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Medicines use reviews

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

Medicines use reviews were introduced as a way for pharmacists to build upon the advice that we give everyday to aid compliance with prescribed medication, both improving quality of care for the patient and saving the NHS money in avoidable hospital admissions.

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

It is regrettable to read how pharmacists shoot themselves in the foot by publicly highlighting the negative effects of medicine use reviews and not talking about their positive impact. Many professions would not wash their dirty linen in public, instead portraying to the outside world that all was well within their profession. I am not in any way condoning pharmacy owners who set high targets for their employees irrespective of the workload, but we ought to be promoting the profession and the services it renders by highlighting some of the positives.

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

With reference to Arwel Richards’s letter (PJ, 21 June 2008, p750), the multiples are increasingly using non-pharmacist area managers. This is worrying because they cannot fully understand the work nuances and pressures of working in a dispensary. Their main raison d’être is to maximise profitability, hence the pressure to meet medicine use review targets.

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

With reference to Mrs Maureen Chapman's comments regarding non-pharmacist Area Managers, and intimating that perhaps they are not as 'professional' as pharmacists. Does she believe that a person with a degree gained at university (yes, the same one as she probably gained hers) in Management does not qualify them to manage a business effectively? In my experience in pharmacy management, the years spent by students studying pharmacy on the many and varied attributes of effective managment are not modules covered to any extent??, so maybe she could consider that before she consigns all 'Professional' and qualified managers to the scrapheap !! Managers should be there to support and coach pharmacists on their business objectives and performance, as in the case of MUR's. My opinion, as a non pharmacist, is that actually it is a valuable service that should be provided to every suitable customer that walks through your doors, and the funding should not play a part in that decision process. If pharmacists started being pharmacists and looking after a patients welfare, instead of wasting their valuable time squabbling and blaming anyone and everyone about this service (and finding every excuse not to do it as part of their professional duty), then maybe, just maybe, pharmacy can concentrate on leading the healthcare needs of the communities in which it serves, like it did before the NHS even existed !!

Gary Latham NotMRPharmS

I'd just like to say to Gary Latham (non-pharmacist manager) that I'm sure we'd all simply love to spend our days doing a Mr Humphreys and saying "I'm Free...to do an MUR" but has he ever counted the number of minutes in a working day and divided it by the number of items checked in a day? Time to do quality MURs often simply just does not exist or would he like to lecture us on effective time management next? I have 32 years of pharmacy and managerial experience to call and IMHO his HO is sadly lacking but I'm happy to engage in a discussion to have the point proved. His attitude is typical of that which keeps experienced pharmacists like myself amongst the serried ranks of locums, to the detriment of the continuity of the service.

dirty linen?

to the previous referred 'dirty linen' - i think the public deserve to know where and how their taxes are being spent. they probably think that MURs are a free service, but indirectly, it's not. i personally think that checking patients know what they're taking and looking out for potential problems et al with their compliance and stuff is part of what we should be doing for free and SHOULD be part of the counselling that we SHOULD provide to all patients for free. i think providing a service that's honest in this way for free builds up a genuine rapport with patients. with 'MUR targets', i'm sure the majority of pharmacists are doing them for the fact that they're getting paid a princely sum of £27 per MUR. if they weren't and genuinely cared for their patients, they'd do it for free and build up their loyalty through providing better customer service. it's all too easy to feign genuine care if a pharmacist knows they're getting paid to care via the MUR fee. isn't it all an act? maybe i think patients and customers deserve better. they deserve to know the where and why, and then they can make up their own minds with all the facts before being ushered into a consultation room for a quick chat. community pharmacy is a business. if it wasn't, it'd be a charity and we'd all work for free.

For free?

I have always believed that the value in what we do wasn't in slaping another label on another pack but in the advice that we give to patients? That payment has swiched (in part) from the dispensing process to the advisory/cognitive role is a good development. Yes there are problems with the way it as been implemented - but in reality how difficult is it to say that there will be a 30 minute wait for prescriptions because the pharmacist is talking to another patient? Staff can still assemble the scripts and report any out of stocks to the patients. Jeff

From Miss B. E. Pawulska, MRPharmS

I was interested in the comments by the anonymous employee pharmacist (PJ, 10 May 2008, p567). As a primary care trust pharmaceutical adviser, I have heard similar stories from locums and agree with Anonymous that some medicines use review claims are fraudulent. I have been told that MUR fees are claimed for advising a patient to take flucloxacillin on an empty stomach, or explaining how to use nystatin mouthwash. Surely, this sort of advice is an essential service.

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

Although I appreciate that medicines use reviews are of great benefit to patients and pharmacists when they are carried out in a professional manner, the current situation when they are driven purely by the need to increase remuneration is unacceptable.

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

I fully agree with Graeme Stafford. Gary Latham is a non-pharmacist area manager for Lloyds Pharmacy with as far as I know less than a years experience in the pharmacy business who nevertheless seems to think he can lecture experienced, busy pharmacists on how to do their jobs. Less pontificating and a little more understanding of the pressures that pharmacists are under would be welcome.There is far too much of this kind of bullying and interference with how we do our jobs. Our first commitment should always be to provide the best possible service to our patients and we should be allowed to get on with the job rather than be denigrated for not doing enough MUR's.