Elsevier

Health Policy

Volume 88, Issues 2–3, December 2008, Pages 258-268
Health Policy

Determinants of the uptake of medicines use reviews (MURs) by community pharmacies in England: A multi-method study

https://doi.org/10.1016/j.healthpol.2008.03.013Get rights and content

Abstract

Objectives

To explore and identify the key determinants influencing the uptake of medicines use reviews (MURs), a new community pharmacy service in England.

Methods

Survey of all primary care organisations (PCOs) in England (n = 303, response rate = 74%) and case study investigations of 10 PCOs, involving interviews with a purposive sample of 43 key stakeholders, including PCO, Local Pharmaceutical Committee and community pharmacy representatives. National data on MUR activity were also analysed and multiple linear regression was used to test determinants of MUR uptake.

Results

The ownership category of the pharmacy was shown to be the most significant determinant of MUR uptake. Rates of MUR provision by multiple pharmacies were almost twice that of independent pharmacies. Interview data corroborated this finding, suggesting that organisational pressure within multiple pharmacies was driving forward MUR activity in some PCOs. Interviewees expressed concern about this quantity driven approach. The PCO survey respondents perceived the greatest barrier to MUR implementation to be a lack of support from general practitioners (GPs). Interviewees reported a lack of communication about MURs between community pharmacists and GPs.

Conclusions

The findings suggest that the organisational setting of the pharmacy is an important factor influencing the uptake of MURs. There is also a need for greater communication and collaboration with GPs regarding the MUR service.

Introduction

Community pharmacies in the United Kingdom (UK) are privately owned businesses contracted by the UK's National Health Service (NHS) to provide pharmaceutical services [1]. Two main ownership categories exist in the UK, multiple (chain) pharmacies, and independent pharmacies. In England, community pharmacies operate under what is termed the ‘national contractual framework for community pharmacy’. In 2000, large scale reform of the NHS was announced, followed by plans to modernise the contractual framework for community pharmacy in England [2], [3]. This heralded one of the largest changes for the profession.

In April 2005, the new national contractual framework for community pharmacy in England came into effect, providing a tiered service structure [4]. Tier one encompasses ‘essential services’, which all community pharmacies are required to provide, including dispensing prescriptions, repeat dispensing and clinical governance requirements. Tier two, which is the focus of this paper, is entitled ‘advanced services’ but currently includes only one service, medicines use review (MUR). This comprises a documented, face-to-face consultation with a community pharmacist. Overall the intention is to improve patients’ understanding of their medication, with enhanced levels of adherence as an outcome [5]. The third tier, ‘enhanced services’, are commissioned by primary care organisations (PCOs)1 to meet local priorities and can include services such as smoking cessation and minor ailments. The provision of ‘enhanced services, one year after the implementation of the contract has been described elsewhere [7], [8], [9], [10].

The provision of MURs by community pharmacists is not mandatory. In order to provide MURs under the NHS, community pharmacists need to have undertaken a programme of training and achieved national accreditation through a competency-based assessment [5], [11]. The community pharmacy premises must also have a suitable private consultation area, which is assessed by the local PCO. A ceiling has been placed on the number of MURs that can be provided by each pharmacy annually. In the first year of operation the ceiling was 250 MURs, the following year this was raised to 400 [12]. The service is free to patients and pharmacists claim reimbursement from the NHS. The reimbursement fee for 2007–2008 was £27 per MUR (approximately US$ 54) [13]. MURs are documented in a structured format using a national MUR form. The patient receives one copy of the form; another is forwarded to the patient's general medical practitioner (GP), giving feedback and highlighting any medication related problems the patient may be experiencing. Although pharmacists can use this route to make drug therapy recommendations, this is not the primary purpose of a MUR.

The introduction of MURs is an example of an intervention which extends the community pharmacist's role beyond the domain of dispensing. Uptake of provision by community pharmacists could be indicative of their willingness to engage in an extended role. However, other factors may influence uptake, including the feasibility of the service in terms of time, staffing resources and financial rewards. Since the introduction of MURs in 2005, uptake of provision has been variable across England. This paper aims to explore and identify the key determinants influencing the uptake of MURs.

Section snippets

Method

We conducted a number of discrete studies to inform this paper. Firstly, monthly MUR activity data were obtained for all 9872 community pharmacies in England for the first two years of operation (April 2005–April 2007) from the Prescription Pricing Division of the NHS Business Services Authority.

A national survey of all PCOs in England was also undertaken. The survey was distributed during February and March 2006 to the PCO individual with primary responsibility for commissioning services from

Response rates

Questionnaires were received from 216 PCOs, a response rate of 74%. Non-respondent PCOs were randomly distributed across England, with no evidence of geographical clustering. Forty-three interviews were conducted, including 10 PCO representatives (Pharmaceutical Advisor, Head of Medicines Management); 10 LPC representatives (Chair or Secretary) and 23 community pharmacists (of which 10 were independent contractors). Seven community pharmacists refused to take part in the study.

Community pharmacy MUR provision

Fig. 1 shows MUR

Discussion

The strengths of this study include its multi-method approach, providing insight into MUR activity and implementation derived from several different sources. Other work has reported MUR activity and PCO views, for a 10% sample of PCOs in England and Wales [20]. This study, however, is the first to present a national picture of MUR activity in England, and explore determinants of MUR uptake with national datasets. Additionally, this paper presents both PCO and community pharmacist views of MURs.

Conclusion

This paper has charted the uptake of a new national service for community pharmacy in England in its first two years and has shown this to be highly variable. The findings suggest that the organisational setting of the pharmacy is an important factor influencing the uptake of MURs and that there is spilt between multiple and independent pharmacies in their approach to the service. This study also indicates a need for greater communication and collaboration with GPs regarding MURs and highlights

Acknowledgements

Part of the research was funded by the Department of Health in England. We would like to thank all community pharmacists and PCO representatives who participated in the study. We also thank the Prescription Pricing Division of the NHS Business Services Authority and The Information Centre for provision of national data.

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