Relationship between deprivation, and the uptake and use of the common ailments service in community pharmacies in Wales.

OBJECTIVES: Since 2013 community pharmacies in Wales have been commissioned to provide a common ailments service (CAS), providing pharmacy medicine without charge to patients. In the first review of national pharmacy data, this study aimed to describe the relationship between provision of CAS and deprivation. METHODS: A retrospective observational study, using CAS claims data from April 2022 to March 2023 collected as part of routine service delivery. Consultation data were matched to the index of multiple deprivation (IMD) decile of the providing pharmacy. Linear regression was used to describe the correlation between CAS claims data and IMD deciles of the pharmacy postcode. KEY FINDINGS: In the study period, 239 028 consultations were recorded. More than twice as many consultations were carried out in pharmacies located in the most deprived decile (33 950) than in pharmacies in the least deprived decile (14 465). Linear regression demonstrated a significant correlation r(10) = -0.927, P < 0.001. There was a strong relationship between greater numbers of consultations and greater deprivation of the pharmacy postcode (R2 = 0.887). This significant correlation with deprivation was also found in the majority of individual conditions. There was no significant correlation between deprivation decile and the number of consultations per patient. CONCLUSIONS: Community pharmacies offer a key resource for tackling health inequalities. Patients in those areas with the greatest need are those most likely to use the CAS in pharmacies and receive the care they need. Commissioning services like this naturally supports deprived communities, through a combination of patient behaviours, location, and accessibility.

Patient safety in remote primary care encounters: multimethod qualitative study combining Safety I and Safety II analysis.

BACKGROUND: Triage and clinical consultations increasingly occur remotely. We aimed to learn why safety incidents occur in remote encounters and how to prevent them. SETTING AND SAMPLE: UK primary care. 95 safety incidents (complaints, settled indemnity claims and reports) involving remote interactions. Separately, 12 general practices followed 2021-2023. METHODS: Multimethod qualitative study. We explored causes of real safety incidents retrospectively ('Safety I' analysis). In a prospective longitudinal study, we used interviews and ethnographic observation to produce individual, organisational and system-level explanations for why safety and near-miss incidents (rarely) occurred and why they did not occur more often ('Safety II' analysis). Data were analysed thematically. An interpretive synthesis of why safety incidents occur, and why they do not occur more often, was refined following member checking with safety experts and lived experience experts. RESULTS: Safety incidents were characterised by inappropriate modality, poor rapport building, inadequate information gathering, limited clinical assessment, inappropriate pathway (eg, wrong algorithm) and inadequate attention to social circumstances. These resulted in missed, inaccurate or delayed diagnoses, underestimation of severity or urgency, delayed referral, incorrect or delayed treatment, poor safety netting and inadequate follow-up. Patients with complex pre-existing conditions, cardiac or abdominal emergencies, vague or generalised symptoms, safeguarding issues, failure to respond to previous treatment or difficulty communicating seemed especially vulnerable. General practices were facing resource constraints, understaffing and high demand. Triage and care pathways were complex, hard to navigate and involved multiple staff. In this context, patient safety often depended on individual staff taking initiative, speaking up or personalising solutions. CONCLUSION: While safety incidents are extremely rare in remote primary care, deaths and serious harms have resulted. We offer suggestions for patient, staff and system-level mitigations.

Cross-sectional survey of patients' need for information and support with medicines after discharge from hospital.

BACKGROUND: Most patients experience changes to prescribed medicines during a hospital stay. Ensuring they understand such changes is important for preventing adverse events post-discharge and optimising patient understanding. However, little work has explored the information that patients receive about medicines or their perceived needs for information and support after discharge. OBJECTIVES: To determine information that hospital inpatients who experience medicine changes receive about their medicines during admission and their needs and preferences for, and use of, post-discharge support. METHODS: Cross-sectional survey with adult medical inpatients experiencing medicine changes in six English hospitals, with telephone follow-up 2-3 weeks post-discharge. KEY FINDINGS: A total of 444 inpatients completed surveys, and 99 of these were followed up post-discharge. Of the 444, 44 (10%) were unaware of changes to medicines and 65 (16%) did not recall discussing them with a health professional, but 305 (77%) reported understanding the changes. Type of information provided and patients' perceived need for post-discharge support differed between hospitals. Information about changes was most frequently provided by consultant medical staff (157; 39%) with pharmacists providing information least often (71; 17%). One third of patients surveyed considered community pharmacists as potential sources of information about medicines and associated support post-discharge. Post-discharge, just 5% had spoken to a pharmacist, although 35% reported medicine-related problems. CONCLUSION: In north-west England, patient inclusion in treatment decisions could be improved, but provision of information prior to discharge is reasonable. There is scope to develop hospital and community pharmacists' role in medicine optimisation to maximise safety and effectiveness of care.

The extent that health professionals suspect and address addiction to medicines in primary care: Findings from a survey in Northwest England.

Addiction to medicines available over the counter or via prescription is of growing international concern. The authors of the current article ran an online survey of health professionals in general medical practice and community pharmacy settings in Northwest England to explore the frequency of suspecting and responding to addiction to medicines. Health professionals reported frequently identifying addiction to medicines among patients including those with long-term pain, mental health problems, sleep disorders, and other substance use disorders, but that these addictions often go unchallenged. This adds to the evidence indicating the under-diagnosis of addiction to medicines in the United Kingdom. Strategies to improve diagnosis and treatment should recognize the diversity of individuals with addiction to medicines.

A cross-sectional study using freedom of information requests to evaluate variation in local authority commissioning of community pharmacy public health services in England.

OBJECTIVES: This study aims to provide a national picture of the extent and nature of public health services commissioned by local authorities (LAs) from community pharmacies across England in financial year 2014/15. DESIGN: Cross-sectional survey of public health services commissioned in community pharmacies by LAs, gathered via freedom of information requests and documentary analysis. SETTING AND PARTICIPANTS: All 152 LAs in England. RESULTS: A total of 833 commissioned services were reported across England (range 3-10 per LA). Four services were commissioned by over 90% of LAs: emergency hormonal contraception (EHC), smoking cessation support, supervised consumption of methadone or other opiates and needle and syringe programmes (NSPs). The proportion of pharmacies commissioned to deliver these services varied considerably between LAs from <10% to 100%. This variation was not related to differences in relevant proxy measures of need. NHS Health Checks and alcohol screening and brief advice were commissioned by fewer LAs (32% and 15%, respectively), again with no relationship to relevant measures of need. A range of other services were commissioned less frequently, by fewer than 10% of LAs.Supervised consumption and NSPs were the most frequently used services, with over 4.4 million individual supervisions and over 1.4 million needle packs supplied. Pharmacies provided over 200 000 consultations for supply of EHC, over 30 000 supplies of free condoms and almost 16 000 chlamydia screening kits. More than 55 000 people registered to stop smoking in a community pharmacy, almost 30 000 were screened for alcohol use and over 26 000 NHS Health Checks were delivered. CONCLUSIONS: There is significant variation in commissioning and delivery of public health services in community pharmacies across England, which correlate poorly with potential benefit to local populations. Research to ascertain reasons for this variation is needed to ensure that future commissioning and delivery of these services matches local need.

The use of community pharmacies in North West England: an observational study.

BACKGROUND: There are few studies of community pharmacy footfall and activity in the existing literature, especially by direct observation. OBJECTIVE: To describe the characteristics of counter interactions between pharmacy staff and customers. METHOD: Structured observation of all interactions between pharmacy staff and customers across the weekly opening hours of five pharmacies diverse in location and ownership. KEY FINDINGS: Three-quarters (76%) of observed interactions were associated with prescriptions, but a significant minority accessed cognitive services. CONCLUSIONS: Dispensing was the primary activity across the diverse range of pharmacies. Reasons for visits are diversifying into advice and services, particularly among younger users.

Inpatient prescribing systems used in NHS Acute Trusts across England: a managerial perspective.

OBJECTIVE: The individualised patient prescription chart, either paper or electronic, is an integral part of communication between healthcare professionals. The aim of this study is to ascertain the extent to which different prescribing systems are used for inpatient care in acute hospitals in England and explore chief pharmacists' opinions and experiences with respect to electronic prescribing and medicines administration (EPMA) systems. METHOD: Audio-recorded, semistructured telephone interviews with chief pharmacists or their nominated representatives of general acute hospital trusts across England. RESULTS: Forty-five per cent (65/146) of the chief pharmacists agreed to participate. Eighteen per cent (12/65) of the participants interviewed stated that their trust had EPMA systems fully or partially implemented on inpatient wards. The most common EPMA system in place was JAC (n=5) followed by MEDITECH (n=3), iSOFT (n=2), PICS (n=1) and one in-house created system. Of the 12 trusts that had EPMA in place, 4 used EPMA on all of their inpatient wards and the remaining 8 had a mixture of paper and EPMA systems in use. Fifty six (86% 56/65) of all participants had consulted the standards for the design of inpatient prescription charts. From the 12 EPMA interviews qualitatively analysed, the regulation required to provide quality patient care is perceived by some to be enforceable with an EPMA system, but that this may affect accuracy and clinical workflow, leading to undocumented, unofficial workarounds that may be harmful. CONCLUSIONS: The majority of inpatient prescribing in hospital continues to use paper-based systems; there was significant diversity in prescribing systems in use. EPMA systems have been implemented but many trusts have retained supplementary paper drug charts, for a variety of medications. Mandatory fields may be appropriate for core prescribing information, but the expansion of their use needs careful consideration.

Delays and interruptions in the acute medical unit clerking process: an observational study.

OBJECTIVES: It is recommended that patients are seen within 4 h of arrival in Acute Medical Units in English hospitals. This study explored the frequency and nature of interruptions and delays potentially affecting the duration of the Acute Medical Unit admission process and the quality of care provided. DESIGN: The admission process was directly observed for patients admitted to the Acute Medical Unit over four one-week periods, November 2009 to April 2011. SETTING: UK teaching hospital Acute Medical Unit. PARTICIPANTS: Hospital staff n = 36. MAIN OUTCOME MEASURES: Patient waiting times, duration of clerking, number of interruptions and/or delays. RESULTS: Thirty-five doctors and one nurse practitioner were observed admitting 71 medical patients, 48/71 (68%) patients were clerked within 4 h of arrival. A delay and/or interruption affected 49/71 (69%) patients. Sixty-six interruptions were observed in 36/71 (51%) of admissions, of these 19/36 (53%) were interrupted more than once. The grade of doctor had no bearing on the frequency of interruption; however, clerking took significantly longer when interrupted; overall doctors grade ST1 and above were quicker at clerking than foundation doctors. Delays affected 31/71 (44%) of admissions, 14/31 (45%) involved X-rays or ECGs; other causes of delays included problems with equipment and computers. CONCLUSION: Interruptions and delays regularly occurred during the admission process in the study hospital which impacts adversely on patient experience and compliance with the recommended 4-h timeframe, further work is required to assess the impact on patient safety. Data obtained from this observational study were used to guide operational changes to improve the process.

Involving community pharmacists in pharmacy practice research: experiences of peer interviewing.

BACKGROUND: Translation of interest in research into active engagement of community pharmacists as research partners/co-researchers remains a challenge. Involving pharmacists in specific research techniques such as peer interviewing, however, may enhance validity of the results. OBJECTIVE: To enhance community pharmacists' involvement in pharmacy practice research through peer interview training. METHOD: A subgroup of participants in a multi-phase pharmacy practice research project trained to do peer interviews. These pharmacist interviewers attended a workshop and were mentored. Comments from their feedback forms and ongoing engagement with the Research Associate were thematically analysed. RESULTS: Positive themes from five interviewers included the importance of the topic and their wish to learn skills beyond their everyday role. The small group format of the training day helped to build confidence. Interviewers felt their shared professional background helped them to capture relevant comments and probe effectively. There were challenges, however, for interviewers to balance research activities with their daily work. Interviewers experienced difficulty in securing uninterrupted time with interviewees which sometimes affected data quality by 'rushing'. CONCLUSION: Community pharmacists can be engaged as peer interviewers to the benefit of the volunteers and research team, but must be well resourced and supported.

Emergency supply of prescription-only medicines to patients by community pharmacists: a mixed methods evaluation incorporating patient, pharmacist and GP perspectives.

OBJECTIVE: To evaluate and inform emergency supply of prescription-only medicines by community pharmacists (CPs), including how the service could form an integral component of established healthcare provision to maximise adherence. DESIGN: Mixed methods. 4 phases: prospective audit of emergency supply requests for prescribed medicines (October-November 2012 and April 2013); interviews with CPs (February-April 2013); follow-up interviews with patients (April-May 2013); interactive feedback sessions with general practice teams (October-November 2013). SETTING: 22 community pharmacies and 6 general practices in Northwest England. PARTICIPANTS: 27 CPs with experience of dealing with requests for emergency supplies; 25 patients who received an emergency supply of a prescribed medicine; 58 staff at 6 general practices. RESULTS: Clinical audit in 22 pharmacies over two 4-week periods reported that 526 medicines were requested by 450 patients. Requests peaked over a bank holiday and around weekends. A significant number of supplies were made during practice opening hours. Most requests were for older patients and for medicines used in long-term conditions. Difficulty in renewing repeat medication (forgetting to order, or prescription delays) was the major reason for requests. The majority of medicines were 'loaned' in advance of a National Health Service (NHS) prescription. Interviews with CPs and patients indicated that continuous supply had a positive impact on medicines adherence, removing the need to access urgent care. General practice staff were surprised and concerned by the extent of emergency supply episodes. CONCLUSIONS: CPs regularly provide emergency supplies to patients who run out of their repeat medication, including during practice opening hours. This may aid adherence. There is currently no feedback loop, however, to general practice. Patient care and interprofessional communication may be better served by the introduction of a formally structured and funded NHS emergency supply service from community pharmacies, with ongoing optimisation of repeat prescribing.

Prescribing errors on admission to hospital and their potential impact: a mixed-methods study.

BACKGROUND: Medication errors are an important cause of morbidity and mortality and adversely affect clinical outcomes. Prescribing errors constitute one type of medication error and occur particularly on admission to hospital; little is known about how they arise. AIM: This study investigated how doctors obtain the information necessary to prescribe on admission to hospital, and the number and potential impact of any errors. SETTING: English teaching hospital-acute medical unit. METHODS: Ethics approval was granted. Data were collected over four 1-week periods; November 2009, January 2010, April 2010 and April 2011. The patient admission process was directly observed, field notes were recorded using a standard form. Doctors participated in a structured interview; case notes of all patients admitted during study periods were reviewed. RESULTS: There were differences between perceived practice stated in interviews and actual practice observed. All 19 doctors interviewed indicated that they would sometimes or always use more than one source of information for a medication history; a single source was used in 31/68 observed cases. 7/12 doctors both observed and interviewed indicated that they would confirm medication with patients; observations showed they did so for only 2/12 patients. In 66/68 cases, the patient/carer was able to discuss medication, 14 were asked no medication-related questions. Of 688 medication charts reviewed, 318 (46.2%) had errors. A total of 851 errors were identified; 737/851 (86.6%) involved omission of a medicine; 94/737 (12.8%) of these were potentially significant. CONCLUSIONS: Although doctors know the importance of obtaining an accurate medication history and checking prescriptions with patients, they often fail to put this into practice, resulting in prescribing errors.

How to enhance public health service utilization in community pharmacy?: general public and health providers' perspectives.

BACKGROUND: Community pharmacists (PHs) in England are increasingly providing a range of public health services. However, the general public view pharmacists as drug experts and not experts in health, and therefore, services may be underutilized. OBJECTIVES: To explore experiences and views of 4 groups of participants, the general public, PHs, general practitioners (GPs), and other stakeholders (STs) on pharmacy-based public health services, and identify potential factors affecting service use. METHODS: The study was undertaken in a locality of North West England. Three focus groups were conducted with the general public (n=16), grouped by socioeconomic status. Fourteen semistructured interviews were undertaken with PHs (n=9), GPs (n=2), and STs (n=3). Discussions/interviews were audio recorded, transcribed verbatim, and analyzed thematically. RESULTS: All 4 groups of participants agreed that community pharmacies are a good source of advice on medicines and minor ailments but were less supportive of public health services. Six factors were identified affecting utilization of pharmacy services: community pharmacy environment, pharmacist and support staff, service publicity, general public, GP services, and health care system and policies. Crucial obstacles that could inhibit service utilization are perceptions of both the general public and other health providers toward pharmacists' competencies, privacy and confidentiality in pharmacies, high dispensing workload, and inadequate financial support. Networking between local health professionals could enhance confidence in service delivery, general awareness, and thus utilization. CONCLUSIONS: Community pharmacy has the potential to deliver public health services, although the impact on public health may be limited. Addressing the factors identified could help to increase utilization and impact of pharmacy public health services.

A community pharmacy-based cardiovascular screening service: views of service users and the public.

OBJECTIVES: To determine whether pharmacy-based cardiovascular disease (CVD) screening reached the desired population, the local population's awareness of pharmacy screening and the views of service users and the general public about CVD screening. METHODS: Pharmacy staff, located in one English Primary Care Trust providing a CVD screening service, issued questionnaires to service users who had undergone screening. Face-to-face street surveys were conducted with members of the general public within the vicinity of each participating pharmacy. KEY FINDINGS: A total of 259 people were screened within the first 6 months of service provision, 97 of whom (37.4%) completed the evaluation questionnaire. In addition, 261 non-service users participated in street surveys. Most respondents among both service users and non-users had at least one risk factor for cardiovascular disease, including smoking and lack of exercise. Responses to statements regarding CVD screening showed a high level of agreement with the need for screening in both groups. However, significantly more service users (90.7%) agreed that a pharmacy was a good place for screening compared to the non-users (77.4%; P < 0.005). Likewise significantly fewer service users agreed that screening should be only carried out by doctors (10.3 compared to 25.3% of non-users; P < 0.005). The overall majority of service users 96 (99.7%) had a positive experience of the screening service, agreeing that they were given enough time and pharmacists made them feel at ease. Only 9% of non-users were aware of the pharmacy service and, although the majority (78.4%) were willing to be screened at a pharmacy, this was significantly lower among males than females (69.9 compared to 82.7%; P < 0.005). Perceived concerns about confidentiality and lack of privacy were among barriers identified to taking up screening. CONCLUSION: Pharmacy-based CVD screening is acceptable to the public. Its uptake could be improved through increased awareness of the service and by addressing concerns about privacy and confidentiality in promotional activities.

Challenges in implementing government-directed VTE guidance for medical patients: a mixed methods study.

BACKGROUND: Implementing venous thromboembolism (VTE) risk assessment guidance on admission to hospital has proved difficult worldwide. In 2010, VTE risk assessment in English hospitals was linked to financial sanctions. This study investigated possible barriers and facilitators for VTE risk assessment in medical patients and evaluated the impact of local and national initiatives. SETTING: Acute Medical Unit in one English National Health Service university teaching hospital. METHODS: This was a mixed methods study; National Research Ethics Service approval was granted. Data were collected over four 1-week periods; November 2009 (1), January 2010 (2), April 2010 (3) and April 2011 (4). Case notes for all medical patients admitted during these periods were reviewed. Thirty-six staff were observed admitting 71 of these patients; 24 observed staff participated in a structured interview. RESULTS: 876 case notes were reviewed. In total, 82.1% of patients had one or more VTE risk factors and 25.3% one or more bleeding risks. VTE risk assessment rose from a baseline of 6.9-19.6%, following local initiatives, and to 98.7% following financially sanctioned government targets. A similar increase in appropriate prescribing of prophylaxis was seen, but inappropriate prescribing also rose. No staff observed in period 1 conducted VTE risk assessment, risk-assessment forms were largely ignored or discarded during period 2; and electronic recording systems available during period 3 were not accessed. Few patients were asked any VTE-related questions in periods 1, 2 or 3. Interviewees' actual knowledge of VTE risk was not related to perceived knowledge level. Eight of the 24 staff interviewed were aware of national policies or guidance: none had seen them. Principal barriers identified to risk assessment were: involvement of multiple staff in individual admissions; interruptions; lack of policy awareness; time pressure and complexity of tools. CONCLUSIONS: National financial sanctions appear effective in implementing guidance, where other local measures have failed.

Returned medicines: waste or a wasted opportunity?

BACKGROUND: Re-use of unused medicines returned from patients is currently considered unethical in the UK and these are usually destroyed by incineration. Previous studies suggest that many of these medicines may be in a condition suitable for re-use. METHODS: All medicines returned over two months to participating community pharmacies and GP surgeries in Eastern Birmingham PCT were assessed for type, quantity and value. A registered pharmacist assessed packs against set criteria to determine the suitability for possible re-use. RESULTS: Nine hundred and thirty-four return events were made from 910 patients, comprising 3765 items worth pound 33,608. Cardiovascular drugs (1003, 27%) and those acting on the CNS (884, 24%) were most prevalent. Returned packs had a median of 17 months remaining before expiry and one-quarter of packs (1248 out of 4291) were suitable for possible re-use. One-third of those suitable for re-use (476 out of 1248) contained drugs in the latest WHO Essential Drugs List. CONCLUSION: Unused medicines are returned in substantial quantities and have considerable financial value, with many in a condition suitable for re-use. We consider it appropriate to reopen the debate on the potential for re-using these medicines in developing countries where medicines are not widely available and also within the UK.

An analysis of returned medicines in primary care.

OBJECTIVE: The number of pharmaceutical items issued on prescription is continually rising and contributing to spiralling healthcare costs. Although there is some data highlighting the quantity, in terms of weight of medicines returned specifically to community pharmacies, little is known about the specific details of such returns or other destinations for wasted medications. This pilot study has been designed to investigate the types and amounts of medicines returned to both general practices (GPs) and associated local community pharmacies determining the reasons why these medicines have been returned. METHOD: The study was conducted in eight community pharmacies and five GP surgeries within East Birmingham over a 4-week period. MAIN OUTCOME MEASURE: Reason for return and details of returned medication. RESULTS: A total of 114 returns were made during the study: 24 (21.1) to GP surgeries and 90 (78.9) to community pharmacies. The total returns comprised 340 items, of which 42 (12.4) were returned to GPs and 298 (87.6) to pharmacies, with the mean number of items per return being 1.8 and 3.3, respectively. Half of the returns in the study were attributed to the doctor changing or stopping the medicine; 23.7 of returns were recorded as excess supplies or clearout often associated with patients' death and 3.5 of returns were related to adverse drug reactions. Cardiovascular drugs were most commonly returned, amounting to 28.5 of the total drugs returned during the study. CONCLUSIONS: The results from this pilot study indicate that unused medicines impose a significant financial burden on the National Health Service as well as a social burden on the United Kingdom population. Further studies are examining the precise nature of returned medicines and possible solutions to these issues.