As we pass the 10-year anniversary of the introduction of the medicines use review (MUR) service, pharmacist Mike Holden looks back and considers what the future could hold for advanced services.

THE MUR service was introduced in April 2005 to address the fact that, although medicines are the commonest medical intervention, their outcomes are not always optimised. For example:

• Between 30 and 50 per cent of prescribed medicines are not taken as recommended¹
• Ten days after starting a new medicine, 30 per cent of patients are already non-adherent¹
• Adverse drug reactions account for 6.5 per cent of hospital admissions, yet over 70 per cent of ADRs are avoidable².

The introduction of MURs was seen as a stepping-stone for pharmacists, shifting the balance from medicines procurement and supply to medicines supply and the provision of patient services.

Slow start

In the early stages, delivery uptake was slow. This was partly due to the accreditation process and the challenges resulting from the administration of the service (e.g. the complex paperwork). However, we are now at a point where 85 per cent of pharmacies in England are delivering about 30 MURs a month (almost 90 per cent of the potential total through those pharmacies).

Overall, the sector is delivering an average of 25 MURs a month (75 per cent of potential), which provides a yearly income of over £9,000 per active pharmacy. More importantly, patients are benefiting from a better understanding of the appropriate and safe use of their medicines. There have been those who have challenged the quality and benefits of MURs, so let us look at the evidence.

I was instrumental in the first evaluation of MUR interventions when we launched the asthma MUR initiative in Hampshire and Isle of Wight back in 2007. This involved collaborating with GP and nurse colleagues to support patients in the correct use of their inhalers. This evaluation³ and the subsequent South Central project⁴ in 2011 demonstrated improved control of their condition in 40 per cent of patients as a result of the MUR intervention.

Since then there has been the Leicester SIMPLE project,5 which also demonstrated improved outcomes and quality of life for patients and, like the previous projects, a positive association with a reduction in hospital admissions.

Very positive

In 2013 there was the introduction of the new medicine service (NMS)6 to deal with the rapid drop off in adherence to newly prescribed treatment in some therapy areas (asthma and COPD, type 2 diabetes, antiplatelet/anticoagulant therapy and hypertension) during the first month after initiation.⁷ The subsequent evaluation of this clinical service was very positive and supported ongoing commissioning. What is clear is that community pharmacists, ably supported by their teams, can add value to patient outcomes.

What about the future?

We have recently seen the introduction of a medicines optimisation ‘movement’, which has the primary goal of maximising the value that a patient derives from their medicines and the value that the whole population experiences from the investment of the NHS in medicines. Pharmacists have a significant, indeed leading role to play in this. Within pharmacy we have traditionally talked about pharmaceutical care, recently redefined by the Pharmaceutical Care Network of Europe⁸ as: “The pharmacist’s contribution to the care of individuals in order to optimise medicines use and improve health outcomes.”

For me, this sums up perfectly the future role of community pharmacy relating to prescription medicines. So how could this work from a contractual perspective? We currently have the supply function, MURs and NMS as separate services within the national contractual framework.

Only Scotland has moved towards contracting pharmaceutical care with the introduction of the chronic medication service,⁹ while pharmacists in New Zealand have also recently seen a significant shift from procurement to the provision of care for patients with long-term conditions (LTC)¹⁰. It may take some time to put in place but we can start the process by removing the cap on the number of MURs and link them to prescription volume (like the NMS) so that more patients gain from the benefits of pharmaceutical care.

We could allow pharmacists to gain the consent of a parent or guardian to provide these services to children. The limitations on target groups for the NMS could be removed so that we include all patients with a new medicine for a long-term condition. Imagine the benefits for a patient starting on an antidepressant.

Unfortunately, these interim options will still leave us, the system – and most importantly, patients – with varied access to pharmaceutical care. It will still leave pharmacists with an option not to provide the advanced services that should be part of their core role. It won’t universally deliver joined-up contracting and provision of pharmaceutical care and it may not create the necessary momentum to shift pharmacy from transactional to interactional care or supply to full pharmaceutical care.

Empowered profession

There has been much talk about having more pharmacists in GP practices. If this role is part of a joined-up virtual pharmaceutical care team across hospitals, GP practices and community pharmacies, it should be a great step forward for the whole profession. However, if it is done in a silo without joining up communication and data, and without enabling community pharmacies to play their important role, it will fail to optimise outcomes for patients and the NHS.

We need to empower professionalism by contracting a pharmaceutical care service across the rest of the UK. It should recognise pharmacists’ professional status and responsibilities, reward the value they deliver, and clearly indicate to patients and other healthcare professionals that this is the core role of pharmacists, wherever they practise.