Fay Bradley

The challenge of integrating community pharmacists into the primary health care team: A case study of local pharmaceutical services (LPS) pilots and interprofessional collaboration

The aim of this paper is to investigate interprofessional collaboration between general practitioners (GPs) and pharmacists involved in the delivery of enhanced pharmacy services under the local pharmaceutical services (LPS) contract in England. Previous research suggests that a number of interprofessional barriers exist between community pharmacists and GPs which hinders the integration of community pharmacists into the primary health care team (PHCT). One of the aims of the LPS contract, introduced in England in 2002 as an alternative to national contractual arrangements, was to enable pharmacists to work more closely with other health care professionals. A two-stage survey was distributed to all pharmacists involved in the first wave of LPS and in-depth interviews undertaken with pharmacists and GPs at six of the LPS sites. Overall the level to which the LPS pharmacists felt integrated into the PHCT did not substantially increase with the introduction of LPS, although co-location was reported to have facilitated integration. New relationships were formed with GPs and existing ones strengthened. A good existing working relationship with GPs was found to be an important factor in the successful operation of the pilots as many were dependent on GPs for patient referrals. The findings suggest that establishing interprofessional collaboration between GPs and pharmacists is a piecemeal process, with a reliance on goodwill and trust-based relationships.

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.

Patient safety in healthcare preregistration educational curricula: multiple case study-based investigations of eight medicine, nursing, pharmacy and physiotherapy university courses

Background We sought to investigate the formal and informal ways preregistration students from medicine, nursing, pharmacy and the allied healthcare professions learn about patient safety. Methods We drew on Erauts framework on formal and informal acquisition of professional knowledge to undertake a series of phased theoretically informed, in-depth comparative qualitative case studies of eight university courses. We collected policy and course documentation; interviews and focus groups with educators, students, health service staff, patients and policy makers; and course and work placement observations. Data were analysed thematically extracting emerging themes from different phases of data collection within cases, and then comparing these across cases. Results We conducted 38 focus groups with a total of 162 participants, undertook 82 observations of practice placements/learning activities and 33 semistructured interviews, and analysed 44 key documents. Patient safety tended to be either implicit in curricula or explicitly identified in a limited number of discrete topic areas. Students were predominantly taught about safety-related issues in isolation, with the consequence of only limited opportunities for interprofessional learning and bridging the gaps between educational, practice and policy contexts. Although patient safety role models were key to student learning in helping to develop and maintain a consistent safety ethos, their numbers were limited. Conclusions Consideration needs to be given to the appointment of curriculum leads for patient safety who should be encouraged to work strategically across disciplines and topic areas; development of stronger links with organisational systems to promote student engagement with organisation-based patient safety practice; and role models should help students to make connections between theoretical considerations and routine clinical care.

The Role of Hidden Curriculum in Teaching Pharmacy Students About Patient Safety

Objective. To examine how hidden and informal curricula shaped pharmacy students’ learning about patient safety. Methods. A preliminary study exploring planned patient safety content in pharmacy curricula at 3 UK schools of pharmacy was conducted. In-depth case studies were then carried out at 2 schools of pharmacy to examine patient safety education as delivered. Results. Informal learning from teaching practitioners was assigned high levels of credibility by the students, indicating the importance of role models in practice. Students felt that the hidden lessons received in the form of voluntary work experience compensated for limited practice exposure and elements of patient safety not adequately addressed in the formal curriculum, such as learning about safe systems, errors, and professionalism. Conclusions. Patient safety is a multifaceted concept and the findings from this study highlight the importance of pharmacy students learning in a variety of settings to gain an appreciation of these different facets.

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.

Evolution of the general practice pharmacist’s role in England: a longitudinal study

Background To address the growing GP workforce crisis, NHS England (NHSE) launched the Clinical Pharmacists in General Practice scheme in 2015. The NHSE scheme promotes a newer, patient-facing role for pharmacists and, currently, there is little insight into the role and activities undertaken. All scheme pharmacists are enrolled on the general practice pharmacist training pathway (GPPTP). Aim To investigate the role evolution and integration of clinical pharmacists in general practice in England. Design and setting Longitudinal survey of all phase 1 GPPTP registrants working in general practice at start of (T1) and 6 months into (T2) training. Method An online longitudinal survey was administered to all phase 1 GPPTP registrants (n = 457) at T1 and T2, measuring their perceived knowledge, skill, and confidence, activities performed, and perceptions of practice integration, environment, and support. Descriptive statistics and non-parametric tests were conducted. Results Response rates were 46% (T1) and 52% (T2); 158 participants completed both questionnaires. Perceived knowledge, skill, and confidence levels increased significantly from T1 to T2 for all areas, except for managing acute or common illness. Scope of practice increased significantly, particularly in patient-facing activities. Sharing office space with administrative staff was common and 13% of participants reported having no designated work area. Perceived integration at T2 was fairly high (median = 5 on a scale of 1–7) but GP clinical support was ‘too little’ according to one-third of participants. Conclusion Findings show not only patient-facing role expansion, but also practice environment and support issues. Pharmacists may appreciate more GP time invested in their development. Practices need to be realistic about this support and not expect an immediate reduction in workload.

How do organisational configuration and context influence the quantity and quality of NHS services provided by English community pharmacies? A qualitative investigation

Community pharmacies are expanding their role into medicines-related healthcare and public health services, previously the domain of physicians and nurses, driven by policies to improve healthcare access for patients and to address problems of increasing demands and rising costs in primary and urgent care services. Understanding the organisational context into which this expansion is taking place is necessary given concerns over the extent to which pharmacies prioritise service volume over the quality of service provision. As part of a larger programme of work, this paper aims to explore stakeholder perceptions of the organisational and extra-organisational factors associated with service quality and quantity in community pharmacy as an established exemplar of private sector organisations providing publicly-funded healthcare. With ethics committee approval, forty semi-structured interviews were conducted with service commissioners, superintendent and front-line pharmacists, purposively selected from across nine geographical areas and a range of community pharmacy organisational types in England. Interviews were audio-recorded, transcribed verbatim and thematically analysed. Findings highlight the perceived importance of appropriate staffing and skill-mix for promoting service quantity and quality in community pharmacy. Organisational cultures which supported team development were viewed as facilitatory whereas those prioritising business targets over service quality seen to be inhibitive. Older local populations and low patient expectations were thought to limit service uptake as was poor integration with wider primary care services. The contractual framework and commissioning processes were also seen as a barrier to increasing service quality, quantity and integration in this sector. These findings suggest that healthcare administrations should take account of organisational and extra-organisational drivers and barriers when commissioning services from private sector providers such as community pharmacies to ensure that the quality of service provision is incentivised in addition to service quantity. Additionally, collaborative working should be encouraged through integrated commissioning mechanisms.