Have medicines use reviews come to represent profit over patient care?

Back in 2005 a new service was introduced for patients in England and Wales: the medicine use review — a great opportunity to showcase the clinical skills of pharmacists. They would spend between 10 and 15 minutes with a patient discussing their medicines and the pharmacy would make £28 each time.

Eight years on, pharmacists are expressing concerns about the pressures they are facing in carrying out these MURs. Although there is a cap of 400 per year on the number of MURs a pharmacy can undertake, it appears that this figure is increasingly being seen as a target by the multiples. MURs are good earners. For the most recent NHS financial year, 2.8 million MURs were claimed by pharmacy contractors, costing the NHS about £79m. 

So what is the culture around these MURs? The Journal spoke to 21 community pharmacists working for a number of multiples to find out what they see as the key challenges.

What emerges is a picture of constant pressure to meet MUR targets, which range from two to four a day to 15 per week, and are often rolled over into the next week if they are not met. The Journal has learnt that some pharmacists face penalities for not meeting the targets, such as no annual pay rise or a possible loss of a bonus.

Locums who do not meet the target may not be hired for the next shift, with some multiples operating a two-tier pay rate for locums: a lower rate for those who do not undertake them and a higher rate for those who do.

What also emerges is how pharmacists want to provide a genuine service but not in such a “tick-box” manner.

One pharmacist from the Co-operative Pharmacy, who has worked there since 1996, told The Journal that she felt under pressure from management to reach her target. “There is more emphasis on profit than patient care. I am more into the clinical aspect of this rather than the money side. I get regular calls from MUR champions to ensure MURs are done,” she declared.

A nine-year qualified pharmacist working at a different company told The Journal: “These multiples are pushing the pharmacists to get the money only. Someone needs to tackle this problem; no one seems to be doing this. My feeling on MURs was to give a benefit for the patient, but I feel it is like a tick-box exercise. Deep down pharmacists know it is not helping patients; it is ripping off the NHS.”

However, Renny Shak, a pharmacist who works for Lloydspharmacy, said: “MURs should be proportionate to the number of items you dispense. I find MURs very useful to myself and to patients.”

“Commoditisation” of services

This pressure to hit MUR targets is being heard regularly by the Pharmacists’ Defence Association. It sees 300 to 600 cases a year where pharmacists are asking it for advice on the delivery of MUR services, which also include the early stages of capability or disciplinary hearings, Mark Pitt, assistant general secretary at the PDA Union, told The Journal.

The PDA has written to the Department of Health expressing its concerns about the “commoditisation of pharmacy services”. The letter says: “MURs are a source for a significant proportion of the conflicts between employers who are intent upon maximising profits and pharmacists who are more inclined to put patient interest first, and this is evidenced by many of the defence episodes in which we are involved.”

There have been three cases in the past 12 months involving the falsification of figures relating to MURs that reached a General Pharmaceutical Council fitness-to-practise committee hearing and in which the pharmacist’s fitness to practise was found to be impaired (see Panel).

But it is a recent unpublished case that has raised the ire of the PDA and which it believes reflects a broader culture at some multiples.
In this case involving the ­Co-operative Pharmacy, which was dismissed by the fitness-to-practise committee, the committee chairman criticised the multiple: “The approach taken by [the regional manager] was inappropriate. It showed a concentration on profit to the exclusion of patient benefit, and demonstrated a lack of understanding of the clinical importance of MURs.”

“The case shines a spotlight on the behaviour prevalent in a number of [pharmacy businesses],” says Mr Pitt. “Some pharmacists buckle under the pressure and report incorrect figures for MURs. We don’t condone this [behaviour], but we understand the pressures people are put under after seeing some of these emails [from management]. Some people want to end their lives because they have submitted MUR figures that could not be verified.”

A pattern emerges: the company does an audit of MURs and finds the figures do not match up. So the company suspends the pharmacist and the company pays back the money to the NHS. “But there is no discussion on what led people to do this,” he says. The PDA’s letter is critical of the GPhC for not publishing the case, arguing that “there could be no large scale organisational learning” from it.

A four-year qualified pharmacist with Superdrug told The Journal: “These pharmacists that make false MURs are … unprofessional, but when they put pressure on you, you do things that you regret. I am not blaming the company for false MURs, but the target could be a trigger for pharmacists.”

The GPhC told The Journal that it does not publish hearing cases if no impairment is found.

Duncan Rudkin, chief executive of the GPhC, stressed that its standards are clear that “incentives or targets” must not compromise patient health or professional judgement. He said staff must be empowered to raise concerns and that pharmacy owners and superintendent pharmacists, who are responsible for meeting these standards, will be held accountable for decisions that they make. “If any employee does feel under undue pressure to meet certain targets, they should raise this with their manager or superintendent pharmacist.”

A spokesman for the Co-operative Pharmacy said it has learnt lessons from the case. “We have clear guidelines for all staff to follow and we ensure that the message regarding completing MURs is to improve the quality of patient care.”

He said that it actively encourages all employees to share any difficulties they may be experiencing with their line manager or the superintendent’s team, and that it also has various support mechanisms in place.  

RPS view

Martin Astbury, President of the Royal Pharmaceutical Society, believes MUR targets place pharmacy leaders in a “conundrum”.

He told The Journal: “On the one hand, the RPS wants pharmacists to develop their clinical skills by providing services like MURs, but at the same time it is aware that many pharmacists would like MURs to disappear altogether as they are worried about hitting those targets set by managers.”

He added: “Worrying about MURs keeps pharmacists awake at night. Pharmacists do not want these targets breathing down their necks, while at the same time they want to provide a full pharmaceutical service to their patients.

“If a superintendent or area manager sets targets for pharmacists in relation to MURs, without personally checking that the target is appropriate to that specific pharmacy on any given day that the target is enforced, then if the targets are found to be inappropriate the GPhC must take action on these individuals, or the organisations they work for.”

Ash Soni, vice-chairman of the RPS’s English Pharmacy Board and owner of two independent pharmacies, says: “I think MUR targets can place pressure on pharmacists if you don’t have enough support staff to do them. The challenge is finding a simplified way of recording interventions in terms of how does that fit into your normal working pattern.”

What do the multiples think?

Multiples believe that they are supporting pharmacists in their jobs, and some think the 400 cap should be abolished. A group of MPs also called for this recently (PJ 2013;291:98). But some of the pharmacists that The Journal spoke to thought that a removal of the cap could place further pressures on pharmacists to conduct MURs.

Kulsum Jina, a community pharmacist working for Co-operative Pharmacy, said: “I would not support the cap removal; it puts more pressure on pharmacists because 400 is quite hard to achieve at the moment. I would be concerned about patient safety being compromised.”

A spokesman for Morrisons told The Journal: “We encourage our pharmacists to carry out professional interventions where appropriate and add value [for] patients by providing MURs. The so-called targets have been set by the Government, as they have limited the number of MURs at 400 per pharmacy per year, which we do not agree with.” Where an MUR is required by a patient it should be provided by the pharmacist, regardless of whether a limit has been reached. This puts the patient first, he added.

Chris Perrington, superintendent pharmacist at Sainsbury’s, said: “We work hard to support our pharmacists to ensure they can meet the maximum target for MURs of 400 so they can help as many customers as possible.

“MURs allow our pharmacists to use their skills as a medicines expert and provide an invaluable service to patients by dramatically increasing the benefits they enjoy from using their medicines effectively.” Sainsbury’s would like to see the 400 cap removed because it thinks its pharmacists are not able to provide the service to all customers who would benefit from it. 

Peter Bainbridge, pharmacy director for Boots UK, told The Journal: “Pharmacists play an important role in having conversations that can improve patients’ lives, and MURs are an important tool to facilitate these conversations. Targets are a reality of life for any pharmacy business, and in the case of MURs it is clear how many MURs (400) will be remunerated each year.

“There is not a set target made by the business for the number of MURs to be delivered each day or week, although many pharmacy teams will choose to divide the annual 400 across the year as an indicator of how they are performing. The delivery of MURs is designed to encourage our pharmacists to support patients with their medicines taking which are the behaviours we want to see our pharmacists adopting … However, inappropriate pressure placed upon any colleague to meet targets is unacceptable and it is not tolerated.”

Superdrug’s superintendent pharmacist Christine Burbage said: “Our pharmacists are set targets on a store-by-store basis, and these are reviewed as part of each pharmacy’s overall business plan.”

Tesco and Lloydspharmacy were unavailable to comment on the MUR issue, although Lloydspharmacy has already publicly said it wants the cap removed (PJ 2013;291:98).

Alastair Buxton, head of NHS services at the Pharmaceutical Services Negotiating Committee, said he could not comment on whether pharmacy contractors were putting any pressure on employee pharmacists to conduct MURs because “there is a conflict of interest as we represent pharmacy contractors”.

Any way forward?

Arguably it makes sense for a cap to be removed since the MUR service should be open to all patients, not just those who fall within the 400 cap. But how can this be done without adding further pressure on pharmacists?

One solution may be that it is left solely to pharmacists to decide who has an MUR and managers do not set targets at all.

One way to enforce this may be to make the MUR payment direct to pharmacists, and not to the pharmacy owner, so there is no temptation by multiples to put pressure on pharmacists to reach targets.

Mr Astbury says: “The answer isn’t to remove the MUR cap; it is to change the model of reimbursement to allow a fair return for owners while maximising pharmacists skills to improve the public’s health.”

His thoughts echo those of one pharmacist who works for Sainsbury’s and who told The Journal: “I wish there was a framework where it is the pharmacist who decides whether it is appropriate or not to do an MUR.”
It is to be hoped that NHS England looks closely at the issue when it considers MURs  as part of its discussions on the community pharmacy contractual framework.

Appendix: what pharmacists think

Boots

Target store range: three MURs per day to at least 15 per week.

It is hard to reach the target as this pharmacy mostly deals with students and travellers. Yes, sometimes I feel pressured to reach the target. I support removal of the cap because MURs should help patients use their medicines effectively. At the end of the day, no matter how much pressure they put [on you], if you can’t physically do the MURs, then you can’t. — One-year qualified pharmacist

[I feel no pressure] because of the patient base we have here. We can get MURs quite easily. There is a good culture at this store. But it depends on the manager, [when they] can punish you for not reaching the target. [They will] sit you down and increase  the target by whatever you missed out. Then you have to do 30 MURs the following week, which is not doable. It is an informal warning. If you do not reach [the target], it keeps rolling over per week, then you don’t get a bonus or pay rise at the end of the year. You are not fired. It could keep rolling over, but some managers may bump it up. I think removing the cap will put pressure on pharmacists. — Two-year qualified relief pharmacist

The target is [reasonable], some days it isn’t. I would probably not like the cap removed. If you miss the target, it gets rolled over and there are discussions with management. Slight pressure from above to do MURs; they tell us it is because of patient care. — Five-year qualified pharmacist

Because this is an unusual store [mostly students and travellers] we feel no pressure to provide MURs. It depends if a patient is eligible. I would not agree with removing the cap because it will put pressure on pharmacists to generate MURs. There is some pressure on other pharmacists to do MURs. There are some instances where the bonus is lost because they did not reach the target. I agree with MURs but not how they would be pushed as it can cause patient safety issues. — Five-year qualified pharmacist

I would be worried what multiples would do if there was no cap. It should be left up to pharmacists to decide on doing a MUR rather than meeting a target. — Five-year qualified locum pharmacist

Co-operative Pharmacy

Target store ranges: two to four MURS per day to eight per week

On some days, you can meet the target, but [on] others it is not easy. I will not compromise patient safety. I would not do an MUR if I was rushed. – Two-year qualified relief manager pharmacist

There is more emphasis on profit than patient care. I get regular calls from MUR champions to ensure MURs are being done. 250 per year should be a realistic target; 400 is too much. — 17-year qualified pharmacist

I believe the cap is unrealistic. I want the cap to go to 250. The [MURs] I am doing are good but they are not supported by GPs. Removal of the cap would create unreasonable targets. There is definitely profit over patient care in these MURs. — 13-year qualified pharmacist

It depends on the store. I usually do MURs in the morning, because the afternoon is busy. Sometimes you feel under pressure, but at the moment I have good dispensers and so can rely on them to help me in the work. Based on having good staff, I can reach this target, but I could not do it if they are not around. The advantage of [removing the cap] is you can do as much as you like, but disadvantage some [multiples] may put profit before patient care. — One-year qualified pharmacist

There is a target but I do not feel pressured at all. It would be difficult [to do them] if you weren’t a busy pharmacy, to find the candidates to fit the [MUR] criteria. If there is no cap, in practice, more pressure then on pharmacists to do them. Patient care may be compromised. — Two-year qualified pharmacist

Lloydspharmacy

Target store range: one or two MURs per day to eight per week

There is always an element of pressure because they want us to reach 400 per year because it is beneficial to the company but sometimes no suitable patients are available. [If you miss a target], essentially it rolls over the next week, but sometimes you can’t achieve it. If you are not up to scratch at all, they will question you. If you are not performing well, they might provide advice or CPD to make you confident. [If the cap were removed] I believe there would be more pressure to do more MURs because it is certain revenue they need to achieve; in some instances you do need to do more MURs. I think 400 is OK. — Seven-year qualified pharmacist

They expect us to do one or two per day, but I don’t find it stressful because my job is to talk to customers, especially during MURs. My manager has not made me feel I do not do enough. If I do 10 MURs, at least six patients benefit from them. I seem to find so much information from talking to patients rather than looking at the BNF. I personally find them rewarding. If you do it with meeting a target in mind, then you will not have met the needs of the patient. — Six-year qualified relief pharmacist

Sainsbury’s

Target store range: two MURs per day

It can be difficult some days to do two MURs per day. Possibly pharmacists can be penalised if they do not meet the MUR targets. Penalty can include refusal to give you a shift as a locum. I think removing the cap is a good idea, because it could be beneficial to some patients. — One-year qualified locum pharmacist

Yes, I feel under pressure because of lack of support of staff to do MURs. Sometimes I do MURs without a dispenser, which is pretty awful. Some managers just ask about the target and don’t care whether you … helped patients in other ways. These multiples are pushing the pharmacists to get the money only. Someone needs to tackle this problem; no one seems to be doing this. My feeling on MURs was to give a benefit for the patient, but I feel it is like a tick-box exercise. Deep down pharmacists know it is not helping patients; it is ripping off the NHS. — Nine-year qualified pharmacist

Tesco

Target store range: Two or three MURs per day

My manager is really good. She is not pressuring me in the wrong way. There are two pay rates; you get a higher rate if you do pharmaceutical services such as MURs and the new medicine service. I believe a lot of pharmacists feel pressure like in some pharmacies, where a pharmacist is called three times a day to see how many MURs are done. Multiples don’t want to lose that money. If you don’t hit the target, then you face a performance management review; you lose out on a pay increase and managers won’t get a bonus or pay rise. — Eight-year qualified pharmacist

I am happy to do them. It is hard to find patients. There is a two-tier locum pay scheme on whether  pharmacists do MURs and other services. There is always pressure; you can’t find staff to cover you [while you do a MUR]. If a branch doesn’t reach 400 they don’t get a pay rise at the end of the year. — 25-year qualified pharmacist

Morrisons

Target store range: no target to eight to 10 MURs per week

Sometimes I feel under pressure because 400 is a lot, and MURs are not suitable for all patients. Some companies do not realise that we see a lot of one-off patients. My argument is that the number aspect is not important, as some people who need them miss out because they do not meet the eligibility criteria. We are just doing it for the numbers. — 40-year qualified pharmacist

Yes, I do feel pressured to reach the target. The cap should not be removed because there would be more pressure to hit targets. — 15-year qualified pharmacist

We try to target 400 per year. There is no pressure to reach 400. I have no opinion on the cap, but it is not good to have pressure on pharmacists. — 13-year qualified pharmacist

Superdrug

Target store range: three to six MURs per week

It is feasible because it is a quiet store, trying to find eligible patients. Pressure is on everyone, but you can’t make [the numbers] up. I think pharmacists who [falsify MUR claims] are stupid … because your career is on the line. 400 is more than enough. Superdrug is fair to locums as there is no two-tier pay scheme if you don’t do MURs. — One-year qualified pharmacist

It is quite challenging to reach the target because we are a small pharmacy. Yes, I feel under pressure to reach the target. We are not penalised, but we get weekly phone calls from our area manager on why you did not reach the target. I’m sure if the cap is removed, they will put a lot of pressure on pharmacists to do MURs. These pharmacists that make false MURs are stupid and unprofessional, but when they put pressure on you, you do things that you regret. I am not blaming the company for false MURs, but the target could be a trigger for pharmacists. — Four-year qualified pharmacist