NHS England wants ‘assurances’ from sector after MUR abuse

Dr Jill Loader: MUR abuse investigation has "damaged" community pharmacy's image
NHS England wants “assurances” that the services pharmacists provide are "effective", in the wake of negative press coverage of medicines use reviews (MURs).

The commissioner’s assistant head of primary care Dr Jill Loader told delegates at the Pharmacy Show on Monday (September 26) that media coverage of inappropriate MURs has caused “some damage” to community pharmacy's image.

“From my perspective, and NHS England's, we need some assurances,” Dr Loader said during an event on the commissioning landscape.

“If pharmacy is going to do more clinical services, we need to make sure they are safe [and] effective,” Dr Loader said.

"We need to measure the impact of those," she added.

In April, the Guardian alleged that managers at Boots routinely pressure pharmacists to conduct unnecessary MURs, allegations which Boots "did not recognise".

Dr Loader also questioned whether MURs are the most effective way for pharmacists to “add value” to the healthcare system.

“I don’t have GPs coming to me and saying, ‘I can’t do without my local pharmacist doing MURs'," she said. “I do have NHS 111 providers and out-of-hospital providers saying, ‘What can we do about urgent medicines supply?”

“We need to look at where the problems are, and where pharmacy can take over and support, rather than duplicate what other people are doing,” she said.

Has the negative press coverage affected how you deliver MURs?

Mr V, Community pharmacist

The MUR service definitely needs revamping to say the least - the difference in quality of how the service is carried out by pharmacists is vast, consequently, some patients benefit more than others. However, the fact that even in the most benfitical situations we will not result in reducing GP time/ workload is ironic.

I dont agree completely with the article posted by Valentine Trodd - a study carried out in 2 individual pharmacies cannot be conclusive for a whole sector.

Pharmacists who would rather MURs scrapped should voice their opinion but beware that it would result in ~11K less funding for every pharmacy, this will result in lower wages, less staff hours and because of the huge number of pharmacists coming into the workforce - will not be a problem for employers to replace us to save money!

The question should now be - What advanced services could pharmacies offer effectively that would:

1) Reduce GP work load/ patient waiting times

2) Not be commisioned the same as the GPs - either commision them the service or us - Otherwise community pharmacists will not add any 'real' value in the eyes of the patients and GPs.

2) Reduce hospital admissions

3) Save the NHS money in the long term.

I think the powers that be should consider for community pharmacy -

A national minor ailments scheme, A medicine wasteage reduction service, a prescribing service for repeat prescriptions/ minor specialist conditions (after suitable training!), blood tests/full health checks.

Pharmacies can and should offer a lot more than the current MUR but scrapping the scheme (+ funding!) will not be good for patients and community pharmacy as a whole.

Valentine Trodd, Community pharmacist

Well put Mr. V. With respect, I only posted reference to that study as an example that for every piece of dubious research in favour of MURs, there is one not in favour. I did say there was no conclusive evidence either way. I would expect a service that is costing as much as the MUR service is costing to be able to prove it's worth - this hasn't as yet happened. 

Matthew Edwards, Community pharmacist

Well said Mr V. A minority view but one which I share.


A Hussain, Senior Management

You make a lot of sense.  Very well put points.

Madni Sheikh, Locum pharmacist

Dr. Loader's concerns for the urgent medicines supply can be resolved by allowing more prescribing rights to pharmacists so that the patients don't get referred to the A & E s or 111's hub surgeries. At present we can  only supply what is available OTC, otherwise refer. But the GPs wouldn't like that to happen, i. e. pharmacists being allowed to prescribe, whereas they have no objections whatsoever in nurses doing so;  look at the flu jab tug of war; and then they say we should  help releive the pressure on  GPs so that the patients don't go and waste their valuable time. Could Dr. Loader convince GPs ot this first?

sanjai sankar, Locum pharmacist

The MUR system should have been monitored for effectiveness and regulated when it was implemented. Its lack of regulation encouraged unethical practices particularly in the early years and we are now facing the consequences...For some, it was a  grab for as much money as possible. I have first hand experience of this.This desire for quantity ( and their for profit) over quality of service has led us to this position. And the bullying was/is still rife by contractors on employees and locums alike...Maybe to a lesser extent now since the Guardian report....It needs urgent reviewing because script numbers are up year on year and other services need to be done. There is no additional staff to cover the extra workload....The majority of Pharmacist employees and locums are fed up because of this...Target culture has diluted quality of services...I think Dr loader is right...

Stephen Gabell, Community pharmacist

I think that MURs (and NMS) are hugely valuable for patients. Not every MUR raises a significant issue, but at the least the patient gets reinforcement of healthy living advice and reassurance that they are taking their medication correctly. At their best, MURs can address significant issues that have not been picked up by anyone else and have a significant benefit for patients.

Some recent examples:

i) I did a MUR  with a patient just after I'd given them a flu jab. Only three meds and all seemed ok until the patient asked if she could take her felodipine at night. After asking why it transpired that her feet and ankles were swelling up a couple of hours after taking felodipine and she was having difficulty putting shoes on. A referral has been made to the GP.

ii) Again, after doing a flu jab I did a MUR with an asthmatic patient and it turned out that although Qvar was being used as prescribed, the patient was still needing to use Ventolin four times a day and was waking during the night. Inhaler technique was fine, so a referral was made to the GP for review.

iii) a patient with lung cancer and on haemodialysis three times a week, taking gabapentin and oxycodone. The patient commented that her neuropathic pain was always much worse after her dialysis, and she was petrified of taking oxycodone following a bad experience with morphine earlier in the year. Neither her GP or palliative care nurse had picked up on either of these issues. I arranged for the patient to have an extra dose of gabapentin after dialysis, and to switch from oxycodone to buprenorphine patches. When I saw her two weeks later she was like a new woman.

These are three examples I can think of off the top of my head, there are many more that are similar. I agree that there are issues around resources being provided to enable pharmacists to conduct clinical services, on top of our usual workload. I also accept that there has been a failure over the last decade to generate an evidence base to show the value of MURs, and this needs to be addressed, but I am sure that I am not the only pharmacist who can give these kinds of examples of positive outcomes from MURs.

N O, Pharmaceutical Adviser

http://psnc.org.uk/our-news/new-research-demonstrates-high-patient-satisfaction-with-murs/ I think this article published on PSNC portal gives more clarity, that not all MURs are dodgy.

Valentine Trodd, Community pharmacist

I think your failing to grasp the point... What you quote is a PATIENT SATISFACTION SURVEY. It doesn't say anything about proving that MURs are effective in solving problems.

As I said, there is NO conclusive evidence...



John Urwin, Community pharmacist

Agreed no conclusive evidence in either direction. The paper quoted is limited in scope and a significant part of it is also a PATIENT SATISFACTION SURVEY. I would agree more research is needed, but remain firmly of the belief that an MUR can be a valuable tool to enhance the benefit of medicine use.

Jay Badenhorst, Superintendent Pharmacist

If a policeman does 100 searches and fund 10 guns does it mean the other 90 were pointless? If a pharmacist does 100 MURs and find 10 people with problems that he fixes does that make the other 90 pointless? You will never know if there is a problem or not unless you have the conversation with them. Why would you not be allowed to get paid for those? GPs DON'T see many people for more than six months (even longer) and yet they still get paid for 'having them on the list' without seeing them or having ANY conversation. I wonder how much money would be saved if GPs were paid for only the consultations they do and not for all the other peripherals. Oh, and it included mailshots which is normally pointless....

Shaun Steren, Pharmaceutical Adviser

I really don't know where to start with this. Did you actually think that a police search of a suspected criminal could be considered analogous to a patient receiving an MUR? I don't think you are trying your hand at satire, so here goes:


Analogy of two events: When two events, x and y, are proven to be similar in particular respect, it is assumed they must share a particular property. In that particular respect, if event x is PROVEN to have that particular property, it can be ASSUMED that event y also has that property. A false analogy is when two events are different in a way in which it cannot be assumed that they share a particular property but are compared as if they do. 

Can you explain to me how a suspected criminal and pharmacy patient are similar in a way, that makes the potential possession of a gun and potential sub-optimal medicine use the same property, and thus makes for a valid analogy? A starter for one - one is a physical search for an inanimate object the other is an opinion of a human response. 

As for the false comparison to a GP consultation, I'm losing the will to live. 


John Urwin, Community pharmacist

Losing the will to live? So its not all bad news.

John Urwin, Community pharmacist

Oops sorry about that, must resist. Thanks for your erudite demolition of Jays posting Shaun. I beg to differ. What Jay was trying to do, in our clumsy pharmacisty, ascientific way was make this point - MURs are about helping people maximise the benefit of their prescribed medication. They are offered (in non-corporate unpressured environments) to patients who are suspected of having problems. Sometimes, on investigation, that proves not to be the case, but the patient can derive benefit from the re-assurance they are taking their medicine correctly. These patients are (superficially) analogous to an un-productive "stop and search". Their mis-identification does not invalidate the concept of the MUR. Yes, we would be in a much better place if research had been done to support this, but absence of evidence does not mean that evidence will not be obtainable if sought in suitably designed studies.

Shaun Steren, Pharmaceutical Adviser

Four thumbs up for an admission that the position is based on 'clumsy' and 'ascientific' (you mean unscientific) reasoning and is without an evidential basis. They either admire your honesty or share your 'pharmacisty' method of deciding what is true.

John Urwin, Community pharmacist

You don't understand sarcasm do you?

Shaun Steren, Pharmaceutical Adviser

I sense when somebody is completely out of their depth and in response tries to make light of everything. So this evidence thing, what is your hypothesis and control? 

A Hussain, Senior Management

John, I imagine you own a pharmacy, whereas the pseudonym owns a keyboard.

Banishing MUR's, regardless of their benefit/lack of benefit, removes funding and will inevitibly result in lower pharmacist pay.  Now that's a whole different type of pressure to being pressurised to do an MUR.

I have not been to my GP for over 10 years, but they will have received payment for having me on their books for this time.  Is this a good use of NHS money?  Clearly not.  But do GP's rely on receiving funding in this way to cover patients that are not as profitable as me? Certainly.  I am not saying that this is a reason for doing bad MUR's before you say anything.

This unfortunately is the murky waters where business meets healthcare.  The pseudonym needs to know that the days of doing 100 items whilst drinking tea and reading magazines is over.

Shaun Steren, Pharmaceutical Adviser

Mr Hussain (a rather subtle pseudonym), with respect, as I have told you before, your insults and slurs do not change the facts of the matter. As regards to MURs paying your bills and my wages:

1) I don't believe I am owed a living. I accept what is happening to the wages and employment prospects of employee/locum pharmacists, something I thought inevitable. Post- extemp, OTC price competition, use of ACTs, doubling of pharmacy schools, development of dispensary robotics/software and the inevitable 'Amazon' model, I have faced the reality head on, without any cry for government handouts. 

2) You should have to explain yourself to the taxpayer, not me. I am fairly confident in guessing that the number of people who would pay a £28 out-of-pocket expense for an MUR would be very small. I am also fairly confident in guessing that most people who have already received an MUR did not know they had just paid £28, albeit indirectly.

3) Your sense of entitlement with regards to the 'reality of business' is quite disturbing. Other independent high street businesses do not get control of entry nor a massive government subsidy, you work in a protected cartel (a very profitable one at that). They face true competition and the daily risk of insolvency. So don't presume to lecture me, my family are two generations of small business owners, I grew up working in one.

A Hussain, Senior Management


You should read your previous posts (if they make any sense to you) to see whether you come across as entitled or not.

I've never seen you describe any aspect of 'work' that you enjoy or believe is acceptable to you.

Paying for healthcare is not something that people in this country really get.  Patients often don't think that we get paid for doing prescriptions.  An example is the "I need you to replace the seretide inhaler that I lost".  I have to tell them that the chancellor doesn't give me the £60 that one costs.

I bought my contract for a price that factored in control of entry, so that was my reality of business.  It takes many years for it to become profitable if you understand basic economics.  If you buy a house for a million pounds, you do not instantly become a millionaire.  It's called a mortgage/loan/debenture.  As a descendent of businessmen I suggest that you should know this and cease lecturing me on how I hope to repay my loans by making a profit.

Not supplying my first name does not make it a pseudonym by the way, it just gives me the ability to answer people like you on a level playing field.



Shaun Steren, Pharmaceutical Adviser

Mr Hussain, you haven't responded to a single argument put forward other than to deflect with how you have bills to pay - yes we all do - it is not a generic answer you can give to anything related to community pharmacy. 

Many employee/locum pharmacists factored in many things that looked assured when they applied to study pharmacy but very few them remain true today. You are not entitled to be free from competition, innovation and dramatic change for whole you working/business life - your assessment, like mine, is a gamble and that is how it ought to be. Like every other business in the U.K. , paying for goodwill can leave you with a worthless shell, you appear to think you are a very special case indeed. 

A Hussain, Senior Management

Yes Shaun you're right and I am wrong.

 All I am saying is that in order to pay employees pharmacies must make money.  There are set ways that pharmacies can make money.  If you work at a pharmacy then you must expect to be asked to perform one of the tasks that make the pharmacy money.

I strongly disagree with bullying pharmacists to perform worthless MUR's, but if you're against carrying out other services, then you deserve the extinction you're heading towards.

The questions you say I'm avoiding are merely twiny accusations.  If your practice is anything like your tone on this site, then you must struggle for work anyway.


Shaun Steren, Pharmaceutical Adviser

I am not discussing community providing services in principle nor am I focussing on what ought to be the case. I'm describing what is the case and contrasting this with the propaganda put forward by interested parties. My tone is one taken by anybody who deals with evidence (or lack of it) and reasoning behind any given point. The tone of any such discussion will be strident by its very nature. 

It may well be the case that the culture of pharmacy is an anti-elitist one, I suspect it is, but that works two ways. The obvious being what we are discussing now - the inability to be disinterestedly self-critical. 

On the other side, this anti-elitism prevents community pharmacy from establishing a high status on the basis of what it does well. The current flu debacle is a case in point. The GP position is incredibly weak, the reasoning behind their argument is flawed and they provide no evidence for any of their claims. In contrast, the pharmacy case can be very strongly reasoned and we do have evidence to support our case. But where is this strident, elitist, water-tight argument? It is hasn't been put forward, we have let ourselves be portrayed as the problem and not the solution. 

I could go on with a multitude of community pharmacy activities. How about MDS? A service which requires a pharmacists unique  knowledge of medicine stability and medicine management. It requires a very diligent attention to detail from the point of prescription ordering to the delivery of the final product. Not to mention a very labour intensive process. The patient benefits of course, but social services, care homes and GPs rely on us for this service and they we would be lost without it (it is fair to say we subsidise them). What do we get paid for this? A pittance. What recognition we get for this? None. Where is the strident argument put forward for this? Nowhere. An argument that could be so tightly reasoned and evidentially supported as to be undeniable. 

We are WEAK and our mouse like tone, sloppy reasoning and failure to use evidence advertises the fact. 

John Urwin, Community pharmacist

Perhaps the best thing we can do is listen to our inner voice repeatedly saying "Don't feed the Trolls"

Shaun Steren, Pharmaceutical Adviser

Well,  by labelling people so dismissively you can avoid dealing with the arguments put forward. You don't seem to perform very well in reasoned argument, so maybe it is best you stick to your insults and slurs. This hypothesis and control thing, what was it you were going to say ? 

A Hussain, Senior Management

Fair point.  Appear to be back under the bridge at the moment.  Or doing an MUR!!

Clapton Chemist, Other healthcare profession

Lets deal only with facts:

1. Contractors want to keep MURs.

2. Majortity of employees/locums want MURs to disappear.

3.There Is no eveidence that MURs make any difference.

N O, Pharmaceutical Adviser

http://psnc.org.uk/our-news/new-research-demonstrates-high-patient-satisfaction-with-murs/............. READ THIS ARTICLE

Valentine Trodd, Community pharmacist

I think your failing to grasp the point... What you quote is a PATIENT SATISFACTION SURVEY. It doesn't say anything about proving that MURs are effective in solving problems.

As I said, there is NO conclusive evidence...



Valentine Trodd, Community pharmacist

Jay, there is no conclusive evidence they make a blind bit of difference - except of course to contractors like yourself. I was under the impression pharmacy was an evidence based practise. 

The only sure things about MURS...

1. They cost the taxpayer a lot of money - about £67 million circa 2012



2. Have no proven benefit

3. Of the actual pharmacists that carry them out, half think they should be scrapped. http://www.chemistanddruggist.co.uk/news/half-readers-call-murs-be-scrapped

4. They have caused irreprable damage to the reputation of the profession (see Guardian articles, etc.)

5. They cause an inordinate amount of stress among pharmacists 



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