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
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
Medicine Use review
Concerns about MUR targets
From Mr W. J. Samson, MRPharmS
I write to express my concern at an emerging trend in community pharmacy. Let me begin by quoting section 2.2 of the Code of Ethics: “Make sure that your professional judgement is not impaired by personal or commercial interests, incentives, targets or similar measures.”
If area managers or owners in community pharmacy were to issue guidance that only the most expensive products were to be recommended by pharmacists, there would, quite rightly, be uproar among the profession.
At the moment, there is an increasing tendency among management to set targets and give incentives with respect to medicines use reviews.
In my own experience as a locum pharmacist, I was warned by an area manager from a large multiple group that my bookings would be terminated if I failed to reach the target number of MURs for the branch in which I was working. If the branch reached its target, the staff and pharmacy manager would receive a bonus. My bonus would be, in the words of the area manager, “to keep my job”.
But mine is not a solitary case. Many pharmacists within the community sector are feeling pressure to deliver more and more MURs. There is no emphasis on quality or patient care, only quantity.
I believe MURs have a valuable place in the range of services offered by community pharmacies, provided they are appropriately applied to patients who will benefit from them and who desire them. Forcing unwanted and useless MURs on unreceptive patients is intrusive, wasteful and disrespectful.
In my view, the only two people who should decide if an MUR is warranted are the patient and the pharmacist. The relationship between the patient and pharmacist is sacrosanct and should not be intruded on by profit-hungry corporate puppets, whatever guise they take.
The economics of the situation are clear to me: companies see MURs as a quick way to recoup money lost from category M price reductions. The only obstacle in its minds is persuading (and in some cases bullying) pharmacists to do more MURs.
In accepting purely quantitative targets and incentives with respect to MURs, pharmacists are in danger of prostituting their intellect, education and professionalism.
I propose that the Royal Pharmaceutical Society should act by prohibiting all pharmacy owners from issuing verbal or written targets to their pharmacists with regard to MUR numbers.
As for us pharmacists, we need to take a stand and not allow our professional integrity and independence to be compromised by coercion and greed.
William John Samson
Stockport, Cheshire
MURs and Targets
The underlying aim of the MUR is, with the patient’s agreement, to improve the patient’s knowledge and use of medicines. This involves the pharmacist:
Ø carrying out a medicines-use review with patients who are on regular long-term medication
Ø discussing patients’ medication with them (or their carer), developing their understanding of the medicine and its use, explaining possible side effects and how it should be used for maximum benefit
Ø attempting to find a solution with patients for any medication problems they experience
Ø providing a report to each patient’s GP, including any recommendations for action
Ø carrying out such reviews on a regular basis (every 12 months) with patients who have been using the pharmacy for the dispensing of their prescriptions for the previous three months.
As such every patient on regular medication is entitled to a review. We absolutely should not be forcing them on patients, but we should be offering them to all relevant patients
There have been some comments about suitability - clearly any patient on regular medicines is suitable, but you cannot predict any benefit until you have performed the process.
Applying the service as intended by the DoH the vast majority of patients will not have any major action points raised, it is simply about ensuring that people understand their medicine and are getting the most from it - you do not have to improve the knowledge is it is already good, but until you ask you cannot know how well they know their medicines!
Nearly all the comments made focus upon the pressure to perform the task by our companies. Yes the companies are interested in the revenue, after all that is why they are in business, but we, the professional, should be interested in undertaking the process, and it is such a simple process. I wrote to the C&D in June to express my view and Graeme Stafford responded suggesting I was living in lalaland. His opinion may be valid but it appears to be the same lalaland that the DoH are in, and not the NHS of 30 years ago.
We need to stop bickering about MURs, and stop making excuses not to do them. Sure there are pharmacies where staffing levels or workload prevent pharmacists completing 400 each year, and I suggest you point this out to your managers and ask them to put this right, but the service is valuable to the profession and the public in more ways than just £28 per MUR and we need to treat them like any other service we offer, after all we don't refuse prescriptions or not counsell patients appropriately because we are too busy!
Maximising MURs can be fun with support
From Mr G. Diamond, MRPharmS
It is unacceptable for pharmacists to be put under pressure to attain medicines use review targets that are unachievable but there needs to be some balance in the argument put by William Samson (PJ, 8 November 2008, p536).
Credibly, targets should be agreed, taking into consideration the pharmacy environment, such as prescription volume, busy versus slow dispensing periods, and the availability of checking technicians or a second pharmacist while MURs are conducted.
Notwithstanding extraneous factors, the training needs of pharmacists may need to be addressed to optimise their ability to prioritise their time management and motivation too.
Some companies offer good incentives and training support for maximising MUR numbers, and it can be good fun giving benefits to the individual patient while the pharmacist and the pharmacy team receive job satisfaction.
However, bullying is not an acceptable method and the benefits of oppressive management styles, which set overtly unreasonable targets, are often short-lived. Rewards for performance were previously linked to prescription volume, good stock control and careful purchasing of lowest price stock, and good cash flow. This still remains the bedrock of running a profitable pharmacy business.
The new contract has been much more than a reconfiguring of community pharmacy services but it is also a challenge to the mindset of many pharmacists, whose practice may not have moved on.
The pharmacy press has had various articles on anecdotes about stressed pharmacists and various member surveys published on this topic on the increasing workload.
Although some pharmacists bemoan the additional services that form the new focus on funding streams via services, such as emergency hormonal contraception, nicotine replacement therapy, MURs, audits, patient surveys and primary care organisation annual monitoring visits, the issue may have been how the profession of pharmacy was unable, or may not have been facilitated well enough, to meet the challenge of change.
Change in management within pharmacy was possibly neglected by the Department of Health, which was not proactive in gaining the full support of grassroots employee pharmacists.
Contributing factors for pharmacists, new and old, may be the lack of business experience of pharmacy degree programmes placing more emphasis on clinical and behavioural sciences and abandoning a desire for a robust and integrated business studies programme for pharmacists.
Perhaps the opportunity to make employee pharmacists believe they are fully part of that change, and be proactive about it, has been an opportunity bypassed by our leaders.
Gerry Diamond
Manchester
GP tells staff to shred MUR forms
From Mr A. M. F. O. El-Dabbagh, MRPharmS
In a joint meeting of pharmacists and doctors, organised to develop partnerships for the two professions, I was shocked when a GP said that he usually tells his staff to shred medicines use review forms the minute he receives them.
He added that MUR forms have too many pages and focus mostly on diet, smoking cessation and weight reduction, which he usually does himself.
I tried to explain to him that, through MURs, pharmacists could highlight a number of potentially dangerous issues, such as patients being prescribed two non-steroidal anti-inflammatory drugs.
Also, they can identify asthmatic patients who have stopped using their steroid inhaler without telling their doctor, putting them at increased risk of an asthma attack. Pharmacists can also help reduce medicines wastage by educating patients during reviews.
There are many other issues that pharmacists can highlight to assist GPs and their patients. I believe we need to increase our efforts to improve partnerships between pharmacists and GPs. Perhaps then they would embrace services, such as MURs, and see the benefit it gives to their patients.
A. El-Dabbagh
Wickford, Essex