good news"

The format of medicines use reviews (MURs) renders a life-saving service worthless, The Locum argues

Floccinaucinihilipilification: The action or habit of estimating something as worthless.

“Worthless” is a very emotive word. It is cold, sterile and unproductive. Do I really think it is fair to refer to MURs as worthless? Am I not diminishing the role of the pharmacist, perhaps even the profession, by suggesting as much?

While I genuinely do believe MURs are worthless, I should start by saying that last year, in the process of conducting an MUR, I made an intervention which saved a patient's life. Surely, the above two statements are hugely contradictory? How can both be true?

Well, essentially it is my belief that patients should be comfortable enough that they feel able to discuss all issues, but particularly those surrounding their medication, with their pharmacist. If your patient needs inviting into a private room, to first sign a form and then have a formal, often rigidly-structured discussion, in order for you to find out how they are getting on with their medication, you are doing something fundamentally wrong in the way you practice pharmacy. As has been suggested so many times, MURs need to change.

Asking for a signature devalues the MUR

I work as a locum, meaning often I never see the same patient twice. Despite this, I like to think I am approachable enough for patients to come and have a chat about their medicines, even if they do not know me from the locum who was working last week. This requires you to be present, attentive, patient and compassionate.

For someone to tell a stranger, albeit a professional, that they are bleeding rectally since taking aspirin, takes a huge amount of courage. I always feel that asking for a signature, so that the contractor gets their £28 and you get booked again, horribly devalues the whole process. It makes me cringe, and I often think patients feel the same sense of unease.

One of the big problems with MURs is their huge variability in delivery. As a locum, patients have told me they have never been asked about their medication by the pharmacy's regular pharmacist. I've also seen the manager of a chain of pharmacies 'conduct' an MUR by simply asking a patient, at the counter, if they are getting on okay with their medicines. "Do you need anything ordering?" was the only addition, before a consent form was thrust at the patient for them to sign, the whole process over in under 10 seconds.

Lack of evidence of cost-effectiveness

Another issue with MURs, in their current form, comes from the lack of evidence of cost-effectiveness and clinical benefit. While admittedly the quantity and quality of evidence is not substantial, it seems that MURs do not have much empirical value and this, during a period of austerity, makes it all the more difficult for pharmacy as a whole to prove its worth.

Many pharmacists feel pressure from management to get the forms signed, due to patronising financial incentives or the worry that you might have employment repercussions should you not be seen to be pulling your weight. This perpetuates the problem of poor quality MURs and undermines the profession. The patient should be our first concern, not just their signature.

In conclusion, while I am a huge proponent of the value of a well run, service-led community pharmacy, I would consider the recent announcement that MURs will only be funded for the first half of the year, pending review, to be good news. Contractors will of course be worried by the potential for this all-too-welcome financial contribution to vanish forever.

However, I would hope that the powers that be have the insight to realise that properly-funded pharmacies up and down the country add value, reduce harm and save lives all day, every day. It's what we do. It just so happens that 95% of the time, we don't have a consent form handy.

The Locum has worked as a community pharmacist in more than 200 pharmacies

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
12 Comments

Andrew Boyle, Community pharmacist

Hybrid MUR (Clinical Medication Use Review with full access to patient record) is the most effective and CP is ideally placed to conduct. We will not progress our role until we can verify with more than just a sketchy SCR.

Leon The Apothecary, Student

I always felt the MUR payment structure was odd for one simple reason; it is paid to the building it was conducted in rather than the professional who conducted it. Completely unpopular opinion especially with contractors but pay the Pharmacist who did it rather than the company they happened to be working for and you would see a fundamental shift in the focus of services from these companies.

Beta Blocker, Primary care pharmacist

The multiples would reduce your salary by £11k straightaway...I have no doubt.

A B, Community pharmacist

I have given up making any clinical recommendations during MURs. They either turn out to be inappropriate, because I don't have the full clinical profile of the patient, or they are ignored.

I simply do what it is, a medicines USE review. I go through the patient's medication and make sure they are taking it at the right times, are able to use the device etc. and give healthy living advice where appropriate.

Of course if I come across something that is blatently dangerous to the patient I will flag it up. But I'm not going to think to myself "hmmm, this patient isn't prescribed the current NICE guideline approved treatment, I better send a note for to the GP for them to shred".

Hopefully the service will be reviewed in Septemeber and will be improved.

Beta Blocker, Primary care pharmacist

This whole article describes my time in Community pharmacy... MURS are a complete waste of time and pressure from management especially at the multiples is to blame for the decline in the quality of MURS.

I mean what is the point in the MUR when you can't access medical records, blood tests and past history. And when you do recommend a change and send the paperwork to the surgery... nothing gets done.

R A, Community pharmacist

The reality is when you have a regular customer and you become familiar with their drug history you review their medication without really thinking when they bring in a prescription! Also when a patient brings a prescription in for a new medication you also review it and make intervention when necessary.

The old reimbursement system worked far better in my humble opinion the MUR is just more paperwork.

 

Ronald Trump, Pharmaceutical Adviser

I agree MURs can be a clinical activity- but they are limited in terms of the degree of intervention you can make. Due to lack of access to patients full clinical history, recent blood results, lack of clinical knowedge/diplomas/prescribing by most (not all) community phrmacists it is hard to make decisions in situ that can be of maximum value. 

 

Surely it is not a cost-effective idea for the NHS to pay for both, an annual MUR in a pharmacy with a community pharmacist and an annual clinical medication review with a practice pharmacist in a GP practice? Bearing in mind the NHS plan to have clinical pharmacists in most GP surgeries in England in the next few years. 

 

Better off reinvesting MUR money into other services pts would want, like trying to prevent self inflicted long term health conditions like diabetes and hyperlipidaemia, or common illness clinics where they can get immediate access.

 

Most dispensing will go to hub and spoke and will move into the digital realm in terms of ordering and delivering meds. Community pharmacy is changing and it has to move towards more novel, effectice services to service. The current MUR model is not fit for purpose and is doing little but to line to pockets of pharmacy owners. Dont be scared! Change is good!

will cockburn, Community pharmacist

Further you might say that MURs are not clinical... so at what point can a professional involved in a conversation with a patient about their treatment choose to ignore their years of training and expertise and not make a clinical intervention or provide clinical advice where it is patently obvious that it is needed! If you talk to a trained clinical professional the conversation will be clinical. Sure to suit their own needs there have been messages given by multiples that they are not clinical. In my pharmacy and in my multiple company all pharmacists are free to offer the MUR which they feel appropriate ( as long as it is professional and meets a certain standard)

will cockburn, Community pharmacist

Oops I’m providing my real name. Forgive me but I and many pharmacists provide time consuming and valuable MURs for patients and that lead to changes in medications prescribed by GPs. I have worked extensively in Primary Care and love the proximity to the patient that the MURs offer. Given time to talk about their medicine use and their condition where relevant patients offer an invaluable source of information to allow best use and tailoring of medicine use. 

Ronald Trump, Pharmaceutical Adviser

Contractors/Multiples obviously against removing MURs for fear money will not be replaced and it is a relatively easy 12k in the coffers for the year. The MUR model in community pharmacy are now outdated and not fit for the future. They are being abused by mulitiples for profit and have demoralised pharmacists due to lack of autonomy and pressure from management. Good news that there days look numbered!

Adam Hall, Community pharmacist

Herewe go! Another bloody locum who thinks we should provide services (eg "discussions with patients about their medicines") for free! I am sick to death of locums thinking we should "do it for free" or who "feel bad about charging for emergency supplies." I'll make a deal with you - you work for me for free and I'll let you reduce my potential income because you feel "profit" is a dirty word!

Ronald Trump, Pharmaceutical Adviser

 

Great article buddy and I completely agree with you. Waste of NHS money. Especially with the growing numbers of pharmacists conducting reviews in surgeries, better value for money to just do one review where practice pharmacists can mop up adherence/usuage issues during clinical meds review. Better of reinvesting money in a service that patients actually want which is evidence based and cost effective for NHS.

 

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