The contribution of the Medicines Use Review (MUR) consultation to counseling practice in community pharmacies § Patient Education and Counseling

United New Formalising the pharmacist’s counseling role by providing payment, represents a means to enhance professional status. Greater emphasis on patient Objective: To understand the contribution of the Medicines Use Review consultation to counseling practice in community pharmacies. Methods: Qualitative study involving ten weeks of observations in two community pharmacies and interviews with patients and pharmacy staff. Results: ‘Traditional’ counseling on prescription medicines involved the unilateral transfer of information from pharmacist to patient. Over-the-counter discussions were initiated by patients and offered more scope for patient participation. The recently introduced MUR service offers new opportunities for pharmacists’ role development in counseling patients about their medicines use. However, the study ﬁndings revealed that MUR consultations were brief encounters dominated by closed questions, enabling quick and easy completion of the MUR form. Interactions resembled counseling when handing out prescription medicines. Patients rarely asked questions and indeterminate issues were often circumvented by the pharmacist when they did. MURs did little to increase patients’ knowledge and rarely affected medicine use, although some felt reassured about their medicines. Pragmatic constraints of workload and pharmacy organisation undermined pharmacists’ capacity to implement the MUR service effectively. Conclusion: Pharmacists failed to fully realise the opportunity offered by MURs being constrained by situational pressures. Practice implications: Pharmacist consultation skills need to be reviewed if MURs are to realise their intended aims.


Introduction
Reforms to the United Kingdom (UK) community pharmacy contract in England and Wales in 2005 sought to address pharmacy's heavy reliance on dispensing prescriptions to generate income by moving to reward patient-centred services [1,2]. The 'Medicines Use Review and Prescription Intervention' (MUR) service is one of a number of policy initiatives which seek to help people better manage their medicines as well as reduce the cost of wasted and inappropriate use of medicines [1,3,4]. MURs involve pharmacists undertaking a private consultation with the patient and aim to improve 'knowledge, concordance and use of medicines' [3]. The MUR involves completion of a national standard form.
Information that the pharmacist is expected to elicit from the patient in order to complete the form includes whether they use the medicine as prescribed, whether they know the medicine's purpose, if the formulation is appropriate and reported side effects. The format of the form is tick-box allowing a yes/no response to questions [3]. Patients are eligible for the service if they are taking two or more medicines and have been receiving pharmaceutical services from the pharmacy for at least three months. Pharmacies are entitled to claim £28 reimbursement from the NHS for each MUR performed with an annual maximum of 400. In England, 1.7 million MURs were conducted in the 2009-2010 financial year costing a total of £47.7m [5]. Pharmacists are required to include, in their discussion, both prescribed and over-the-counter (OTC) use of medicines within the MUR. The MUR initiative is in tune with other UK health policy commitments such as patient choice [6,7], re-shaping care around the patient [8] and greater involvement of patients in their medicines management [9]. Similar medication review schemes are provided in Australia [10], United States [11] and New Zealand [12]. Formalising the pharmacist's counseling role by providing payment, represents a means to enhance professional status. Greater emphasis on patient contact and counseling has been advocated by professional bodies and those wishing to reprofessionalise pharmacists' activities [13][14][15].
Most patient-pharmacist interactions still occur on the 'shopfloor' when the pharmacist supplies dispensed medicines to patients. This encounter, described in the UK as 'counseling', typically seeks to ensure that the directions on the labels of dispensed products are understood [16]. Variations have been reported in how pharmacists counsel on prescribed medicines; for example, information on directions, medicine name, and indications for use were given more frequently than information on side effects, cautions and interactions [17,18]. However, the community pharmacist's consultative role remains undeveloped and the concept of patient counseling ill defined [19]. Shah and Chewning [20] found that the definition of patient counseling varied across studies with half conceptualising patient-pharmacist communication as information provision. The predominantly information-based focus of patient-pharmacist interaction means that counseling in the pharmacy context carries a somewhat different meaning to that in other settings, such as psychotherapy, where there is a process of subjective scrutiny and greater engagement with, and contribution from, the client [19,21].
Another patient-pharmacist interaction relates to OTC sales of medicines. These are initiated by the patient and involve the offer of a professional opinion about a course of action, whist allowing the final decision to lie with the patient [22]. This level of indeterminacy requires negotiation and contrasts with counseling offered on dispensed medicines where patients' information needs may be assumed to have been addressed by the General Practitioner (GP) [21]. Although OTC interactions potentially offer more scope for the pharmacist to explore patient perspectives and concerns, they are usually problem-specific and have attracted criticism as lost opportunities to discuss wider health issues [21,23].
MURs present an opportunity for pharmacists to extend their currently limited counseling role in wider discussions of patient beliefs and concerns about their medicines. This paper aims to contextualise and better understand MUR consultations as they occur in the 'real world' setting of pharmacy practice and explores what they may additionally offer over 'traditional' patientpharmacist interactions for prescription and OTC medicines.

Methods
Following approval from a local NHS Research Ethics Committee, two pharmacies, a multiple and an independent were recruited purposefully via personal contacts. Consent was obtained from the pharmacists and support-staff for five weeks of observations in each pharmacy. One-week placements over a 12-month period between November 2008 and October 2009 allowed the data collection and analysis phases to proceed simultaneously. Pharmacies were requested to display posters within the pharmacy to promote patient awareness of the study.
Observation notes were made (by AL) of all pharmacy activities, the working environment, staff-patient conversations and all activities relating to MURs. Ethnographically orientated unstructured observation methods were used which involved detailed observation of behaviour and talk to better understand the social setting in which people function in their natural environment. AL recorded all aspects of the phenomenon and the context in which they occurred that seemed relevant to the situation being studied. This produced rich qualitative data in order to uncover behaviours or patterns of which the participants themselves may not have been aware [24]. The triangulation of direct observation (researcher's accounts) with accounts provided by respondents in inter-views provided a powerful means of understanding the complexity of respondents' views, how these may shift contextually, the situational pressures which underlie them, and the resulting difference in what people 'say' and what they 'do' [25].
All pharmacists and support-staff were requested to identify and invite patients for MURs as per normal practice and to introduce the research to all those who accepted the offer of an MUR. All such patients agreed to be included in the research and for their MUR to be observed, at which point AL was introduced and explained what was involved. Thus, AL was able to observe nearly all MURs taking place during the period of fieldwork while he was undertaking observation in the pharmacies. All extracts from the observation notes that are presented in this paper are taken from detailed notes written up after each observation, rather than verbatim quotes. Pseudonyms have been used in quoted extracts to maintain respondents' anonymity.
After the MUR patients were invited to take part in an interview about their experience. A topic guide was developed and tailored to the specific details and context of the MUR which preceded it (Box 1). The topic guide was used to stimulate an open discussion of topics and issues that were most salient for respondents rather than to impose the researcher's framework of understanding [25]. After the pharmacy observations, pharmacists and support-staff interviews were held to discuss their perceptions of MURs. Topic guides were developed to explore pharmacist (Box 2) and supportstaff (Box 3) perceptions of the MUR service. As with the patient interviews, staff interviews were individually tailored to clarify, confirm and extend the observational data.

Analysis
Data analysis started during the early stages of data collection. The focus of the observations and the interview topic guide were revised during the data collection period. This inductive approach is considered to be good qualitative practice [25,26]. All observation field note documents were typed up and all the interviews transcribed verbatim. The data were then imported into N-Vivo8.
A thematic approach to analysing the qualitative data was used and involved initially reading and re-reading each section of the text and collating them under different headings or 'codes'. The aim of coding is to ensure all the data that relates under the same Box heading can be retrieved with ease [26]. Categories from the interview transcripts and observation field notes were constructed based upon what was observed and reported in interviews. Box 4 provides an illustration of a section of the coding framework that was developed for the code 'workload pressures and targets'. Coded extracts were then systematically read through and the contents condensed so that all the different issues that were raised were recorded. Consideration was then given to how these issues might be grouped together in broader themes which were then synthesised and narrated. The principle of constant comparison were used to test and refine these themes. A detailed explanation of the data analysis process used is described by Ziebland and McPherson [26].

Study sites
The multiple pharmacy was located in a relatively affluent town, on a busy high street. The healthcare counter was located at the rear of the shop alongside the dispensary. The area did not allow private discussions so people could be overheard when speaking to pharmacy staff. The consultation room, installed to provide the MUR service, was located nearby and seldom used for other purposes. The room was well lit and contained two chairs and a small table.
The independent pharmacy was in a similarly affluent but residential suburb. The dispensary was behind the healthcare counter towards the rear and raised above the rest of the shop. Again there was no obvious place for private discussion. The consultation room was next to the dispensary and had been adapted for MURs from an existing office. The room had a window with net curtains allowing privacy and was rarely used for discussions with patients other than MUR consultations.

Pharmacist counseling during supplies of prescription medicines
Field notes included observations and reflections from 114 patient-staff dispensing interactions (see Box 5 for coding framework). Observations revealed that most patients came to the dispensary to fill their prescriptions. Patients' initial interaction was usually with pharmacy support-staff and limited to enquiries about when the patients' medicines would be ready to collect. Phrases typically used by the pharmacy staff to indicate their agenda to fill Rebecca: If you take less than 8 a day, then yes. Bye.

Observation Wk2 Independent
The above extract is a representative illustration of the unilateral approach that pharmacists took to counseling [19]. In this case, information about drowsiness was transmitted without first establishing whether the patient understood or was knowledgeable about this. During routine collection of prescriptions, information was typically delivered in an instructional manner with little twoway communication as illustrated by the following representative extract: Jane [pharmacist]: There's a note on your prescription that your metformin has been reduced from three times a day to twice a day, is that right? Patient: Yes.
Jane: Do you know about that? Patient: Yes. Jane: I wanted to make sure.

Observation Wk3 Multiple
Patients appeared comfortable with, or at least to accept this arrangement, for the provision of information. Questions asked by the pharmacist such as 'have you had this before?', 'has the doctor gone through this with you?' or 'do you know your dose of [medicine] has been increased?' received minimal responses from patients. Others have argued that the scope for providing new advice to patients is limited [21]. Occasionally, patients' asked questions, but these were mostly to clarify the practicalities of taking the medicine, such as the dose. There was an assumption that patients knew about their repeat medicines. However, evidence suggests that this may not be the case and additional support may be required [27,28] even though patients may believe that routine information on repeat medication is unnecessary and pharmacists are accessible for further information if required [29,30]. Pharmacists, working within real life constraints of a busy dispensary, were not observed actively identifying patients who may have needed additional support but rather confined their input to confirming the doctors' instructions.

Pharmacist-patient interactions over-the-counter
Field notes included observations and reflections on 100 customer-staff OTC interactions (see Box 5 for coding framework). The wide range of medicines and retail products available meant that there was an apparent freedom for customers to ask about a variety of health issues. OTC sales of medicines were routinely undertaken by medicines counter assistants (MCA). Customer-MCA interactions have been shown to be complex, characterised by multiple discourses in which both parties commit, to legitimise the MCA as a medical advisor [31]. Customer-pharmacist discussion in OTC interactions tended to be conversational and tailored to patients' specific requests for advice and information:

Observation Wk3 Multiple
As is illustrated in the above extract OTC discussions were more open and conversational in nature than counseling on prescribed medicines. In fielding enquiries directly from customers, the pharmacist often needed to establish something about the customers' circumstances and an understanding of the problem before recommending a treatment. The interactional focus was more 'patient-centred' or, as previous literature suggests, consumer-led [21]: [Discussion continues, after which patient purchases the medicine]

Observation Wk5 Independent
In this illustrative extract the pharmacist discussed with the customer adjusting the dose of the medicine according to her needs. However, the pharmacist neglected to enquire into the customer's lifestyle or other matters that may have been relevant to her weight management. Nevertheless, many OTC interactions served to address specific customer-initiated requests for advice and resembled what Pilnick describes as a 'stepwise' counseling approach, where knowledge and competence were explored in the encounter [19]. In these circumstances, customers who approached the pharmacy staff for advice appeared both familiar with and accepted the role of the pharmacist as an accessible adviser. However, the shop-floor environment was not conducive to more detailed or personal discussions.

MUR interactions
3.1.3.1. Participant response rate. Fifty-four patients gave consent for AL to observe their MUR consultation [32] and 34 patients agreed to be interviewed about their experience of the MUR. Most patient interviews were conducted at the pharmacy (two at the University), lasted around 45 minutes and all were audio-recorded.

The MUR consultation (see Box 5 for coding framework)
When inviting patients, pharmacists and staff often presented the MUR as a quick activity to ''check'' their medicines. Once patients had agreed and were seated, MUR consultations followed a similar pattern, directed by the pharmacist's use of the MUR form. Some patients reported surprise at being approached ad hoc. This was a deviation from the standard pharmacist interaction described above, and to which they were accustomed and so they felt unprepared for an extended consultation. However, most did not mind this approach [33]. Pharmacists began with a brief explanation of the purpose of the MUR. Patient-pharmacist roles and expectations were therefore constructed from the onset through the pharmacist's announcement of the agenda:

Kate [Pharmacist]
: This is to check your medicines that you're on and that they're not interacting with anything over-the-counter. . .

MUR 30 -Multiple
A question-answer sequence then followed where the pharmacist would ask the patient questions about their prescribed and OTC medicines. This enabled the MUR form to be completed quickly. All pharmacists were observed simultaneously completing the MUR form and talking to patients. Patients typically offered minimal responses to the closed nature of the pharmacist's questions:

MUR 11 -Multiple
This extract illustrates the procedural way most MURs were carried out by this pharmacist. All pharmacists dominated the consultation with nearly half of all patients observed not to ask any questions during the encounter (Table 1). Pharmacists did allow patients to talk and responded adequately to queries such as whether medicines could be taken together. However, they relied heavily on reference to the prescriber's instructions to circumvent or close down discussion of more indeterminate medicine-related matters: Jane [Pharmacist]: The fleconide, you take two twice a day?
Patient: I take one twice a day.
Jane: The doctor's got you down as two twice a day.
Patient: I take one in the morning and one at night. Jane: You need to have a word with the doctor. . .

MUR 19 -Multiple
Although MURs aim to investigate patient's understanding and use of medicines, patients often spoke of their illness. In several MURs pharmacists were seen to be cautious about prying into patients' medical affairs and in their interviews revealed an aversion to discussing sensitive issues. As is exemplified by the following extract the format of the MUR did not facilitate a discussion of the patient's medical condition or related concerns:

MUR 7 -Independent
The above extract shows a lack of pharmacist's curiosity to explore the uncertainty expressed by the patient about her diagnosis resulting in a lost opportunity to discuss something the patient might have found useful. Instead, the pharmacist provided information about how the medicine worked. Likewise, pharmacists were observed frequently embedding unsolicited advice about side effects on medicines in their discourse with patients. On a few occasions, patients did indicate during the MUR that they found the information provided useful: Patient: I have some antihistamines. . . that's ok isn't it with the coproxamol?
Rebecca [Pharmacist]: If they're the one-a-day ones then they're fine with everything that you're on. . .if you have dry eyes, and you find that you are using the drops more, than it might be the antihistamines that are doing that.

MUR 13 -Independent
Patients accepted advice when the pharmacist was able to frame the perceived benefits for the patient or convince them of avoiding future harm:

MUR 15 -Multiple
As a result of his MUR, the patient had stopped his glucosamine tablets and was going to speak to the diabetic nurse and his GP. Although the patient was content to do this, the pharmacist did not feel the need to contact the nurse or GP directly. Likewise, when patients revealed an unusual side effect or reported following personal regimes of medicine taking, the pharmacist dealt with these issues in a succinct and apparently superficial manner: Patient: . . .I find sometimes at night if I take three paracetamol for the pain it works.

Rebecca [Pharmacist]: You shouldn't really do that.
Patient: I find if I take three when the pain is bad it gets me to sleep.
Rebecca: Well, it's best to take two.
Patient: I don't do it often. . .

MUR 18 -Independent
As the extracts illustrate, the response of the pharmacist allowed the MUR to continue. However, the patient revealed in her interview a lack of acceptance of the pharmacist's advice as she reported that she would persist in her habit of taking three paracetamol. Rather than working with the patient, pharmacists took an inflexible view in circumstances where medication was being used in ways other than had been prescribed. The questions asked during the MUR consultation were therefore not focused on how to manage the patient's illness better with the aid of medicines, but whether the medicines were being used in a way that was acceptable in terms of the pharmacist's opinion and advice. Pharmacists occasionally asked at the end of the MUR whether the patient had any questions about their medicines; few responded to take up the invitation.

Patient experiences
Patients' reported being unfamiliar with the MUR, supporting previous research indicating patients' low expectation and a This was the number of prescribed and OTC medicines that were mentioned by the pharmacist or patient during the MUR and interviews. b The number of direct questions asked by pharmacists is presented here. However, pharmacists also used statements to confirm that patients were taking a particular medicine or taking a particular dose. These have not been included in the count. c There was one MUR where a patient and a carer were both present. Nine questions were asked; the carer asked five questions (one about his own health) and the patient asked four questions.
knowledge of the pharmacist's role [34]. Thirteen of the 37 patients interviewed reported previously having had an MUR; however, few could remember any details of this or actions taken as a result. The lack of purpose for the MUR, patients' inability to set their own agenda, as well as the structured way the consultation was framed, left some patients with the impression they were helping with a task the pharmacist was required to complete rather than taking part in a consultation for their own benefit: Esther: I don't mind, to me if I can help...I like to do it and it makes me feel good that I've helped somebody. . .

Patient interview -Independent
Most patients reported their MUR had not improved their knowledge and rarely affected their use of medicines (Box 6). Many patients already felt knowledgeable about medicines that had been prescribed for their long-term conditions. Nevertheless, a few patients reported parts of their MUR to be useful: Mia: . . .she said you need to go and see the asthma nurse. . .I thought I was on the most I could go on and I'd have to tolerate it but she said that they can help you more. . .

Patient interview -Multiple
Comfort: I think it gives you more confidence, it does me, gives me more confidence to think I'm doing the right thing and taking the right medicine

Patient interview -Multiple
Most patients appreciated and valued the time the pharmacist spent with them and described the MUR as ''satisfying'' or ''interesting''. The pharmacist was viewed as a knowledgeable expert and this served to reassure patients about their medicines (Box 6).
3.1.6. Staff views 3.1.6.1. Participant response rate. All pharmacy staff within both pharmacies were invited to be interviewed to discuss their perceptions of MURs. Five pharmacists who had been observed throughout the study were interviewed as well as 12 (out of 14) regular support-staff.

Organisational constraints
Every one of the five pharmacists was observed adopting several roles, as evidenced by other research [34], including dispenser, patient advocate, manager and health service provider. Pharmacists' heavy engagement in the dispensing process meant that most MURs were performed opportunistically when the pharmacy was less busy. With no additional staffing, MURs had been poorly integrated into the pharmacists' daily activities. In their interviews, pharmacists indicated that they felt constrained to speed through the MUR by the need to return to their 'routine' duties in the pharmacy (Box 6). Pharmacists, particularly those working for the multiple, reported feeling pressurised to deliver a targeted number of MURs. One pharmacist revealed that she purposefully chose patients on fewer medicines or simpler regimes that could be performed quickly despite acknowledging that those on more medicines or complex regimes potentially stood to benefit more: Jane: . . . you see a massive script, you think I don't want to do an MUR on that. But though, probably they would be the best people who would get the most out of it. You see a prescription that's got maybe two items on it, dead easy. . .the emphasis is on targets so . . .how conscious are you that you're going to be returning to a full checking bench? Jane: Very. You can't switch off from the fact that you know that's going on. And that's in the back of your mind. . .when you know that you're exceptionally busy, it puts you under a pressure and you really just want to get through that, those questions as quickly as possible. Because, you know you're going to go back to bedlam. . .You can't switch off from that, because that's part of your responsibility as well. Employee pharmacist, Multiple Theme: MUR target & pressure: Rebecca: . . .And I think Rose [owner] definitely understands though, which is why she has totally said that, I know it's very difficult to go from a busy setting, like you say, in the checking mode, in that mode and then to go to this whole consultative role. . . Employee pharmacist, Independent Researcher: . . .what support have you had with these Medicines Use Reviews? Apart from the support to be accredited? Kate: Yeah, no, they just pretty much throw you in at the deep end, they just don't want to know. They just want to know if you're meeting target. . . Employee pharmacist, Multiple Support-staff interviews Theme: Absent pharmacist: Lucy: I think it's frustrating from the fact that you know people are waiting for prescriptions and you're having to say 'the pharmacist has got a patient in with her at the moment'. People just want to go, don't they? They want their prescription, they're not bothered about why she's interviewing another patient. . .

Dispenser, Independent
Leah: There's also people that come in and ask specifically to speak to the pharmacist . . . they don't want us, they want the pharmacist. . .

Counter assistant, Multiple
it's quantity and not necessarily quality. . .So I think people are trying to get, do the easiest ones possible to get the numbers rather than concentrating on getting those that perhaps would benefit from it.

Employee pharmacist, Multiple
Support-staff reported tensions with patients who were awaiting prescriptions and with those wishing to speak with a pharmacist while the pharmacist was performing an MUR (Box 6). Support-staff were aware that they could interrupt the pharmacist in these circumstances and made personal judgements between interrupting a private consultation and appeasing waiting patients.

Discussion
Pharmacists in this study adhered to a format for conducting MURs which was largely determined by the structure of the MUR form. Although pharmacists fulfilled their obligation of asking the questions, the consultation left patients little scope for a more open discussion of their medicines. Pharmacists delivered information in an instructional manner in a way that was similar to their interaction with patients while dispensing medicines. These findings support previous literature indicating that the pharmacist's conversational turn aims to promote their agenda rather than altering in response to what the patient said; the pharmacist remained focused on the medicine rather than the patient's illness [35,36]. MURs have been criticised for promoting a professional agenda focusing on patient compliance, rather than concordance [37]. Consultation skills such as responding to patient cues, using open questions and eliciting the patient's perspective have been identified by others as areas that pharmacists need to improve [38]. Constrained by their remit, pharmacists were reluctant to engage with contentious or problematic issues and this meant that opportunities were lost for meaningful engagement. Far from providing an opportunity to develop skills and extend their professional authority, the routinised nature of the MUR reduced the pharmacists' scope for exercising professional judgement and autonomy. Nevertheless, most patients valued the time the pharmacist spent with them and the privacy of the MUR consultation. They saw pharmacists as knowledgeable experts who were able to reassure them about their medicines, supporting evidence that suggests benefit in developing community pharmacists' role both as a reviewer of patients' medicines and as an adviser [39].
In contrast to their handling of the MURs, this study showed that pharmacists could provide customised information in responding to patient requests for advice about minor ailments. In these circumstances, patients appeared both familiar with and accepted the role of the pharmacist as an accessible adviser. The autonomy and willingness of the pharmacists to accommodate patient preferences during OTC discussions was in contrast to their constrained approach when discussing prescribed medicines during the MUR. Whereas the pharmacists' role in dispensing and OTC activity could be conceptualised as a transformative activity, where the inert drug is transformed into a medicine for the individual patient [40,41], MUR activity was not observed to contribute to this process. Adopting a formulaic approach when filling out the questions on the MUR form left little room for discussions beyond the simple 'checking' of medicines.
The perceived pressure to pursue a targeted number of MURs was more prominent within the multiple and pharmacists reported dissatisfaction over the issue. Other studies have reported similar findings [42,43] suggesting that pharmacies are being remunerated for MURs which are not targeted at patients who may benefit most, leading to concerns over their value [44]. In this way, the commercialisation of MUR activity challenged rather than enhanced pharmacists' professional status; a finding highlighted by others [42,45]. Harding and Taylor warned simply: 'asking structured, formulaic questions' [41]. The MURs observed were at odds with policy commitments and strategies to develop a responsive service which is individually tailored and patientcentred [1,9].
To our knowledge this is the only observational study that has explored patient-pharmacist interactions and MUR consultations as they occurred naturally in practice. These findings make a significant contribution to the analysis of current pharmacy practice adding to existing doubts about the extent to which the MUR service is meeting its stated aims [42]. Limitations of this study include the unknown effect of the researcher's presence on the pharmacy staff's behaviour and on the pharmacist and patient during the MUR consultation. The longitudinal nature of the study was intended to reduce the extent to which participants modify behaviour as a result of a heightened awareness of the observer. Furthermore, audio or video recording the MUR consultation would have provided verbatim data. Nevertheless, it was decided that hand written notes would be used by the researcher to record the MUR consultation because of ethical considerations [32]. Only two pharmacies were investigated and the observations made by one researcher. Further research of patients' experience of MURs is clearly needed and in a wider and more diverse range of community pharmacy settings. Additional research should also investigate whether better targeting of MURs improves their outcome or whether this depends upon widening the pharmacist's remit when performing an MUR and improving their consultation skills.

Conclusion
MURs provide a nationally recognised counseling role for UK community pharmacists. However, several factors hindered pharmacists' capacity to engage effectively with patients. Pharmacists' heavy commitment to the dispensing process meant there was poor integration of the MUR service into their routine workload. Patients were unaccustomed to having a consultation with the pharmacist and lacked awareness of what it could offer. Consultations therefore served professional objectives rather than being patient-centred. The interactions and advice given within MUR consultations were predominantly instructional and resembled interactions about dispensed medicines. During OTC consultations, pharmacists involved patients to a greater extent indicating they already have many skills to effectively engage patients in decisions about their healthcare. However, pharmacists failed to take full advantage of the opportunities offered by MURs to fully involve patients, being constrained by situational pressures and commercial intent.
Theme: Staffing: Cath: . . .it's not practical for us to get two pharmacists . . .it's expense you're paying for two pharmacists at once. . . again it's money isn't it? How practical would it be to get another pharmacist. . . Counter assistant, Independent Stef: . . .they won't give us two pharmacists every day will they. . .so long as one is available. Counter assistant, Multiple

Practice implications
Although well intentioned, the MUR service is not realising its aim to improve patients' knowledge, understanding and use of medicines. Substantial changes to current practice are needed. If pharmacists are to engage in new consultative services a review of their communication skills training is required so they can better elicit and engage with patients' perspectives and concerns about taking medicines. Changes to policy also need to be considered particularly the way organisations implement and incentivise pharmacists to perform MURs so that patients who may benefit most are better targeted and pharmacists have the requisite space and time to incorporate MURs within their routine practice.