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

A realist evaluation of the development of extended pharmacist roles and services in community pharmacies

BACKGROUND

Internationally, community pharmacy models of care have been moving away from a focus on dispensing to extended, clinically-focused roles for pharmacists.

OBJECTIVES

To identify how community pharmacy strategies were being implemented in Aotearoa New Zealand; how changes were expected to influence health and health system outcomes; what extended services were being delivered; the responses of pharmacists, other health professionals and consumers to these developments; and the contexts and mechanisms supporting the successful implementation of new community pharmacy services.

METHODS

A realist evaluation methodology was employed, to explore a complex policy intervention. Realist evaluation explores the contexts (C) within which initiatives are introduced and identifies the mechanisms (M) triggered by different contexts to produce outcomes (O). Realist evaluation processes iteratively develop, test, and refine CMO configurations. In this study, initial programme theories were developed through key government and professional policy documents, then refined through key informant interviews, a survey and interviews with pharmacists and intern (pre-registration) pharmacists, and finally, 10 case studies of diverse community pharmacies.

RESULTS

Four intermediate health service outcomes were identified: development of extended community pharmacist services; consumers using extended community pharmacist services; more integrated, collaborative primary health care services; and a fit-for-purpose community pharmacy workforce. Enabling and constraining contexts are detailed for each outcome, along with the mechanisms that they trigger (or inhibit).

CONCLUSIONS

There are wide-ranging and disparate levers to support the further development of extended community pharmacy services. These include aligning funding with desired services, undergraduate educators and professional leaders setting expectations for the pharmacists' role in practice, and the availability of sufficient funding and time for both specific extended service accreditation and broader postgraduate training. However, no simple "fix" can be universally applied internationally, nor even in pharmacies within a single jurisdiction, to facilitate service development.

Developing a quality framework for community pharmacy: a systematic review of international literature

OBJECTIVE

To identify the defining features of the quality of community pharmacy (CP) services and synthesise these into an evidence-based quality framework.

DESIGN

Systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

International research evidence (2005 onwards) identified from six electronic databases (Embase, PubMed, Scopus, CINAHL, Web of Science and PsycINFO) was reviewed systematically from October 2022 to January 2023. Search terms related to 'community pharmacy' and 'quality'.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Titles and abstracts were screened against inclusion or exclusion criteria, followed by full-text screening by at least two authors. Qualitative, quantitative and mixed-method studies relevant to quality in CP were included.

DATA EXTRACTION AND SYNTHESIS

A narrative synthesis was undertaken. Following narrative synthesis, a patient and public involvement event was held to further refine the quality framework.

RESULTS

Following the title and abstract screening of 11 493 papers, a total of 81 studies (qualitative and quantitative) were included. Of the 81 included studies, 43 investigated quality dimensions and/or factors influencing CP service quality; 21 studies assessed patient satisfaction with and/or preferences for CP, and 17 studies reported the development and assessment of quality indicators, standards and guidelines for CPs, which can help define quality.The quality framework emerging from the global literature consisted of six dimensions: person-centred care, access, environment, safety, competence and integration within local healthcare systems. Quality was defined as having timely and physical access to personalised care in a suitable environment that is safe and effective, with staff competent in the dispensing process and pharmacy professionals possessing clinical knowledge and diagnostic skills to assess and advise patients relative to pharmacists' increasingly clinical roles.

CONCLUSION

The emerging framework could be used to measure and improve the quality of CP services. Further research and feasibility testing are needed to validate the framework according to the local healthcare context.

To be or not to be: The identity work of pharmacists as clinicians

This study explores how pharmacists legitimise the expansion of their clinical work and considers its impact on pharmacists' professional identity work. In the context of pharmacy in the English NHS, there has been an ongoing policy shift towards pharmacists moving away from 'medicines supply' to patient-facing, clinical work since the 1950s. Pharmacists are continuously engaging in 'identity work' and 'boundary work' to reflect the expansion of their work, which has led to the argument that pharmacists lack a clear professional identity. Drawing insights from linguistics and specifically Van Leeuwen's 'grammar of legitimation', this study explains how the Pharmacy Integration Fund, a nationally funded learning programme, provides the discursive strategies for pharmacists to legitimise their identity work as clinicians.

Enhancing the service quality of community pharmacies for non-prescription medicines based on the perspectives of pharmacists and patients: a qualitative study

BACKGROUND

Pharmacies in several countries are encountering a fierce competition from both local and international rivals, resulting in significant challenges in maintaining competitiveness and market share. Pharmacies are important locations for those seeking non-prescription medicines and are equipped to manage a wide variety of ailments. However, despite the large number of previous qualitative studies on the service quality of community pharmacies, very few studies have explored the service quality dimensions, specifically for non-prescription medications. In this study, we aimed to explore pharmacists' and patients' perception of potential pharmacy service quality for dispensing non-prescription medicines.

METHOD

Purposive and snowball sampling techniques were used to recruit and select qualified pharmacists and patients in the major cities of Thailand. Multiple face-to-face and telephone interviews were recorded, transcribed, and analysed systematically using the interpretive method of content analysis.

RESULTS

The participants reported several service attributes for dispensing of non-prescription medicines by community pharmacies. An analysis of the interviews revealed competence, communication, rapport, patient-centredness, and physical environment as the main themes related to service quality dimensions. Specifically, physical environment was categorized into two sub-themes, namely, hygiene and ambience.

CONCLUSIONS

Service quality dimensions of community pharmacies for non-prescription medications were supported by dyadic perspectives - pharmacist and patient perspectives. The findings of the study contribute to community pharmacy research by focusing on the potential dimensions of service quality, especially for non-prescription medicines.

A national survey of pharmacists and interns in Aotearoa New Zealand: provision and views of extended services in community pharmacies

Background

Changes in pharmacy models of care, services and funding have been occurring internationally, moving away from the traditional dispensing role to more extended patient-facing roles utilising pharmacists’ clinical skills. This study aimed to identify the extended services offered by community pharmacy in Aotearoa New Zealand and the barriers and facilitators to extended services provision. The study is unique in that it includes intern (pre-registration) pharmacists.

Methods

An online survey, conducted in 2018, of all pharmacists and intern (pre-registration) pharmacists working in a community pharmacy. Data were analysed using descriptive statistics and regression analyses.

Results

The results are based on replies from 553 community pharmacists and 59 intern pharmacists (response rate: 19 and 26% respectively). Both pharmacists (83%) and interns (85%) want to work at the top of their scope of practice. Wide variation exists in the specific services individual pharmacists offer. Most pharmacists were accredited to supply the emergency contraceptive pill (95%), sildenafil for erectile dysfunction (86%) and trimethoprim for uncomplicated urinary tract infection (85%). Fewer were able to immunise (34%) or to supply selected oral contraceptives (44%). Just under a quarter could provide a Medicines Use Review (MUR) or Community Pharmacy Anticoagulation Management Service (CPAMS). Of the pharmacists not already accredited, 85% intended to gain accreditation to supply selected oral contraceptives, 40% to become vaccinators, 37% to offer CPAMS and 30% MUR. Interns expressed strong interest in becoming accredited for all extended services.

Poisson regression analyses showed key factors supporting the likelihood of providing extended services were owner and management support and appropriate space and equipment. Being excited about the opportunities in community pharmacy, having employer funding and time for training and sufficient support staff were also statistically significant.

Conclusions

Pharmacists need time and a supportive management structure to enable them to deliver extended services. Health policy with a greater strategic emphasis on funding services and pharmacist training, and developing technician support roles, will help to minimise or eliminate some of the barriers to role expansion both in Aotearoa New Zealand and internationally.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07158-w.

Supporting patients with long-term conditions in the community: Evaluation of the Greater Manchester Community Pharmacy Care Plan Service

The Greater Manchester Community Pharmacy Care Plan (GMCPCP) service provided tailored care plans to help adults with one or more qualifying long-term condition (hypertension, asthma, diabetes and COPD) to achieve health goals and better self-management of their long-term conditions. The service ran between February and December 2017. The aim of this study was to investigate the impact of the service on patient activation, as measured by the PAM measure (primary outcome). Secondary outcomes included quality of life (EQ-5D-5L, EQ-VAS), medication adherence (MARS-5), NHS resource use and costs, systolic and diastolic blood pressure, HDL cholesterol ratio levels and body mass index (BMI). A before and after design was used, with follow-up at 6-months. A questionnaire was distributed at follow-up and telephone interviews with willing participants were used to investigate patient satisfaction with the service. The study was approved by the University of Manchester Research Ethics Committee. Quantitative data were analysed in SPSS v22 (IBM). A total of 382 patients were recruited to the service; 280 (73%) remained at follow-up. Ten patients were interviewed and 43 completed the questionnaire. A total of 613 goals were set; mean of 1.7 goals per patient. Fifty percent of goals were met at follow-up. There were significant improvements in PAM, EQ-5D-5L and EQ-VAS scores and significant reductions in systolic blood pressure, BMI and HDL cholesterol ratio at follow-up. Mean NHS service use costs were significantly lower at follow-up; with a mean decrease per patient of £236.43 (±SD £968.47). The mean cost per patient for providing the service was £203.10, resulting in potential cost-savings of £33.33 per patient (SD ± 874.65). Questionnaire respondents reported high levels of satisfaction with the service. This study suggests that the service is acceptable to patients and may lead to improvements in health outcomes and allows for modest cost savings. Limitations of the study included the low response rate to the patient questionnaire.

Applying a whole systems lens to the general practice crisis: cross-sectional survey looking at usage of community pharmacy services in England by patients with long-term respiratory conditions

OBJECTIVE

UK policy initiatives aiming to extend community pharmacy services to moderate patient demands and to reduce general practitioners' (GPs) workload have had limited success. This study used marketing theory to identify factors that could influence patients to make better use of community pharmacies within the primary care pathway.

DESIGN

Cross-sectional postal survey design applying the '7Ps marketing mix' ('product', 'price', 'place', 'promotion', 'people', 'process' and 'physical evidence').

SETTING

Greater Manchester, England.

PARTICIPANTS

Patients with asthma or chronic obstructive pulmonary disease registered at two GP practices.

PRIMARY OUTCOME

Patient preference for community pharmacy services.

RESULTS

The response rate was 29% (289/1003). Most respondents preferred to use GP practices for invasive/diagnostic services (product) while preferring using community pharmacy for medicines supply and minor ailments (place). Stronger preference for using GP practices over community pharmacy was significantly associated with gender (male>female), age group (≥65 years) and healthcare services previously accessed at the pharmacy. Respondents perceived they would be more likely to use community pharmacy services if pharmacists offered them enough time to discuss any concerns (73.3%) (price), if community pharmacies had private/clean consultation rooms (70%-73%) (physical evidence) and if pharmacy staff had strong interpersonal skills (68%-70%) (people). Respondents were divided on likelihood of using community pharmacy services if pharmacists could access their whole medical record but wanted pharmacists to add information about their visit (59.6%) (process). Respondents would be encouraged to use community pharmacy for healthcare services if they were offered services by pharmacy staff or recommended/referred to services by their GP (44%) (promotion).

CONCLUSIONS

Using the 7Ps marketing mix highlighted that community pharmacies having staff with strong interpersonal skills, good quality consultation rooms and integrated information systems could positively influence patients to use community pharmacies for management of long-term conditions. There are opportunities for community pharmacies to alleviate GP workload, but a whole system approach will be necessary.