Many patients who attend for eye examinations, particularly the elderly, are sometimes prescribed a number of medicines about which they may be confused or they have some concerns about their use.
Historically, optometrists might have referred back to the GP but now we have a range of services based in the community pharmacy to help support patients with their medicines, that the optometrist could refer to instead. The most relevant service would be Medicines Use Review (MUR).
The MUR forms part of the Community Pharmacy Contract which was introduced in April 2005, modified in 2011, and was the first advanced service for community pharmacy.
The contract is the agreement between the pharmacy contractor and the NHS and has three levels of service:
• Essential services – which must be provided by all pharmacy contractors and would include dispensing prescriptions, providing advice on over the counter queries
• Advanced services – which are available nationwide and would include the Medicines Use Review and the New Medicines Service
• Enhanced services – these are negotiated currently with the local NHS body and they are based on the local need. Examples would include services for drug misusers, the supply of emergency hormonal contraception, smoking cessation, chlamydia testing and others, depending on the demography of the area
The pharmacy contract reflects the shift from dispensing and towards the delivery of services that has been occurring in community pharmacy over the last 20-30 years. Pharmacists are no longer expected to just dispense and hand out prescriptions; mostly this is done by the dispensing assistants or technicians.More and more pharmacies now have accuracy checking technicians who do the final accuracy check (the pharmacist having done the clinical check earlier in the process). This leaves the pharmacists to be involved in the advanced and enhanced services, which generally only they can do.
Involvement in the advanced and enhanced services is more rewarding professionally for a pharmacist as it allows them to use their range of clinical and consultation skills.
So what is an MUR?
A MUR is a planned face-to-face consultation between a pharmacist and a patient to discuss their medicines, both prescribed and non-prescribed.
The review is adherence-centred and aims to help increase patients’ knowledge and understanding of their medicines, including how and why they should be taken. It also provides an opportunity to discuss any medicine-related issues from the patient’s perspective and discuss solutions.
What are the steps of the MUR?
Specifically, the patient’s knowledge and use of drugs is improved by:
• Establishing the patient’s actual use, understanding and experience of taking drugs (how do they actually take their medicines)
• Identifying, discussing and assisting in finding solutions to any poor or ineffective use of drugs by the patient (eg not taking their medicines as directed, taking them at the wrong time or using a device incorrectly)
• Identifying side effects and drug interactions that may affect the patient’s compliance with their medicines and giving advice on how to minimise the risk of side effects or referring them back to their prescriber if the side effect is unacceptable
• Improving clinical and cost effectiveness of drugs prescribed to patients, thereby reducing wastage of such drugs. Identify medicines no longer used which can then be flagged to be removed from their repeat slip by the prescriber.
A set of suggested questions has been developed which pharmacists can use to guide the conversation with the patient; the use of the questions is not compulsory, but pharmacists often find them useful to obtain the maximum amount of information from the patient’s perspective as possible.
MURs are not intended to be a clinical review where the pharmacist assesses the appropriateness of the prescribed medicine for the patient and their condition. However, sometimes clinical issues may arise that can also be discussed with the prescriber.
Pharmacists have to record certain data about the MUR (the national MUR dataset), but they will generally keep additional notes related to the MUR to support the continuing care of the patient.
Where there is an issue the patient’s GP needs to be made aware of they will be sent an MUR feedback form and a phone call if needed.
[CaptionComponent="2421"]Who can provide a MUR?
All pharmacy contractors in the UK can provide the service as long as they meet the following criteria
These include:
• Providing all the essential services and clinical governance
• The premises must have a consultation room to ensure privacy and confidentiality during the consultation
• Pharmacists conducting MUR consultations must be accredited and have submitted their MUR certificate to NHS England
Are there different types of MUR?
The majority of MURs are planned. Planned MURs occur when the patient is invited for a consultation. They are for;
• Patients taking multiple medicines (ie more than one, unless for a high-risk medicine) and those with long-term conditions
• Patients who have had their prescriptions dispensed at the pharmacy for at least the previous three months
• A patient can have a maximum of one MUR every 12 months
An unplanned MUR, known as Prescription Intervention MUR’s is much less common and is simply a MUR which is triggered by a significant adherence problem which comes to light during the dispensing of a prescription. It is over and above the basic interventions, relating to safety, which a pharmacist makes as part of the dispensing service.
Examples would include a patient who isn’t ordering their medicines at the expected intervals as identified from the patients medication record which could indicate they are not taking them correctly; or they still have asthma symptoms despite taking the required medicines, which could prompt a review of their inhaler technique during the consultation. The three month rule and maximum of one every 12 months does not apply to intervention MUR’s
Whatever type of MUR is undertaken, planned or intervention, all the medicines being taken by the patient should be considered and that includes complementary (herbal or homeopathic) and over the counter (OTC) medicines.
Who can have an MUR?
As stated before, MURs must only be provided for patients who have been using the pharmacy for the dispensing of their prescriptions for the previous three months. However, pharmacies must undertake at least 70% of their MURs on patients that fall within the national target groups.
National target groups for MURs
Three national target groups for MURs were introduced in October 2011; a fourth group was agreed in September 2014 (cardiovascular risk) and was implemented from January 1 2015. The national target groups are:
1 Patients taking high risk medicines
2 Patients recently discharged from hospital who had changes made to their medicines while they were in hospital. Ideally patients discharged from hospital will receive an MUR within four weeks of discharge but in certain circumstances the MUR can take place within eight weeks of discharge
3 Patients with respiratory disease
4 Patients at risk of or diagnosed with cardiovascular disease and regularly being prescribed at least four medicines.
From April 1, 2015 community pharmacies must carry out at least 70% of their MURs within any given financial year on patients in one or more of the above target groups.
Can children have an MUR?
The MUR needs to be conducted with the patient not the parent. However, a MUR could be conducted with a patient who is a child if they are competent (ie they have the capacity to give informed consent) and are able to fully engage in the discussion with the pharmacist. Under the current regulatory framework it is not possible to conduct a MUR for the parent, carer or guardian of a person who is not competent.
Were an MUR to be conducted with a competent child, the pharmacist should be aware of the local safeguarding (child protection) policy and guidelines and should know where to refer any young person where there are concerns.
I would encourage optometrists and their teams to make contact with their local pharmacists to discuss the services they offer from their pharmacy, and how they may be of benefit to their patients. By working together, integrated working between pharmacy and optometry can help support patient centred care, support GPs and streamline access to care.
Both pharmacy and optometry have premises in large numbers of community locations and this helps to remove many of the access problems patients in rural and deprived areas may have. Both optometry and pharmacy have regular, ongoing contact with patients that could be used more effectively.
Perhaps you could also help pharmacy get better at managing minor eye conditions to reduce GP referrals and signpost more effectively. Could we do more to support eye care in the pharmacy by reminding patients who are purchasing eye products to have a regular eye test? I am sure there are many possibilities for us to work together in the care of our patients.
Liz Ogle is a pharmacist and Boots teacher practitioner at Aston University