Medicines Use Reviews (MURs) : a case study in two community pharmacies

The Medicines Use Review and Prescription Intervention (MUR) service was commissioned as part of the 2005 community pharmacy contract for England and Wales. The aim of the MUR service is to improve patients’ knowledge and use of medicines and to reduce avoidable medicines waste. MURs form part of a Government strategy that aims to improve patients’ adherence to medicines in order to optimise health gain and reduce cost associated with unused medicines. MURs are also seen as a ‘concordance review’ and pharmacy’s professional bodies acknowledge the service as a means to further the professional role of community pharmacists. However, it remains uncertain from studies investigating the outcomes of MURs, the extent to which the service is benefitting patients. One significant drawback to previous studies is the lack of in-depth investigation of the MUR consultation and the patients’ perspective of the service. This thesis provides valuable insights into what occurs during an MUR consultation and investigates the patient’s perspective of the service and that of the pharmacy staff. This work also explores whether the MUR policy aims are being realised in practice and translated into more effective use of medicines. Ten weeks of fieldwork observations were undertaken in two English community pharmacies. One-week placements were made over a 12-month period between November 2008 and October 2009. Observations were made of all pharmacy activities, including fifty-four MUR consultations. Thirty-four patients subsequently agreed to be interviewed about their experience of the MUR. Eight patients were observed to decline the offer of an MUR, of which three patients were interviewed about the reasons why they declined. After the pharmacy observations were completed, five pharmacists and twelve support staff interviews were held to discuss professional perspectives of MURs. The findings from this study suggest that the MUR service is a modern and developing service but one that remains unestablished. Patient awareness of MURs was poor and nearly all MURs were initiated by the pharmacist; no patients were referred from the GP. Pharmacy staff did not actively seek to recruit patients who may benefit most from an MUR and the majority were invited in ad hoc manner. Patients were given little time to consider whether to take part in an MUR and were insufficiently informed of their purpose or personal value. MURs were framed as a monitoring activity and most patients reported that the MUR did little to improve their knowledge of their medicines and rarely affected their use. They perceived their GP to have the main authority over their medicines. Patients considered that significant medicine-related problems would be best resolved by talking to the GP rather than with the pharmacist during an MUR. In effect, a supplier induced demand for MURs was observed. Nevertheless, all patients reported feeling comfortable speaking to the pharmacist during an MUR and most described the consultation in positive terms. Most patients viewed the pharmacist as a knowledgeable expert and some felt reassured about their medicines following an MUR. Observations of the MUR consultation revealed pharmacists were subordinate to the ‘technology’ of the MUR form and adhered to its ‘tick-box’ format. Pharmacists used predominantly closed questions which enabled the MUR form to be completed efficiently, but this forestalled wider discussion of the patient’s health and medicines. The MUR service was at odds with the intention to create a patient-centred service. When complex or indeterminate issues were raised, these were often circumvented or the patient referred to the GP. Pharmacists reported in their interviews that they welcomed MURs and the resultant potential to raise their profile with patients. However, they were unclear about what they wanted to advise during an MUR and how patients might gain maximum benefit from the review. They also reported concerns over patient recruitment, organisational pressures to pursue a target number of MURs and difficulties integrating MURs within their existing activities. MURs were pragmatically accommodated alongside existing duties without additional resource. Support staff reported feeling discomfort when they were left to explain to patients and customers why the pharmacist was absent during an MUR and described using various strategies and personal judgements to deal with waiting patients. This study has important implications for patients, professionals and policy makers. Patients should be aware that the MUR service is funded by the NHS and is available for them to use. More support from GPs is needed to identify patients who may most benefit from an MUR. This study highlights the need for consultation and communication skills training for pharmacists, so they are able to effectively elicit patient beliefs, concerns and preferences about medicines during the MUR. Organisations also need to reconsider the way they motivate pharmacists to undertake MURs to avoid unintended consequences for patient care. Policy makers should reconsider strategies that are based on rationalised policies as a means to improving patient adherence to medicines. Effective services need to be responsive to the patient’s individual circumstance and preference. Further research is needed into MURs in a wider and more diverse range of pharmacy settings in order to explore these issues further

A Qualitative Exploration to Understand Access to Pharmacy Medication Reviews: Views from Marginalized Patient Groups

This is an open access article distributed under the Creative Commons Attribution License which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. This research was led by the Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham NG7 2UH, UK.Background: Vulnerable patients from marginalized groups (e.g., people with disabilities, people experiencing homelessness, black and minority ethnic communities) experience higher rates of ill-health, inequitable access to healthcare and low engagement with screening services. Addressing these disparities and ensuring healthcare provision is impartial and fair is a priority for the United Kingdom (UK) healthcare system. Aim: Using Levesque’s access conceptual framework, this study explored the views of patients from marginalized groups, specifically on how access to pharmacy services could be improved and their experiences of receiving a medication review service. Method: Qualitative data were collected via semi-structured interviews on patient experiences of pharmacy services and how access to these could be improved (n = 10). Interviews of patients who had received a medication review from their pharmacist were also conducted (n = 10). Using an interpretivist approach, five ‘demand-side’ dimensions of Levesque’s access conceptual framework were explored (ability to perceive a need for medication support, their ability to seek this support, ability to reach the pharmacy, ability to pay and engage). Results: The findings exposed the medicine, health and social care challenges of vulnerable people and how these are often not being adequately managed or met. Using the access formwork, we unpack and demonstrate the significant challenges patients face accessing pharmacy support. Discussion: Pharmacy organizations need to pay attention to how patients perceive the need for pharmacy support and their ability to seek, reach and engage with this. Further training may be needed for community pharmacy staff to ensure services are made accessible, inclusive and culturally sensitive. Effective engagement strategies are needed to enable the provision of a flexible and adaptable service that delivers patient-centred care. Policy makers should seek to find ways to reconfigure services to ensure people from diverse backgrounds can access such services

Medicines Use Reviews (MURs) : a case study in two community pharmacies

The Medicines Use Review and Prescription Intervention (MUR) service was commissioned as part of the 2005 community pharmacy contract for England and Wales. The aim of the MUR service is to improve patients’ knowledge and use of medicines and to reduce avoidable medicines waste. MURs form part of a Government strategy that aims to improve patients’ adherence to medicines in order to optimise health gain and reduce cost associated with unused medicines. MURs are also seen as a ‘concordance review’ and pharmacy’s professional bodies acknowledge the service as a means to further the professional role of community pharmacists. However, it remains uncertain from studies investigating the outcomes of MURs, the extent to which the service is benefitting patients. One significant drawback to previous studies is the lack of in-depth investigation of the MUR consultation and the patients’ perspective of the service. This thesis provides valuable insights into what occurs during an MUR consultation and investigates the patient’s perspective of the service and that of the pharmacy staff. This work also explores whether the MUR policy aims are being realised in practice and translated into more effective use of medicines. Ten weeks of fieldwork observations were undertaken in two English community pharmacies. One-week placements were made over a 12-month period between November 2008 and October 2009. Observations were made of all pharmacy activities, including fifty-four MUR consultations. Thirty-four patients subsequently agreed to be interviewed about their experience of the MUR. Eight patients were observed to decline the offer of an MUR, of which three patients were interviewed about the reasons why they declined. After the pharmacy observations were completed, five pharmacists and twelve support staff interviews were held to discuss professional perspectives of MURs. The findings from this study suggest that the MUR service is a modern and developing service but one that remains unestablished. Patient awareness of MURs was poor and nearly all MURs were initiated by the pharmacist; no patients were referred from the GP. Pharmacy staff did not actively seek to recruit patients who may benefit most from an MUR and the majority were invited in ad hoc manner. Patients were given little time to consider whether to take part in an MUR and were insufficiently informed of their purpose or personal value. MURs were framed as a monitoring activity and most patients reported that the MUR did little to improve their knowledge of their medicines and rarely affected their use. They perceived their GP to have the main authority over their medicines. Patients considered that significant medicine-related problems would be best resolved by talking to the GP rather than with the pharmacist during an MUR. In effect, a supplier induced demand for MURs was observed. Nevertheless, all patients reported feeling comfortable speaking to the pharmacist during an MUR and most described the consultation in positive terms. Most patients viewed the pharmacist as a knowledgeable expert and some felt reassured about their medicines following an MUR. Observations of the MUR consultation revealed pharmacists were subordinate to the ‘technology’ of the MUR form and adhered to its ‘tick-box’ format. Pharmacists used predominantly closed questions which enabled the MUR form to be completed efficiently, but this forestalled wider discussion of the patient’s health and medicines. The MUR service was at odds with the intention to create a patient-centred service. When complex or indeterminate issues were raised, these were often circumvented or the patient referred to the GP. Pharmacists reported in their interviews that they welcomed MURs and the resultant potential to raise their profile with patients. However, they were unclear about what they wanted to advise during an MUR and how patients might gain maximum benefit from the review. They also reported concerns over patient recruitment, organisational pressures to pursue a target number of MURs and difficulties integrating MURs within their existing activities. MURs were pragmatically accommodated alongside existing duties without additional resource. Support staff reported feeling discomfort when they were left to explain to patients and customers why the pharmacist was absent during an MUR and described using various strategies and personal judgements to deal with waiting patients. This study has important implications for patients, professionals and policy makers. Patients should be aware that the MUR service is funded by the NHS and is available for them to use. More support from GPs is needed to identify patients who may most benefit from an MUR. This study highlights the need for consultation and communication skills training for pharmacists, so they are able to effectively elicit patient beliefs, concerns and preferences about medicines during the MUR. Organisations also need to reconsider the way they motivate pharmacists to undertake MURs to avoid unintended consequences for patient care. Policy makers should reconsider strategies that are based on rationalised policies as a means to improving patient adherence to medicines. Effective services need to be responsive to the patient’s individual circumstance and preference. Further research is needed into MURs in a wider and more diverse range of pharmacy settings in order to explore these issues further

Quality improvement in community pharmacy: a qualitative investigation of the impact of a postgraduate quality improvement educational module on pharmacists understanding and practice

open access articleObjective Quality improvement (QI) is increasingly featuring in the United Kingdom (UK) National Health Service (NHS) agenda to promote safety, effectiveness and patient experience. However, the use of QI techniques by healthcare professionals appears limited and constrained with only isolated examples of good practice. This study explores QI within the pharmacy context. Focusing on the community pharmacy ‘Healthy Living Pharmacy scheme’, this study aims to explore changes in QI understanding resulting from a postgraduate QI educational intervention. Methods Four focus groups were held involving 13 community pharmacists enrolled onto a newly developed postgraduate QI educational module. Two focus groups were held before and two after the module’s completion. Knowledge of QI and practical applications following the learning was explored. Key findings Three themes emerged: pharmacists’ motivation for learning about QI, conceptual understanding and translation into practice. Pharmacists expressed positive views about learning new skills but expressed logistical concerns about how they would accommodate the extra learning. Prior knowledge of QI was found to be lacking and its application in practice ineffectual. Following completion of the QI module, significant improvements in comprehension and application were seen. Pharmacists considered it too soon to make an assessment on patient outcomes as their improvements required time to effectively embed changes in practice. Conclusions Quality improvement forms an important part of the NHS quality and safety agenda; however, community pharmacists may not currently have adequate knowledge of QI principles. The postgraduate educational intervention showed promising results in pharmacist’s knowledge, organisational culture and application in practice

An exploration of the experiences of professionals supporting patients approaching the end of life in medicines management at home. A qualitative study

BACKGROUND: The management of medicines towards the end of life can place increasing burdens and responsibilities on patients and families. This has received little attention yet it can be a source of great difficulty and distress patients and families. Dose administration aids can be useful for some patients but there is no evidence for their wide spread use or the implications for their use as patients become increasing unwell. The study aimed to explore how healthcare professionals describe the support they provide for patients to manage medications at home at end of life. METHODS: Qualitative interview study with thematic analysis. Participants were a purposive sample of 40 community healthcare professionals (including GPs, pharmacists, and specialist palliative care and community nurses) from across two English counties. RESULTS: Healthcare professionals reported a variety of ways in which they tried to support patients to take medications as prescribed. While the paper presents some solutions and strategies reported by professional respondents it was clear from both professional and patient/family caregiver accounts in the wider study that rather few professionals provided this kind of support. Standard solutions offered included: rationalising the number of medications; providing different formulations; explaining what medications were for and how best to take them. Dose administration aids were also regularly provided, and while useful for some, they posed a number of practical difficulties for palliative care. More challenging circumstances such as substance misuse and memory loss required more innovative strategies such as supporting ways to record medication taking; balancing restricted access to controlled drugs and appropriate pain management and supporting patient choice in medication use. CONCLUSIONS: The burdens and responsibilities of managing medicines at home for patients approaching the end of life has not been widely recognised or understood. This paper considers some of the strategies reported by professionals in the study, and points to the great potential for a more widely proactive stance in supporting patients and family carers to understand and take their medicines effectively. By adopting tailored, and sometimes, 'outside the box' thinking professionals can identify immediate, simple solutions to the problems patients and families experience with managing medicines

‘Our Care through our Eyes’: a mixed methods,evaluative study of a service user,co-produced education programme to improve inpatient care of children and young people admitted following self-harm

Introduction: Within Europe, the UK has one of the highest rates of self-harm, with a particularly high prevalence in children and young people (CYP). CYP who are admitted to paediatric hospital wards with self-harm are cared for by registered children's nurses who have been identified to lack specific training in caring for this patient group. This may impede the delivery of high quality care. Therefore, this study aims to co-produce, implement and evaluate an education programme for registered children's nurses to improve their knowledge, attitudes and confidence when caring for CYP admitted with self-harm. Methods and analysis: This mixed-methods evaluative study will involve a three-stage design. Stage 1: A priority-setting workshop will be conducted with 19 registered children's nurses. A Delphi technique will be used to establish consensus of information needs. Stage 2: An online educational intervention will be co-produced with 25 CYP and 19 registered children's nurses based on the priorities identified in Stage 1. Stage 3: The intervention will be implemented and evaluated with 250 registered children's nurses at a single hospital. Online Likert scale questionnaires will be administered at baseline and postintervention to assess levels of knowledge, attitudes and confidence in caring for CYP who self-harm. Descriptive and inferential statistics will be used to analyse the data. Statistical significance will be assessed at the 5% (two-sided) level. One-to-one qualitative interviews will also be undertaken with approximately 25 participants to explore any perceived impact on clinical practice. An interpretive descriptive approach will guide qualitative data collection and analysis. Ethics and dissemination: This study aims to develop, trial and evaluative a service-user, co-produced education programme for acute hospital registered children's nurses to improve the care of CYP admitted due to self-harm. The study has ethical approval from the National Health Services Research Ethics Committee and full governance clearance

Towards equity: a qualitative exploration of the implementation and impact of a digital educational intervention for pharmacy professionals in England.

Background: Patients belonging to marginalised (medically under-served) groups experience problems with medicines (i.e. non-adherence, side effects) and poorer health outcomes largely due to inequitable access to healthcare (arising from poor governance, cultural exclusion etc.). In order to promote service equity and outcomes for patients, the focus of this paper is to explore the implementation and impact of a new co-produced digital educational intervention on one National Health Service (NHS) funded community pharmacy medicines management service. Methods: Semi-structured interviews with a total of 32 participants. This included a purposive sample of 22 community pharmacy professionals, (16 pharmacists and 6 pharmacy support staff) all who offered the medicine management service. In order to obtain a fuller picture of the barriers to learning, five professionals who were unable to complete the learning were also included. Ten patients (from a marginalised group) who had received the service (as a result of the digital educational intervention) were also interviewed. Drawing on an interpretative analysis, Normalisation Process Theory (NPT) was used as a theoretical framework. Results: Three themes are explored. The first is how the digital learning intervention was implemented and applied. Despite being well received, pharmacists found it challenging completing and cascading the learning due to organisational constraints (e.g. lack of time, workload). Using the four NPT constructs (coherence, cognitive participation, collective action and reflexive monitoring) the second theme exposes the impact of the learning and the organisational process of ‘normalisation’. Professional reflective accounts revealed instances where inequitable access to health services were evident. Those completing the intervention felt more aware, capable and better equipped to engage with the needs of patients who were from a marginalised group. Operationally there was minimal structural change in service delivery constraining translation of learning to practice. The impact on patients, explored in our final theme, revealed that they experience significant disadvantage and problems with their medicines. The medication review was welcomed and the discussion with the pharmacist was helpful in addressing their medicine-related concerns. Conclusions: The co-produced digital educational intervention increases pharmacy professionals’ awareness and motivation to engage with marginalised groups. However structural barriers often hindered translation into practice. Patients reported significant health and medicine challenges that were going unnoticed. They welcomed the additional support the medication review offered. Policy makers and employers should better enable and facilitate ways for pharmacy professionals to better engage with marginalised groups. The impact of the educational intervention on patients’ health and medicines management could be substantial if supported and promoted effectively

Exploring the impacts of organisational structure, policy and practice on the health inequalities of marginalised communities: illustrative cases from the UK healthcare system

The file attached to this record is the author's final peer reviewed version. The Publisher's final version can be found by following the DOI link.This paper explores how organisational structure, policies and practices in healthcare can inadvertently disadvantage marginalised populations (e.g. individuals from ethnic minority backgrounds) and reinforce health inequalities. We draw upon three diverse UK healthcare settings (long term care institutions, high security hospitals and community pharmacies) to illustrate how systemic injustices negatively impact on access to care, treatment and health outcomes. The first case study considers the care of older people within nursing homes; specifically the disempowering effects of this service structure and impacts of choice reduction upon health and their access to health provision. The second case study explores the impact of security restrictions upon patients within high security hospitals, focusing particularly on the maintenance of relationships and support networks outside of the hospital. The third and final case study, draws upon the national community pharmacy medicine management service to illustrate ways in which policies and guidelines inadvertently obstruct patients' engagement with the service within a community setting. We draw upon these settings to highlight inequalities within different contexts and to illustrate the ways in which well intended services can inadvertently disadvantage marginalised communities in multiple ways