How pharmacists push NHS services
Documents obtained by the BBC reveal the techniques used by large pharmacy companies to maximise their income from providing certain services for the NHS in England.
The NHS pays pharmacies for extra services on top of the essential functions laid down in their basic contract. But questions have been raised about whether staff are pressurised into over-prioritising these opportunities to boost revenue or may treat them as a lucrative but perfunctory box-ticking exercise.
These services include Medicines Use Reviews (MURs), which assess whether patients are using their medication properly, and the New Medicine Service (NMS), which involves guidance to individuals given a new prescription for certain health conditions.
Under Freedom of Information, we obtained instructions issued to their branches about conducting MURs and NMS from the five largest pharmacy chains (excluding the supermarkets) - Boots, Lloyds, Rowlands, Superdrug and Well. The material includes advice on how to persuade patients to participate and stresses the profits that can be generated.
The documents disclose that Superdrug staff have been told: "Even though the patient has a choice of accepting or declining an MUR, it is important to make sure this is not emphasised during the conversation."
The company's internal advice adds: "At no point should you relate offering the MUR service to the patient as a benefit for the pharmacist or the pharmacy in general."
Superdrug's Best Practice guide for pharmacies urges them not to miss MUR opportunities just to save time when there are other customers waiting in a queue, as that approach "would be detrimental to your pharmacy performance". Instead the other customers should be asked to wait.
Other chains also pay a great deal of attention to the language their employees should use. Rowlands warns its staff offering MURs to "be prepared for KILLER questions" which could make them flustered and speechless.
These include: "Are you making money from this?" - to which the recommended answer is: "The NHS provides a fee to pharmacists for the time we spend on an MUR, which means this is a free service for patients and you will not have to pay anything."
Boots and Lloyds advocate using phraseology referring to a "need" to talk to the patient about their prescription for the New Medicine Service.
MURs can be a valuable process, particularly when targeted at patients taking several medicines or other high-risk categories, in ensuring the medication is being used in the most effective manner. Similarly, the New Medicine Service can usefully help patients with particular long-term conditions embark most productively on a new form of treatment.
However, the cost is substantial. In 2015-16, the NHS in England paid pharmacies £92m for MURs. For each MUR, the companies receive £28, but the NHS imposes a maximum of 400 for each pharmacy in each financial year. This can amount to £11,200 per branch. (The NMS payment structure is more complicated).
The disclosures also indicate the extent to which companies may push their pharmacists and other staff to maximise these NHS payments. There is a lot of emphasis from some firms on seizing all opportunities, setting and monitoring targets, and detailed countering of objections.
This issue has caused concern at the Pharmacists' Defence Association, the body which represents professional pharmacists. "MUR is a good service, but the problem is the way that it works," according to Mark Pitt, the PDA's assistant general secretary.
He said: "Pharmacists are put under huge pressure to meet targets for MURs and the NMS, whether or not they are achievable, while they try to get on with the day job of ensuring patients get their medication safely."
Mr Pitt added: "It can be a battle between doing the right thing professionally for patients and commercial pressure from the company."
The MUR system was introduced in 2005. The Co-operative pharmacy chain then told its branches that the result was "we are being paid for a service we already deliver", and that: "In the majority of cases, there are no additional costs to carry out MURs. Therefore, the benefit to the pharmacy is pure profit."
The Co-op pharmacy business is now under new management and has been re-branded as Well. According to Well, the people who wrote this no longer work for the firm.
Boots uses the term Medicine Check Ups (MCUs) for MURs. The company tells branch staff: "Driving MCUs should be one of your top priorities." On the NMS, it advises: "It increases patient loyalty and potential lock-in."
Well instructs its staff: "Once the maximum number of 400 MURs has been completed you must stop providing the service until the 1 April."
Any further reviews, whether or not they help patients, would not bring a firm extra income. It is clear from the published data that very few of England's 12,000 or so pharmacies across all companies told the NHS they carried out significantly more than 400 MURs in the last financial year. However, approximately 5,000 reported a number in the range 390 to 410.
The guidance from Rowlands informs staff that "income from these nationally commissioned services is clear profit to your branch".
Pharmacies sometimes find that locum pharmacists are not keen to pursue MURs. Rowlands advises that these cases should be discussed with area management and states: "Locums not delivering services may be removed from bookings."
Like some other firms, Lloyds encourages its pharmacists to do MURs in residential care homes, but it adds: "There will be cost associated with you leaving your pharmacy to visit the care home for MURs ... To make your visit financially worthwhile, you will need to take this into consideration."
In general, private sector firms are not covered by the Freedom of Information Act, which gives access to information held by public bodies. One exception is for companies providing pharmaceutical services on behalf of the NHS, although this is not widely known and the industry receives a limited number of FOI requests compared with public authorities.
The pharmacy companies deny that their commercial interests distort medical considerations or the informed consent of patients.
Jane Devenish, NHS standards pharmacist at Well, said: "The welfare of our patients is our overriding concern. Once the service cap is reached, the patient will still receive appropriate advice from our dedicated pharmacy teams as part of their ongoing responsibility to provide pharmaceutical care."
A Superdrug spokesperson said: "All our guidance is very clear that the core purpose of an MUR is to help the patient. The points you raise have been taken out of context. We ask our pharmacists to use their professional judgement at all times. At Superdrug, we put the patient's needs before profits which is why currently less than 5% of our pharmacies have reached the permitted limit of MURs."
Boots responded: "Our professional standard is clear: pharmacy services must be for the benefit of patients, not the attainment of commercial targets. Boots provides these services because they are fundamental in helping patients to make the most of their medicines. Pharmacy services are certainly not prioritised on grounds of deriving a commercial benefit."
Lloyds said: "The intention is certainly not to mislead patients. We reject any inferences that our pharmacists would have greater concern for profitability than the value the service would deliver to patients."
Rowlands did not respond to a request for comment.
- You can follow Martin Rosenbaum on Twitter as @rosenbaum6