From Mr A. Richards, MRPharmS
I was carrying out locum duties recently at a supermarket pharmacy when a floor manager arrived, who told me that I had to undertake two medicines use reviews that day. His second conversational gambit was to tell me that he was taking me off the company’s accredited pharmacy locum list. I think this was a direct result of my telling him what he could do with his first instruction.
Any primary care pharmacist could have seen what was going to happen with MURs. We live in an imperfect world and to use MURs as a means of compensating for revenue lost following the reduction in payment for Category M medicines is ill-considered. We now have a situation where MURs are seen by some as an income stream and valued accordingly.
I welcome this opportunity to start a debate on how far managers — qualified and non-qualified — can go in telling a pharmacist what to do. I would be interested to know the views of superintendent pharmacists regarding this and if they condone interference in the running of a pharmacy. The manager I had dealings with had no idea of my workload, no idea of my staffing level, no precognition regarding the presentation of suitable patients for MURs and, in all probability, no idea of what an MUR is other than it attracts a payment.
I believe that this situation is unacceptable and if this culture is allowed to prevail then MURs will lose their credibility with the purchasers (primary care trusts) and with GPs, who have been advised that MURs will have a positive clinical outcome for patients and are not simply designed as an income stream.
Arwel Richards
Winchester, Hampshire
From Ms C. Tizzard, MRPharmS
The savings to the NHS have in fact been greater than this, as for every pharmacy failing to achieve the target of 400 MURs the NHS also saves potentially up to £10,800, which previously would have been paid as part of the dispensing fee. This sum, multiplied by the number of registered pharmacies in the UK is a phenomenal amount.
It is easy to see why employee pharmacists, especially those working for large multiple and supermarkets, feel under such pressure to complete MURs. For if each of their pharmacies fail to reach target, the shareholders (or in my case the private equity bosses) are looking at a huge potential loss of profit. My employer is expecting pharmacists to agree to a performance contract requiring us to complete two MURs a day, and book in two for the pharmacist(s) covering our day(s) off or holidays. Failure to “succeed” in one’s contract results in no bonus or pay rise. Needless to say, most of my MURs end up being the “two quick items” type, rather than benefiting the patients who need them most.
The most disturbing thing is that I find myself, as I check every prescription, thinking “can I do an MUR” and it distracts me from providing the advice and level of customer service that my customers have come to expect. It is sad that the 10 minutes spent with a new mother discussing infant feeding or the regular customer wanting advice on vitamins do not now count for anything nor, apparently, do the revenues generated by needle exchange, supervised methadone or patient group directions.
MURs can be an important part of the pharmacist’s role, but are not our sole purpose for being. We must remain the accessible face of the NHS and not be confined to a consulting room at the expense of contact with the general public.
Annual MURs should be carried out by pharmacists based at GP surgeries, and funded accordingly. Most patients are used to having a review at the surgery, and this would enable compliance to be checked and necessary changes made without delay. The intervention-type MUR should still be carried out in the community pharmacy setting. I have done many of these at the appropriate times over my 10 years of practice, as a necessary part of my job — long before payment for them was made.
Claire Tizzard
Herne Bay, Kent
From Mr H. G. Buadi, MRPharmS
I do not wholly agree with Stephanie Bancroft (PJ, 14 June 2008, p731) that some locum pharmacists will have to know the patient in order to carry out an annual MUR. These are the kinds of barrier pharmacists put up and this is prevents us pushing practice to the next level. Pharmacists are supposed to be experts in medicines and I do not believe that checking compliance and advising patients on the correct use of medicines require prior preparation. I do sometimes refer to the BNF when patients ask difficult questions; after all it is a reference resource.
I have enjoyed an excellent working relationship with my local surgeries and this has resulted in a number of recommendations being acted upon by GPs by way of MUR action plans. Most of my patients have suffered several adverse effects from their medicines, which were unknown to them. MURs on such patients have highlighted these adverse effects and doctors have been quick to act on my recommendations, with patients benefiting immensely. Some patients have acknowledged this by writing testimonials to this effect.
I have had referrals from doctors and nurses alike for medication reviews, which I believe emanates from the positive impact MURs are having on patients. My primary care trust has saved some money by switching patients from treatment doses of proton pump inhibitors to maintenance doses. One patient was being prescribed 28 tablets of Dostinex on a monthly basis with a dosage of one tablet twice weekly. After an MUR, I realised that the hospital had changed her dose to half a tablet twice weekly —what a waste of an expensive medicine, because this patient needed only four tablets.
About 70 per cent of my MUR patients have been happy with the service; this is evident by their eagerness to have an MUR again the following year. When patients benefit from an MUR by way of positive impact on their health or volunteering vital drug information, they become indebted to you and this goes a long way to lift the image of pharmacist in the health care setting.
I would conclude that pharmacists start auditing MURs and also document activities like signposting, self-care and all services we provide for free to the public. In so doing, we can make a case for the immense contribution our profession makes towards the well-being of patients. Also, some employees, especially locums, just ignore services such as MURs when it is obvious that it will or might benefit patients. As a matter of fact it is not always possible to predict the benefits of an MUR to a patient until it is actually carried out.
Finally, the annual limit of MURs can be reduced by raising the monetary value per MUR so pharmacists can concentrate on other equally important services.
Henry Buadi
London
From Mrs M. A. Chapman, MRPharmS
Has our professional standing sunk so low that any level of retail management is superior to a pharmacist? I have every sympathy with Mr Richards. What is the point of achieving so called professional status after a long educational slog to have people with non-pharmaceutical backgrounds telling us what to do?
Would lawyers, medical doctors, and accountants put up with such a situation?
Maureen Chapman
Wirral, Merseyside
Mrs Maureen Chapman MRPharmS
Gary Latham NotMRPharmS
dirty linen?
For free?
From Miss B. E. Pawulska, MRPharmS
The PCT has to pay for this activity, but has no way of ensuring quality. Under contract monitoring arrangements, only a small number of previously anonymised MUR forms can be shown to the PCT pharmacist. My guess is that these would not include examples such as those mentioned above.
Barbara Pawulska
Emsworth, Hampshire
From Mrs P. S. B. Maycock, MRPharmS
Pharmacists are always willing to talk to patients about their medicines and explain anything that the patient does not understand and this is something I have been doing for the past 40 years. Many patients have appreciated the time spent with them to discuss when, how and why they take a particular medicine. Patients often forget to ask their doctor but always know they can ask us as the profession that knows about medicines.
I realise that businesses need to make a profit but the pressure under which pharmacists are put to complete a certain number of MURs, whether or not they are appropriate, simply to compensate for the reduction in payments negotiated by our representatives, is unacceptable. Many non-pharmacist managers do not appreciate that we have many professional duties and discussing medication with patients is only one of them. We should not be put under pressure to “do the easy MURs to make up the numbers” as I have heard suggested.
I feel strongly that, nationally, we should have followed the example set by the Cornwall and Isles of Scilly Primary Care Trust and proposed that patient group directions for such things as minor ailments and out-of-hours supply should be the basis for remuneration. This would have benefited the medical profession by taking away many unnecessary consultations and pharmacists by allowing us to use our knowledge and expertise.
Sue Maycock
Truro, Cornwall
Gary Latham NotMRPharmS