The MUR and Prescription Intervention Service was decommissioned on 31st March 2021.

The MUR and Prescription Intervention Service consisted of accredited pharmacists undertaking structured adherence-centred reviews with patients on multiple medicines, particularly those receiving medicines for long-term conditions. National target groups were agreed in order to guide the selection of patients to whom the service would be offered.

Pharmacists and community pharmacy contractors practising in Wales should visit the Community Pharmacy Wales website for information on MURs as this service is still commissioned in Wales.

The legal basis for the service was provided by the Secretary of State Directions. The service specification provided a ‘plain English’ version of the Directions:

The Pharmaceutical Services (Advanced and Enhanced Services) (England) Directions 2013

MUR service specification (August 2013)

The MUR service was an Advanced Service within the NHS Community Pharmacy Contractual Framework. It was a structured review that was undertaken by a pharmacist to help patients to manage their medicines more effectively.

The MUR involved the pharmacist reviewing the patient’s use of their medication, ensuring they understood how their medicines should be used and why they have been prescribed, identifying any problems and then, where necessary, providing feedback to the prescriber. An MUR Feedback Form was provided to the patient’s GP where there was an issue for them to consider. An MUR was not usually conducted more than once a year.

A Prescription Intervention was simply an MUR which was triggered by a significant adherence problem which came to light during the dispensing of a prescription. It was over and above the basic interventions, relating to safety, which a pharmacist makes as part of the dispensing service.

An MUR was a way to:

• improve patients’ understanding of their medicines;
• highlight problematic side effects and propose solutions where appropriate;
• improve adherence; and
• reduce medicines wastage, usually by encouraging the patient only to order the medicines they required.

An MUR was not:

• a full clinical review;
• an agreement about changes to medicines;
• a discussion about the medical condition beyond that which was needed to achieve the above objectives; or
• a discussion on the effectiveness of treatment based on test results.

What did it involve?

The pharmacist would normally ask the patient to bring their medication (including purchased medicines) with them to the review.

A set of suggested questions was developed which pharmacists could use to guide the conversation with the patient; the use of the questions was not compulsory, but pharmacists may have found them useful to obtain the maximum amount of information from the patient’s perspective as possible.

What may the discussions with the patient have included?

• What the patient thought each medicine was for and when and how they took it;
• How compliant they were with the prescriber’s instructions;
• How and when they took medication labelled ‘as required’ or ‘as directed’;
• Advice on tolerability and perceived side effects;
• Dealing with practical problems in ordering, obtaining, taking and using medicines;
• Identification of unwanted medicines, e.g. where the patient was no longer taking the medicine;
• Identification of a potential change of dosage form to facilitate effective use with due regard to formularies and cost implications (the final decision would lay with the patient’s GP); and
• Proposals for dose or strength optimisation provided it did not impact on the patient’s clinical management.

Pharmacists had to record certain data about the MUR (the national MUR dataset), (see MUR record keeping and data requirements section below) but they would generally keep additional clinical notes related to the MUR to support the continuing care of the patient.

Where there was an issue that the patient’s GP needed to be made aware of or to consider they would be sent an MUR Feedback Form.

Where could I conduct an MUR?

MURs were originally designed to be provided in the pharmacy. However, from 1st September 2020 MURs could also be provided by phone or video consultation, where this was clinically appropriate, and without the contractor having to seek prior approval from NHS England and Improvement (NHSE&I).

Additionally, it was possible to conduct MURs in other venues. The regional NHSE&I team needed to give consent to  contractors wishing to carry out consultations off the pharmacy premises (see the Conducting MURs off the  premises section below).

Who could have an MUR?

It was for the pharmacist to decide which patients received this service, however, pharmacies had to undertake at least 70% of their MURs on patients that fell within the national target groups (see the National target groups section below).

MURs could only be provided for patients who had been using the pharmacy for the dispensing of their prescriptions for the previous three months (this did not, however, apply to Prescription Intervention MURs).

Could children have an MUR?

The MUR needed to be conducted with the patient in order to comply with the Directions. An MUR could have been conducted with a patient who was a child if they were competent (i.e. they had the capacity to give informed consent) and were able to fully engage in the discussion with the pharmacist. It was not possible to conduct an MUR for the parent, carer or guardian of a person who was not competent.

If an MUR had been conducted with a competent child, the pharmacist should have been aware of the local Safeguarding (child protection) policy and guidelines and should have known where to refer any young person where there were concerns.

Pharmacy premises needed to meet national standards to ensure that MURs took place in a confidential environment.

Consultation areas needed to meet the following requirements:

• The patient and the pharmacist could sit down together;
• They could talk at normal speaking volumes without being overheard by staff or customers; and
• The area was clearly signed as a private consultation area.

Contractors needed to notify their regional NHSE&I team before they started providing MURs, using the PREM1 form. Compliance with the service requirements was subject to verification by NHSE&I as part of their contract monitoring arrangements.

PREM1 form (PDF)

PREM1 form (Microsoft Word)

The completed form should have been sent to the regional NHSE&I team.

It was advisable for a consultation area to include a table or workbench. Contractors may also have wished to include space for a computer terminal to be installed in the consultation area. Contractors should also have give consideration to possible future uses of consultation areas when they were being installed, for example, if the pharmacy was commissioned to provide diagnostic testing services in the future, it may have needed hand washing facilities in the consultation area.

Any Higher Education Institution (HEI) could provide training and competency assessments for the MUR service. A national competency framework was used as the basis for these assessments.

There were a number of providers who ran courses and/or competency assessments. Additionally some academic institutions that provided postgraduate clinical programmes, such as diplomas, ensured their courses developed and tested the skills of students in order to meet the requirements of the MUR competencies.

For those who had existing skills in this area of practice, the completion of any course prior to undertaking a competency assessment was not obligatory, i.e. pharmacists may put themselves through a competency assessment whenever they felt fit to do so. Once the course was completed, the pharmacist needed to send a copy of their certificate to the regional NHSE&I team before they could begin providing the MUR service.

MUR course with assessment

Skills for MURs (Medway School of Pharmacy)

WCPPE/Welsh School of Pharmacy

Postgraduate courses which include MUR assessment

University of Bath – Postgraduate Certificate, Diploma and MSc

Queen’s University Belfast – PG Cert/PG Dip/MSc in Community Pharmacy programme

Assessments only

University of Manchester/CPPE Online assessment

New targeting requirements applied to MURs conducted from 1st October 2019; these changes were agreed as part of the 5-year Community Pharmacy Contractual Framework agreement.

Seventy per cent of MURs conducted from 1st April 2020 to 31st December 2020 had to be within the following two target groups:

• patients taking high-risk medicines; or
• patients recently discharged from hospital who had changes made to their medicines while they were in hospital.

From 1st January 2021, 70% of MURs had to be targeted solely at high-risk medicines.

High-risk medicines

A high risk medicine, for the purposes of targeted MURs, was a medicine which was of one of the descriptions referenced in the table below and was on the list of medicines that were high risk medicines that was published by the NHSBSA.

If a patient was prescribed one high-risk medicine they could receive an MUR; all other MURs had to be conducted on patients who were prescribed two or more medicines. All patients who received an MUR should have experienced the same level of service regardless of their condition, i.e. MURs covered all the patient’s medicines, not just those that fell within a target group.

How were the high risk medicines chosen?

In June 2011, PSNC and NHS Employers convened a high-risk medicines reference group which included representatives from the National Patient Safety Agency, the National Prescribing Centre, the Royal College of Physicians, the Royal Pharmaceutical Society and UK Medicines Information. The group was chaired by Martin Stephens, National Clinical Director for Hospital Pharmacy at the Department of Health and Social Care.

It was agreed that the following principles should determine the list of high-risk medicines:

• the medicines should be associated with preventable harm, for example, avoidable hospital admissions;
• medicines should be selected where harm can be caused to the patient by omission, overuse or incorrect use and where the benefits of not taking the medicine are foregone; and
• the type of harm caused by the medicines could be prevented by an MUR and the pharmacist will have the skills, knowledge and information to deliver it.

The group considered the evidence from recent data and a literature review on medicines that cause admissions to hospital to help inform their decision on the list. There were a number of other high-risk medicines discussed at the meeting; however, the group was clear that the focus should be on medicines where an MUR could improve patient safety and that the purpose of an MUR was not to address problems associated with dosage but with medicines use.

Post-discharge MURs

Post-discharge MURs were a target group until 31st December 2020. From 1st January 2021, 70% of MURs had to be targeted solely at high-risk medicines.

Guidance was published in January 2012 showing how the New Medicine Service (NMS) and post-discharge MURs could be used to provide a seamless care pathway for patients who transferred from hospital to the community setting. It was developed and published by NHS Employers and PSNC working with a hospital and community pharmacy reference group. The guidance was also endorsed by the Royal Pharmaceutical Society.

Guidance for community pharmacy about engaging with hospital colleagues

Guidance for hospital colleagues about engaging with community pharmacy 

Template national referral form

Template patient information leaflet

Patients had to be prescribed two or more medicines to be eligible for a post-discharge MUR.

From 1st September 2020, it was no longer a contractual requirement that written consent was obtained from patients prior to the provision of MURs.

Instead, verbal consent could be obtained and a record of that made in the pharmacy’s clinical record for the service. These changes were agreed by the Department of Health and Social Care and NHSE&I, following a proposal to move to a verbal consent model made by PSNC.

Prior to service provision, verbal consent had to be sought from each patient. In seeking consent, contractors needed to ensure that the patient was made aware that the consent enabled:

• the provision of the service;
• the sharing of information between the pharmacy and the patient’s general practice if needed, to enable appropriate care in the provision of the service;
• the sharing of information about the service with NHSE&I as part of service monitoring; and
• the possible sharing of information about the service with NHSE&I and the NHS Business Services Authority (NHSBSA)  as part of post-payment verification (PPV).

Pharmacists providing MURs had to keep records of each one provided using a national dataset.

Contractors had to provide a summary of their MURs conducted on a quarterly basis to NHSE&I (the NHSBSA collected this information on behalf of NHSE&I). However, during the period of the COVID-19 pandemic, NHSE&I did not require contractors to provide this summary.

Record keeping and the MUR dataset

The requirements to use the MUR form to record the MUR consultation and to give a copy of the completed form to the patient were removed on 1st July 2012. They were replaced by a requirement for contractors to capture and retain an MUR dataset for every MUR undertaken:

MUR dataset (following 2019-20 CPCF changes)

From 1st October 2019, cardiovascular risk and respiratory disease were removed from the MUR target groups, which meant a change to the national dataset.

The data collected from each MUR needed to be kept for two years from the date the service was completed and may be stored electronically.

Pharmacists may have kept additional clinical records over and above the MUR dataset to support their ongoing care of the patient.

MUR worksheet

PSNC developed an MUR worksheet for use when providing an MUR. Contractors/pharmacists were free to develop their own approach to making records of MURs as long as they ensured they collected the MUR dataset as a minimum.

PSNC MUR worksheet (following 2019-20 CPCF changes) (Microsoft Word)

PSNC MUR worksheet following 2019-20 CPCF changes) (PDF)

Reporting information on the MUR service to NHSE&I (via the NHSBSA)

Contractors who provided the MUR service had to collate information on the MURs provided each quarter and provide this to NHSE&I; the NHSBSA collected this information on behalf of NHSE&I. If a contractor normally provided MURs but did not do so in a specific quarter, there was no requirement for the contractor to submit a ‘nil-return’ submission of data to the NHSBSA.

Each contractor who provided MURs had to submit their completed quarterly MUR electronic reporting templates to the NHSBSA.

Contractors had to submit the completed MUR electronic reporting templates to the NHSBSA within 10 working days from the last day of the quarter the data refers to (last day of June, September, December and March).

There were two ways to submit the electronic reporting templates to the NHSBSA and contractors could choose which method to use:

1. Online form
2. Electronic Reporting Template

Further information and links to the online form and electronic reporting template were available on the NHSBSA website.

A paper-based approach could be taken to collating this data throughout the quarter so that contractors could then submit the data to the NHSBSA at the end of the quarter. The following form was designed to allow this paper-based collation of data:

PSNC MUR data collation sheet (Microsoft Word)

PSNC MUR data collation sheet (PDF)

Contractors were required to contact the patient’s GP if an issue was identified during the MUR where the pharmacist believed the GP should be informed. In this circumstance, the pharmacist should have completed a copy of the nationally approved MUR feedback form and sent it to the GP practice. This form was developed by the Professional Relationships Working Group (PRWG), which included NHS Employers, PSNC and the British Medical Association (BMA) General Practitioners Committee (GPC).

Using the approved MUR feedback form did not preclude the pharmacist from contacting the patient’s GP via telephone or face to face if an urgent issue was identified with the patient during the MUR. This could then be followed up in writing using the feedback form.

MUR Feedback Form (Microsoft Word eForm)

MUR Feedback Form (PDF)

PSNC was previously contacted by contractors and LPCs because local GPs had queried the wording in the MUR Feedback Form which put the responsibility to follow up with the patient on the GP practice, rather than the patient being asked to make an appointment with their GP. The MUR Feedback Form was designed by PSNC, the GPC of the BMA and NHS Employers and the wording regarding referral back to the GP practice was proposed by the practising GPs representing the GPC.

The rationale for this approach was that it allowed the GP practice to deal with the issue as they see fit, which may require an appointment with the patient’s usual GP, or it may have involved another practice team member, such as a practice nurse, dealing with the query. It also provided flexibility for the GP practice to manage the issue by telephoning the patient if that was deemed an appropriate alternative to an appointment in the practice. The GPC view was that this approach provided more flexibility for practices to manage queries in the best way for their patients and using the full range of skills within their team, rather than requiring all queries to be dealt with via a face to face appointment with a GP.

A frequently asked question was about the differentiation between MURs and Prescription Intervention MURs. There was only one service; it is what prompted the review that was the differentiating factor.

Regular MURs could have been prompted pro-actively by identification of a certain group of patients (for example, those in the national target groups (see National target groups for MURs section above) that subsequently led to an invitation for an MUR.

A Prescription Intervention MUR was more reactive, in the sense that it was the response to a significant adherence problem with a person’s medication that subsequently led to an MUR being conducted. The issue or issues that prompted the pharmacist to offer an MUR in this circumstance were likely to be highlighted as part of the dispensing process. Commonly the issues would highlight the need for the patient to develop their understanding of their medicines in order to improve their own use of the medicines.

The same consultation occured for MURs and Prescription Intervention MURs, i.e. establishing the patient’s actual use, understanding and experience of taking all their medicines; identifying, discussing and assisting in the resolution of poor or ineffective use of drugs by the patient; identifying side-effects and drug interactions that may affect the patient’s compliance with instructions given to him/her; and improving the clinical and cost-effectiveness of drugs prescribed to patients thereby reducing the wastage of such drugs.

Were dose optimisation and dose synchronisation prescription interventions?

It would not have been sufficient for a pharmacist to simply complete an MUR form solely relating to a proposed dose optimisation or synchronisation as an MUR. However, dose optimisation and synchronisation could clearly have been included as part of a regular or Prescription Intervention MUR.

Examples

The following examples were provided to assist pharmacists in determining what may and may not have been considered a Prescription Intervention MUR:

Scenario 1. A prescription requested 56 Lisinopril 10mg tablets TWO to be taken daily. You recommended to the GP that the patient could be changed to 28 Lisinopril 20mg tablets ONE to be taken daily.

This intervention alone would not have led to a Prescription Intervention MUR, but could habve been included as a recommendation if an MUR was initiated for another reason.

Scenario 2. A patient presented at the pharmacy with a prescription for 28 days of Aspirin and you knew that they came to the pharmacy last week for a 28 day prescription of Simvastatin. When you looked at the patient’s PMR you realised that their medicines needed to be synchronised and contacted the surgery to ask them to amend the quantities on the next prescription.

This intervention alone would not have led to a Prescription Intervention MUR, but it could have been included as a recommendation if an MUR was initiated for another reason.

Scenario 3. A Fluticasone inhaler was added to a patient’s inhaler regimen; when you dispensed the prescription you checked that the patient understood when to use the new medication. Whilst talking to the patient, it transpired that they had not been using their medication as they needed to do to obtain the most benefit. You decided that the patient needed more advice than the brief counselling that you were able to provide at the time of dispensing and invited the patient for an MUR.

This intervention could have led to a Prescription Intervention MUR.

Though the MUR service was designed to be provided in the pharmacy, it was possible to conduct MURs in other venues. The regional NHSE&I team had to give consent to contractors wishing to carry out consultations off the pharmacy premises, and this consent could be for:

• a specific premises (e.g. a specific room in a local GP practice); or
• a specific premises or a category of premises for a category of patients (e.g. a care home for care home residents); or
• specific premises for a specific patient (e.g. in a patient’s own home).

Contractors could use PSNC’s PREM2 forms to make applications to their regional NHSE&I team:

Application to undertake MURs off the pharmacy premises at alternative premises with a consultation area:

Form PREM2A (PDF)         Form PREM2A (Microsoft Word)

Application to undertake MURs off the pharmacy premises at alternative premises for a particular patient on a particular occasion:

Form PREM2B (PDF)          Form PREM2B (Microsoft Word)

Application to undertake MURs off the pharmacy premises at alternative premises or a category of premises for a particular category of patients:

Form PREM2C (PDF)          Form PREM2C (Microsoft Word)

The completed form had to be sent to the regional NHSE&I team.

NHSE&I’s Pharmacy Manual detailed the procedure regional NHSE&I teams had to follow when they receive applications from contractors to provide MUR services at premises other than the listed pharmacy premises or by telephone.

The fee for providing the MUR and the Prescription Intervention Advanced Service was set out in Part VIC of the Drug Tariff; these fees were claimed via the FP34C Submission Form. The fee for provision of an MUR was £28.

MUR statistics

MURs in 2019/2020 and 2021

Q. Could a contractor provide 250 MURs in the first half of 2019/20?
A. No. A maximum of 200 MURs only could be provided in the first half of 2019/20 (1st April 2019 – 30th September 2019) as was stated in Part VIC in the Drug Tariff. Any additional MURs (contractors could provide a maximum of 250 MURs in 2019/20) could be conducted in the second half of 2019/2020, i.e. from 1st October 2019 onwards.

Q. A contractor only provided 100 MURs in the first half of 2019/20, could they still provide MURs in the second half of 2019/20?
A. Yes. Carrying out 200 MURs in the first half of 2019/20 was not a pre-requisite requirement for providing further MURs in the second half. Contractors could still provide 250 MURs across 2019/20 (with a maximum of 200 MURs in the first half of 2019/20).

Q. If a contractor only provided 100 MURs in the first half of 2019/20, could they only provide 50 MURs in the second half of 2019/20 or could they provide 150?
A. If a contractor only provided 100 MURs in the first half of 2019/20, they could provide an additional 150 MURs in the second half of 2019/20.

Q. How many MURs could a contractor provide in 2020/21?
A. A total of 100 MURs could be provided in 2020/21.

Q. Did the target groups for MURs change in 2020/21?
A. Until 31st December 2020, 70% of MURs had to be targeted at high-risk medicines or patients who had recently been discharged from hospital. From the date that the NHS Discharge Medicines Service was introduced (1st January 2021) 70% of MURs had to be targeted solely at high-risk medicines.

Q. When was the MUR service decommissioned?
A. The MUR service was decommissioned at the end of the 2020/21 financial year.

General MUR questions

Q. How did contractors let their regional NHSE&I team know that they were starting to provide MURs?
A. Once both the pharmacy premises meet the requirements for MURs and the pharmacist had become accredited by a Higher Education Institution (HEI) to provide the service (by successfully completing an assessment, based on the nationally agreed competency framework), the contractor needed to notify their regional NHSE&I team using the PREM1 form.

Q. How did the ‘three month rule’ apply to MURs?
A. The Directions required the pharmacy to have provided pharmaceutical services to the patient for the previous three months before an MUR. So for an MUR conducted in April you would have expected to see dispensing recorded on the PMR to cover supplies during the previous three months, i.e. January to March. Prescriptions did not need to be dispensed every single month, so if prescriptions authorising two months supply were dispensed in January and March that would have met the requirements. If prescriptions for a single month’s supply were dispensed in January and March, then February would not have been covered and the pharmacy would not be considered to have been providing pharmaceutical services to the patient in that particular month, and therefore the pharmacy would not be deemed to have been providing pharmaceutical services for the previous three months. Note: The three month rule did not apply to Prescription Intervention MURs.

Q. Could a pharmacist have done an MUR for a patient who was only taking one medicine?
A. Yes, but only in one specific circumstance. The service requirements set out in the Directions only allowed an MUR to be conducted with patients on multiple medicines; however, there was one exception to this rule, where a patient was taking a single medicine which fell into the ‘high risk medicines’ category. If a patient was taking one high risk medicine they could receive an MUR; all other MURs had to be conducted on patients on multiple medicines.

Q. Did an MUR count if there were no recommendations to the patient’s GP at the end of the process?
A. Yes. The MUR was focussed on developing the patient’s understanding of their medicines. There did always have to be a change in the patient’s medication as a result of the MUR.

Q. Could MURs be carried out on patients in a care home that were supplied with medication from the pharmacy?
A. Yes, as long as your regional NHSE&I team consented to you conducting MURs at alternative premises. You would have needed to conduct the MUR face to face with the patient; it may also have been sensible to feed back any recommendations to the Care Home staff, provided you had the patient’s permission to share this information.

Q. Could another individual, for example, a pre-registration pharmacy trainee have sit in on an MUR consultation with the pharmacist and patient?
A. The Directions state that the MUR must not be overheard by other visitors to the pharmacy or by any other person including pharmacy staff. However, providing the patient consented to another individual being present during the MUR consultation it would have been acceptable for a pre-registration trainee to sit in on the consultation providing all other requirements in the Directions were being met.

Q. Could children have an MUR?
A. The MUR needed to be conducted with the patient in order to comply with the Directions. An MUR could have been conducted with a patient who is a child if they were competent (i.e. they had the capacity to give informed consent) and were able to fully engage in the discussion with the pharmacist.

Q.  Could you provide MURs while you were waiting for your MUR certificate to arrive?
A. No. A condition of the Directions was that the pharmacist had an MUR certificate and that a copy of the certificate was supplied to NHSE&I prior to providing the service.

Q. If you were a pharmacist working in different regions, did you need to notify each regional NHSE&I team before providing the MUR service?
A. The community pharmacy contractor had the responsibility to provide the regional NHSE&I team with a copy of the MUR certificate of all pharmacists providing the MUR service in the pharmacy before each pharmacist could undertake MUR consultations. However, a regional NHSE&I team may have accepted a copy of the MUR certificate from locum pharmacists, who may have worked in several different pharmacies, but there was no obligation on the regional NHSE&I team to do so. Because the contractor had the obligation to notify NHSE&I and produce a copy of the MUR certificate, many contractors may have preferred to submit the copy certificate themselves, to avoid NHSE&I later finding the  contractor in breach.

Q. How long should records of MURs be kept?
A. A copy of the record should be kept for at least two years after the date on which the MUR took place.

Q. Would I have needed to get patient consent each time a patient had an MUR? For example, if the patient had an MUR last year and 12 months had passed, would I have needed to get consent again?
A. Yes, consent would need to have been obtained each time a patient had an MUR. The General Pharmaceutical Council’s publication Guidance on Consent states ‘Getting consent is an ongoing process between you and the patient. Consent cannot be presumed just because it was given on a previous occasion’.

National MUR target groups

Q. If a patient fell within two or more of the national target groups, would this have meant that they were eligible for more than one MUR?
A.  No.  The target groups should have been used to select which patients would be eligible for an MUR.  Once a patient was eligible for an MUR then that should have covered all of the medicines that they were taking.

Q. What would have happened if there was a patient who was eligible for a post discharge MUR but also had a number of new medications prescribed? Could the patient have received both the NMS and an MUR?
A. No. The pharmacist should have made a decision based on the information they had about a patient’s medicines as to which of the services would benefit the patient most and therefore which service to have offered the patient.

Q. Would patients discharged from outpatient clinics and intermediate services have been eligible for a post-discharge MUR?
A. No. The post-discharge MURs were for inpatients that had had a change to their medicines while they were in hospital.

Q. If patients were re-admitted to hospital a number of times and had changes to their medicines could they have had more than one MUR per year?
A. The Directions stated that a patient may not have more than one MUR service consultation in any one period of twelve months unless in the reasonable opinion of the registered pharmacist the patient’s circumstances have changed sufficiently to justify one or more further consultations during this period. Consequently pharmacists should have used their professional judgment to decide whether it was appropriate to provide an MUR in this situation.

Q. Was there a breakdown of the proportion of targeted MURs that a pharmacist needed to complete for each of the four target groups?
A. No. The 70% could include MURs for patients from any of the four target groups.

Q. Did the 70% target deny access to the service for a group of patients that would benefit?
A. Contractors could conduct MURs on patients who were not in the four target areas (70%) at their own discretion where they feel that patients would benefit from the service. PSNC and NHS Employers selected the national target groups on the basis that these were areas where community pharmacy could make a valuable contribution to patient care.

MURs initiated as a result of a prescription intervention

Q. What was the difference between regular MURs and Prescription Intervention MURs?
A. They were the same service but reflected different triggers for provision of the service. A prescription intervention MUR was triggered by a significant adherence issue that came to light during the dispensing of a prescription; the regular MUR was a routine review not triggered by a problem with the patient’s adherence to their regimen. For a standard MUR, the pharmacy was required to have provided pharmaceutical services for a minimum of three months. This requirement did not apply in the case of a prescription intervention triggered MUR.

Q. Was it necessary to complete the same records for regular MURs and prescription intervention MURs?
A. Yes.

Q. Could you perform a prescription intervention type MUR by talking to a patient in the pharmacy, without conducting a patient interview in a consultation area?
A. No. As with regular MURs, a prescription intervention MUR required a full MUR to be conducted following the requirements laid down in the Directions.

Q. When you performed a prescription intervention MUR did you only have to review the medicines that had highlighted the need for the intervention?
A. No. A prescription intervention MUR was a full MUR conducted on all the patient’s medicines.

Q. Could a patient have a prescription intervention MUR if they were having problems with their OTC medicines?
A. The prescription intervention MUR was triggered at the time when the patient presented a prescription, and there was reason for the pharmacist to believe that the patient may have been experiencing significant problems with their use of medicines. The problems may have involved OTC medicines interacting with prescribed medication, but problems which arise that are identified independently of a dispensing episode would not have triggered a prescription intervention MUR.

Q. Could you perform a prescription intervention MUR for a patient who had not received their prescribed medication from your pharmacy for the last three months?
A. Yes, as the three month rule did not apply to prescription intervention MURs. N.B. this was not the case in Wales.

Consultation areas/rooms

Q. Did a consultation area have to provide visual privacy?
A. No. The MUR requirements did not require visual privacy to be provided; however, some degree of visual privacy would normally be provided by materials that are commonly being used in the construction of consultation areas.

Q. Could NHSE&I have stopped a contractor from using a consultation area that was unsuitable for wheelchair access?
A. A contractor had to ensure that there was no discrimination against people with disabilities. If the consultation area was not accessible by people with a disability, the pharmacy should have made suitable alternative arrangements. This could have included carrying out the MUR in the shop area when the premises are closed to the public, providing the service over the telephone or via video conferencing, or on alternative premises convenient to the patient. The consent of the regional NHSE&I team would have been needed to use alternative premises.

Q. Could I have conducted an MUR on the counter or another quiet area of the pharmacy, if the patient did not want to go into the consultation area?
A. No. The Directions required the consultation to be carried out in an acceptable location, and patient consent to carry out the MUR elsewhere could not overrule this requirement. If the patient did not want to go into the consultation area, the consultation could have been carried out in the public area of the pharmacy when the pharmacy is closed. Alternatively the consultation could have been carried out over the telephone or via a video consultation. Additionally regional NHSE&I teams may have consented to the consultation being carried out in the patient’s home.

Q. Was a Enhanced Disclosure and Barring Service (DBS) certificate required to carry our MURs in patients’ homes?
A. Almost all NHS staff are DBS checked, and whilst not mandatory for community pharmacists, it is a sensible precaution to require a check for anyone who has unsupervised access to a child or vulnerable adult. When being asked to approve a pharmacist to conduct MURs in a patient’s home, it would have been an appropriate point at which NHSE&I  could require a DBS check. In this circumstance PSNC believed the cost of the DBS check should have been paid for by NHSE&I.

Fees and funding issues

Q.Why were the numbers of MURs that each pharmacy could undertake capped each year?
A. This was so we do not go over the annual budget for the MUR service.

Q. When were contractors paid for providing an MUR?
A. Contractors declared how many MURs they had provided during the month on the FP34(C) submission form. The Pricing Authority made the payment for these MURs at the same time as the payment was made for the month in questions prescriptions.

Q. If the regional NHSE&I team claim the pharmacy did not comply with the Essential Service requirements, could it withhold payments for MURs undertaken or claw back payments already made?
A. The only sanction that was available to a regional NHSE&I team which believed the pharmacy did not meet the requirements, was through the procedures for breach of the Terms of Service or through action by the NHS Counter Fraud Service if it believed that fraudulent claims had been made. This could not be done administratively.

Q. If on a monitoring visit the regional NHSE&I team decided that the Essential Service requirements were not met, what action would have followed?
A. The regional NHSE&I team would have notified the contractor, informally or formally, of the areas of non-compliance. If the non-compliance was substantial and clear, the regional NHSE&I team may have advised the contractor not to undertake further MURs until the problems had been rectified. In such circumstances, if the contractor did not accept that they was non-compliant with the requirements, the contractor should have requested formal written notification of the defect to be remedied if the regional NHSE&I team had not already produced a report in the course of the monitoring exercise. The contractor may have consulted the LPC for advice, and it may have been able to arbitrate in cases of dispute. Once a written notice identifying non-compliance had been received, the contractor should not have provided further MUR services until it had remedied the defect notified by the regional NHSE&I team.

Below is a number of resources which were produced by PSNC and other organisations to support pharmacists when they were providing MURs.

Getting started with MURs

NMS and MURs – top tips from community pharmacies

East Lancashire LPC MUR resource – Guide to better MURs

10 steps to success with MURs

Guidance for conducting MURs – a guide on conducting MURs produced by Derbyshire’s PCTs and community pharmacists as part of the Community Pharmacy Framework Collaborative

The PSNC, ‘Get a Free Medicines Check from your Local Pharmacist’ campaign materials allowed contractors and LPCs to promote the availability of MURs to patients.

Colour poster            Black and White poster

Clinical conditions/therapy areas

Asthma UK / PSNC / MIMS MUR support pack (PDF)

British Lung Foundation – Respiratory medicines use review – consultation guide for COPD and asthma patients

British Lung Foundation – Respiratory medicines use review – consultation guide for COPD and asthma patients

Devon LPC COPD MUR+

Devon LPC acne MUR toolkit

Devon LPC diabetes MUR toolkit

Devon LPC psoriasis MUR toolkit

Consultation areas/rooms

PSNC guidance on chaperone policies

Communicating with patients

University of Reading – The Medicines Use Review – patient satisfaction survey (September 2016)

Mencap – The Disability Partnership’s Pharmacy Project (July 2016):

• Resource booklet
• How to take my medicine sheet
• How to take my medicine chart

MUR: Understand your medicines – a booklet for the public

PSNC and NHS Employers updated the text of the above booklet to reflect the new patient consent arrangements introduced in October 2011 and the changes to the NHS structure in 2013.

MUR: Understand your medicines – updated text

‘Think Pharmacy’ poster – Medicines Use

Pfizer Scratch card  – This scratch card was launched in October 2014 as part of Pfizer’s ongoing campaign to raise awareness of medicines optimisation. The aim was to increase patient interaction with the pharmacy team to create opportunities to engage patients which pharmacy services such as MURs and the New Medicine Service.

Resources to support the campaign can be ordered from accesspfizer.co.uk

Further resources

PSNC Briefing 061/16: Services Factsheet – MUR guide for other healthcare professionals (October 2016)

PSNC Briefing 038/17: A summary of literature relating to Medicines Use Reviews (June 2017)

PSNC Briefing 087/13: Advanced services and Pre-registration Trainees (20th August 2013)
Following media reports that pre-registration trainees have been allowed to provide MUR and NMS consultations without supervision by a pharmacist, PSNC has issued guidance to contractors.

PricewaterhouseCoopers (PwC) – The value of community pharmacy: full report and summary report.
This report contains a chapter which provides PwC’s assessment of the value associated with community pharmacy’s current role in providing the MUR service in England.

Video of an MUR – this shows an example of an MUR and may provide useful insight for those who are not familiar with the service: