Andrew Wagner

Determinants of the uptake of medicines use reviews (MURs) by community pharmacies in England: A multi-method study

OBJECTIVES To explore and identify the key determinants influencing the uptake of medicines use reviews (MURs), a new community pharmacy service in England. METHODS Survey of all primary care organisations (PCOs) in England (n=303, response rate=74%) and case study investigations of 10 PCOs, involving interviews with a purposive sample of 43 key stakeholders, including PCO, Local Pharmaceutical Committee and community pharmacy representatives. National data on MUR activity were also analysed and multiple linear regression was used to test determinants of MUR uptake. RESULTS The ownership category of the pharmacy was shown to be the most significant determinant of MUR uptake. Rates of MUR provision by multiple pharmacies were almost twice that of independent pharmacies. Interview data corroborated this finding, suggesting that organisational pressure within multiple pharmacies was driving forward MUR activity in some PCOs. Interviewees expressed concern about this quantity driven approach. The PCO survey respondents perceived the greatest barrier to MUR implementation to be a lack of support from general practitioners (GPs). Interviewees reported a lack of communication about MURs between community pharmacists and GPs. CONCLUSIONS The findings suggest that the organisational setting of the pharmacy is an important factor influencing the uptake of MURs. There is also a need for greater communication and collaboration with GPs regarding the MUR service.

Changing patient consultation patterns in primary care: An investigation of uptake of the Minor Ailments Service in Scotland

OBJECTIVES To study the impact and potential predictors of uptake of patient registrations and supplied medicines under the Minor Ailments Scheme (MAS) in Scotland. The MAS was introduced in 2006, intending to improve health care access by re-directing patients from primary care to community pharmacies. METHODS Numbers of dispensed MAS items and patient registrations were obtained for all community pharmacies in Scotland for the period 2006-2009. Local demographic and socioeconomic characteristics were attributed to community pharmacies as potential predictors of MAS service uptake. RESULTS There were significantly more MAS registrations in community pharmacies located in the most deprived areas. MAS registrations in rural areas were significantly lower than in urban areas. Rates of MAS items supplied ranged from 219.9 to 3604.6 items per 10,000 Health Board population in 2008/09. Urban pharmacies supplied 72.6 MAS items per month compared to 43.3 items per month by rural pharmacies. 96.7 items per month were supplied by pharmacies in the most deprived areas compared to 53.2 items per month in the least deprived areas. CONCLUSION There has been geographical variation in uptake of the MAS service. Community pharmacies under multiple ownership engaged in MAS activity to a greater extent than independent pharmacies, with higher uptake in community pharmacies located in deprived and urban areas.

Organisational and extraorganisational determinants of volume of service delivery by English community pharmacies: a cross-sectional survey and secondary data analysis

Objectives This study aimed to identify the organisational and extraorganisational factors associated with existing variation in the volume of services delivered by community pharmacies. Design and setting Linear and ordered logistic regression of linked national data from secondary sources—community pharmacy activity, socioeconomic and health need datasets—and primary data from a questionnaire survey of community pharmacies in nine diverse geographical areas in England. Outcome measures Annual dispensing volume; annual volume of medicines use reviews (MURs). Results National dataset (n=10 454 pharmacies): greater dispensing volume was significantly associated with pharmacy ownership type (large chains>independents>supermarkets), greater deprivation, higher local prevalence of cardiovascular disease and depression, older people (aged >75 years) and infants (aged 0–4 years) but lower prevalence of mental health conditions. Greater volume of MURs was significantly associated with pharmacy ownership type (large chains/supermarkets>>independents), greater dispensing volume, and lower disease prevalence. Survey dataset (n=285 pharmacies; response=34.6%): greater dispensing volume was significantly associated with staffing, skill-mix, organisational culture, years open and greater deprivation. Greater MUR volume was significantly associated with pharmacy ownership type (large chains/supermarkets>>independents), greater dispensing volume, weekly opening hours and lower asthma prevalence. Conclusions Organisational and extraorganisational factors were found to impact differently on dispensing volume and MUR activity, the latter being driven more by corporate ownership than population need. While levels of staffing and skill-mix were associated with dispensing volume, they did not influence MUR activity. Despite recent changes to the contractual framework, the existing fee-for-service reimbursement may therefore not be the most appropriate for the delivery of cognitive (rather than supply) services, still appearing to incentivise quantity over the quality (in terms of appropriate targeting) of services delivered. Future research should focus on the development of quality measures that could be incorporated into community pharmacy reimbursement mechanisms.

Influence of population and general practice characteristics on prescribing of minor tranquilisers in primary care

Prevalence of generalised anxiety disorders is widespread in Great Britain. Previous small-scale research has shown variations in minor tranquiliser prescribing, identifying several potential predictors of prescribing volume. Objective: This study aimed to investigate the relationship between general practice minor tranquiliser prescribing rates and practice population and general practice characteristics for all general practices in England. Methods: Multiple regression analysis of minor tranquiliser prescribing volumes during 2004/2005 for 8,291 English general practices with general practice and population variables obtained from the General Medical Services (GMS) statistics, Quality and Outcomes Framework (QOF), 2001 Census and 2004 Index of Multiple Deprivation (IMD). Results: The highest rates of minor tranquiliser prescribing were in areas with the greatest local deprivation while general practices situated in areas with larger proportions of residents of black ethnic origin had lower rates of prescribing. Other predictors of increased prescribing were general practices with older general practitioners and general practices with older registered practice populations. Conclusion: Our findings show that there is wide variation of minor tranquilisers prescribing across England which has implications regarding access to treatment and inequity of service provision. Future research should determine the barriers to equitable prescribing amongst general practices serving larger populations of black ethnic origin.

Equity in the distribution of community pharmacies in England: Impact of regulatory reform:

Objectives: To examine whether relaxation of control of entry regulations for community pharmacy contracts in England, introduced in 2005, affected the distribution of community pharmacies relative to population need indicators. Methods: Community pharmacy locations and population need indicators were used to calculate three summary measures of distributional equity across Primary Care Trust (PCT) areas (n = 152): the Gini coefficient, Atkinson Index and community pharmacies per PCT population. The indicators were adjusted for need using data from NHS GP contract Quality and Outcomes Framework disease registers, deprivation, all-cause mortality and elderly population rates. Results: Numbers of community pharmacies increased by 397 (4%) between 2005 and 2007 with three supermarket chains accounting for 152 (38%) of new pharmacies. Over one-quarter of PCTs experienced increases of 5% or more in community pharmacies per capita between 2005 and 2007. Gini and Atkinson indicators showed small increases in distributional equity across all population needs indicators. Conclusion: Deregulation was associated with more community pharmacies per capita and a small increase in geographic equity of community pharmacy distribution at PCT level. Future research should continue to monitor how pharmacy distribution changes over time and assess the extent to which the new regulatory framework has allowed clustering of pharmacies which could result in increased inequity below PCT level.