Viewpoint

With the community pharmacy contractual framework under negotiation, one key question being asked will be about the future of Medicines Use Reviews (MURs). They are 14 years old (where has that time gone?) and as they reach adolescence, it is fair to say they have had a difficult infancy and childhood. It took a considerable amount of time and effort to get them off the ground and the sector is only delivering around three-quarters of MUR potential. There have been mumblings that pharmacists, under pressure to deliver the numbers, are choosing simple patients to review rather than the ones that really need help.

On a more positive note, the Murray Review of Community Pharmacy Services published in December 2016 and commissioned by NHS England, said that “ultimately MURs should evolve into full clinical medication reviews utilising independent prescribing as part of the care pathway”. There is hope for the humble MUR!

If you are looking from the outside in (i.e. as NHS England or as a taxpayer), you will be asking what difference do MURs make? What value are we getting from the £97 million (2018/19) spent on this activity? How else could we spend this money to get potentially better outcomes?

Of course, we can’t answer these questions but they are important when deciding what is included in a new contract and what is not.

At the end of this article, I’ll share with you my two most recent MURs to illustrate why I believe MURs can be worth every single penny.  I don’t believe the discussions I had with these patients were extraordinary but the individuals think otherwise.

I know that every MUR I have done has made a difference. But who else knows? Well the patient does; they are always very grateful for the time we have spent together and they may even tell their family and friends. And in some situations, the GPs I work with know because I ensure they are fully engaged in a change that’s required. But aside from a small handful of individuals, the impact of these 15-20 minute conversations is unknown to the system.

Of course, I’m not alone in making the most of MURs. Many pharmacists across the country will be having similar conversations to mine, with unknown impact and outcomes. The current MUR form tells us a little bit about what goes on in the consultation but tells us nothing about the patient experience and what happens to them next.

The NHS will never know about the harm that now won’t happen nor the improved health gain from taking their medicine correctly, and it’s impossible to know what impact a lifestyle behavioural change will have on preventing further disease progression.

We are not measuring the right things and as such, I’m fearful that an excellent service could become history before it comes of age. Of course, not everyone wants MURs to remain. With huge funding pressures in community pharmacy, the pressures to deliver the numbers get ever greater. However, every one of the 400 MURs per pharmacy, is an opportunity to make a huge difference to someone’s life, prevent harm and improve value for the NHS. But if we lose MURs, will they be replaced with something or will the opportunity be lost forever?

MURs are not perfect but with a few tweaks, such as combining it with the New Medicine Service (NMS) to create a holistic medicines optimisation service, and measuring patient reported outcomes and actions, we will have something that will continue to make a difference and can demonstrate real value. The service can be better integrated into the GP contractual framework and Long Term Plan priorities, maybe with jointly held objectives. Formalising pharmacy medicines optimisation within a long-term condition pathway, working alongside clinical pharmacists in the Primary Care Network (PCN), would be the icing on the cake. Particularly for high risk patients. Providing more flexibility around the 400 per year would help, to allow those who are engaged to make even more of a difference. Finally, let’s think carefully about the measures we put in place to ensure we can evaluate the difference made and to ensure we support the right behaviours.

So here are my stories ….

Patient 1

Middle-aged male on a range of medicines including a diuretic, beta blocker, statin, anti-arrhythmic and an oral anticoagulant. He has a complicated cardiac history including several ablations for arrythymia, a pacemaker and two episodes of defibrillation following arrest. He was under the cardiologist.

We quickly established a rapport and going through his medicines, most of which he was taking as intended. He revealed he was taking his edoxaban five days out of 7. This was because he had developed IBS symptoms which he felt were due to the edoxaban and so was modifying how often he took it, without understanding the impact. Listening further, he explained that he had been on warfarin and ‘a bright young GP’ had switched him and he hadn’t really settled on edoxaban since. I explained how his medicine worked and together we explored what it was for and his fears around taking and not taking the drug. As the conversation progressed, he trusted me enough to disclose he was only taking it ‘maybe 2 days a week’. Following, an honest conversation about his higher risk of stroke, we agreed I would write a note to his GP, and he would follow-up with his consultant. We agreed that it was important for him to take an anticoagulant but other options could be explored.

The outcome? He came back into the pharmacy shortly afterwards, hugely grateful. Following my note to the GP, she called him a couple of days later and they had agreed he would fully comply with his edoxaban for six weeks after which they would review again. His tummy issues remained about the same and more likely to be down to the number of high protein shakes he was drinking as part of his fitness regime. This patient is now a partner in how he reduces his stroke risk, and much better informed about his options.

More so, he feels more in control.

Patient 2

80 year old male with COPD receiving a Rx for Salbutamol and Beclometasone inhalers and oral prednisolone. It was the double batch (168 tablets) of  rescue oral steroids on his prescription that set off the alarm bells and my curiosity to find out more.

The gentleman was more than happy to spend a few minutes in the consultation room and thought it was marvellous that pharmacists were able to support the NHS in this way. He happily consented to the MUR and off we went. I started with understanding a little bit more about his medical history. He had recently been to an outpatient appointment with the elderly care consultant as Parkinson’s Disease was suspected and he had been given the all clear. His COPD had worsened over the last six months and he was advised by the consultant that his tremors were likely to be caused by the salbutamol inhaler. As a result my patient stopped using it completely.

I asked him to show me how he used his inhaler. His technique was one of the worse I have seen and without going into all the issues here, the result was that he was swallowing rather than inhaling most of the drug. He had been using it every 1-2 hours and so almost certainly experiencing tremor as a result of oropharynx absorption and not getting the drug into the airways to help with his breathing. His inhaled steroid technique was similarly incorrect and he had never been given a spacer. No surprise that he was struggling with his breathing and experiencing side effects. When we went through it together, he was so relieved that he could do something practical for himself that could potentially give him more control over his symptoms. We discussed that his COPD could be getting worse but in the short-term he could get to grips (literally) with his inhaler technique to make the most of the medicines he did have. Truly his technique was so bad, that there must be an improvement!

And then we came onto his oral steroids. He admitted he was confused about these and did not really understand what he should be doing with them. He therefore took them continuously. No break. No steroid card, No protection for osteoporosis. The GPs continued to prescribe, no questions asked. We had a conversation about how this medicine should be taken in the future but how important it was for him to stick with it until he could review with his GP and possibly taper off, without an abrupt stop. He was taking 20mg a day.

And the outcome? On paper, one MUR. In reality, I wrote a note to the GP, the patient has an appointment the following week and instructions to review and potentially decrease oral prednisolone (reserving for exacerbations), a Rx for a spacer and a regular review of inhaler technique. He has promised to come back and see me in a few weeks so I can find how he is doing and to check his inhaler use.

If someone had done this before his referral, he may not have needed to go.

Are MURs worth it?  Ask my patients.