Releasing GP capacity with pharmacy prescribing support and New Ways of Working: a prospective observational cohort study

GPs' and pharmacists' views of integrating pharmacists into general practices: a qualitative study

BACKGROUND

Practice-based pharmacists (PBPs) have been introduced into general practice across the UK to relieve some of the pressures within primary care. However, there is little existing UK literature that has explored healthcare professionals' (HCPs') views about PBP integration and how this role has evolved.

AIM

To explore the views and experiences of GPs, PBPs, and community pharmacists (CPs) about PBPs' integration into general practice and their impact on primary healthcare delivery.

DESIGN AND SETTING

A qualitative interview study in primary care in Northern Ireland.

METHOD

Purposive and snowball sampling were used to recruit triads (a GP, a PBP, and a CP) from across five administrative healthcare areas in Northern Ireland. Sampling of practices to recruit GPs and PBPs commenced in August 2020. These HCPs identified the CPs who had most contact with the general practices in which the recruited GPs and PBPs were working. Semi-structured interviews were recorded, transcribed verbatim, and analysed using thematic analysis.

RESULTS

Eleven triads were recruited from across the five administrative areas. Four main themes in relation to PBPs' integration into general practices were revealed: evolution of the role; PBP attributes; collaboration and communication; and impact on care. Areas for development were identified such as patient awareness of the PBP role. Many saw PBPs as a 'central hub-middleman' between general practice and community pharmacies.

CONCLUSION

Participants reported that PBPs had integrated well and perceived a positive impact on primary healthcare delivery. Further work is needed to increase patient awareness of the PBP role.

Clinical pharmacists in primary care general practices: evaluation of current workforce and their distribution

BACKGROUND

General practices in primary care across England are increasingly employing clinical pharmacists to help tackle the workforce crisis and alleviate pressure. Clinical pharmacists can provide administrative and clinical duties, including non-medical prescribing, advice on polypharmacy and medicines optimisation. The aim of this study was to investigate the distribution of clinical pharmacists in general practice across England, and explore the relationship between the distribution and regional demography.

METHODS

This study used publicly available government database from various sources pertaining to primary care general practice workforce and population demographics of England. The number and distribution of pharmacists working within general practices in England were analysed and compared across practices considering general practitioner (GP), nurse and patient population in the practices, patients age ≥ 65 years and over and the Index of Multiple Deprivation (IMD) scores.

RESULTS

Twenty two percentage (1469 of 6674) of practices in England were found to have access to a clinical pharmacist, equating to 1358 full-time equivalent (FTE) pharmacists and a mean pharmacist FTE of 10.07 (95% CI 8.40, 11.75, SD = 9.84) per Clinical Commissioning Group (CCG). A significant relationship between pharmacist FTE and the number of patients 65 years and older [r (132) = 0.75, P < 0.001)] was observed; however, the distribution was not related to population deprivation scores.

CONCLUSIONS

Approximately one in five general practices in England have access to a clinical pharmacist. Further research is needed to ensure wider and equitable distribution based on workforce needs and practice population demography.

General practitioners' perceptions of pharmacists working in general practice: a qualitative interview study

BACKGROUND

Pharmacists are being increasingly employed as part of general practice teams globally, and their input has been associated with several clinical and economic benefits. However, there is a paucity of research focussing on general practitioners' (GPs') perceptions of pharmacist integration into practices in countries where this novel role for pharmacists is yet to become commonplace.

OBJECTIVE

To explore GPs' perceptions of integrating pharmacists into general practices and to identify the behavioural determinants of GPs integrating pharmacists into practices.

METHODS

Semistructured interviews were conducted with GPs practising in Ireland, who were sampled using a combination of purposive, convenience, and snowball sampling. Interviews were audio-recorded and transcribed verbatim, which then were analysed using conventional content analysis and directed content analysis employing the Theoretical Domains Framework (TDF).

RESULTS

Seventeen GPs were interviewed between November 2021 and February 2022. Seven TDF domains were identified as predominant in influencing GPs' perceptions of pharmacist integration into general practices. These perceptions were mostly positive, especially regarding patient outcomes, cost savings, and improving access to care. However, there were concerns about funding the role, affecting others' workloads, and pharmacists' training needs to work in practices.

CONCLUSION

This study's theory-informed insight provides a deeper understanding of GPs' perceptions of pharmacists working in general practice and behaviours which can be targeted to help optimize integration. These findings should be utilized in future service development to preempt and address GPs' concerns ahead of pharmacist integration, as well as to inform the development of general practice-based pharmacist roles going forward.

Social prescribing for frequent attenders in primary care: An economic analysis

Background

Social prescribing (SP) is a mechanism to link patients with community groups and third sector organizations. It offers a complimentary approach to the traditional medical models to address psychosocial needs of patients more effectively and in turn aims to reduce demand on the NHS. The aim of this study was to explore the economic benefits related to changes in the use of healthcare resources following a social prescribing intervention in four primary care practices in Wales.

Methods

Quantitative data from routine healthcare usage was collected from the 78 participants pre and post-intervention. The participants were grouped into frequent attenders (FA) (n = 21) and frequent (n = 57) non-attenders (FNA), and a cost analysis was conducted to estimate cost variances based on healthcare unit usage over the length of the pilot intervention. These were then extrapolated forward to identify potential healthcare savings.

Results

The SP as an intervention generated the largest cost saving for FAs. The cost variance when FAs participated in the intervention shows there is a direct cost saving of £6,113 or £78.37 per participant over the 5 months of the intervention.

Conclusions

Results suggest there may be a cost saving associated with SP interventions, however caution should be exercised in interpreting the results due to the lack of control group in this study The cost saving were largest for FAs, where the intervention reduced healthcare unit usage as well as actual and inferred impact on associated healthcare costs. This suggests that in practice to generate the maximum cost benefit SP interventions could be targeted at FAs.

New ways of working releasing general practitioner capacity with pharmacy prescribing support: a cost-consequence analysis

BACKGROUND

General practice in the United Kingdom is experiencing a workforce crisis. Greater multidisciplinary working, including more general practice pharmacists, is seen as part of the solution. However, it is unknown what impact and cost-consequences that pharmacists may have in freeing general practitioner (GP) capacity.

OBJECTIVE

To evaluate the cost-consequences of additional pharmacists in releasing GP capacity.

METHODS

This cost-consequences evaluation of a prospective observational cohort study in 15 urban practices involving 69 GPs in 1 locality serving a population of 82,000 people. GPs recorded the time they spent addressing key targeted prescribing activities during 5 distinct 2-week audit periods. Pharmacists performed these key prescribing activities to release GP capacity. An additional 225 h of pharmacists' time per week was committed to the locality. Standardized staff costings were used to estimate the financial impact. Prescribing indicator performance was assessed against the other 7 localities within the health board.

RESULTS

When compared with employing extra nonsalaried GPs this required an estimated additional investment of £16.73 (range £5.97-20.87) per h to free GP capacity. This achieved a sustainable 47% (73 h per week, F(4,56) = 16.05, P < 0.001) reduction in GP time spent on key prescribing activities; equating to 4.9 h (95% confidence interval 3.1-6.7) per practice per week. No significant step changes in locality safety and quality prescribing measures, and no negative effects on locality-level prescribing cost-efficiency work were observed.

CONCLUSION

Appropriately resourced general practice pharmacy teams delivered prescribing cost-efficiencies as well as sustainably freeing GP capacity by performing key prescribing activities.

Barriers and facilitators to implementation of non-medical independent prescribing in primary care in the UK: a qualitative systematic review

OBJECTIVES

To support workforce deficits and rising demand for medicines, independent prescribing (IP) by nurses, pharmacists and allied health professionals is a key component of workforce transformation in UK healthcare. This systematic review of qualitative research studies used a thematic synthesis approach to explore stakeholders' views on IP in primary care and identify barriers and facilitators influencing implementation.

SETTING

UK primary/community care.

PARTICIPANTS

Inclusion criteria were UK qualitative studies of any design, published in the English language. Six electronic databases were searched between January 2010 and September 2021, supplemented by reference list searching. Papers were screened, selected and quality-appraised using the Quality Assessment Tool for Studies with Diverse Designs. Study data were extracted to a bespoke table and two reviewers used NVivo software to code study findings. An inductive thematic synthesis was undertaken to identify descriptive themes and interpret these into higher order analytical themes. The Diffusion of Innovations and Consolidated Framework for Implementation Research were guiding theoretical anchors.

PRIMARY AND SECONDARY OUTCOME MEASURES

N/A.

RESULTS

Twenty-three articles addressing nurse, pharmacist and physiotherapist IP were included. Synthesis identified barriers and facilitators in four key stages of implementation: (1) 'Preparation', (2) 'Training', (3) 'Transition' and 4) 'Sustainment'. Enhancement, substitution and role-specific implementation models reflected three main ways that the IP role was used in primary care.

CONCLUSIONS

In order to address global deficits, there is increasing need to optimise use of IP capability. Although the number of independent prescribers continues to grow, numerous barriers to implementation persist. A more coordinated and targeted approach is key to overcoming barriers identified in the four stages of implementation and would help ensure that IP is recognised as an effective approach to help alleviate workforce shortfalls in the UK, and around the world.

PROSPERO REGISTRATION NUMBER

CRD42019124400.

The standards of practice for delivery of polypharmacy and chronic disease medication reviews by general practice clinical pharmacists: a consensus study

Background General practice in the UK is experiencing a crisis. Greater multidisciplinary working is a potential solution. The new general practice contract in Scotland encourages this and includes a new pharmacotherapy service to be delivered by General Practice Clinical Pharmacists (GPCPs). Consensus is lacking for the standards of practice for delivery of pharmacotherapy medication reviews (which are polypharmacy and chronic medication reviews) as part of this service. Aim To identify and validate standards of practice for polypharmacy and chronic disease medication (pharmacotherapy level 3) reviews conducted by GPCPs. Method A two-phased mixed-methods consensus methodology was used. Phase 1: An expert group of GPCPs (n = 4) and clinical pharmacist managers (n = 2) responsible for delivering the pharmacotherapy service used a Modified Nominal Group Technique to generate potential standards. Phase 2: Two-round Delphi survey involving GPCPs with ≥ 1 year of experience of working in general practice (n = 159). Results The expert group identified 44 potential standards of practice for polypharmacy and chronic disease reviews. Practicing GPCPs indicated during the Delphi phase that the 44 standards were applicable to practice. The standards of practice covered seven main categories: skills, environment, qualifications, qualities and behaviours, knowledge, process and experience. Conclusion Practicing GPCPs indicated that the standards identified by the expert group are acceptable and valid for current practice and the delivery of polypharmacy and chronic medication reviews. The application of these standards to practice may help GPCPs and general practices to ensure equitable delivery of patient care.

Educational supervision to support pharmacy professionals' learning and practice of advanced roles

Pharmacy professionals are increasingly moving into advanced roles, including in primary care. In England, the publicly funded Pharmacy Integration Fund (PhIF) enabled employment and training of pharmacy professionals in new patient-facing roles, including general practice and care homes. In recognition of the need for support and supervision during work-based learning and building on established support structures in medicine and nursing, one of the providers of PhIF funded learning developed a supervision structure which mirrors arrangements for postgraduate medical specialty training. This paper describes what informed this supervision model, with a particular focus on educational supervision, its delivery, and the training which was developed to support supervisors. This supervision enabled pharmacy professionals moving into primary care to practise safely, manage workplace challenges, extend their roles and make progress with their education. This model illustrates the benefits of supervision in supporting post-registration learning to facilitate the development of advanced patient-facing clinical roles.

Introducing multi-component cardiovascular health screening into existing Abdominal Aortic Aneurysm (AAA) screening programmes in the UK: a qualitative study of programme staff views

BACKGROUND

Cardiovascular disease is a major contributor to poor health in the UK and the leading cause of death in England. Peripheral arterial disease and high blood pressure are conditions that identify individuals at high cardiovascular disease risk, likely to benefit from cardiovascular risk management. Both conditions remain considerably underdiagnosed and untreated. The National Health Service abdominal aortic aneurysm (AAA) screening programmes represent an opportunity to screen for these conditions with potentially minimal additional effort or cost. We explored AAA screening programme staff views on the proposed introduction of such additional screening within AAA screening.

METHODS

Nine focus groups and seven follow-on interviews were undertaken with 38 AAA screening staff. Our study methods were oriented broadly towards a grounded theory methodology, and data were analysed using thematic analysis.

RESULTS

Three themes were identified: (i) 'Perceptions of patient experience and health-related outcomes', (ii) 'Opportunities and challenges for programme staff', and (iii) 'Maintaining and improving programme standards'. Staff talked about the high uptake of AAA screening, staff experience and skills in their role, and the programme's high quality standards as both opportunities and potential challenges linked to the proposed additions to AAA screening. While positive about the potential to improve patients' health outcomes, participants had questions about the practicalities of incorporating additional procedures within their time- and resource-constrained context, and how this may reconfigure work processes, roles and relationships.

CONCLUSIONS

The proposed additions to the programme require taking staff's views into account. Key areas that need to be addressed relate to ensuring follow-up support for patients, clarity around staff responsibilities, and availability of sufficient resources for the programme.

Role dimensions of practice nurses and interest in introducing advanced nurse practitioners in general practice in Ireland

Background

Internationally many countries have implemented strategies to enhance primary care, to strengthen their health systems to cope with an aging population, the rise of chronic conditions, and increased costs. Primary care has the potential to address these challenges, however, general practitioners are increasingly struggling to meet patient demand resulting from a growing and aging population. Expanding the role of general practice nurses to advanced nurse practitioner (ANP) level has worked internationally and could equally be a solution to the Irish context. However, their current role must first be established as well as their level of interest in becoming an ANP.

Aim

To explore the role of general practice nurses and their interest in becoming an ANP.

Design

A survey design.

Method

A purposeful sample of general practice nurses (n = 40) was undertaken between April and June 2019. Data were analyzed using the Statistical Package for Social Science (SPSS V 25.0; IBM).

Results

General practice nurses appear to have an agenda in relation to activities associated with wound care, immunizations, respiratory and cardiovascular issues. Just over half of the respondents were not interested in becoming an ANP. Their perceived challenges associated with the implementation of the role include a lack of support from general practitioners, a lack of resources, insurance issues, and a lack of understanding of the role. Challenges were associated with undertaking further training and their experience of having more work transferred to general practice without concomitant reallocation of resources.

Conclusion

General practice nurses have extensive clinical experience to deliver major improvements in primary care. Educational opportunities need to be provided for upskilling existing general practice nurses to advanced practice level. Greater understanding of the role and the potential contribution of the role in general practice is required among medical colleagues and the public.

Associations of primary care workforce composition with population, professional and system outcomes: retrospective cross-sectional analysis

Background: Diversification of types of staff delivering primary care may affect professional, population and system outcomes. Aim: To estimate associations between workforce composition and outcomes. Design and Setting: Cross-sectional analysis of 6210 GP practices in England in 2019. Method: Multivariable regression analysis relating numbers of staff in four groups (GPs; Nurses; Health Professionals; and Health Associate Professionals) to patient access and satisfaction, quality of clinical care and prescribing, use of hospital services, GP working conditions, and costs to National Health Service. Results: More GPs were associated with higher satisfaction for patients and GPs, More workers of other types had opposite associations with these outcomes. More Nurses and Health Associate Professionals were associated with lower cost per prescription but more prescribing activity. More GPs were associated with higher costs per prescription and lower use of narrow-spectrum antibiotics. Except for Health Associate Professionals, more staff were associated with more hospital activity. Higher NHS costs were associated most with more Nurses and least with more Health Professionals. The effects of different staff types on outcomes were largely independent. Conclusion: Professional, population and system outcomes show a variety of associations with primary care workforce composition. More Nurses are associated with lower quality in some aspects and higher costs and activity. More Health Professionals and Health Associate Professionals associates less than additional GPs with higher costs, but is associated with lower patient and GP satisfaction.

General practitioners' experiences with, views of, and attitudes towards, general practice-based pharmacists: a cross-sectional survey

Background

There is limited United Kingdom (UK) literature on general practice-based pharmacists’ (PBPs’) role evolution and few studies have explored general practitioners’ (GPs’) experiences on pharmacist integration into general practice. Therefore, this study aimed to investigate GPs’ experiences with, views of, and attitudes towards PBPs in Northern Ireland (NI).

Methods

A paper-based self-administered questionnaire comprising four sections was mailed in 2019 to 329 general practices across NI and was completed by one GP in every practice who had most contact with the PBP. Descriptive analyses were used and responses to open-ended questions were analysed thematically.

Results

The response rate was 61.7% (203/329). There was at least one PBP per general practice. All GPs had face-to-face meetings with PBPs, with three-quarters (78.7%, n = 159) meeting with the PBP more than once a week. Approximately two-thirds of GPs (62.4%, n = 126) reported that PBPs were qualified as independent prescribers, and 76.2% of these (n = 96/126) indicated that prescribers were currently prescribing for patients. The majority of GPs reported that PBPs always/very often had the required clinical skills (83.6%, n = 162) and knowledge (87.0%, n = 167) to provide safe and effective care for patients. However, 31.1% (n = 61) stated that PBPs only sometimes had the confidence to make clinical decisions. The majority of GPs (> 85%) displayed largely positive attitudes towards collaboration with PBPs. Most GPs agreed/strongly agreed that PBPs will have a positive impact on patient outcomes (95.0%, n = 192) and can provide a better link between general practices and community pharmacists (96.1%, n = 194). However, 24.8% of GPs (n = 50) were unclear if the PBP role moved community pharmacists to the periphery of the primary care team. An evaluation of the free-text comments indicated that GPs were in favour of more PBP sessions and full-time posts.

Conclusion

Most GPs had positive views of, and attitudes towards, PBPs. The findings may have implications for future developments in order to extend integration of PBPs within general practice, including the enhancement of training in clinical skills and decision-making. Exploring PBPs’, community pharmacists’ and patients’ views of this role in general practice is required to corroborate study findings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01607-5.

Competencies required for General Practice Clinical Pharmacists providing the Scottish Pharmacotherapy Service: A modified eDelphi study

Due to work load pressures in primary care, increasing efforts are being made internationally to implement pharmacists working alongside general practitioners. While there is wide interest in the contributions pharmacists can make within primary care, there is limited research which explores the competencies pharmacists need to safely and effectively provide care in this arena. Therefore, a modified eDelphi study was conducted between July 2019 and January 2020 among pharmacists working in General Practice in Scotland in order to (a) generate a list of competencies required to undertake pharmacotherapy tasks within General Practice using content analysis; and (b) establish consensus regarding the importance of these competencies using a rating scale ranging from 1 ("not important") to 10 ("very important"). A framework of competencies was developed, containing eight competency categories with a total of 31 individual competency items. Overall, study participants considered all eight competency categories as being important, with a mode of 10 and a median >8; agreement among participants was high, with the majority of individual competency items rated 8 or above by more than 75% of participants. There was, however, variation in responses with regards to specific tasks such as medicines reconciliation and medication compliance reviews. Findings indicate that the GP setting requires a broad set of competencies-covering areas including the use of IT systems; clinical knowledge; and communicating with patients and other healthcare professionals. This implies that further emphasis on clinical and consultation skills should be added to training programmes aimed at GP pharmacists; furthermore, ongoing support is also needed with regards to generic skills such as the use of IT systems, documentation, and general procedures and processes within primary care, some of which might need to be tailored to the specific practice context.

'I thought it would be a very clearly defined role and actually it wasn't': a qualitative study of transition training for pharmacists moving into general practice settings in Wales

OBJECTIVE

Pharmacists are increasingly contributing to the skill mix of general practice surgeries to help alleviate pressures faced by UK doctors working in primary care. However, they need support in overcoming barriers to their integration. The purpose of this work was to evaluate a programme designed to support pharmacists' transition to working in general practice settings. We explored the learning needs of pharmacists', the barriers and enablers to their integration and provide recommendations based on our results.

INTERVENTION

A qualitative evaluation of a 1-year transition programme in Wales starting in September 2018 to support pharmacists' transition to working in general practice settings.

DESIGN AND SETTING

We employed an interpretative phenomenological approach involving 10 pharmacists across Wales enrolled on the transition to general practice training programme, and their tutors. Data were collected across two sequential phases: in phase 1 telephone interviews were held with pharmacists midway through their training; in phase 2, focus groups were conducted with both pharmacists and tutors towards the end of the programme.

RESULTS

Pharmacists enter general practice settings with a variety of prior experience. The programme provided a framework that pharmacists found helpful to map their experience to but the programme needed to be flexible to individual learning needs. The tutor role was typically regarded as the most valuable component, but interaction with the wider general practice team was critical to ease the transition. Pharmacists encountered a lack of clarity about their role which impeded their integration into the workplace team.

CONCLUSIONS

A formal programme with a designated tutor can support pharmacists' transition into general practice settings. The programme's competency framework facilitated reciprocal understanding of the pharmacist's role in the team, helped to manage expectations and enhanced collaborative practice. Recommendations to facilitate pharmacist integration into general practice settings are provided.

Implementation of pharmacist-led services in primary care: A mixed-methods exploration of pharmacists' perceptions of a national educational resource package

Background:

To help alleviate the global pressure on primary care, there has been an increase in the number of clinical pharmacists within primary care. Educational resources are necessary to support this workforce and their development within this role. An educational resource package was developed in Scotland to support the General Practice Clinical Pharmacists (GPCPs), containing a hard copy Competency and Capability Framework (CCF), an online platform (TURAS) and both clinical and educational supervisors in 2016.

Objective:

To examine the implementation of a competency-based educational resource package through the exploration of pharmacists’ perceptions of its adoption, acceptability, appropriateness, and feasibility.

Methods:

Participants were GPCPs who had been part of a national training event between 2016 and 2018. The participants were given the opportunity to complete an online questionnaire or a semi-structured telephone interview. Both data collection tools were based on Proctor’s model of implementation outcomes: adoption, acceptability, appropriateness and feasibility. Areas covered included GPCPs’ perceptions and level of adoption of the educational resource package developed to support them in their role.

Results:

Of a potential 164 participants, 52 (31.7%) completed the questionnaire and 12 (7.3%) completed the interview. GPCPs indicated widespread adoption and were accepting of the resources; however, it was suggested that its value was undermined, as it was not associated with a qualification. The appropriateness and feasibility of the resources depended on GPCPs’ individual situation (including current role, previous job experience, time available, support received from peers and supervisors, and perceptions of resources available).

Conclusions:

The suitability of the CCF was evidenced by participants’ adoption and acceptance of the resource, indicating the necessity of a competence-based framework to support the GPCPs’ role. However, its suitability was hindered in terms of varied perceptions of appropriateness and feasibility. Despite the limited sample size, the results indicate that the value of these resources should be promoted across primary care; nevertheless further facilitation is required to allow GPCPs to fully engage with the resources.

A systematic review of general practice-based pharmacists' services to optimize medicines management in older people with multimorbidity and polypharmacy

BACKGROUND

Few studies have evaluated roles of general practice-based pharmacists (PBPs), particularly in optimizing medicines management for older people with both multimorbidity and polypharmacy.

OBJECTIVE

To explore the types and effectiveness of services provided by PBPs, either alone or in collaboration with other primary health care professionals, that sought to optimize medicines management for older people with multimorbidity and polypharmacy.

METHODS

Eight electronic databases and three trial registries were searched for studies published in English until April 2020. Inclusion criteria were randomized controlled trials, non-randomized controlled trials and controlled before-and-after studies of services delivered by PBPs in primary care/general practice, for patients aged ≥65 years with both multimorbidity and polypharmacy that focused on a number of outcomes. The Cochrane risk of bias tool for randomized trials (RoB 1) and the Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I) assessment tool were used for quality assessment. A narrative synthesis was conducted due to study heterogeneity.

RESULTS

Seven studies met inclusion criteria. All included studies employed PBP-led medication review accompanied by recommendations agreed and implemented by general practitioners. Other patient-level and practice-level interventions were described in one study. The limited available evidence suggested that PBPs, in collaboration with other practice team members, had mixed effects on outcomes focused on optimizing medicines management for older people. Most included studies were of poor quality and data to estimate the risk of bias were often missing.

CONCLUSION

Future high-quality studies are needed to test the effects of PBP interventions on a well-defined range of medicines management-related outcomes.

Towards transforming community eye care: an observational study and time-series analysis of optometrists' prescribing for eye disorders

OBJECTIVES

This study aimed to provide evidence on the therapeutic prescribing activity by community optometrists in Scotland and to determine its impact on workload in general practice and ophthalmology clinics.

STUDY DESIGN

Scottish administrative healthcare data for a 53-month period (November 2013-April 2018) were used to analyse non-medical prescribing practice by optometrists.

METHODS

Using interrupted time-series regression (Autoregressive Integrated Moving Average), we assessed the impact of optometrist prescribing on ophthalmology outpatient attendances and general practice prescribing for eye disorders.

RESULTS

A total of 54,246 items were prescribed by 205 optometrists over the study period. Since the commencement of data recording, optometrist prescribing activity increased steadily from a baseline of zero to 1.2% of all ophthalmic items prescribed. Neither the monthly number of items prescribed nor the size of optometric workforce were associated with a reduction in ophthalmology outpatient appointments over time.

CONCLUSIONS

Optometrists increasingly contribute to community ophthalmic prescribing in Scotland, releasing capacity and lessening general practice, but not secondary care workload. There appears to be an underutilisation of optometrists related to the management of dry eye, which represents an opportunity to release further capacity.

Multiplicity and complexity: a qualitative exploration of influences on prescribing in UK general practice

OBJECTIVES

Despite widespread availability of evidence-based guidelines to inform rational use of medicines, considerable unwarranted variation exists in prescribing. A greater understanding of key determinants of contemporary prescribing in UK general practice could inform strategies to promote evidence-based prescribing. This study explored (1) current influences on prescribing in general practice and (2) the possibility that general practice-based pharmacists (PBPs) may contribute to greater engagement with evidence-based prescribing.

DESIGN

Semistructured, telephone interviews and a focus group were conducted, audio-recorded and transcribed verbatim. Thematic analysis was undertaken.

PARTICIPANTS

General practice prescribers: general practitioners (GPs), PBPs, nurses.Key informants: individuals within the National Health Service (NHS) with responsibility for influencing, monitoring and measuring general practice prescribing.

SETTING

General practices and NHS organisations in England.

RESULTS

Interviews with 17 prescribers (GPs (n=6), PBPs (n=6), nurses (n=5)) and 6 key informants, and one focus group with five key informants were undertaken between November 2018 and April 2019. Determinants operating at individual, practice and societal levels impacted prescribing and guideline use. Prescribers' professional backgrounds, for example, nursing, pharmacy, patient populations and patient pressure were perceived as substantial influences, as well as media portrayal and public perceptions of medicines.Prescribers identified practice-level determinants of prescribing, including practice culture and shared beliefs. Key informants tended to emphasise higher-level influences, including NHS policies, availability of support and advice from secondary care and generic challenges associated with medicines use, for example, multimorbidity.Participants expressed mixed views about the potential of PBPs to promote evidence-based prescribing in general practice.

CONCLUSION

Prescribing in UK general practice is influenced by multiple intersecting factors. Strategies to promote evidence-based prescribing should target modifiable influences at practice and individual levels. Customising strategies for medical and non-medical prescribers may maximise their effectiveness.

Public perceptions and experiences of the minor ailment service in community pharmacy in Scotland

BACKGROUND

The Minor Ailment Service (MAS) in Scottish community pharmacy allows eligible people to gain improved access to care by providing free treatment for self-limiting conditions.

OBJECTIVE

To determine the perceptions and experiences of individuals using MAS and to quantify the potential impact on usage of other healthcare services.

METHODS

A cross-sectional survey was conducted of patients accessing MAS across Scotland during June and July 2018. Questionnaire items included reasons for choosing treatment through MAS, which other services they may have accessed had MAS not been available, experiences of consultation, overall satisfaction, and perceived effectiveness of treatment. Those accessing MAS were given a study pack including an information sheet, pre-piloted questionnaire, and pre-paid return envelope. Participants had the option to consent to an optional one-week follow up questionnaire that focused on perceived effectiveness of treatment after seven days and any further access to healthcare services such as general practice, emergency departments or repeat pharmacy visits.

RESULTS

There were 1,121 respondents to the initial questionnaire. Most reported 'convenient Location' as the main reason for their access to community pharmacy (n=748; 67.1%). If MAS had not been available, 59% (n=655) of participants reported that they would have accessed general practice for treatment of their minor ailment. Experience of consultations was also rated highly with all ten outcome measures scoring 'Excellent' overall. Satisfaction was reported positively with most participants reporting full satisfaction with the overall experience (n=960; 87.2%). At one-week follow up, 327 participants responded, over 85% (n=281) did not require further access to care to treat their minor ailment and 99.7% (n=326) said they would use MAS again.

CONCLUSIONS

Positive perceptions and experiences of those using MAS demonstrate a highly regarded service in terms of satisfaction and experience of consultation. The capacity for MAS to impact on the use of higher-cost healthcare services is evidenced through the number of participants who reported these services as a point of access to care should community pharmacy not be available. This national evaluation demonstrates MAS to be a positively experienced service and outlines the factors determining access for treatment of minor ailments.

Medication adherence and clinical outcomes in dispensing and non-dispensing practices: a cross-sectional analysis

BACKGROUND

Most patients obtain medications from pharmacies by prescription, but rural general practices can dispense medications. The clinical implications of this difference in drug delivery are unknown. This study hypothesised that dispensing status may be associated with better medication adherence. This could impact intermediate clinical outcomes dependent on medication adherence in, for example, hypertension or diabetes.

AIM

To investigate whether dispensing status is associated with differences in achievement of Quality and Outcomes Framework (QOF) indicators that rely on medication adherence.

DESIGN AND SETTING

Cross-sectional analysis of QOF data for 7392 general practices in England.

METHOD

QOF data from 1 April 2016 to 31 March 2017 linked to dispensing status for general practices with list sizes ≥1000 in England were analysed. QOF indicators were categorised according to whether their achievement depended on a record of prescribing only, medication adherence, or neither. Differences were estimated between dispensing and non-dispensing practices using mixed-effects logistic regression, adjusting for practice population age, sex, deprivation, list size, single-handed status, and rurality.

RESULTS

Data existed for 7392 practices; 1014 (13.7%) could dispense. Achievement was better in dispensing practices than in non-dispensing practices for seven of nine QOF indicators dependent on adherence, including blood pressure targets. Only one of ten indicators dependent on prescribing but not adherence displayed better achievement; indicators unrelated to prescribing showed a trend towards higher achievement by dispensing practices.

CONCLUSION

Dispensing practices may achieve better clinical outcomes than prescribing practices. Further work is required to explore underlying mechanisms for these observations and to directly study medication adherence rates.

Barriers to effective prescribing in older adults: applying the theoretical domains framework in the ambulatory setting - a scoping review

BACKGROUND

As the population ages, potentially inappropriate prescribing (PIP) in the older adults may become increasingly prevalent. This undermines patient safety and creates a potential source of major morbidity and mortality. Understanding the factors that influence prescribing behaviour may allow development of interventions to reduce PIP. The aim of this study is to apply the Theoretical Domains Framework (TDF) to explore barriers to effective prescribing for older adults in the ambulatory setting.

METHODS

A scoping review was performed based on the five-stage methodological framework developed by Arksey and O'Malley. From 30 Aug 2018 to 5 Sep 2018, we conducted our search on PubMed, CINAHL, EMBASE, the Cochrane Database of Systematic Reviews, and Web of Science. We also searched five electronic journals, Google and Google Scholar to identify additional sources and grey literature. Two reviewers applied eligibility criteria to the title and abstract screening, followed by full text screening, before systematically charting the data.

RESULTS

A total of 5731 articles were screened. Twenty-nine studies met the selection criteria for qualitative analysis. We mapped our results using the 14-domain TDF, eventually identifying 10 domains of interest for barriers to effective prescribing. Of these, significant domains include physician-related factors such as "Knowledge", "Skills", and "Social/Professional Role and Identity"; issues with "Environmental Context and Resources"; and the impact of "Social Influences" and "Emotion" on prescribing behaviour.

CONCLUSION

The TDF elicited multiple domains which both independently and collectively lead to barriers to effective prescribing for older adults in the ambulatory setting. Changing the prescribing climate will thus require interventions targeting multiple stakeholders, including physicians, patients and hospital/clinic systems. Further work is needed to explore individual domains and guide development of frameworks to aid guide prescribing for older adults in the ambulatory setting.

Professional roles of general practitioners, community pharmacists and specialist providers in collaborative medication deprescribing - a qualitative study

Background

Collaborative care approaches between general practitioners (GPs) and pharmacists have received international recognition for medication optimization and deprescribing efforts. Although specialist providers have been shown to influence deprescribing, their profession so far remains omitted from collaborative care approaches for medication optimization. Similarly, while explorative studies on role perception and collaboration between GPs and pharmacists grow, interaction with specialists for medication optimization is neglected. Our qualitative study therefore aims to explore GPs’, community pharmacists’ and specialist providers’ role perceptions of deprescribing, and to identify interpersonal as well as structural factors that may influence collaborative medication optimization approaches.

Method

Seven focus-group discussions with GPs, community pharmacists and community specialists were conducted in Hesse and Lower Saxony, Germany. The topic guide focused on views and experiences with deprescribing with special attention to inter-professional collaboration. We conducted conventional content analysis and conceptualized emerging themes using the Theoretical Domains Framework.

Results

Twenty-six GPs, four community pharmacists and three community specialists took part in the study. The main themes corresponded to the four domains ‘Social/professional role and identity’ (1), ‘Social influences’ (2), ‘Reinforcement’ (3) and ´Environmental context and resources’ (4) which were further described by beliefs statements, that is inductively developed key messages. For (1), GPs emerged as central medication managers while pharmacists and specialists were assigned confined or subordinated tasks in deprescribing. Social influences (2) encompassed patients’ trust in GPs as a support, while specialists and pharmacists were believed to threaten GPs’ role and deprescribing attempts. Reinforcements (3) negatively affected GPs’ and pharmacists’ effort in medication optimization by social reprimand and lacking reward. Environmental context (4) impeded deprescribing efforts by deficient reimbursement and resources as well as fragmentation of care, while informational and gate-keeping resources remained underutilized.

Conclusion

Understanding stakeholders’ role perceptions on collaborative deprescribing is a prerequisite for joint approaches to medication management. We found that clear definition and dissemination of roles and responsibilities are premise for avoiding intergroup conflicts. Role performance and collaboration must further be supported by structural factors like adequate reimbursement, resources and a transparent continuity of care.

Funding pharmacists in general practice: A feasibility study to inform the design of future economic evaluations

BACKGROUND

Funding is a significant barrier to employing general practice pharmacists.

OBJECTIVE(S)

To explore the feasibility of determining the cost-benefit of pharmacists in Australian general practice.

METHODS

Two part-time pharmacists were employed by general practices in Canberra, Australia. Diaries of the pharmacists were analysed to determine time worked and participation in income-generating activities, including Government-funded programs: Asthma Cycle of Care, Home Medicine Reviews, and Health Care Assessments. Scenarios using different practice and business models were entered into value-cost models to determine the income generated by the pharmacists relative to their salary.

RESULTS

Over 19 weeks, pharmacists A and B supported 47 and 23 Asthma Cycle of Care activities, generating income to the general practice of AU$4,700 and AU$2,300, respectively. The pharmacists spent 36.4 and 24.1 hours on activities usually conducted by general practitioners (GPs), allowing additional time for GP-patient consultations. Value-cost models determined AU$0.61 - AU$1.20 income generation by pharmacists per AU$1 salary.

CONCLUSIONS

It was feasible to determine the value-cost ratios of employing pharmacists in general practice using these methods. Future work should focus on developing a robust business model that includes health care system savings resulting from practice pharmacist interventions, determined from randomised controlled trials.

Evaluation of the General Practice Pharmacist (GPP) intervention to optimise prescribing in Irish primary care: a non-randomised pilot study

OBJECTIVE

Limited evidence suggests integration of pharmacists into the general practice team could improve medicines management for patients, particularly those with multimorbidity and polypharmacy. This study aimed to develop and assess the feasibility of an intervention involving pharmacists, working within general practices, to optimise prescribing in Ireland.

DESIGN

Non-randomised pilot study.

SETTING

Primary care in Ireland.

PARTICIPANTS

Four general practices, purposively sampled and recruited to reflect a range of practice sizes and demographic profiles.

INTERVENTION

A pharmacist joined the practice team for 6 months (10 hours/week) and undertook medication reviews (face to face or chart based) for adult patients, provided prescribing advice, supported clinical audits and facilitated practice-based education.

OUTCOME MEASURES

Anonymised practice-level medication (eg, medication changes) and cost data were collected. Patient-reported outcome measure (PROM) data were collected on a subset of older adults (aged ≥65 years) with polypharmacy using patient questionnaires, before and 6 weeks after medication review by the pharmacist.

RESULTS

Across four practices, 786 patients were identified as having 1521 prescribing issues by the pharmacists. Issues relating to deprescribing medications were addressed most often by the prescriber (59.8%), compared with cost-related issues (5.8%). Medication changes made during the study equated to approximately €57 000 in cost savings assuming they persisted for 12 months. Ninety-six patients aged ≥65 years with polypharmacy were recruited from the four practices for PROM data collection and 64 (66.7%) were followed up. There were no changes in patients' treatment burden or attitudes to deprescribing following medication review, and there were conflicting changes in patients' self-reported quality of life.

CONCLUSIONS

This non-randomised pilot study demonstrated that an intervention involving pharmacists, working within general practices is feasible to implement and has potential to improve prescribing quality. This study provides rationale to conduct a randomised controlled trial to evaluate the clinical and cost-effectiveness of this intervention.

Delegating home visits in general practice: a realist review on the impact on GP workload and patient care

BACKGROUND

UK general practice is being shaped by new ways of working. Traditional GP tasks are being delegated to other staff with the intention of reducing GPs' workload and hospital admissions, and improving patients' access to care. One such task is patient-requested home visits. However, it is unclear what impact delegated home visits may have, who might benefit, and under what circumstances.

AIM

To explore how the process of delegating home visits works, for whom, and in what contexts.

DESIGN AND SETTING

A review of secondary data on home visit delegation processes in UK primary care settings.

METHOD

A realist approach was taken to reviewing data, which aims to provide causal explanations through the generation and articulation of contexts, mechanisms, and outcomes. A range of data has been used including news items, grey literature, and academic articles.

RESULTS

Data were synthesised from 70 documents. GPs may believe that delegating home visits is a risky option unless they have trust and experience with the wider multidisciplinary team. Internal systems such as technological infrastructure might help or hinder the delegation process. Healthcare professionals carrying out delegated home visits might benefit from being integrated into general practice but may feel that their clinical autonomy is limited by the delegation process. Patients report short-term satisfaction when visited by a healthcare professional other than a GP. The impact this has on long-term health outcomes and cost is less clear.

CONCLUSION

The delegation of home visits may require a shift in patient expectation about who undertakes care. Professional expectations may also require a shift, having implications for the balance of staffing between primary and secondary care, and the training of healthcare professionals.

Exploring learning needs for general practice based pharmacist: Are behavioural and influencing skills needed?

Background

Embedding pharmacists in general practice has been shown to create cost efficiencies, improve patient care and free general practitioner capacity. Consequently, there is a drive to recruit additional pharmacists to work within general practices. However, equipping pharmacists with behaviour and influencing skills may further optimise their impact. Key elements which may enhance behaviour and influencing skills include self-efficacy and resilience.

Objective

This study aimed to: 1) Assess general practice pharmacists' self-efficacy and resilience. 2) Explore differences primarily between pharmacists reporting lower and higher self-efficacy, secondarily for those reporting lower and higher scores for resilience.

Methods

All 159 NHS Greater Glasgow and Clyde general practice pharmacists were invited to complete an online survey in May 2019. The survey captured anonymised data covering: demographics; professional experience; qualifications, prescribing status and preferred learning styles. Unconscious learning needs for behavioural and influencing skills were assessed using validated tools: the new general self-efficacy scale (GSES) and short general resilience scale (GRIT). Participants' responses were differentiated by the lowest quartile and higher quartiles of GSES and GRIT scores, and analysed to identify differences.

Results

The survey was completed by 57% (91/159) of eligible pharmacists; mean age 38 (range 24-60) years; 91% were of white ethnicity and 89% female. The median time qualified was 14 (1-38) years and 3 (1-22) years working in general practices. Overall pharmacists scored well on the GSES, mean 25 (SD 3; 95%CI 24.4-25.6), and GRIT, mean 30 (SD 4; 95%CI 29.6-30.4), out of a maximum 32 and 40 respectively. A significant positive correlation between GSES and GRIT scores was found (Pearson's r=0.284, p=0.006). However, no significant differences were identified between pharmacists scoring in the lower and upper quartiles by GSES or GRIT. Overall respondents reported their preferred learning styles were activists (46%) or pragmatists (29%). The majority (91%) preferred blended learning methods as opposed to 38% or less for a range of online methods.

Conclusions

General practice pharmacists on average scored highly for self-efficacy and resilience. Higher scores did not appear to be associated with demographic, years of practice, professional or educational experience. Prospective interventions to support those with lower scores may enhance and optimise pharmacists' effectiveness in general practice.

A cross-sectional survey of the pharmacy workforce in general practice in Scotland

BACKGROUND

In Scotland, there has been significant investment in pharmacy teams in general medical practices over recent years, aligned to current government policy.

OBJECTIVES

To characterize the national pharmacy workforce including activities undertaken, perceived competence and confidence, as well as perception of integration of the intervention.

METHODS

A cross-sectional survey of all pharmacists and pharmacy technicians in general practices. Survey items were demographics, activities undertaken and experiences. The NoMAD tool (Improving the Normalization of Complex Interventions) was included as a measure of perspectives of implementation. Post-piloting, a questionnaire link was sent to all pharmacists (n = 471) and pharmacy technicians (n = 112). A total NoMAD score was obtained by assigning 1 (strongly disagree) to 5 (strongly agree) to each item.

RESULTS

Responses were received from 393 (83.4%) pharmacists and 101 (91.8%) pharmacy technicians. Three quarters of pharmacists (74.6%) and pharmacy technicians (73.3%) had been qualified for over 10 years. Two-thirds of pharmacists (68.4%) were independent prescribers, with three quarters (72.3%) currently prescribing. Respondents worked in a median of two practices and were providing a range of activities including medication/polypharmacy reviews, medicines reconciliation, prescribing efficiencies and training. Respondents reported high levels of competence and confidence (median 8, scale 0-10 highest). Median NoMAD total score (scale 20-100 highest, Cronbach's alpha 0.89) was 80 for pharmacists and 75 for pharmacy technicians, P ≤ 0.001.

CONCLUSIONS

The general practice pharmacy workforce in Scotland is experienced, well-qualified and integrated within general practices, delivering a range of activities. These findings have implications for workforce planning and future education and training.

Development of an education and support framework for pharmacists working in GP practice

OBJECTIVES

To evaluate the educational support provided for three cohorts of pharmacists to inform an educational support framework for this new career path.

METHODS

This study evaluated training using mixed methods and measured the development of competence and confidence in the professional role as a pharmacist in GP Practice. Data were collected via pro formas before training events, and evaluation questionnaires immediately after events. Qualitative and quantitative content analysis was applied. The outcome evaluation collected data via a repeated measure of self-assessed competency and confidence via an online questionnaire at three time points. Logistic regression identified predictors of competency and confidence at the end of structured training.

KEY FINDINGS

Evaluation of training events was very positive. The theme of clinical and consultation skills was the most professionally satisfying, followed by teamwork and support. However, early work in practice was focussed on management and systems. There were significant improvements in competence and confidence over time. Independent predictors of increased competence in the role in GP Practice were having an Independent prescriber (IP) qualification or undertaking the IP course and having had additional health board training and support.

CONCLUSIONS

Formal training was well received. Early local support from health boards and GP Practices would enable pharmacists to get an earlier grasp of tasks relating to 'management and systems' so they could focus on more rewarding clinical tasks. Being an independent prescriber (or working towards this) is essential for the development of competence in this role. An educational support framework model is proposed.

Skill-mix change in general practice: a qualitative comparison of three 'new' non-medical roles in English primary care

BACKGROUND

General practice is currently facing a significant workforce challenge. Changing the general practice skill mix by introducing new non-medical roles is recommended as one solution; the literature highlights that organisational and/or operational difficulties are associated with skill-mix changes.

AIM

To compare how three non-medical roles were being established in general practice, understand common implementation barriers, and identify measurable impacts or unintended consequences.

DESIGN AND SETTING

In-depth qualitative comparison of three role initiatives in general practices in one area of Greater Manchester, England; that is, advanced practitioner and physician associate training schemes, and a locally commissioned practice pharmacist service.

METHOD

Semi-structured interviews and focus groups with a purposive sample of stakeholders involved in the implementation of each role initiative were conducted. Template analysis enabled the production of pre-determined and researcher-generated codes, categories, and themes.

RESULTS

The final sample contained 38 stakeholders comprising training/service leads, role holders, and host practice staff. Three key themes captured participants' perspectives: purpose and place of new roles in general practice, involving unclear role definition and tension at professional boundaries; transition of new roles into general practice, involving risk management, closing training-practice gaps and managing expectations; and future of new roles in general practice, involving demonstrating impact and questions about sustainability.

CONCLUSION

This in-depth, in-context comparative study highlights that introducing new roles to general practice is not a simple process. Recognition of factors affecting the assimilation of roles may help to better align them with the goals of general practice and harness the commitment of individual practices to enable role sustainability.