Perceptions of medicines use reviews — the views of community pharmacists within a West Yorkshire primary care trust

April 2008 saw the third anniversary of the introduction of medicines use reviews (MURs) as an advanced service within the community pharmacy contractual framework in England.¹ MURs are designed to “improve patient knowledge, concordance and use of medicines”.¹ Community pharmacists are expected to achieve this by:

• Establishing a patient’s actual use, understanding and experience of taking medicines
• Identifying, discussing and resolving poor or ineffective use of medicines
• Identifying side effects and drug interactions that may affect a patient’s willingness to take medicines
• Improving the clinical and cost effectiveness of prescribed medicines and reducing medicines wastage

Reports from November 2006 show that the uptake of MURs was very slow^2–5 with only 40 per cent of contractors receiving remuneration for this service, thereby leaving millions of pounds allocated by the Department of Health unclaimed.⁶ There are now signs that the MUR service is being taken more seriously, with positive indications that they can deliver real benefits to patients such as when monitoring repeat prescriptions,⁷ reinforcing advice in the treatment of asthma or to ensure good inhaler technique.⁸ The number of accredited pharmacists has, thus, more than doubled from 7,100 in February 2006 to approximately 16,000 in November 2007.⁹ Over this period the volume of MURs conducted per month rose even more from approximately 33,000 to 94,000 per month.⁹ These figures suggest that pharmacists are committed to MUR training and that, on average, in comparison with 2006, each pharmacist is recruiting more patients. Not surprisingly, the monthly cost of providing an MUR service is now well in excess of £2m and questions inevitably arise as to whether this advanced pharmaceutical service is delivering a quality service and value for money.²

Studies have shown that many pharmacists believe that conducting MURs is a good idea but believe there are barriers, including lack of time and poor patient uptake.^4,10 The level of awareness of this new role of the pharmacist by GPs and patients is variable and it is not universally accepted that it is of value.¹¹ The All-Party Pharmacy Group has suggested that, although doctors approve of pharmacists’ enhanced role in principle, poor communication and a lack of integration between surgeries and pharmacies may undermine its impact.¹¹ For the service to be successful, effective collaboration between all those involved, especially GPs, is essential.¹¹ Arguably, pharmacists will need to shift their comfort zone from the dispensary to the consultation area. They will need a greater skill mix within the dispensary and they will have to increase their delegation of tasks in order to make better use of their time.

The purpose of the present study was to explore, with local community pharmacists, their experience of conducting MURs and, in particular, to identify the extent to which training had prepared them for this role and to ascertain their views on the ways in which MURs have impacted upon professional relationships with GPs. The specific objectives of the study were to explore with community pharmacists:

• Their approach to identifying and recruiting appropriate patients for MUR
• Whether conducting MURs affected their relationship with patients
• Whether conducting MURs affected their relationship with GPs
• Their perception of the relevance and quality of MUR training received and how well this prepared them to carry out MURs

Method

After receiving approval from the primary care trust’s research governance lead, pharmacists were recruited from within a former PCT area in Yorkshire from a pool of 22 who had been accredited to provide an MUR service. Pharmacists who were accredited but who had not conducted any MURs were included in order to explore their reasons for not providing an MUR service. A letter was sent explaining the aims of the study and what was expected from their involvement. Following receipt of the letter, pharmacists were telephoned and a semi-structured interview was conducted if this was convenient. If not, a mutually convenient time was arranged for the interview to be conducted.

A topic guide was devised in order to explore, in an open manner, the aims of the study. Written notes were made during the interviews which were then transcribed. The transcript was read several times and analysed for content, and appropriate themes developed. All information collected was treated in confidence and reported anonymously.

Findings

A total of 21 of the 22 accredited pharmacists available participated in the study and, of these, 14 (67 per cent) were providing an MUR service (as evidenced by their having claimed remuneration). Although the number claiming payment was fewer than those accredited, it was higher than the proportion reported nationally in 2006.⁹ The number of MURs being conducted per month ranged from two to 35 per pharmacy. All the pharmacists worked in premises with a high prescription volume of over 8,000 items per month. Six had a second pharmacist or an accredited checking technician to ensure continuity of the dispensing process while MURs were being conducted.

Of those who were not providing an MUR service, one claimed that the available remuneration would not compensate for the effort required to provide a service of the required quality and another complained of a poor relationship with the local GP so did not think that setting up an MUR service would be worthwhile.

Relationship with patients 

The views of the community pharmacists confirmed that the process of asking patients questions and enabling misunderstandings to be identified and corrected provided invaluable contact time with patients. This had previously been limited, as part of a dispensing service. Pharmacists reported that conducting MURs had increased patients’ confidence in the pharmacist and raised the profile of the pharmacist as an accessible health care professional:

It improves [patient-pharmacist relationship] as you spend one-on-one time with the patient, helping them to understand how and why they must take their medicines.
(Pharmacist 1, from an independent pharmacy)

It makes the patients more confident in the pharmacist, especially if the intervention is implemented. It improves customer loyalty — they are more likely to come back.
(Pharmacist 2, from a multiple pharmacy)

There was some concern, however, in the present study, that MURs might have a negative impact on other patients waiting for their prescriptions to be dispensed while the pharmacist was busy conducting MURs. This serves as reminder that it is important to maintain the continuity and efficiency of the essential dispensing service.

Recruiting patients for MURs 

Pharmacists commonly recruited patients belonging to a specific therapeutic group, such as asthma or cardiovascular disease, because they had more knowledge in those areas. Many looked for opportunities that would lead to MURs, such as patients who had run out of medicines or patients who were already seeking advice. Generally, appointments for MURs were made on an ad-hoc basis rather than by a formal system but some used a mixture of the two approaches. The reported problem with appointment systems was that they often led to patients not attending, or cancelling. This often occurred, even when telephone reminders were made, and led to the pharmacists feeling rejected and demotivated to arrange further MURs. A concern was also expressed that patients may have a perception that the pharmacist’s advice might conflict with that of the doctor, and that MURs might be considered by patients and GPs to be a money-making exercise. Genuine concern was expressed by one pharmacist:

We have tried making appointments with patients a couple of times but both times they didn’t show up. . . . It makes me not want to make the effort with other patients, especially if I have spent time trying to organise our workload or locum [support] around appointments. . . . Sometimes patients think pharmacists are out to make money or want to change the medication the doctor has prescribed to a cheaper one. They also worry that they are going against the doctor’s wishes.
(Pharmacist 3, from a multiple pharmacy)

Some pharmacists found that patients were reluctant to participate with an ad hoc approach because they had made other plans for the day. Paradoxically, when the pharmacy was busy, it was hard to find time to conduct MURs and when it was quiet there were no suitable patients fitting the required inclusion criteria. This recruitment problem has already been identified in a Lloydspharmacy study.¹²

Many employers set targets for MURs. These varied from six to 10 MURs per week in some pharmacies and, in some instances, personal MUR targets were set by pharmacists themselves. Difficulties in recruiting patients led some to reflect on their employing company’s strategy for encouraging pharmacists to conduct MURs. There were mixed opinions as to whether pharmacists thought these targets realistic or appropriate. One pharmacist commented:

The company is pushing too hard for MURs. . . . The method of payment causes increased pressure to perform. This should be changed to banded payment or service payment.
(Pharmacist 4, from a multiple pharmacy)

A variety of tactics were employed to recruit patients. These included offering health related inducements such as first aid kits, stuffing bags and putting stickers on the bags, and training front-line staff to identify patients. Some thought targets were only realistic if locum support was available. Some pharmacists received locum support to conduct MURs while others were offered none, and some refused locum cover because they thought it would not enhance their productivity. If locum support was provided then the amount of MURs expected in an eight-hour day varied from three to 16. Some thought that setting targets may lead to MURs being conducted for the sake of it. A pharmacist based in an independent pharmacy put the difficulty of finding sufficient time to conduct MURs simply: “Pharmacists are currently trying to juggle too many things,” she said.

Relationships with GPs 

There were varied levels of professional relationships and awareness of MURs within GP practices reported by the pharmacists. These contrasted from having no communication at all to receiving extensive feedback on how the recommendations of the pharmacist had been implemented. However, a predominant view was that GPs were cynical about the value of MURs and tended to see them as a way of increasing the pharmacist’s income. The pharmacists thought that some GPs felt that the MUR review sheets served little purpose other than a form-filling exercise. One pharmacist reflected on the attitude of GPs:

A mixed bag. Some are interested, some are not. It can even vary within the practice. I think they feel MURs are a bit pointless and just a way of pharmacists making money.
(Pharmacist 5, from a multiple pharmacy)

Another pharmacist thought that GPs do appreciate the time spent by pharmacists on MURs but may be constrained if they are too busy. She added:

I’m unsure whether they [GPs] are responding to the interventions made — they only call if necessary.
(Pharmacist 6, from a multiple pharmacy)

In some instances pharmacists were unsure whether or not GPs were reviewing MUR paperwork and thought it was often scanned into patient records without being seen by the GP. This was demotivating for some pharmacists, who believed that the time and effort spent was wasted. The main suggestions to improve GP/pharmacist relationships were with regard to increasing promotion of MURs locally and nationally by the professional bodies, and developing initiatives to improve communication between GPs and pharmacists.

Training 

The pharmacists had undertaken a variety of accreditation courses including the online assessment offered by the Centre for Pharmacy Postgraduate Education (CPPE) and the courses run by the University of Reading (certificate of competence in medicines use review) and Medway School of Pharmacy (skills for the future). There was mixed opinion on how well the pharmacists believed that the type of accreditation chosen prepared them for MURs. They thought the CPPE course prepared them well for completion of paperwork and understanding the service specification but was less helpful in terms of developing consultation skills and how to target different therapeutic areas. As one participant put it:

It prepared me pretty well . . . on form filling.
(Pharmacist 5, from a multiple pharmacy)

By contrast, pharmacists thought that both the Reading and Medway courses, although enjoyable, were heavily clinical and too in-depth. MURs are intended to help ensure patients are taking their medicines appropriately, not to provide a full medication review:

It only prepared for the academic side. It was very detailed. I learnt the practical aspects afterwards.
(Pharmacist 2, from a multiple pharmacy)

Many of the pharmacists thought the accreditation processes had not prepared them for face-to-face consultations, communicating with patients or keeping patients within time constraints. These practical aspects were learnt after receiving accreditation by conducting MURs and attending further training such as that run by local pharmaceutical committees, employers and CPPE events such as “Helping patients take their medicines”. Some pharmacists thought that peer review sessions or shadowing would be useful to discuss their experience of MURs and others thought that no further training would be of benefit.

Conclusion

This study demonstrates that there is still considerable uncertainty among practising pharmacists as to how best to select and recruit patients for MURs and whether the intended aims of MURs are being realised. Although the advisory role of the community pharmacist is, at last, being financially rewarded, a lack of perceived benefit by the profession itself and by GPs could jeopardise the significant milestone achieved in bringing enhanced and advanced advisory services into the contract.

One of the most encouraging aspects of this study is the endorsement by community pharmacists that conducting MURs does help to improve patients’ understanding and correct use of medicines which in turn enhances confidence and loyalty. However, community pharmacists will need to ensure that routine aspects of their service, such as the timely dispensing of prescriptions, do not suffer as a result of prioritising their advisory role.

It would appear that pharmacists think there are GPs who do not sufficiently value the information provided by an MUR, although the extent to which this view is held outside of this PCT is not known. If such attitudes are typical of those elsewhere in the UK, pharmacists will be discouraged from conducting MURs because to do so is likely to be counterproductive in terms of building inter-professional relationships. The reasons for such perceived negative attitudes among some GPs are not known. It would be prudent to carry out research with GPs themselves and also to establish the quality of documented advice proffered by pharmacists who conduct MURs. Arguably, as independent practitioners, pharmacists should take responsibility for providing advisory services to patients and a copy of such advice for GPs is only needed for information. Furthermore, community pharmacists having read-access to patients’ electronic care records could help to negate the impact of some of these communication difficulties.

There has been much debate over the robustness of the current accreditation process. It has been suggested that current gaps in education and training have resulted in the ineffective delivery of MUR services and highlight the need for some enhanced clinical knowledge.¹³

Our findings indicate that, rather than focusing on clinical aspects, there may be greater value in preparing pharmacists more thoroughly in the communication skills required to recruit patients appropriately for MURs. This sort of approach is likely to establish the advisory role of the pharmacist on a more professional footing than that which is encouraged by target-setting aimed at increasing MUR numbers without giving due consideration to the individual needs of patients. We recommend that the implementation of such training should be given urgent consideration in order to maintain the long-term sustainability of the advisory role of community pharmacists.

This paper was accepted for publication on 17 April 2008.

References

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