The MUR
Invitations to take part in MURs were typically initiated by the pharmacy staff in an ad hoc way when patients attended to collect prescriptions. Both pharmacies had previously tried making appointments with patients but these were seen to be problematic when patients did not attend. Particularly in the independent, patients with whom the staff appeared to have a good relationship were typically selected for an MUR. Although GPs can refer patients, no MURs were initiated via this route. MURs were not understood by patients to be a collaborative activity involving or relevant to, the GP but as a quick pharmacy oriented activity to “check” their medicines:
Primrose: The lady came up to me and said would I mind going through my medication with the pharmacist and just to kind of make sure that we both knew why this medication was being prescribed and it was just something that chemists are having to do now.
Patient 56yr. F
Among most patients involved in this study the pharmacist did not identify many, or even any, problems with their medicines. Most patients reported the consultation had not improved upon their knowledge of their medicines and rarely affected their use. They were generally satisfied with the current level of knowledge they had about their medicines, being familiar with drugs prescribed for long-term conditions:
Jill: [Sighs] Well I don’t think I’ve got no more knowledge. I think it’s just that I’ve been on these for so long and once you’ve been on them for so long, the doctor does make sure that you’re alright with them.
Patient 64yr. F
Despite a lack of evidence that the MUR service was achieving its intended policy aims, nearly all patients spoke of the MUR positively, describing the review as “satisfying” or “interesting”. All patients reported feeling comfortable speaking with the pharmacist who they saw as a knowledgeable expert on medicines. Furthermore, they valued the time the pharmacist spent with them, commenting that this had made them feel special, and appreciated the opportunity to speak to them privately. Most accounts suggested that the pharmacist had reassured patients about their medicines:
Researcher: To what extent then did you personally find the review useful?
Esther: Well, I think it gave me a bit of confidence that the pharmacist was caring enough to go though all my medication to make sure I was happy with it…and that I knew what I was doing…
Patient 61yr. F
Comfort: I think it gives you more confidence, it does me, gives me more confidence to think I’m doing the right thing and taking the right medicine
Patient 72yr. F
Although pharmacy staff tended to invite patients with less complicated medicine regimes, there were a few instances during the MUR where the pharmacist identified particular concerns about the patient’s health or medicine. In these cases, rather than intervene directly and on the patient’s behalf, pharmacists preferred to place the onus on patients to return to their GP for resolution of these issues. In the following example the pharmacist identifies a potential deterioration in the patients’ asthma control. Whilst this event may not have been highlighted unless the pharmacist had initiated the MUR, the limited remit and lack of collaboration with the GP led to the pharmacist closing off discussion and failing to ensure that the issue was resolved:
Jane [Pharmacist]: The Ventolin…
Mia [Patient]: Which ones that? [The patient looks in her bag and takes out a Ventolin inhaler].
Jane: That’s the one, how often do you use that?
Mia: It depends, but I'm using it a lot.
Jane: Are you using it eight puffs or more?
Mia: More than that.
Jane: You should go to see the asthma nurse or doctor because the others are not doing their job. If it’s been a few days you need to see them
a
.
MUR 32
The follow-up interview with the patient revealed that the pharmacist’s advice appeared to have been accepted although it is not known whether the suggestion was subsequently followed through:
Researcher: … Did you pick up anything that you didn’t already know?
Mia: …Only that uh I needed to go back, ‘cause the Ventolin. I just thought it was me getting worse… I thought I was on the most I could go on, you know and I’d have to tolerate it. But with her saying that, she said that they can help you more.
Patient 66yr. F
In another case, having discovered non-adherence to a diuretic tablet, the pharmacist encouraged the patient to take the medicine as prescribed. A shared decision was made about informing the GP which was done via the MUR documentation:
The conversation turns to the patient’s furosemide…
Moya [Patient]: I don’t have ankle swelling so I don’t take them [furosemide] every day.
Rebecca [Pharmacist]: You need to take them every day as if you don’t then the kidneys have to work more.
Moya: I will mention that to him [the GP], I've got to see him.
Rebecca: I’ll put that on the [MUR] form [Rebecca explains that the patient should be taking the tablet daily as the fluid builds up and “it’s harder for the kidneys to work to clear the fluid”].
Rebecca: Is it ok for me to let the GP know?
Moya: Yes, I’m seeing him next week.
MUR 9
In the follow-up interview with the patient it was found that without the MUR, the patient would not have brought up the matter with the GP. The patient’s awareness that the pharmacist would be informing her GP through the MUR form both legitimised and encouraged her to raise the matter with the GP:
Moya: … You see my frusemide …I thought well I don’t get any swelling of my ankles so do I need it every day? So, I get a bit naughty and I don’t take them every day. And so of course the pharmacist got on to me and so I’ve got to tell the doctor…whether it is something I should be taking every day…
Researcher: OK, would you have discussed it with the doctor if the pharmacist hadn’t mentioned it?
Moya: No, no I’d probably wouldn't …I might have thought about it and thought well better not say anything else because I might not be doing the right thing [laughs]… but I will mention it. I’ll have to because that form’s gone to him [laughter].
Patient 79yr. F
Another important finding that emerged from the data was how some patients anticipated that the MUR might affect their relationship with the GP. A few patients expressed their awareness of a difference in professional status and hierarchy between pharmacists and GPs and the possibility their doctor might be annoyed to find the pharmacist ‘interfering’ with their medicines without this being clearly sanctioned by the prescriber. As a result, some felt wary of the pharmacist’s involvement or felt that they were going behind the doctor’s back, and that MURs had the potential to cause inter-professional tension or conflict:
Ashley: I don’t think they [GP] like it, outside interference…being from a novice, a pharmacist or anybody else…
Patient 67yr. M
Nicola: I just recently started taking paracetamols…I did ask the doctor if I could take up to six and she said eight. So I just wanted to make sure with the other tablets…I wouldn’t want my doctor to know that [laughs]… I didn’t want to upset the doctor by thinking I was asking her if it was OK to take them … But I just wanted to check…
Patient 68yr. F
The pharmacist perspective
All the pharmacists interviewed reported enjoying the activity of undertaking an MUR as this provided greater personal patient contact and added diversity to their daily routines. However, they also recognised barriers to effective implementation of the service. MURs were being shoehorned alongside existing duties without additional resource. Lack of patient awareness of the availability and potential value of the service made recruiting patients difficult. As a result, pragmatic strategies were employed by pharmacy staff to offer MURs to patients who met the minimum inclusion criteria and who were judged likely to respond to an invitation. Patients with many medicines or those who were perceived to have more complex conditions such as mental illness were avoided for fear that the consultation would be too lengthy. Moreover, organisational pressure on pharmacists to avoid financial loss by meeting targets for the number of completed MURs was evident, particularly among those working in the chain pharmacy:
Jane: Well, it’s not ideal because you’re looking at figures rather than the actual quality of the service that you’re giving…
Employee pharmacist, Multiple
Added to these organisational constraints, when pharmacists were asked about the value of MURs as an inter-professional collaborative activity, they reported that patients were not referred from their GPs and they received little or no feedback from them about any recommendations they made regarding medicines which resulted from the MUR. Consequently, MURs were not seen to foster inter-professional collaboration: rather, pharmacists reported the opposite view:
Kate: I don’t think they’re [GP's] keen on us doing it, to be honest, to be truthful.
Employee pharmacist, Multiple