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Russell Foulsham, Nader
Siabi, Sandeep Nijjer and
Soraya Dhillon are from the University of Hertfordshire
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The latest figures are in: 33,000 medicines use reviews completed in nine months. With 7,000 pharmacists accredited to perform them that equates to just five MURs per pharmacist in real terms. The current expectation from the Department of Health allowed for 200 reviews per pharmacy before April 2006. What has gone wrong?
The new school of pharmacy at Hertfordshire has appointed a practice
team led by one of us (RF) which includes pharmacists from hospital and
community pharmacy. Members of the team have varied experience of MUR
to date and over the past 12 months have been working with pharmacists
in Hertfordshire and Bedfordshire supporting MUR training and gaining
a valuable insight to their future needs. This article reflects the experience
to date.
What is an MUR?
A medicines use review (and pharmacist intervention review) is exactly
what it says. It looks at the patient’s compliance with taking
their medicines as directed by the clinician. The pharmacist then can
make recommendations to the patient (eg, lifestyle advice), carer or
other health care professionals to improve compliance and reduce drug-related
problems. The pharmacist does not usually have access to the patient’s
medical history or test results, but they can empower patients by increasing
their understanding about their medicines or condition.
A lack of resources is a major problem faced by community pharmacists,
both in terms of time and staff cover. One multiple expects that a pharmacist
only requires six minutes with a patient, which is possible if the patient
is on only two drugs.
The longest consultation took 40 minutes with a confused patient on 12
different drugs who required a compliance chart to be produced. The process
will become quicker as technology improves, for example, dispensing software
companies can produce a pre-populated set of forms on a computer in the
counselling room. The use of trained dispensing staff is of great benefit,
because they can assemble
prescriptions for final check by the pharmacist and complete some of
the paperwork in advance if the patient has a pre-booked appointment.
A major challenge is the lack of acceptance of the pharmacist’s
role by both GPs and patients. Patients are used to a six-monthly or
annual review at their surgery, although they actually see the pharmacist
more often than the GP or practice nurse.
There are currently no financial inducements for GPs to respond to a
pharmacist’s recommendations under the general medical service
quality and outcomes framework except as part of an incentive scheme.
This may change with local commissioning since reductions in wastage
could be reused in other parts of the local health economy. By prior
consultation with their major surgeries, pharmacists can explain the
benefits of this concordance review and agree how GPs wish to see the
recommendations set out, thereby working as a team for the patient’s
benefit.
Another issue is the lack of suitable consultation areas currently available.
For example, a project was recently run in Harrow Primary Care Trust
with funding from our local research network for pharmacists to attempt
level 3 reviews in their pharmacies — but only eight out of 53
contractors had suitable premises. The situation is improving now as
many contractors realise the financial rewards of being able to provide
advanced and enhanced services. An example of this is a large multiple
which invested in providing counselling areas and funding all its pharmacists
to gain accreditation resulted in its pharmacies undertaking 20 per cent
of all MURs in England up to December 2005.
The paperwork is time-consuming and awkward to complete. One suggestion
for the review of the forms between the Pharmaceutical Services Negotiating
Committee and the DoH is to produce just three pages in a landscape format,
which will reduce the juggling of bits of paper.
MURs can be rewarding for pharmacists and appear to work best for regular
customers from GP practices with which the pharmacist has a good rapport.
This enables the patient to be honest about their compliance and the
GP to act on the recommendations leading to real pharmaceutical care
for patients. Accreditation
The current accreditation process for pharmacists to be able to undertake
MURs is not robust enough. It checks competency on filling in the form
correctly and noting major interactions but not on the pharmacist’s
clinical and communication skills. There is no uniformity of approach
by the various accrediting institutions, which vary from submitting
case studies to a time limited multiple choice examination. A number
of “clinical” postgraduate courses allow pharmacists to
develop the necessary skills to undertake reviews as research studies
have shown there was a significant difference between the problems
found by the average community pharmacist and those with additional
clinical training. For the average community pharmacist there appears
to be a lack of support and feedback when actually undertaking MURs. Provision of training
In Hertfordshire and Bedfordshire, the university recognised the lack
of support that was available when the new community pharmacy contract
started in April 2005 and worked with the local pharmaceutical committees
and PCTs to obtain funding from the local workforce development department
to provide MUR workshops. Two workshops were produced that ran at venues
throughout both counties. The first workshop was an introduction to
MURs, involving explaining the process of completing the paperwork
to pharmacists, and developing communication skills. The second workshop
looked at case studies in specific chronic diseases. The feedback from
participants was positive, particularly around learning from other
pharmacist’s experiences.
We have evaluated the gaps in the current education and training process
required to underpin MUR, and these are: communication skills (with clinicians),
consultation skills (with patients), underpinning clinical knowledge
and skills, confidence, decision-making, and influencing skills to engage
patients and health professionals.
Pharmacists have access to a vast array of resources to develop their
clinical knowledge, both in the form of open learning (they choose the
times for study) and taught courses. The Centre for Pharmacy Postgraduate
Education and most universities provide courses. Our university runs
a number of short courses for nurses and paramedics which are suitable
for pharmacists, and is developing an MSc in advancing pharmacy practice
for pharmacists.
We are also exploring a support platform for pharmacists to provide MURs
in the form of a peer review forum on our university intranet and access
to experienced teacher practitioners. The way forward
In the future, We would like to see academia working together with
practice to develop a more robust evaluation framework, and for PCTs
to support
community pharmacists by engaging GP and patient involvement in the
process. We would also like to see a mechanism for providing peer
support and peer
review. |
The
Pharmaceutical Journal