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Parastou Donyai, senior lecturer at Kingston University,
and Melandi van den Berg, teacher-practitioner for Alliance Pharmacy
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In broadcasting the series “Big Brother” Channel 4 has reintroduced
a small element of Orwellian speech into contemporary language. George
Orwell’s novel ‘1984’ (first published in 1949) is,
of course, riddled with words peculiar at the time but now in the Oxford
English Dictionary. Another well-known example is the term “thought
police”, which describes those who suppress ideas deviating from
what they believe to be correct thinking. On thought and language, Orwell
wrote: “But if thought corrupts language, language can also corrupt
thought.” This is a point to ponder.
Language is not just a mode of communication — it is inseparable
from thinking and reasoning. It orders perception and constructs and
creates social interaction. The Plain English Campaign has been advocating
the use of clear and concise language for over 25 years. Its guide “How
to write medical information in plain English” recommends: “Be
prepared to explain your jargon words and acronyms — will your
audience know them?” In the context of the community pharmacy,
what does the phrase “medicines use review” (MUR) mean to
those unaccustomed to this new language?
The new community pharmacy contract introduced in England and Wales in
April 2005 encompasses essential, advanced and enhanced services. MUR,
an advanced service, can be offered by community pharmacy contractors
once they comply with requirements for essential services and their premises
and pharmacists are accredited. There were 10,580 pharmacy contractors
in England and Wales on 31 March 2006. Those who had made arrangements
to provide advanced services before 1 October 2006 can be paid for up
to 400 MURs in the financial year 2006/07; those that entered or enter
arrangements on or after 1 October can be paid for 200 MURs.
Although the number of MURs performed each month has risen since April
2005, steady-state has been reached in the past six months, with around
3,000 pharmacies claiming for approximately 33,000 MURs each month. Thus,
less than a third of pharmacies are conducting an average of 10 MURs
in any month, 18 months after the launch of the new contract.
Research presented at the Health Services Research and Pharmacy Practice
Conference in April identified a number of barriers to pharmacists providing
MURs. For MUR-accredited pharmacists, these were related to lack of support
from primary care trusts, the need to get premises accredited and problems
with patient
recruitment. For non-accredited pharmacists, in addition to the above,
barriers included unwillingness to become involved, lack of time and
the need to become accredited. We propose that the phrase “MUR” itself
might present a barrier.
The Swiss linguist Ferdinand de Saussure outlined the science of signs,
or semiotics. Fundamental to his thinking is that a linguistic sign consists
of two parts: a concept (the signified) and its associated speech sound
(the signifier). Take the example of the concept of a train (a series
of railway carriages drawn by a locomotive) and the sound of the spoken
word “train”. Saussure argued that the sign is arbitrary
in that the nature of the signified, the signifier and their relationship
is not fixed. There is no natural or intrinsic relation
between the two. For example, the signifier sounds different in other
languages.
A more difficult argument to grasp is Saussure’s claim that the
signifieds themselves are arbitrary. For example, in England a distinction
is made between the train running on the underground railway in London
and the train running on the national railway by use of “tube” and “train”,
respectively, whereas in some countries no such distinction exists — one
word is used for all railroad carriages drawn by a locomotive. Nothing
predetermines the nature of the signified or the signifier so language
is not just a naming process but, instead, dependent on a system of extrinsic
relationships. For example, what makes a train the 8.30am Euston-to-Birmingham
train is not the physical nature of the train, but its relationship to
other trains.
In the context of the MUR, we have a newly created signifier, the phrase “MUR” and
a newly created signified, the MUR service. First consider the signified.
According to the Pharmaceutical Services Negotiating Committee, an MUR
service aims to improve the patient’s knowledge and use of medicines
through “a structured concordance-centred review”. It involves
establishing the patient’s use of medicines and his or her understanding
and experience of medication; identifying, discussing and resolving any
poor or ineffective medication, side effects or drug interactions; and
improving clinical- and cost-effectiveness. However, these services have
been the mainstay of pharmacy for some decades and few would argue they
are new. So the newly created signified is merely a by-product of the
reorganisation of services under the 2005 national contractual
framework for pharmacy, to facilitate
remuneration.
Now consider the new signifier and each component. The word “medicines” is
probably the least problematic if we assume it is compatible with the
general concept of a drug or other preparation for treatment or disease
prevention. However, “use” can be problematic if meant to
signify the taking or consumption of the medicine. It is known that about
half of patients on long-term medicines do not take these as prescribed — in
fact these are the very patients who are to benefit from the MUR. In
including a word inextricably linked to what the non-adherent patient
is not doing, “use” has the potential to act as a barrier
to the service. Then there is the word “review” which can
be associated with the notion of formal assessment and critical evaluation.
It can also signify a one-sided judgemental analysis on the part of a
reviewer and, as such, is not intrinsically linked with concordance.
Brought together, these connotations of the word “review” could
act as barriers to a service that is meant to be concordance-centred.
We note with interest that Alliance Pharmacy has spearheaded its public
MUR campaign using the phrase “medicines check-up”. A check-up
is, of course, an immediately recognisable term associated with a characteristic
routine of assessment by GPs, dentists and optometrists. Market research
conducted by Alliance has shown that the phrase “medicines check-up” may
be a more helpful signifier for this new pharmacy service although the
full impact remains to be seen. We suggest that
regardless of the language used, the impetus to move forward with the
MUR service, the
signified, must come from within the
profession.
Just as Orwellian words have transcended the book and found meaning externally,
we believe that the true designation of an MUR will evolve with time
and as a consequence of the relationship of MURs within the systems that
govern the practice of pharmacy, in which we all play a part. |
The
Pharmaceutical Journal