A hospital-based independent domestic violence advisor service: demand and response during the Covid-19 pandemic.

BACKGROUND AND AIM: Recent UK policy has focussed on improving support for victims of domestic violence and abuse (DVA), in healthcare settings. DVA victims attending hospital are often at highest risk of harm, yet DVA support in hospitals has been inadequate. A targeted service supporting high risk DVA victims, was implemented at a hospital Trust in North West England. The service was provided by Independent Domestic Violence Advisors (IDVAs). This paper assesses the activity in the hospital-based IDVA service during the COVID-19 pandemicand addresses the research questions: What was the demand for the service? How did the service respond? What facilitated this response? METHODS: A mixed-methods study was undertaken. Quantitative data on referrals to the service were examined using simple descriptive statistics and compared to other DVA services. Semi-structured interviews were undertaken with IDVAs and other hospital staff involved with the service and the data subjected to thematic analysis. RESULTS: The quantitative analysis showed that referrals dropped at the start of lockdown, then increased and continued to rise; the qualitative findings reiterated this pattern. Referrals came from a range of departments across the Trust, with the majority from A&E. Pre-pandemic, the population supported by the service included higher proportions of males and people aged 40 and over than at other IDVA services; this continued during the pandemic. The qualitative findings indicated a flexible response during the pandemic, enabled by strong working relationships and by using workarounds. CONCLUSIONS: The hospital-based IDVAs provided an efficient, flexible serviceduring the COVID-19 pandemic. Referrals increased during the first lockdown and subsequent relaxing of restrictions. Locating the IDVAs within a team working across the organisation, and building good working relationships facilitated an effective disclosure and referral route, which endured through social restrictions. The IDVAs supported high-risk victims who may otherwise not have been identified in traditional community-based DVA settings during the pandemic. Hospital-based IDVA services can broaden access by supporting vulnerable, at risk populations whose needs may not be identified at other services.

Post-discharge care following acute kidney injury: quality improvement in primary care.

BACKGROUND: Over the past decade, targeting acute kidney injury (AKI) has become a priority to improve patient safety and health outcomes. Illness complicated by AKI is common and is associated with adverse outcomes including high rates of unplanned hospital readmission. Through national patient safety directives, NHS England has mandated the implementation of an AKI clinical decision support system in hospitals. In order to improve care following AKI, hospitals have also been incentivised to improve discharge summaries and general practices are recommended to establish registers of people who have had an episode of illness complicated by AKI. However, to date, there is limited evidence surrounding the development and impact of interventions following AKI. DESIGN: We conducted a quality improvement project in primary care aiming to improve the management of patients following an episode of hospital care complicated by AKI. All 31 general practices within a single NHS Clinical Commissioning Group were incentivised by a locally commissioned service to engage in audit and feedback, education training and to develop an action plan at each practice to improve management of AKI. RESULTS: AKI coding in general practice increased from 28% of cases in 2015/2016 to 50% in 2017/2018. Coding of AKI was associated with significant improvements in downstream patient management in terms of conducting a medication review within 1 month of hospital discharge, monitoring kidney function within 3 months and providing written information about AKI to patients. However, there was no effect on unplanned hospitalisation and mortality. CONCLUSION: The findings suggest that the quality improvement intervention successfully engaged a primary care workforce in AKI-related care, but that a higher intensity intervention is likely to be required to improve health outcomes. Development of a real-time audit tool is necessary to better understand and minimise the impact of the high mortality rate following AKI.

Implementing post-discharge care following acute kidney injury in England: a single-centre qualitative evaluation.

OBJECTIVES: We sought to understand the factors influencing the implementation of a primary care intervention to improve post-discharge care following acute kidney injury (AKI). DESIGN: Qualitative study using semi-structured interviews and thematic analysis. SETTING: General practices in one Clinical Commissioning Group area in England. PARTICIPANTS: A total of 18 healthcare staff took part in interviews. Participants were practice pharmacists, general practitioners, practice managers and administrators involved in implementing the intervention. RESULTS: We identified three main factors influencing implementation: differentiation of the new intervention from other practice work; development of skill mix and communication across organisations. Overall, post-AKI processes of care were deemed straightforward to embed into existing practice. However, it was also important to separate the intervention from other work in general practice. Dedicating staff time to proactively identify AKI on discharge summaries and to coordinate the provision of care enabled implementation of the intervention. The post-AKI intervention provided an opportunity for practice pharmacists to expand their primary care role. Working in a new setting also brought challenges; time to develop trusting relationships including an understanding of boundaries of clinical expertise influenced pharmacists' roles. Unclear and inconsistent information on discharge summaries contributed to concerns about additional work in primary care. CONCLUSIONS: The research highlights challenges around post-discharge management in the primary care context. Coordination and communication were key factors for improving follow-up care following AKI. Further consideration is required to understand patient experiences of the interface between secondary and primary care. The issues pertaining to discharge care following AKI are relevant to practitioners and commissioners as they work to improve transitions of care for vulnerable patient populations.

Organisational factors associated with safety climate, patient satisfaction and self-reported medicines adherence in community pharmacies.

BACKGROUND: Evidence suggests that community pharmacy service quality varies, and that this may relate to pharmacy ownership. However little is known about wider organisational factors associated with quality. OBJECTIVE: To investigate organisational factors associated with variation in safety climate, patient satisfaction and self-reported medicines adherence in English community pharmacies. METHODS: Multivariable regressions were conducted using data from two cross-sectional surveys, of 817 pharmacies and 2124 patients visiting 39 responding pharmacies, across 9 diverse geographical areas. Outcomes measured were safety climate, patient satisfaction and self-reported medicines adherence. Independent variables included service volume (e.g. dispensing volume), pharmacy characteristics (e.g. pharmacy ownership), patient characteristics (e.g. age) and areal-specific demographic, socio-economic and health-needs variables. RESULTS: Valid response rates were 277/800 (34.6%) and 971/2097 (46.5%) for pharmacy and patient surveys respectively. Safety climate was associated with pharmacy ownership (F8,225 = 4.36, P < 0.001), organisational culture (F4, 225 = 12.44, P < 0.001), pharmacists' working hours (F4, 225 = 2.68, P = 0.032) and employment of accuracy checkers (F4, 225 = 4.55, P = 0.002). Patients' satisfaction with visit was associated with employment of pharmacy technicians (ß = 0.0998, 95%CI = [0.0070,0.1926]), continuity of advice-giver (ß = 0.2593, 95%CI = [0.1251,0.3935]) and having more reasons for choosing that pharmacy (ß = 0.3943, 95%CI = [0.2644, 0.5242]). Satisfaction with information received was associated with continuity of advice-giver (OR = 1.96, 95%CI = [1.36, 2.82]), weaker belief in medicines overuse (OR = 0.92, 95%CI = [0.88, 0.96]) and age (OR = 1.02, 95%CI = [1.01, 1.03]). Regular deployment of locums by pharmacies was associated with poorer medicines adherence (OR = 0.50, 95%CI = [0.30, 0.84]), as was stronger patient belief in medicines overuse (OR = 0.88, 95%CI=[0.81, 0.95]) and younger age (OR = 1.04, 95%CI = [1.01, 1.07]). No patient outcomes were associated with pharmacy ownership or service volume. CONCLUSIONS: This study characterised variation in the quality of English community pharmacy services identifying the importance of skill-mix, continuity of care, pharmacy ownership, organisational culture, and patient characteristics. Further research is needed into what constitutes and influences quality, including the development of validated quality measures.

Implementing new care models: learning from the Greater Manchester demonstrator pilot experience.

BACKGROUND: Current health policy focuses on improving accessibility, increasing integration and shifting resources from hospitals to community and primary care. Initiatives aimed at achieving these policy aims have supported the implementation of various 'new models of care', including general practice offering 'additional availability' appointments during evenings and at weekends. In Greater Manchester, six 'demonstrator sites' were funded: four sites delivered additional availability appointments, other services included case management and rapid response. The aim of this paper is to explore the factors influencing the implementation of services within a programme designed to improve access to primary care. The paper consists of a qualitative process evaluation undertaken within provider organisations, including general practices, hospitals and care homes. METHODS: Semi-structured interviews, with the data subjected to thematic analysis. RESULTS: Ninety-one people participated in interviews. Six key factors were identified as important for the establishment and running of the demonstrators: information technology; information governance; workforce and organisational development; communications and engagement; supporting infrastructure; federations and alliances. These factors brought to light challenges in the attempt to provide new or modify existing services. Underpinning all factors was the issue of trust; there was consensus amongst our participants that trusting relationships, particularly between general practices, were vital for collaboration. It was also crucial that general practices trusted in the integrity of anyone external who was to work with the practice, particularly if they were to access data on the practice computer system. A dialogical approach was required, which enabled staff to see themselves as active rather than passive participants. CONCLUSIONS: The research highlights various challenges presented by the context within which extended access is implemented. Trust was the fundamental underlying issue; there was consensus amongst participants that trusting relationships were vital for effective collaboration in primary care.

GPs' views of health policy changes: a qualitative 'netnography' study of UK general practice online magazine commentary.

BACKGROUND: Shifts in health policy since 2010 have brought major structural changes to the English NHS, with government stating intentions to increase GPs' autonomy and improve access to care. Meanwhile, GPs' levels of job satisfaction are low, while stress levels are high. PulseToday is a popular UK general practice online magazine that provides a key discussion forum on news relevant to general practice. AIM: To analyse readers' reactions to news stories about health policy changes published in an online general practice magazine. DESIGN AND SETTING: A qualitative 'netnography' was undertaken of readers' comments to PulseToday. METHOD: A sample of readers' comments on articles published in PulseToday was collated and subjected to thematic analysis. RESULTS: Around 300 comments on articles published between January 2012 and March 2016 were included in the analysis, using 'access to care' as a tracer theme. Concern about the demand and strain on general practice was perhaps to be expected. However, analysis revealed various dimensions to this concern: GPs' underlying feelings about their work and place in the NHS; constraints to GPs' control of their own working practices; a perceived loss of respect for the role of GP; and disappointment with representative bodies and GP leadership. CONCLUSION: This study shows a complex mix of resistance and resignation in general practice about the changing character of GPs' roles. This ambivalence deserves further attention because it could potentially shape responses to further change in primary care in ways that are as yet unknown.

Getting messier with TIDieR: embracing context and complexity in intervention reporting.

BACKGROUND: The Template for Intervention Description and Replication (TIDieR) checklist and guide was developed by an international team of experts to promote full and accurate description of trial interventions. It is now widely used in health research. The aim of this paper is to describe the experience of using TIDieR outside of trials, in a range of applied health research contexts, and make recommendations on its usefulness in such settings. MAIN BODY: We used the TIDieR template for intervention description in six applied health research projects. The six cases comprise a diverse sample in terms of clinical problems, population, settings, stage of intervention development and whether the intervention was led by researchers or the service deliverers. There was also variation in how the TIDieR description was produced in terms of contributors and time point in the project. Researchers involved in the six cases met in two workshops to identify issues and themes arising from their experience of using TIDieR. We identified four themes which capture the difficulties or complexities of using TIDieR in applied health research: (i) fidelity and adaptation: all aspects of an intervention can change over time; (ii) voice: the importance of clarity on whose voice the TIDieR description represents; (iii) communication beyond the immediate context: the usefulness of TIDieR for wider dissemination and sharing; (iv) the use of TIDieR as a research tool. CONCLUSION: We found TIDieR to be a useful tool for applied research outside the context of clinical trials and we suggest four revisions or additions to the original TIDieR which would enable it to better capture these complexities in applied health research: An additional item, 'voice' conveys who was involved in preparing the TIDieR template, such as researchers, service users or service deliverers. An additional item, 'stage of implementation' conveys what stage the intervention has reached, using a continuum of implementation research suggested by the World Health Organisation. A new column, 'modification' reminds authors to describe modifications to any item in the checklist. An extension of the 'how well' item encourages researchers to describe how contextual factors affected intervention delivery.

Understanding the implementation of 'sick day guidance' to prevent acute kidney injury across a primary care setting in England: a qualitative evaluation.

OBJECTIVES: The study sought to examine the implementation of sick day guidance cards designed to prevent acute kidney injury (AKI), in primary care settings. DESIGN: Qualitative semistructured interviews were conducted and comparative analysis informed by normalisation process theory was undertaken to understand sense-making, implementation and appraisal of the cards and associated guidance. SETTING: A single primary care health setting in the North of England. PARTICIPANTS: 29 participants took part in the qualitative evaluation: seven general practitioners, five practice nurses, five community pharmacists, four practice pharmacists, two administrators, one healthcare assistant and five patients. INTERVENTION: The sick day guidance intervention was rolled out (2015-2016) in general practices (n=48) and community pharmacies (n=60). The materials consisted of a 'medicine sick day guidance' card, provided to patients who were taking the listed drugs. The card provided advice about medicines management during episodes of acute illness. An information leaflet was provided to healthcare practitioners and administrators suggesting how to use and give the cards. RESULTS: Implementation of sick day guidance cards to prevent AKI entailed a new set of working practises across primary care. A tension existed between ensuring reach in administration of the cards to at risk populations while being confident to ensure patient understanding of their purpose and use. Communicating the concept of temporary cessation of medicines was a particular challenge and limited their administration to patient populations at higher risk of AKI, particularly those with less capacity to self-manage. CONCLUSIONS: Sick day guidance cards that focus solely on medicines management may be of limited patient benefit without adequate resourcing or if delivered as a standalone intervention. Development and evaluation of primary care interventions is urgently warranted to tackle the harm associated with AKI.

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

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

The policy work of piloting: Mobilising and managing conflict and ambiguity in the English NHS.

In spite of their widespread use in policy making in the UK and elsewhere, there is a relatively sparse literature specifically devoted to policy pilots. Recent research on policy piloting has focused on the role of pilots in making policy work in accordance with national agendas. Taking this as a point of departure, the present paper develops the notion of pilots doing policy work. It does this by situating piloting within established theories of policy formulation and implementation, and illustrating using an empirical case. Our case is drawn from a qualitative policy ethnography of a local government pilot programme aiming to extend access to healthcare services. Our case explores the collective entrepreneurship of regional policy makers together with local pilot volunteers. We argue that pilots work to mobilise and manage the ambiguity and conflict associated with particular policy goals, and in their structure and design, shape action towards particular outcomes. We conclude with a discussion of the generative but managed role which piloting affords to local implementers.

How a moderated online discussion forum facilitates support for young people with eating disorders.

INTRODUCTION: Young people with eating disorders are at risk of harm to their social, emotional and physical development and life chances. Although they can be reluctant to seek help, they may access social media for information, advice or support. The relationship between social media and youth well-being is an emotive subject, but not clearly understood. This qualitative study aimed to explore how young people used a youth-orientated, moderated, online, eating disorders discussion forum, run by an eating disorders charity. METHODS: We applied a netnographic approach involving downloading and thematically analysing over 400 messages posted August-November 2012. RESULTS: Data analysis generated five themes: Taking on the role of mentor; the online discussion forum as a safe space; Friendship within the online forum; Flexible help; and Peer support for recovery and relapse prevention. Forum moderation may have influenced the forum culture. DISCUSSION: Our findings are consistent with literature about youth preferences for mental health self-care support. A young person's decision to use this discussion forum can be construed as pro-active self-care. A moderated online discussion forum can make a positive contribution to support for youth with eating disorders, countering negative media perceptions of online groups. CONCLUSION: This study adds to knowledge about how young people access support via social media. Online discussion forums can be safe and acceptable spaces for youth to access help. Further research could provide insights into the impact of forum moderation.

Associations between Extending Access to Primary Care and Emergency Department Visits: A Difference-In-Differences Analysis.

BACKGROUND: Health services across the world increasingly face pressures on the use of expensive hospital services. Better organisation and delivery of primary care has the potential to manage demand and reduce costs for hospital services, but routine primary care services are not open during evenings and weekends. Extended access (evening and weekend opening) is hypothesized to reduce pressure on hospital services from emergency department visits. However, the existing evidence-base is weak, largely focused on emergency out-of-hours services, and analysed using a before-and after-methodology without effective comparators. METHODS AND FINDINGS: Throughout 2014, 56 primary care practices (346,024 patients) in Greater Manchester, England, offered 7-day extended access, compared with 469 primary care practices (2,596,330 patients) providing routine access. Extended access included evening and weekend opening and served both urgent and routine appointments. To assess the effects of extended primary care access on hospital services, we apply a difference-in-differences analysis using hospital administrative data from 2011 to 2014. Propensity score matching techniques were used to match practices without extended access to practices with extended access. Differences in the change in "minor" patient-initiated emergency department visits per 1,000 population were compared between practices with and without extended access. Populations registered to primary care practices with extended access demonstrated a 26.4% relative reduction (compared to practices without extended access) in patient-initiated emergency department visits for "minor" problems (95% CI -38.6% to -14.2%, absolute difference: -10,933 per year, 95% CI -15,995 to -5,866), and a 26.6% (95% CI -39.2% to -14.1%) relative reduction in costs of patient-initiated visits to emergency departments for minor problems (absolute difference: -£767,976, -£1,130,767 to -£405,184). There was an insignificant relative reduction of 3.1% in total emergency department visits (95% CI -6.4% to 0.2%). Our results were robust to several sensitivity checks. A lack of detailed cost reporting of the running costs of extended access and an inability to capture health outcomes and other health service impacts constrain the study from assessing the full cost-effectiveness of extended access to primary care. CONCLUSIONS: The study found that extending access was associated with a reduction in emergency department visits in the first 12 months. The results of the research have already informed the decision by National Health Service England to extend primary care access across Greater Manchester from 2016. However, further evidence is needed to understand whether extending primary care access is cost-effective and sustainable.

Patient-centred professionalism in pharmacy: values and behaviours.

PURPOSE: Research on patient-centred professionalism in pharmacy is scarce compared with other health professions and in particular with pharmacists early in their careers. The purpose of this paper is to explore patient-centred professionalism in early career pharmacists and to describe reported behaviours. DESIGN/METHODOLOGY/APPROACH - This study explored patient-centred professional values and reported behaviours, taking a qualitative approach. In all, 53 early-career pharmacists, pharmacy tutors and pharmacy support staff, practising in community and hospital pharmacy in England took part; the concept of patient-centred professionalism was explored through focus group interviews and the critical incident technique was used to elicit real-life examples of professionalism in practice. FINDINGS: Triangulation of the data revealed three constructs of pharmacy patient-centred professionalism: being professionally competent, having ethical values and being a good communicator. RESEARCH LIMITATIONS/IMPLICATIONS: It is not known whether our participants' perspectives reflect those of all pharmacists in the early stages of their careers. The data provide meaning for the concept of patient-centred professionalism. The work could be extended by developing a framework for wider application. Patient-centred professionalism in pharmacy needs further investigation from the patient perspective. PRACTICAL IMPLICATIONS: The findings have implications for pharmacy practice and education, particularly around increased interaction with patients. SOCIAL IMPLICATIONS: The data contribute to a topic of importance to patients and in relation to UK health policy, which allocates more directly clinical roles to pharmacists, which go beyond the dispensing and supply of medicines. ORIGINALITY/VALUE: The methods included a novel application of the critical incident technique, which generated empirical evidence on a previously under-researched topic.

An exploration of the utility of appraisals for the revalidation of pharmacy professionals in community pharmacy in Great Britain.

BACKGROUND: With revalidation in pharmacy in the United Kingdom fast approaching, appropriate systems of revalidation in community pharmacy are required. With little known about the potential use of appraisals for evaluating fitness to practice in pharmacy professionals (pharmacists and pharmacy technicians) in this sector, research was undertaken to explore their potential utility in a revalidation process. OBJECTIVES: To examine existing structures and processes in community pharmacy appraisals in Great Britain (ie, England, Scotland, and Wales) and consider the views of pharmacy stakeholders on if, and how, appraisals could contribute to revalidation of pharmacy professionals. METHODS: Semi-structured telephone interviews were conducted with senior staff (eg, superintendents and professional development managers) from chain community pharmacies as well as pharmacy managers/owners from independent pharmacies. Senior staff from locum agencies and pharmacy technician stakeholders were also interviewed. RESULTS: Appraisals were in place for pharmacists in most chain pharmacies but not in independent pharmacies. Locum pharmacists were not appraised, either by the companies they worked for or by the locum agencies. Pharmacy managers/owners working in independent pharmacies were also not appraised. Pharmacy technicians were appraised in most chain pharmacies but only in some independent pharmacies. Where appraisals were in operation, they were carried out by line managers who may or may not be a pharmacist. Appraisals did not seem to cover areas relevant to fitness to practice but instead focused more on performance related to business targets. This was particularly true for those in more senior positions within the organization such as area managers and superintendent pharmacists. CONCLUSIONS: Existing systems of appraisal, on their own, do not seem to be suitable for revalidating a pharmacy professional. Considerable changes to the existing appraisal systems in community pharmacy and employer engagement may be necessary if they are to play a role in revalidation.

Existing arrangements for monitoring community pharmacies in England: can they have a role in the revalidation of pharmacists?

BACKGROUND: Maintaining and regulating professional competence in health care is a growing concern. Tasked with developing a system of revalidation for pharmacy professionals, the pharmacy regulator in Great Britain commissioned a series of studies to evaluate existing sources of evidence as potential contributors to the revalidation process. OBJECTIVES: To explore the utility of existing regulatory inspections and service commissioners' contract monitoring processes in the community pharmacy sector as sources of evidence of the fitness to practice of pharmacists in England. METHODS: Thirteen semistructured telephone interviews conducted with representatives of the regulatory Inspectorate and community pharmacy commissioners. RESULTS: Interviewees described current processes for inspecting and monitoring community pharmacy premises and the services they provided. Their focus was primarily on the pharmacy and not on the pharmacist. Views were given as to how the roles of the Inspectorate and service commissioners might be developed to incorporate aspects of revalidation. Particular issues were raised in relation to the revalidation of self-employed locum and independent owner pharmacists. CONCLUSIONS: Existing inspection and contract monitoring processes have little utility in providing evidence of the fitness to practice of individual community pharmacists in England. However, there may be potential for the Inspectorate and service commissioners to develop a role in revalidation, particularly for locum pharmacists and/or independent pharmacy owners. Moreover, they may take a role in providing the infrastructure required to support the process of revalidation for community pharmacists. Current financial pressures and restructuring in the National Health Service, however, are obstacles to the development of revalidation processes.

Revalidation arrangements for pharmacy professionals in industry and academia in Great Britain: a qualitative study.

BACKGROUND: Pharmacy, like other health professions in Great Britain (GB), is currently considering potential future revalidation arrangements for its members. To date, evidence about performance appraisal arrangements for pharmacy professionals working in nonpatient-facing sectors has been scarce. OBJECTIVES: This study aimed to explore the use of appraisals and other sources of evidence for the purposes of revalidating pharmacy professionals working in the pharmaceutical industry and in academia. METHODS: A qualitative study was undertaken; the sampling strategy was purposive and telephone interviews were carried out with pharmacy professionals working in pharmaceutical companies and schools of pharmacy in GB. The interviews were semistructured and the topic guides were designed to elicit participants' experiences of appraisal systems and views about the relevance of such systems to revalidation. The data generated were analyzed using the framework technique. RESULTS: Fourteen pharmacists and pharmacy technicians working in pharmaceutical companies and schools of pharmacy in GB took part in interviews. All participants had experience of appraisals but did not tend to link these to revalidation. Other sources of evidence relating to work performance were described and some aspects of pharmaceutical industry requirements were seen as potentially relevant to revalidation. The importance of being assessed by someone with an adequate understanding of the area of practice was emphasized in both sectors. CONCLUSIONS: Although industry and academia are "nonpatient-facing" sectors, much work undertaken within them is still professional pharmacy practice. There are defined governance roles in industry, which need to be undertaken by reliable and competent practitioners. Those responsible for any future revalidation system in pharmacy must ensure it is underpinned by an adequate and up to date understanding of the context and nature of the work undertaken by those it covers to ensure that measures of fitness to practice are valid.

Who do you think you are? Pharmacists' perceptions of their professional identity.

OBJECTIVES: The aim of this study was to examine pharmacists' perceptions of their professional identity, both in terms of how they see themselves and how they think others view their profession. METHODS: A qualitative study was undertaken, using group and individual interviews with pharmacists employed in the community, hospital and primary care sectors of the profession in England. The data were recorded, transcribed verbatim and analysed using the framework method. KEY FINDINGS: Forty-three pharmacists took part in interviews. A number of elements help determine the professional identities of pharmacists, including attributes (knowledge and skills), personal traits (aptitudes, demeanour) and orientations (preferences) relating to pharmacists' work. The study identified the presence of nine identities for pharmacists: the scientist, the medicines adviser, the clinical practitioner, the social carer, the medicines maker, the medicines supplier, the manager, the business person and the unremarkable character. While the scientist was the strongest professional identity to emerge it nevertheless seemed to overlap and compete with other professional identities, such as that of the medicines maker. CONCLUSIONS: The relatively high number of identities may reflect some degree of role ambiguity and lack of clear direction and ownership of what makes pharmacists unique, but also suggests a flexible view of their role.

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

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

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

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