MURs and the NMS at discharge

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CPD MODULE

module 247pharmacymagazine.co.uk

continuingprofessionaldevelopment

the

programme

pharmacy magazine

First in professional development

GOALTo describe how communitypharmacists can support the dischargeprocess using the New Medicine Serviceand medicines use reviews.

OBJECTIVES:After completing this module you should be able to:• Identify common medicine-related problemsthat result after a patient’s discharge fromhospital

• Produce an action plan for conductingpost-discharge MURs and NMS consultations.

forthismodule

Contributing author: Nina Barnett, consultantpharmacist & visiting professor at King’s College London

MURs and theNMS at discharge

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Introduction During a stay in hospital a patient’smedicines may be changed. Studies suggest that almost half of all patients may experience an error with theirmedicines after they have been dischargedfrom hospital. Community pharmacists can now use both medicines use reviews(MURs) and the New Medicine Service(NMS), as well as information from hospitalcolleagues, to improve patient care. The transfer of patients and their

medicines from secondary to primary care,and vice versa, can lead to:• The incorrect transmission of information• Unintended changes in medication• Intended changes in medication not beingfollowed through (e.g. changes inmedicine, dose or formulation)

• Continuation of medication that shouldhave been discontinued.

Figure 1 (overleaf) outlines the steps thatneed to be in place to ensure that medicinesare obtained and used by patients asintended after discharge from hospital.

The standard contract for NHS hospitalshas, since April 2010, required them toshare discharge summaries with a patient’sGP within 24 hours of leaving hospital. The information provided should include a summary of diagnosis and details of any

Welcome to the two hundred and forty seventh module in the Pharmacy Magazine Continuing ProfessionalDevelopment Programme, which looks at MURs and the NMS when a patient is discharged from hospital.

Journal-based educational programmes are animportant means of keeping up to date with your clinicaland professional knowledge. Completion of this modulewill contribute to the nine pieces of CPD that must berecorded each year.

Before reading this module, test your existingunderstanding of the subject by completing the pre-testat www.pharmacymagazine.co.uk. Then, after studyingthe module in the magazine or online, work through the post-test on the website to check your answers.Record your learning using your personal PharmacyMagazine online log.

The RPS Faculty and advancing yourprofessional developmentPharmacy Magazine’s CPD programme can form part of yourprofessional development, providing you with essentialknowledge and skills. It can also be considered alongsideother activities for inclusion in your RPS Faculty portfolio.

The RPS Faculty is a professional recognition programmefor all pharmacists in all sectors at all stages of their careerand involves assessment of a practice-based portfolio thatrecognises their professional development.

This allows you to demonstrate to others your level ofattainment and stage of advanced practice. It also helps youto identify what you need to know at different stages of yourcareer. Start your Faculty journey by accessing the portfolioand tools at www.rpharms.com/Faculty.

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This module is suitable for use by community pharmacists as part of their continuing professional development. After reading this module in the magazine or online, complete the scenarios and post-test atwww.pharmacymagazine.co.uk and include in your personal learning log.CPD is one aspect of professional development and can be consideredalongside other activities for inclusion in your RPS Faculty portfolio.

This module is also online at pharmacymagazine.co.uk

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medication prescribed at the time of the patient’s discharge. The contract (and the NHS Constitution) also requires hospitals to give patients a copy of their discharge letter.However, the Care Quality Commission (CQC) has found that this happens in only seven of the 12 areas it studied. All hospitals are expected to have a policy on

discharge medicines and, increasingly, the aim ofthis is to reduce preventable problems (includingunplanned readmissions) due to medicines issuesafter discharge. The hospital’s pre-discharge assessment

attempts to take into account: • The patient’s previous care needs

• Changing medication needs (including compliance aids)

• Likely changes as a result of admission• Transport needs and social needs (e.g. patientliving alone)

• Possible vulnerabilities (e.g. frail elderly, terminally ill, learning disability, mental healthproblems)

• Eligibility for NHS continuing care (sometimesreferred to as continuing healthcare).

Patients may be discharged to their own home or transferred to a community hospital or carehome. Hospitals sometimes categorise dischargesas ‘simple’ or ‘complex’, although there is nostandardisation in this terminology.

A ‘simple’ discharge can be defined here as one that: a. Will involve minimal disturbance to thepatient’s activities of daily living

b. Does not prevent or hamper a return to theirusual place of residence

c. Will not require a significant change in supportoffered to the patient and his/her carer in thecommunity.

A ‘complex’ discharge is where one or more of these criteria do not apply. Patients may sometimes have a ‘rapid

discharge’ with specific staff (part of a rapid discharge team) designated to facilitate this in order to release a hospital bed. Patients may be discharged home or to a less intensive care setting, such as intermediate or transitional care.In addition, complex patients may be identified

as having issues around polypharmacy. Whereasthis previously referred to the number ofmedicines prescribed, it has recently beenclassified as ‘appropriate’ (where best evidencehas been used to prescribe and medicines use has been optimised) or ‘problematic’ (where theintended benefit of medicines does not occur ormultiple medications are used inappropriately).(See: kingsfund.org.uk/sites/files/kf/field/field_publication_file/polypharmacy-and-medicines-optimisation-kingsfund-nov13.pdf)

Purpose of MURsAn update to Direction 4(2) of The PharmaceuticalServices (Advanced and Enhanced Services)(England) Directions 2013 outlined the purpose of a MUR as follows: “… with the patient’sagreement, to improve the patient’s knowledgeand use of drugs by, in particular: a. Establishing the patient’s actual use,understanding and experience of taking drugs

b. Identifying, discussing and assisting in theresolution of poor or ineffective use of drugs by the patient

c. Identifying side-effects and drug interactionsthat may affect the patient’s compliance withinstructions given to them by a healthcareprofessional for the taking of drugs

d. Improving clinical and cost-effectiveness ofdrugs prescribed to patients, thereby reducingthe wastage of such drugs.”

In Wales, services are provided as part of theDischarge Medicines Review (DMR) service

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Figure 1: The medicine pathway across admission and discharge

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Figure 2: The ideal patient pathway

Admission Discharge

Critically reviewing and

updating patients’

medication records

(reconciliation)

Medication review and repeat

prescribing

Support for adhering tomedication

Source: Care Quality Commission (2009). Managing patients’ medicines after discharge from hospital

Patient admittedto hospital withlist of up-to-datemedicinesobtained from theGP and patient.Hospitalpharmacists then carry outmedicinesreconciliation to establish whatthe patient iscurrently taking.

Treatment receivedin hospital.Changes tomedication may be made. Patientdischarged with acopy of dischargeletter. Dischargesummary sent toGP and communitypharmacist withdetails of changesto medication.

GP criticallyreviews changesand updates thepatient record with the details in the dischargesummary. Thisensures that any appropriatechanges made in hospital aredocumented on the patient recordand prescriptionschanged.

GP invites patientto a consultation.Patient’smedication is discussed and potentialmedication errorsand adversereactions arespotted and dealtwith. Wherenecessary, a repeatprescription isissued and reviewdate set.

Patients do notalways take theirmedicines asintended. Furthermonitoring isrequired toidentify patientswho may not betaking theirmedicines asintended so thatsupport can beprovided asappropriate.

Admission Discharge

Critically reviewing and

updating patients’

medication records

(reconciliation)

Medication review and repeat

prescribing

Support for adhering tomedication

Pharmacy Magazine CPD modulesprovide you with knowledge to help you to develop and advance your practice and can be recorded in your Faculty portfolio.

Start your journey now by accessing the Faculty portfolio, tools and resources atwww.rpharms.com/Faculty.

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introduced in November 2011. Through supp-orting patients recently transferred between care settings, it aims to ensure that changes tomedicines are followed up in the community. It differs from MURs in England in that the firstpart of the DMR service is to ensure dischargemedicines reconciliation is undertaken (e.g.between hospital and home within four weeks of discharge) and the patient’s GP is alerted to any discrepancies.

Support for using and taking medication,including medicines adherence, is also part of the DMR service through a discussion with thepatient. Any discrepancies identified at dischargeare followed up with the patient to ensure that all issues have been resolved. A recent evaluationsuggested that the DMR service was cost-effectiveand provides health benefits to patients fromavoided adverse events. An electronic DMRservice has recently been introduced in Wales.In Scotland, the Chronic Medication Service,

underpinned by a framework, provides supportfor patients with long-term conditions. Patientsregister with a pharmacy of their choice.Pharmacists identify patients’ pharmaceuticalneeds and develop a medicines care plan. Serialprescriptions are enabled, working with the GPpractice through electronic communication andrecording. The service focuses on developingtherapeutic partnerships between GPs,community pharmacists and patients to improve care.In Northern Ireland, the ‘Managing your

medicines’ service is available to patientsconsidered at risk of medication-relatedproblems. This may be through taking manymedicines or high-risk medicines and for thosewho have compliance issues, poor medicinessupport or a recent hospital discharge with major medication changes. MURs can also beundertaken in community pharmacies. Initiallytargeted for patients with respiratory conditions,this has recently been extended to supportpatients with diabetes.

Description of the NMSThe NMS is a pharmacist consultation service,which provides an initial interview and follow-up review to support patients newly started on medicines for the following long-termconditions/therapy areas:

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Table 1: Medicine-related factors leading to poor outcomes from treatment for inclusion in post-discharge MURs or the NMS

Problem Causes General points Medicine-specific points

‘High risk’medicinesassociated with hospitaladmissions andreadmissions

NSAIDsAspirinDiureticsWarfarin

These four medicines account for half to two-thirds of medicine-related hospitaladmissions

Including OTCIncluding OTC

Refer to current guidance on INR test results and the‘currency’ of a patient’santicoagulation book.NMS includes antiplatelets and anticoagulants. Other NMSmedicines focus on optimisingmanagement of long-termconditions

Adherence Not able to obtain medicines/ordering medicines

Not taking a medicine eitherdue to unintentional causes,which may be physical orcognitive (e.g. unable toaccess or swallow medicine;forgetting), or intentional,which may be due to patientbeliefs and/or concerns aboutmedicines

Taking wrong medicines (e.g. continuing to take afterdiscontinued; inadvertentduplication of treatment)

Taking too little

Taking too much

Taking OTC or herbalmedicines that interact or are contraindicated

Taking other people’smedicines

These issues relate to how thepatient is obtaining and usinghis/her medicines and falldirectly within the remit of a MUR

NMS interview scheduleincludes identification ofadherence issues

Follow-up NMS allowsidentification of adverseeffects, lack of efficacy (insome cases) and adherenceissues for the specifiedcondition/therapy group

Concordantconversations

Patient not given sufficient or appropriate informationabout the condition beingtreated or the risk or benefitof treatment relevant tohis/her specific situation

Has not been asked orinvolved in discussions about treatment andtreatment options leading to a lack of engagement due tounaddressed concerns aboutmedicine or not thinking it isneeded. As a result, patientdoes not feel part of thedecision-making process

Exploring the patient’s healthbeliefs and wishes is essentialif he/she is to accept what hasbeen prescribed

The CQC has stated: “It isimportant that patients aregiven clear information abouttheir medicine and possibleside-effects, and then have anopportunity to discuss howthe regimen is working out. At a national level, however,between 11 and 34 per cent of people say they are notgiven enough information on leaving hospital”

This is particularly an issuefor medicines where there isno immediate apparentpatient benefit (e.g. antihypertensives)

You can complete this module online atpharmacymagazine.co.uk and record yourlearning outcomes and the impact on yourpractice in your personal learning log

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• Asthma and COPD• Type 2 diabetes• Antiplatelet/anticoagulant therapy• Hypertension.The Pharmaceutical Services (Advanced andEnhanced Services) (England) Directions 2013state that if a patient is started on a course oftreatment in hospital that is to continue afterdischarge, a community pharmacist mayundertake a NMS consultation following referral

from a hospital-based healthcare professionalinvolved in the patient’s care. No specific methodof referral is mandated but there is a nationaltemplate available at psnc.org.uk. Hospital teams may use this referral form

to facilitate communication around dischargemedicines and some hospitals have includedelements of the form in their standard electronicdischarge letter, a copy of which is given to thepatient on leaving hospital.

Some hospitals contact community pharmacistsby telephone to provide a verbal referral and mayoffer to fax or email a copy of the discharge letterthrough secure routes.More recently, hospital-to-community electronic

referral systems have been established. Examplesare described within a recently produced RPStoolkit including the ‘Refer to pharmacy’ systemused in East Lancashire Hospitals NHS Trust,which is fully integrated into hospital andcommunity systems, and the PharmOutcomessystem, used in Newcastle hospitals.It is important to establish how the referral will

be communicated within the relevant pharmacyto ensure effective follow-up. In outpatient services, it is common for

hospital prescribers to recommend initiation of medication to the patient’s GP and this caninclude a medication suitable for the NMS. There is an opportunity to work with hospitaloutpatient services to encourage use of the NMS,linking with community pharmacists, throughrecommendation to GPs and during outpatientconsultations with patients.The CQC concluded that improvements were

needed to improve the quality and safety ofpatient care in relation to medicines managementafter discharge from hospital. The ‘ideal’ patientpathway in relation to medicines is described inFigure 2.Community pharmacists can contribute to Step

5: “Support for adhering to medication” throughMURs and the NMS.

How post-discharge MURs and the NMS can helpThe overall aim of the MUR service is to improvepatient knowledge of medication via a concordantconsultation, resulting in more effective use ofmedicines. In the context of discharge MURs, the aims of the MUR service may be outlined asfollows:

Establishing the patient’s actual use ofmedicines, including their understanding and experience of the medicine The patient may have changes in medication,dose, strength, frequency and formulation, as well as being on high-risk drugs (e.g. anti-platelets, diuretics, NSAIDs and anticoagulants).The MUR will establish the patient’s perception,

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Table 2: NMS interview schedule standard and alternative questionsNMS question

Have you had the chance tostart taking your newmedicine yet?

How are you getting on with it?

Are you having any problemswith your new medicine orconcerns about taking it?

Do you think it is working?(Prompt: is this differentfrom what you wereexpecting?)

Do you think you are gettingany side-effects orunexpected effects?

People often change the timethey take their medicines ormiss taking doses for a widerange of reasons. When doyou take your medicine? Howdoes that fit into your day?How many doses have youmissed in the last week?

Do you have anything elseyou would like to know aboutyour new medicine? Is thereanything you would like meto go over again?

Alternative question

How much of your newmedicine have you felt able totake so far, if any?

What changes have younoticed since starting yourmedicine? OrWhat problems or concerns, if any, do you have about yourmedicine?

How well do you think it isworking for you? (Prompt: howdifferent is this from what youwere expecting?)

What unexpected effects orside-effects, if any, have younoticed from the medicine?

How many doses of yourmedicine have you missed in the last week?

What else would you like todiscuss or revisit?

Possible discussion

If the patient has not started taking the medicine, then explore the reasons for this by moving to the non-adherence issues below. The pharmacist can thengo back and address other reasons/concerns/need forinformation at the end of the interview

This is an open question to get the patient talking and to bring out any issues that are important to him/her.These can be dealt with here rather than waiting untilthe appropriate question below

This helps the patient consider both the benefits of themedicine and any untoward effects, which they may not directly attribute to a medicine (e.g. cough linked to ACE inhibitor use). It also acknowledges that it is notunusual to have problems taking a new medicine andencourages discussion of any issues

This gives a chance to mention that some patients willnot feel any different if some of these drugs are working.What do they know about what it is for? What do theywant to know? (e.g. how the drug works?) Some patientsmay be more confident in taking the medicine if theyhave a rational explanation of how the drug helps theircondition

If the patient feels different, it may lead them to changetheir behaviour, even though it is not a side-effect of the drug. This may also be an opportunity to fill in aYellow Card. This is a chance to discuss whether side-effects are likely to be transitory and what can be doneto minimise them. If severe, the pharmacist couldsuggest a return to the prescriber and possibly stoppingthe drug. This could also be an alert to serious side-effects that may occur and would involve an immediateneed to take action

This type of question is well accepted as it recognisesthat missing doses of medication is common anddemonstrates a non-judgmental approach. It isnecessary to explore the patient’s perception of theiradherence challenges and their understanding of theirneed for the medicine. The pharmacist can then supportthe patient considering how they want to manage theiradherence. Both practical and perceptual reasons fornon-adherence should be considered and these areoften combined. In addition, consideration ofappropriateness is important (e.g. missing a morningdose of a diuretic because the patient has a long busjourney). The pharmacist can then help the patientwork out the best solution for him/her

Use this to give the patient the chance to raise anyissues that you have not covered, some of which may beunrelated to the NMS medicine in question. This allowsyou to refer and signpost appropriately, as well asaddress any other issues arising from the consultation

(Adapted from psnc.org.uk/wp-content/uploads/2013/07/NMS_interview_schedule_without_notes.pdf)

Read ‘Community pharmacy services – guidance forhospitals’ (nhsemployers.org/case-studies-and-resources/2012/01/community-pharmacy-services---guidance-for-hospitals) and the more recent RoyalPharmaceutical Society ‘Hospital referral to communitypharmacy’ toolkit (rpharms.com/support-pdfs/3649---rps---hospital-toolkit-brochure-web.pdf).• How does your local hospital communicateinformation about medicines with primary care?

• What are the governance arrangements around this?

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Reflection exercise 1


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knowledge and experience of their medication,including any changes that have been made.

Identifying, discussing in a concordant manner and working towards solutions in situations where there is deemed to be poor or ineffective use of medicines Ascertaining the actual use of medicines ratherthan their prescribed use from a patient’sperspective is important, as is looking atintentional and unintentional changes inmedication, dosing route, timing and whether the drug is to be taken with, before or after food.

Identifying medication side-effects and potentialinteractionsSide-effects may affect patient compliance. A MUR also allows OTC medication and herbalremedies to be discussed in terms of possibleinteractions.

Improving the cost-effective use of medicineswith a view to reducing wasteThis involves improving adherence, explaining therepeat prescription process and encouraging thereturn of unwanted medicines to the pharmacyfor safe disposal. This is especially importantwhere medication has been discontinued.As community pharmacists will be aware,

the NMS aims to provide benefits for patients and the NHS by:• Improving health outcomes for patients throughimproved adherence and, therefore, the efficacyof medicines

• Identifying adverse effects in order to optimisemanagement

• Encouraging cross-sector and multi-disciplinaryworking to provide seamless care

• Promoting and supporting self-care of long-term conditions

• Reducing medicines waste • Reducing avoidable healthcare utilisationincluding medicines-related hospitaladmissions

• Providing an opportunity for both the patientand pharmacist to share decision-makingregarding ways forward and to agree levels of self-care appropriate to the individual’ssituation.

A number of issues that contribute to pooroutcomes are highlighted in Table 1.

Note: a MUR is not a clinical medication review. The types of interventions intended during a MURare described in the national service specification:

Possible interventions during a MUR Advice on medicines usageAim: To develop compliance via concordance.

Advice on ‘when required’ medicationAim: To clarify and document ‘when required’medication use to avoid accidental under- andoverdose.

Appropriate use of different dosage formsAim: To counsel on best use (e.g. inhaler technique, soluble, sublingual use, patches).

Advice on tolerability of medicinesAim: To recognise side-effects and counsel onpredicted side-effects, management and the reporting of ADRs via the Yellow Card scheme.

Dealing with practical problemspreventing adherenceAim: To address issues on obtaining medication,especially ordering and avoiding running out, andsynchronisation of quantities.

Advice on medication ‘as directed byprescriber’Aim: To provide detailed instructions on how andwhen to take the medication.

Identify medicines no longer to be takenAim: To avoid unintentional consumption of discontinued medication.

Identify a dose or strength changeAim: To advise on pharmaceutical optimisation(e.g. one 40mg tablet instead of two 20mg tablets).

Identify generic v. branded prescribingAim: To facilitate cost-effective prescribing wherethere are no restrictions.

Identify branded v. generic prescribingAim: To facilitate the prescribing of brandedproducts where the formulation or medicinerequires continuity of brand.

Supporting adherenceWhen considering a MUR after a patient has beendischarged from hospital, the emphasis should beon supporting adherence with the aim of trying to improve treatment outcomes by reducing both

MURs and the NMS can significantly improve patient care after discharge from hospital



medication errors and adverse drug incidents.Community pharmacists do not have access tomedical notes, have limited information ondiagnosis and condition management (includingrationale for choice of medicines and any testsdone and their results) and may have difficultyinfluencing, instigating and following up changesin medication. These are issues that would be covered in a

clinical medication review rather than a MUR.

Interventions through the NMSThe NMS is an evidence-based service that allowspharmacists to provide continuity of care forpatients on new medication. Evidence has beenpublished recently to support the continuation of the service (see References & informationsources). Through the initial interview andmandatory follow-up, the patient continues to besupported. The service is accessible to house-bound patients (and others who choose to use it remotely) as it may be provided by telephone.In any pharmacist-led consultation, it is

important to give patients the opportunity to raisequestions at the beginning as they will be morereceptive to a pharmacist’s advice if they havetheir questions addressed first. The NMS, as a structured consultation around

specific questions, can lead to a variety ofinterventions. There are a number of suggestedquestions, which may be asked in a closed or open way. Many practitioners find that open (alternative) questions lead to a greaterunderstanding of patient needs around medicinessupport (see Table 2).

Providing post-discharge MURsThere is plenty of scope to improve the supportthat patients get after discharge from hospital.Views differ as to the ‘ideal’ time to conduct aMUR after discharge. Factors to consider are:• How many days’ supply of medicines the patientis likely to have when discharged from hospital

• Whether the patient has been using his/her ownmedicines while in hospital.

Having the right informationCommunity pharmacies do not generally receiveany information about patients admitted to or discharged from hospital. This is particularlyrelevant in light of the CQC report, which madespecific mention of the provision of medicinesdischarge information to community pharmacistsand indicates that patient confidentiality need notbe a barrier to information sharing under the NHSConfidentiality Code of Practice. The Summary Care Record, previously only

available to hospital-based pharmacists, is nowbeing rolled out to community pharmacists. This, together with integrated electronic referralsystems, now means that community pharmacistscan receive updated patient medication lists fromboth hospital and GP practices. It should be notedthat the SCR may reflect the recent, rather thanmost up-to-date record. There are a small number of community

pharmacies linked with GP practices electronicallyusing ‘hybrid’ systems, with direct access toclinical information and discharge summaries.

Planning post-discharge MURsTalk to your local GPs about supporting patientsafter discharge from hospital and suggest that youtrial the provision of post-discharge MURs with a small number of patients initially. Include thefollowing points in your discussion:• Potential benefits of MURs, scope of service,examples of issues that may be discussed

• Ask the GPs which patients they feel could benefit, how they might refer to you and howthey would like information shared with themafter a MUR

• Explain how your pharmacy meets NHSinformation governance requirements and whatinformation the GP could provide to supportyou (e.g. discharge letters).

Discussions with the patient may include:• Medicines reconciliation (hospital and post-discharge)

• The patient’s perception of the need for and use of medicines, including identifying any medicines stopped

• Patient adherence, tolerability, side-effects• Problem-solving regarding ordering, obtaining,taking and using medicines.

Under the service specification for MURs, thereare two criteria for reporting the findings of aMUR to the patient’s GP:

• Items within the MUR action plan that need to be considered by the GP or practice

Within seven days of conducting a MUR, thepharmacist is required to forward the overviewaction plan page to the GP and a professionaljudgement is required as to whether theconsultation page is also required. The GP is able to request all paperwork of the completedMUR as required.

• No items within the action plan thatneed to be considered by the GP/practice

A completed form need not be sent to theGP/practice, but they should be notified that a MUR has been completed within a month of it being carried out.

Information governance arrangementsPost-discharge MURs need to be considered in light of information governance (IG)requirements:

Electronic discharge form Where a discharge summary is faxed to a community pharmacy, the fax machine must be secure as there is patient identifiable information that can be seen. The IG lead should identify the risks associated with this.Consideration also needs to be given to the

storage of faxes, the visibility of the fax machineto members of staff and other patients, and thestorage and disposal of faxes in a secure manner.This is relevant to both discharge MURs andhospital referrals for the NMS.

Computer MUR forms Computer forms may be used to conduct a MURand will require password protection, back-upand secure printing facilities, and considerationgiven to their secure transport.

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Key information• Patient details: name, NHS number, address, contacttelephone number, discharge date

• Patient allergies: including details of reactions if known• Details of primary healthcare team: communitypharmacist, GP and any other relevant information

• Medicines list: including new, stopped or changedmedicines, and hospital recommendations and follow-up

• Referrer details: name, title, organisation, contactphone, fax and email, request for contact after the NMS.

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Hospital referral form

What can you do, working with your local hospitaltrusts, to implement the recommendations in the RoyalPharmaceutical Society’s ‘Getting the medicines right’document? (rpharms.com/medicines-safety/getting-the-medicines-right.asp)

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Read the updated guidance on the MUR service(October 2013). It is recommended pharmacistsparticipate in peer reviews to improve their practiceand to assure the quality of the MURs they provide. • How could you integrate peer-review into yourpractice with appropriate regard for patientconfidentiality?

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While it is possible within NHS IT systems to email these forms, some pharmacies still donot have NHS accounts. New systems are beingdevised to allow other secure web-based access,such as electronic referral pathways. These mustbe encrypted and comply with NHS informationgovernance requirements.

Paper-based MUR forms Storage of completed MURs, and partially and fully completed NMS forms (and their safedisposal), should be in line with IG arrangements.This should include the transfer of forms in asecure manner to the GP practice. Where hospitalreferrers are contacted after a NMS consultation,IG arrangements are required for any transfer ofinformation.

Improving transfer of care and promoting the NMSIn July 2011, the Royal Pharmaceutical Societylaunched ‘Keeping patients safe when theytransfer between care providers – getting themedicines right’, a campaign to improve information at transfer of care. Both dischargeNMS and MURs can support this. There is a national template that healthcare

professionals in secondary care can use to referpatients for discharge MURs or the NMS but anumber of hospitals are looking at modifyingtheir discharge letters to incorporate informationrelevant to NMS and discharge MURs, such asmandatory fields for medicines changes and newmedicines prescribed. These changes are likely tobe integrated with other developments such as

electronic medicines reconciliation and electronicprescribing. Modifications to discharge lettershave promoted referrals for the NMS and aredetailed on page 7 of the RPS guidance. At London North West Hospitals Trust, a

local initiative to support patients at risk of preventable medicines-related readmission hasbeen extended to promote referrals for dischargeMURs and the NMS in advance of electronicsystems being in place. Patients started on a NMS medicine, or those

who were considered to potentially benefit from adischarge MUR, were given a personalised referralletter and a verbal recommendation to access the services, following counselling on theirmedicines. However, feedback from communitypharmacists and patients showed that this did not promote uptake of the services. Community pharmacists were keen to

contact patients soon after discharge but weregenerally unaware that admission or dischargehad taken place and often did not have patientcontact numbers. The referral pathway has nowbeen modified to include: • Consenting patients agree to relevantinformation, including their phone number,being given to their nominated pharmacy toallow telephone follow-up. The patient is also given a copy of the patient leaflet from‘Community pharmacy services – guidance forhospitals’

• Consent is documented on the medication chart• Community pharmacists are alerted to theopportunity of a discharge MUR or NMS bytelephone when the patient is being discharged

• Contact between community pharmacist andpatient is promoted (e.g. by telephone soonafter discharge) enabling the pharmacist to offerthe appropriate service

• The referral is documented on the PMR system to alert the pharmacist to the potentialfor a NMS consultation or a MUR when thepatient next attends.

The future and next stepsThere is general agreement that post-dischargeMURs and the NMS have the potential to benefitpatients. Local work is needed to continue to find ways of raising patient awareness anddevelop information sharing with communitypharmacists. However, pharmacists can alsodevelop local post-discharge MUR policies incollaboration with GPs and hospital colleagues.In light of the continuing climate of austerity in

the NHS, services such as MURs and NMS post-discharge must be evaluated in terms of reductionof waste through improving adherence and thereduction in medicines errors after discharge. NHS operating frameworks have consistently

said that significant gains in quality and prod-uctivity are possible by encouraging co-operationat the interface. This includes health and socialcare, as well as primary and secondary care. They even go as far as suggesting that theintegration of these services is the key to seamlesscare. There is recognition that emergencyadmissions could be reduced or even prevented by implementing fully integrated services.

ConclusionPost-discharge NMS consultations and MURsoffer community pharmacy the opportunity tobecome an integral part of a patient’s pathwaybetween secondary and primary care. They canaid medication adherence, reduce waste andencourage patient participation in their own care,and will continue to have an important role insupporting medicines optimisation.

• Holland R et al. Does home-based medication review keep older people out of hospital? The HOMER randomisedcontrolled trial. BMJ 2005; 330:293

• Forster et al. Adverse drug events occurring following hospital discharge. J Gen Intern Med 2005; 20:317-323• Petty D. Can medicines management services reduce hospital admissions? PJ 2008; 280:123-125• PSNC MUR service specification. psnc.org.uk/wp-content/uploads/2013/06/MUR-service-spec-Aug-2013-

changes_FINAL.pdf • Royal Pharmaceutical Society (2013). Medicines optimisation: helping patients to make the most of medicines. Good

practice guidance for healthcare professionals in England. rpharms.com/promoting-pharmacy-pdfs/helping-patients-make-the-most-of-their-medicines.pdf

• Royal Pharmaceutical Society (2014). Hospital referral to community pharmacy: an innovators’ toolkit to support the NHS in England. rpharms.com/support-pdfs/3649---rps---hospital-toolkit-brochure-web.pdf

• NICE (2015). Medicines optimisation guidance. NICE guideline (NG5) • NHS Quality, innovation, productivity and prevention challenge: an introduction for clinicians

dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_113806 • Clifford S et al. Patient-centred advice is effective in improving adherence to medicines.

Pharm World Sci 2006; 28:165-170 • Elliott RA, Barber N, Clifford S, Horne R, Hartley E. The cost-effectiveness of a telephone-based pharmacy advisory

service to improve adherence to newly prescribed medicines. Pharm World Sci 2008 Jan 30(1):17-23• Gray A. Refer-to-pharmacy: pharmacy for the next generation now! A short communication for pharmacy.

Pharmacy 2015, 3, 364-371. mdpi.com/2226-4787/3/4/364

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References & information sources

• Which hospitals/wards might you need to develop arelationship with in order to receive more referrals forpatients with long-term conditions appropriate for apost-discharge NMS consultation?

• What do you need to know about a patient’s admissionand hospital stay to undertake a discharge MUR?

• What channels of communication are available to youand how could you document referrals securely?

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MURS AND The NMS AT DiSChARge CPD record

* If as a result of completing your evaluation you have identified another new learning objective, start a new cycle. This will enable you to start at Reflect and then go on to Plan, Act and Evaluate.This form can be photocopied to avoid having to cut this page out of the module. You can also

complete the module atwww.pharmacymagazine.co.uk and record on your personal learning log

May 2016

Pharmacy Magazine


viii CPD MARCH 2014 PHARMACY MAGAZINE PULL OUT AND KEEP

1. Which statement is TRUE?The NMS:

a. Optimises medicines usethrough provision ofinformation, education andadherence support for patientswith long-term conditions onspecific groups of medicines

b. Is the same as a MUR butfocuses on one newlyprescribed medicine at a time

c. May not be provided post-discharge for patientswho have not attended a localhospital

d. Can only be provided for anew medicine prescribed by a GP

2. The Summary Care Recordcan be used as part of theNMS or a MUR to:

a. Provide up-to-date hospitaldischarge informationincluding diagnosis,treatment and prescribedmedicines to allow dischargeMURs or the NMS to occur

b. Give the patient a copy oftheir latest medications post-hospital discharge

c. Support accurate medicationhistory with a patient’s ownrecords, PMR and hospitaldischarge referral

d. Link the communitypharmacy with the GPpractice

3. When should the full MURform be sent to the relevantGP following a post-discharge review?

a. Every timeb. Only if the GP requests itc. When there are norecommended changes

d. Only at the end of the month

4. MURs are available in:a. England and N. Irelandb. All four countries of the UK c. Scotland as a specified part ofthe CMS

d. Wales, where they are calledDischarge Medication Review

5. A referral into the NMS whendispensing the first scriptfor an item covered in theservice specification isrequired from:

a. Any primary healthcarepractitioner

b. The patient’s GP or hospitaldoctor only

c. No referral is neededd. The patient or carer

6. What percentage of MURseach year are required tobe targeted?

a. 70 per centb. 50 per centc. 33 per centd. 25 per cent

7. A post-discharge MUR isused to identify:

a. Long-term medicationinitiated by GPs

b. Adherence to national clinicalguidelines (e.g. NICE)

c. Clinical choice of medicinesd. Formulations that areunsuitable

8. Electronic referral for theNMS requires:

a. Information governanceapproval

b. The patient to attend thepharmacy for a review

c. A nhs.net account in thecommunity pharmacy

d. The patient to have an urgentneed for a NMS

Activity completed. (Describe what you did to increase your learning. Be specific)(ACT)

Date: Time taken to complete activity:

What did I learn that was new in terms of developing my skills, knowledge and behaviours? Have my learning objectives been met?*(EVALUATE)

Do I need to learn anything else in this area? (List your learning action points. How do you intend tomeet these action points?)(REFLECT & PLAN)

How have I put this into practice? (Give an example of how you applied your learning). Why did it benefit my practice? (How did your learning affect outcomes?)(EVALUATE)

Use this form to record your learning and action points from this module on MURs and the NMS at Discharge or record on your personal learning log at pharmacymagazine.co.uk.You must be registered on the site to do this. Any training, learning or development activitiesthat you undertake for CPD can also be recorded as evidence as part of your RPS Faculty practice-based portfolio when preparing for Faculty membership. So start your RPS Facultyjourney today by accessing the portfolio and tools at www.rpharms.com/Faculty.

You can also record in your personal learning log at pharmacymagazine.co.uk

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viii CPD OCTOBER 2015 PHARMACY MAGAZINE LEARNING SCENARIOS FOR THIS MODULE AT WWW.PHARMACYMAGAZINE.CO.UK PULL OUT AND KEEP

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MURs and the NMS at discharge

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