|  Pharmacists want clarification on where a medicines use review
stops and a clinical medication review starts, according to research
presented
at the Health Services Research and Pharmacy Practice conference held
at Keele University earlier this month (see Meetings,
p465).
Rebecca Elvey, a research associate at the School of Pharmacy and Pharmaceutical
Sciences, University of Manchester, presented the results of a study
commissioned by the Department of Health into the early experiences of
implementing MURs. Last summer, 44 interviews were carried out with primary
care trust leads, local pharmaceutical committee representatives and
community pharmacists at various sites around England.
The interviews revealed that, although MURs were designed to improve
concordance and patients’ understanding of medicines, pharmacists
were making clinical recommendations seen as inappropriate by PCTs and
GPs. Ms Elvey concluded that further training for pharmacists on the
appropriate use of MURs may be necessary to ensure that they are successfully
embedded into community pharmacy service provision and fulfil their potential.
As part of a larger, structured evaluation of the MUR service in Wales,
Rhian Thomas, a clinical pharmacist, was commissioned by the Welsh School
of Pharmacy, Cardiff University, to organise a one-day workshop, held
in Wales in December 2006, to gain a consensus on key priorities for
change to the existing MUR service. The workshop was attended by 35 participants,
including community pharmacists, GPs and local health board representatives.
The need for central guidance on the MUR process from the Welsh Assembly
Government was identified as participants’ top priority. “There
is a lot of confusion out there between what is an MUR and what is a
clinical medication review,” explained Ms Thomas.
Andrea Hilton, a research pharmacist within the Hull and East Riding
Pharmacy Research Network, presented a local evaluation that also suggested
pharmacists find it difficult to distinguish between MURs and clinical
reviews. She described findings from a small focus group, held at the
end of last year, which involved four pharmacists (representing pharmacists
working for multiples, independents and as locums) with a view to exploring
local implementation of the MUR service.
One theme that came out of the group was that pharmacists need and want
clarification about the extent of their clinical input and responsibilities
following an MUR, said Ms Hilton. The group considered the accreditation
process for MURs to be clinical, she explained, which could add to the
confusion about where an MUR stops and a clinical medication review starts.
The focus group also said that inadequate information about MURs has
led to communication between pharmacists and GPs being problematic, that
pharmacists find maintaining normal pharmacy services and providing MUR
services difficult, and that people who could benefit from MURs, such
as those who are housebound, do not always receive them.
Angela Alexander, senior clinical lecturer at the Centre for Inter-professional
and Postgraduate Education and Training, University of Reading, who chaired
one of the MUR sessions, believes that part of the problem is that it
is impossible to divorce drug usage issues from clinical issues. “[Resolving]
usage issues relates to achieving a good clinical effect,” she
explains. When pharmacists are doing MURs, they may unearth clinical
issues and, although they are not being paid to do a clinical review,
they cannot ignore these, she adds.
“The point is that whoever is carrying out the MUR needs to have
a basic understanding of what clinical benefits are achievable if usage
problems
are resolved. If this was not the case, anyone could carry out an MUR,” she
says.
Alison Blenkinsopp, professor of the practice of pharmacy in the department
of medicines management at Keele University, also chaired an MUR session
at the conference. She suggests that it may not be that the accreditation
process is too clinical; the issue may be that pharmacists’ MUR
consultation skills are not assessed in the process. “Review of
actual skills would help to get the content and balance right in MURs.
Anecdotally many pharmacists, once they start doing MURs, find they can
benefit from some practical training on managing the consultation, with
some feedback on the content as well as the style,” she says.
Professor Blenkinsopp believes that it would be useful for pharmacists
new to MUR to be able to get some peer feedback on their early reviews.
She explains that this is happening in some parts of the England already.
For example, within Surrey Primary Care Trust experienced MUR pharmacists
are operating as mentors
or “buddies” (PJ, 24 February, p213)
and at Burntwood, Lichfield and Tamworth PCT the medicines management
team are offering peer review and feedback on MUR reports.
Christopher Cutts, director of the Centre for Pharmacy Postgraduate Education,
a provider of MUR accreditation, comments that the CPPE assessment does
not expect anything more clinical than one would expect from an up-to-date
generalist pharmacist. “CPPE assessment looks at drug options,
formulation choices, dosages, interactions, side effects and contraindications.
MURs are meant to be patient-focused, looking at the patients’ needs
about their medicines, but pharmacists need to be mindful they may unearth
complex clinical issues. And hence they will need to know what to do
next.”
Barbara Parsons, head of pharmacy practice at the Pharmaceutical Services
Negotiating Committee, who also attended the conference, told The
Journal: “The
introduction of a new service which radically changes the way community
pharmacists practise is bound to raise questions and take time to implement.” She
says that the attitudinal studies presented at the conference show that
the elements identified by the PSNC in its 10 steps to successful MURs
were correct and much work has been done to facilitate change. For example,
a shorter
MUR form is currently being tested (PJ, 7 April, p387), directions
have been changed to allow MURs to be conducted away from the pharmacy
with PCT consent, and the involvement of GPs has been encouraged from
the outset with new resources developed to assist this.
“MUR was intended to be about education and practical advice for
patients. Community pharmacists are likely to feel more confident if
their clinical
knowledge is up to date and this provides important context for the review,” says
Ms Parsons.
“I notice from the research that there was no indication of how
long the pharmacists and other health care professionals had been involved
in
MURs, but the papers gave a snapshot in time of the attitudes and opinions
of a relatively small sample. With over half of all community pharmacists
now accredited it will be interesting to see how pharmacists’ attitudes
evolve as the service becomes embedded into practice,” she says.
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The
Pharmaceutical Journal