use both MURs and the NMS,as well as information fromhospital colleagues, to improvepatient care. Figure 1 from theCQC’s 2009 report shows thesteps that need to be in placeto ensure that medicines areobtained and used by patientsas intended after dischargefrom hospital, and the idealpatient pathway in relation tothis. Community pharmacy cancontribute to the final stage ofthis pathway (‘support foradhering to medication’)through MURs.

Aims of the MUR serviceThe overall aim of the MURservice is to improve patientknowledge of medication via aconsultation, resulting in more

changed, and a report by theCare Quality Commission (CQC)in 2009 highlighted that almosthalf of all patients mayexperience an error with theirmedicines after they have beendischarged. The transfer ofpatients and their medicinesfrom secondary care to primarycare and vice versa can lead to:• Incorrect transmission ofinformation• Unintended changes inmedication• Intended changes inmedication not being followedthrough (e.g. changes inmedicine, dose or formulation)• Continuation of medicationthat should have beendiscontinued.

Community pharmacists can

This module considers thetransfer of patients and theirmedication from secondarycare to primary care and howthis can be supported with theprovision of medicines usereviews (MURs) and the newmedicine service (NMS) as partof medicines optimisation.

IntroductionAfter discharge from hospital,problems with medicinesinclude the risk of unintendedmedicine changes, unintendednon-adherence and thepossibility of adverse drugreactions, which may result inpoorer outcomes includingreadmission to hospital.

During a stay in hospital, a patient’s medicines may be

T R A I N I N G M AT T E R S MAY 2016

effective use of medicines.Some 50 per cent of MURs are required to fall into certaincategories, as specified in thePharmaceutical Services(Advanced and EnhancedServices) (England) Directions2011. These categories nowinclude patients:• Taking a high risk medicine

(NSAIDs, anticoagulants,antiplatelets, respiratorymedicines) • Recently discharged fromhospital who had changesmade to the drugs they weretaking while they were inhospital• Prescribed certain respiratorydrugs• Diagnosed with or at risk of cardiovascular disease andregularly being prescribed atleast four medicines.

In the context of dischargeMURs, the aims of the MURservice are as follows:• Establishing patients’ actualuse of medicines, includingtheir understanding andexperience of the medicines• Identifying, discussing in a concordant manner andworking towards medicinessolutions in situations wherethere is deemed to be poor orineffective use of medicines• Identifying side effects andpotential interactions • Improving the cost effectiveuse of medicines, with a viewto reducing waste.

The MUR is not a clinicalmedication review. In theprimary care environment,

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Contributing author: Nina Barnett, consultant pharmacist, older people.

C P D M O D U L E

Welcome to our CPD module series for community pharmacytechnicians. Written in conjunction with the PharmacyMagazine CPD series, it will mirror the magazine’s programmethroughout the year. The series has been designed for you touse as part of your continuing professional development.Reflection exercises have been included to help start you offin the CPD learning cycle.

CURRENT THINKING ON... MUR AND NMS

AT DISCHARGEMODULE NUMBER: 67

AIM: To describe how community pharmacy cansupport the discharge process using the new medicineservice (NMS) and medicines use reviews (MURs).

OBJECTIVES: After completingthis module, pharmacytechnicians will:● Be aware ofthe problemsthat can occurwith patientmedication afterdischarge fromhospital● Understandhow the NMS canhelp to improvepatient care● Understand how MURs canalso be of benefit after hospital discharge.

CPDSUPPORT

REFL

ECT

EVA

LUAT

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ACT

PLAN

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Figure 1

Admission Discharge Support foradhering tomedication

Criticallyreviewing and

updatingpatient

medicationrecords

(reconciliation)

Medicationreview and

repeatprescribing

Patient is admitted tohospital with a list ofup-to-date medicines,obtained from the GPand patient. Hospitalpharmacists thencarry out medicinesreconciliation toestablish what thepatient is currentlytaking.

Treatment is receivedin hospital. Changesto medication maybe made. Patient isdischarged with acopy of dischargeletter. Dischargesummary is sent toGP and communitypharmacists withdetails of changes to medication.

GP critically reviewschanges and updatesthe patient recordwith the details in thedischarge summary.This ensures that anyappropriate changesmade in hospital aredocumented on thepatient record, andthe prescription ischanged.

GP invites the patientto a consultation.Patient’s medication is discussed andpotential medicationerrors and adversereactions are spottedand dealt with.Where necessary, arepeat prescription isissued and a reviewdate set.

Patients do notalways take theirmedicines asintended. Furthermonitoring isrequired to identifypatients who may notbe taking theirmedicines as intendedso that support can be provided asappropriate.

tech matters CPD p36-37.LN_G_fever 13/05/2016 16:50 Page 36

community pharmacists areallowed access to patients’summary care records, but very few have this set up yet.Therefore, most will havelimited information ondiagnosis, conditionmanagement (includingrationale for choice ofmedicines and any tests doneand their results) and may havedifficulty influencing,instigating and following upchanges in medication. Theseare issues that would becovered in a clinical medicationreview rather than a MUR.

Aims of the NMSThe NMS is an evidence-basedservice that allows pharmaciststo provide continuity of carefor patients. Through an initialinterview and a mandatoryfollow up, the patient issupported. The service isaccessible to houseboundpatients and others whochoose to use it remotely, as itcan be provided by telephone.In any consultation, it isimportant to share the agendawith the patient and give themthe opportunity to ask

questions. They will be morereceptive to the pharmacist’sagenda if they have theirquestions addressed first.

As a structured consultationaround specific questions, theNMS can lead to a variety ofinterventions. There are anumber of suggestedquestions, which may be askedin a closed or open way. Manypractitioners find that the openquestions (i.e. those beginningwith words like ‘how’, ‘what’and ‘when’) lead to betterdiscovery of patient needs.

In relation to hospitaldischarge, the NMS aims toprovide benefits for patientsand the NHS by:• Improving health outcomesfor patients through improvedadherence and thereforeefficacy of medicines • Identifying adverse effects inorder to optimise management• Encouraging cross-sector andmultidisciplinary working toprovide seamless care • Promoting and supportingself-care of long-term

conditions, includingsupporting healthy lifestyles• Reducing medicines waste• Reducing avoidablehealthcare utilisation, includingmedicines-related hospitaladmissions• Providing an opportunity forthe patient and pharmacist toshare the medicines-relatedagenda around the NMS, sharedecision-making regardingways forward and agree levelsof self care appropriate to theindividual situation.

Providing post-dischargeMURsThere is plenty of scope toimprove the support thatpatients get after dischargefrom hospital. Views differ asto the ‘ideal’ time to conductan MUR after discharge, butfactors to consider are:• The number of days’ supplyof medicines the patient islikely to have when they aredischarged from hospital• Whether the patient willhave been using their ownmedicines in hospital.

Talk to your local GPs aboutsupporting patients after

discharge from hospital andsuggest that you trial theprovision of post-dischargeMURs with a small number ofpatients initially. Include thefollowing in your discussion:• Potential benefits of MUR,scope of service, examples ofissues that may be discussed• Ask the GP which patientsthey feel could benefit, howthey might refer to you andhow they would like theinformation to be shared with them after an MUR• Explain how the pharmacymeets NHS InformationGovernance requirements andwhat information the GP couldprovide to support you (e.g.discharge letter).

Discussions with the patientmay include:• Medicines reconciliation(hospital and post-discharge) • Patient perception of theirneed for and use of medicines,including identifying anymedicines stopped• Patient adherence,tolerability, side effects

• Solving problems withordering, obtaining, taking and using medicines.

Improving transfer of careIn July 2011, the RoyalPharmaceutical Society (RPS)launched a campaign toimprove information attransfer of care, known as‘Keeping patients safe whenthey transfer between careproviders – getting themedicines right’. Both thedischarge NMS and MURs cansupport this.

There is a national templatethat healthcare professionals insecondary care can use to referpatients for a discharge MURor NMS, within appropriategovernance arrangements.However, a number of hospitalsare looking at modifying theirdischarge letters to incorporateinformation relevant to NMSand discharge MURs, such asmandatory fields for medicineschanges and new medicinesprescribed.

At London North WestHospitals Trust, a local initiativeto support patients at risk ofpreventable medicines-relatedreadmission was extended topromote referrals for dischargeMURs and NMS. Patientsstarted on an NMS medicine,or those who were considered

to potentially benefit from adischarge MUR, were given apersonalised referral letter anda verbal recommendation toaccess the services, followingverbal counselling onmedicines. However, feedbackfrom community pharmacistsand from patients showed thatthis did not promote uptake ofthe services. Communitypharmacists were keen tocontact patients soon afterdischarge, but were generallyunaware that admission ordischarge had taken place andoften did not have patientcontact numbers.

Using PDSA (plan, do, study,act) cycles and working withcommunity pharmacists, thereferral pathway has beenmodified to include:• Gaining verbal consent from

patients during counselling for communication of relevantinformation for referral to theirnominated pharmacy, includinggiving their phone number tothe community pharmacist toallow telephone follow up• Documenting consent on the medication chart• Alerting communitypharmacists to the opportunityof discharge MUR or NMS bytelephoning them when thepatient is being discharged• Promoting contact betweenthe community pharmacist andpatient (e.g. by telephone soonafter discharge) for thecommunity pharmacist to offerthe appropriate service• Community pharmacistsdocumenting the referral onpatient medication recordsystems to alert the pharmacistof the potential for NMS orMUR when the patient nextattends.

More recently, hospital-to-community electronic referralsystems have been established.Examples are described within an RPS toolkit, including the‘Refer to Pharmacy’ systemused in East LancashireHospitals NHS Trust, which isfully integrated into hospitaland community systems. Seepage 17 for more information.

ConclusionPost-discharge NMS and MURsoffer community pharmacy theopportunity to become anintegral part of the patient’spathway between secondaryand primary care. If they canimprove adherence, reducewaste and encourage patientparticipation in their own care,they will continue to have animportant role in supportingmedicines optimisation.

MAY 2016 T R A I N I N G M AT T E R S 37

C P D M O D U L E

Go to www.tmmagazine.co.uk to answer the CPD questions. When you pass, you’ll be able to download a certificate to showcase your learning.You can also add this to your online, personalised learning log.

reflectiveexercise

• Which hospitals/wards might you need to develop arelationship with in order to receive more referrals forpatients with long-term conditions appropriate for a post-discharge NMS consultation?• What does the pharmacy need to know about a patient’sadmission and hospital stay to undertake a discharge MUR?• What channels of communication are available to you andhow could you document referrals securely?

Next month: We focus on antibiotic resistance.

“Almost half of all patients may experience an error with

their medicines after they havebeen discharged”

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