Medicines Use Review
[MUR]
Liz Stafford
LPC/PCT liaison
Outline





Context
Understanding potential benefits of MURs
Identifying potential barriers & how to overcome them
Good practice examples
Key Success Factors
Context



NHS Community Pharmacy contract 2004.
- Advanced tier
- Requires accreditation of pharmacist & premises
Nationally agreed fee funded by budgetary savings as a result of
changes to the national medicines reimbursement scheme
for community pharmacists.
Aimed at helping patients manage their medicines more
effectively and should be integrated with GP practice systems
and the Primary Care team.
Differences
Medicines Use Review :




Help people use their
medicines more effectively
Clinical Medication Review:

Repeat prescription list &
patient interview

Mostly technical issues that
can be actioned by
pharmacist/patient

Some patients referred for
more detailed clinical review
Enable patients to get the
most effective & appropriate
treatment for them
Full medical history and
patient interview
Mostly clinical
MUR
A concordance based review to which the patient is asked to bring
all their medication (including purchased medicines) :







What the patient thinks each medicine is for and how to take it
How compliant they are with the prescriber’s instructions
How and when they take medication “prn” or “mdu”
Advice on tolerability and perceived side effects
Practical issues e.g. ordering, obtaining/taking/using medicines
Identification of unwanted medicines; no longer taking it
Identification of potential cost savings e.g. dose/ strength
optimisation (if no impact on patient’s clinical management
plan).
Compliance & Concordance
(= Time Factor to Understand & Negotiate)



Patient related factors
- misunderstanding the treatment (or condition)
- forgetting
- patients’ beliefs
- denial
- embarassment
- lack of social support
Treatment related factors
- fear, or experience of, side-effects
- complex regimen ; frequent dosing; method of administration
Condition related factors
- no, or mild, symptoms ; sever symptoms
What an MUR is not !




A full clinical review
An agreement about changes to medication
A discussion about the medical condition beyond that which is
needed to obtain the MUR objectives
A discussion on the effectiveness of treatment based on test
results.
Facts
Around 50% of patients do not comply with some
element of prescribed treatment; a large proportion of GP
appointments are taken by patients with long term
conditions; and a high proportion of hospital readmissions in the elderly are a direct result of poor
compliance with prescribed medication.
Potential benefits


Patients :
- improved health outcomes & quality of life
- encourages self care ; ownership of condition & treatment
GPs, Commissioners, Primary Care team:
- reduction in secondary care admissions
- cost savings from prescribing budget i.e. waste, efficiencies.
- can save time and can improve quality of QOF reviews and
clinical reviews if MUR is done first.
- opportunity to integrate care pathways as part of service
redesign
- opportunity to support “long term conditions” closer to home
Potential Barriers

New service for community pharmacists, GPs and patients
- not well communicated, nor understood, nor designed.

Confusion about level of review and purpose.

Increase in GPs’ workload in many cases.


Not meaningful nor useful to GPs if not integrated as part of
practice systems.
Format not user friendly ; cannot be easily entered on practice
I.T. systems (- will change and be electronic)
Potential Barriers

Although part of the community pharmacy contract since 2004,
it was underestimated how long it would take for community
pharmacists to be able to deliver the service :
-
development of new patient facilities/ consultation rooms
pharmacist accreditation with HEI
pharmacist workload / delivery of new contract
development of support staff
re-engineering of community pharmacy practice.
confidence
communications
From barriers to benefits




Pharmacists - discuss with GPs patient selection e.g. respiratory
patients, elderly on more than 4 items or those that the practice
does not usually see ? Some MURs will be opportunistic.
Agree local arrangements for sending MURs to GP practice : to
whom & how e.g. “no action” forms in a bundle monthly; what
about those needing attention? Summary form ?
Practices - identify patients (coloured dot on script?); integrate
MURs e.g attach to patient notes before QOF or clinical review.
GPs - review MURs with pharmacists – give feedback
MURs – going forward



Increase patient awareness with support from GPs, PCT team
- terminology “ Medicines Check Up”
Referrals
- Prior to annual medical reviews
- From “fallers” units in hospitals
- Via community matrons, district nurses, social services, etc.
- For care home and housebound patients
Share good practice and benefits
Some typical MUR outcomes





Ormskirk – patient with frequent scripts for salbutamol was
invited for MUR.Poor control of asthma (according to indicators)
When MUR was sent to GP practice it was discovered that the
patient was not flagged as an asthmatic.
Patient taking lorazepam routinely at night did not know why.
He had been prescribed it “prn” in hospital and when he came
out it continued to be prescribed, so he just took it every night.
Patient using Avesco (steroid) inhaler was using it ad.hoc. not
as prescribed
Patient using steroid inhaler had oral thrush. He was referred to
get treatment and advised to rinse mouth after each inhalation
During checking of inhaler technique it was found that one
patient was double dosing by activating two puffs instead of one
Key learnings







Average time spent face to face with a patient was 15.2
minutes. Total average time on recruitment, preparation, form
filling, patient contact and follow up was 45 minutes
Over 40% of patients were receiving medicines from 2 BNF
categories
30% were receiving medicines from 3 or more BNF categories
70% of customers were over 55 years old
45% male, 55% female
87% thought that pharmacists should offer such a service
95% of customers were satisfied with the service
Integrated Service –examples


As agreed with one GP practice, stable hypertensives (normally
seen annually) are sent for a MUR at 6 months when they have
their B.P. taken by the pharmacy (commissioned via PBC).
This enables GPs to gain QOF payment.
In Poole PCT, MUR is the starting point to involve community
pharmacists in a new care pathway for COPD.
The next level of service involves providing the pharmacist with
more information from the GP practice so they can assess
symptom control, provide specific health promotion & referrals.
Integrated Service – example


Patients may be selected for the repeat dispensing service, for
example, after their annual medical review e.g for 6 months or
12 months, etc.
- Pharmacist carries out MUR just before referring patient back
to the GP for their next annual review, so that GP has MUR
information at this point.
- Pharmacist could also remind patient when blood tests, etc.
are required (if GP attaches this information to RD request)
Estimated that 80% of repeat prescriptions could be handled by
community pharmacy.
Key Success Factors




The WILL to make it happen and realise the benefits!
Excellent local communication between community pharmacists,
GPs, practice managers, nurses, community matrons, PCT
personnel and patients /patient groups.
Mutual understanding of protocols, parameters & preferred
target patient groups.
Repeat dispensing will help to align the process.