Using communities of practice as a lens for exploring experiential pharmacy learning in general practice: Are communities of practice the way forward in changing the training culture in pharmacy?

BACKGROUND: Currently, there is little experiential learning in general practice (GP) during UK undergraduate and postgraduate pharmacy education and training. AIM: To apply educational theories to explore pharmacy stakeholders' perceptions of placements in general practice and contribute to the development of a model of experiential learning for pharmacy. METHODS: Qualitative, semi-structured interviews, conducted as part of two studies exploring experiential learning in general practice, with learners and their GP based supervisors. Interviews explored experiences of learning and practice, and what aided or hindered this. An abductive approach to analysis combined inductive coding with deductive, theory-driven interpretation using Lave and Wenger's concept of "Communities of Practice". RESULTS: Forty-four interviews were conducted, with learners and placement supervisors. Participants valued placements for providing authentic patient-facing learning experiences in the workplace, facilitated through legitimate peripheral participation by supervisors and supported by the use of pre- and de-briefing. Learners benefitted from support from their supervisor(s) and other staff during their day-to-day learning (informal learning), whilst also having protected time with their supervisors to discuss learning needs or go through workplace-based assessments (formal learning). Lack of clarity regarding which and how competencies should be assessed / demonstrated in general practice challenged monitoring progress from peripheral to full participation. Findings suggest that GP placements provide opportunities for learning about the patient journey between care settings; to work effectively with multidisciplinary teams; and consolidation and application of consultation / communication skills learning. CONCLUSIONS: The learning culture of GP supports learners' development, providing time and opportunities for meaningful and authentic workplace learning, with healthcare professionals acting as supervisors and mentors. These findings can usefully inform implementation of meaningful learning opportunities in primary and secondary care for those involved in pharmacy education and training.

A qualitative exploration of pharmacovigilance policy implementation in Jordan, Oman, and Kuwait using Matland's ambiguity-conflict model.

BACKGROUND: As Arab countries seek to implement the 'Guideline on Good Pharmacovigilance Practice (GVP) for Arab countries', understanding policy implementation mechanisms and the factors impacting it can inform best implementation practice. This study aimed to explore the mechanisms of and factors influencing pharmacovigilance policy implementation in Arab countries with more established pharmacovigilance systems (Jordan, Oman), to inform policy implementation in a country with a nascent pharmacovigilance system (Kuwait). RESULTS: Matland's ambiguity-conflict model served to frame data analysis from 56 face-to-face interviews, which showed that policy ambiguity and conflict were low in Jordan and Oman, suggesting an "administrative implementation" pathway. In Kuwait, policy ambiguity was high while sentiments about policy conflict were varied, suggesting a mixture between "experimental implementation" and "symbolic implementation". Factors reducing policy ambiguity in Jordan and Oman included: decision-makers' guidance to implementors, stakeholder involvement in the policy's development and implementation, training of policy implementors throughout the implementation process, clearly outlined policy goals and means, and presence of a strategic implementation plan with appropriate timelines as well as a monitoring mechanism. In contrast, policy ambiguity in Kuwait stemmed from the absence or lack of attention to these factors. Factors reducing policy conflict included: the policy's compliance with internationally recognised standards and the policy's fit with local capabilities (all three countries), decision-makers' cooperation with and support of the national centre as well as stakeholders' agreement on policy goals and means (Jordan and Oman) and adopting a stepwise approach to implementation (Jordan). CONCLUSIONS: Using Matland's model, both the mechanism of and factors impacting successful pharmacovigilance policy implementation were identified. This informed recommendations for best implementation practice in Arab as well as other countries with nascent pharmacovigilance systems, including increased managerial engagement and support, greater stakeholder involvement in policy development and implementation, and undertaking more detailed implementation planning.

Community pharmacy integration within the primary care pathway for people with long-term conditions: a focus group study of patients', pharmacists' and GPs' experiences and expectations.

BACKGROUND: This study aimed to use marketing theory to examine the views of patients, pharmacists and general practitioners (GPs) on how community pharmacies are currently used and to identify how community pharmacy services may be better integrated within the primary care pathway for people with long-term conditions (LTCs). METHODS: A qualitative research design was used. Two focus groups were conducted with respiratory patients (n = 6, 5) and two with type 2 diabetes patients (both n = 5). Two focus groups were held with pharmacists (n = 7, 5) and two with GPs (both n = 5). The "7Ps marketing mix" ("product", "price", "place", "promotion", "people", "process", "physical evidence") was used to frame data collection and analysis. Data was analysed using thematic analysis. RESULTS: Due to the access and convenience of community pharmacies ("place"), all stakeholder groups recommended using community pharmacies over GP practices for services such as management of minor ailments, medication reviews and routine check-ups for well managed LTCs ("product"). All stakeholder groups preferred pharmacy services with clear specifications which focused on specific interventions to reduce variability in service delivery and quality ("process"). However, all stressed the importance of having an appropriate system to share relevant information, allowing pharmacists and GPs two-way flow ("process"). Pharmacists and GPs mentioned difficulties in collaborating with each other due to inter-professional tensions arising from funding conflicts, which leads to duplication of services and inefficient workflow within the primary care pathway ("people"). Patients and GPs were sometimes doubtful of community pharmacies' potential to expand services due to limited space, size and poor quality consultation rooms ("physical evidence"). However, all stakeholder groups recommended promoting community pharmacy services locally and nationally ("promotion"). Patients felt the most effective form of promotion was first-hand experience of high quality pharmacy services and peer word-of-mouth. The added value of using pharmacy services was faster access and convenience for patients, and freeing up GPs' time to focus on more complex patients ("value"). CONCLUSIONS: Using the 7Ps marketing mix highlighted factors which could influence utilisation and integration of community pharmacy services within the primary care pathway for patients with LTCs. Further research is needed to identify their relative importance.

Patient and public perspectives of community pharmacies in the United Kingdom: A systematic review.

BACKGROUND: The United Kingdom has been at the forefront of enhancing pharmacist roles and community pharmacy services, particularly over the past decade. However, patient and public awareness of community pharmacy services has been limited. OBJECTIVE: To identify and synthesize the research literature pertaining to patient and public perspectives on: existing community pharmacy services, extended pharmacist roles and strategies to raise awareness of community pharmacy services. SEARCH STRATEGY: Systematic search of 8 electronic databases; hand searching of relevant journals, reference lists and conference proceedings. INCLUSION CRITERIA: UK studies investigating patient or public views on community pharmacy services or pharmacist roles from 2005 to 2016. DATA EXTRACTION AND SYNTHESIS: Data were extracted into a grid and subjected to narrative synthesis following thematic analysis. MAIN RESULTS: From the 3260 unique papers identified, 30 studies were included. Manual searching identified 4 additional studies. Designs using questionnaires (n = 14, 41%), semi-structured interviews (n = 8, 24%) and focus groups (n = 6, 18%) made up the greatest proportion of studies. Most of the studies (n = 28, 82%) were published from 2010 onwards and covered perceptions of specific community pharmacy services (n = 31). Using a critical appraisal checklist, the overall quality of studies was deemed acceptable. Findings were grouped into 2 main themes "public cognizance" and "attitudes towards services" each with 4 subthemes. DISCUSSION AND CONCLUSIONS: Patients and the public appeared to view services as beneficial. Successful integration of extended pharmacy services requires pharmacists' clinical skills to be recognized by patients and physicians. Future research should explore different approaches to increase awareness.

Development, Feasibility, Impact and Acceptability of a Community Pharmacy-Based Diabetes Care Plan in a Low-Middle-Income Country.

Informed by existing research, mostly from high-income countries, this study aimed to develop and test the feasibility of a community pharmacy person-centred goal-setting intervention for people living with type 2 diabetes in a low-middle-income country-Nigeria. The Medical Research Council (MRC) guidance for developing complex interventions framed the intervention development. Patients participated in monthly community pharmacist consultations over six months. Self-reported and clinical outcome measures were collected at baseline and study completion and analysed in STATA V.14. Twenty pharmacists in 20 pharmacies completed the research and enrolled 104 patients. Of these, 89 patients had complete study data, and 70 patients also completed a post-study evaluation questionnaire. In addition, 15 patients and 10 pharmacists were interviewed. All outcome measures showed statistically significant improvements (p < 0.05). Clinical outcomes (BMI, waist circumference, and fasting plasma glucose) improved significantly. Mean patient activation measure (PAM©), quality of life (EQ-VAS©), and medication adherence improved from baseline to study completion. Eighty-eight per cent of questionnaire respondents were satisfied with the service. Interviews indicated care plan acceptability, patient satisfaction, empowerment, and service enthusiasm. Identified barriers to the consultations included time and technology. This study developed a feasible, effective, well-perceived community pharmacy diabetes care plan in Nigeria.

Using normalisation process theory to understand implementation of integrated multi-sector pre-registration trainee pharmacy technician training.

BACKGROUND: The pre-registration trainee pharmacy technician (PTPT) integrated training programme is a workforce intervention designed to train PTPTs in multiple sectors. The programme recruited 35 PTPTs to 2-year training posts which involved employment in one sector, and a minimum of 12 weeks' work-based training in ≥2 further settings each year. AIM: To identify facilitating and inhibiting factors to implementation of the PTPT integrated training programme and make recommendations on ways to embed and maintain PTPT integrated training in routine practice. METHODS: Normalisation Process Theory (NPT) constructs were used as a framework for analysis. Semi-structured interviews (14 PTPTs, 15 supervisors) explored PTPTs' learning and practice experiences over their 2-year training. A survey explored training outcomes (confidence and preparedness to practise) of integrated (n = 31) and single sector PTPTs (n = 39). RESULTS: Whilst some understood the intervention well, others had differing understandings of its purpose and potential benefits (coherence). Educational and practice supervisors acknowledged the importance of regular communication but reported difficulties implementing this due to time constraints (cognitive participation). PTPTs benefitted from having an educational supervisor oversee learning and progress over 2-years, and a practice supervisor for their day-to-day learning. PTPTs' experiences of supervision were inconsistent due to variation in supervisors' availability, knowledge, experience, and level of support (collective action). Participants perceived the PTPT integrated training as supporting development of a flexible pharmacy technician workforce able to work across sectors. The survey found that integrated PTPTs felt significantly more prepared than single-sector PTPTs to work in different settings (reflective monitoring). CONCLUSIONS: PTPTs on the programme had better ability to work in different sectors. Improving implementation requires clear understanding of the intervention's purpose by all stakeholders; clarity on supervisors' roles/contributions; and effective communication between supervisors to create effective learning opportunities. Findings can inform implementation of future multi-sector education and training globally.

Preparing pharmacists for the Community Pharmacist Consultation Service: a questionnaire survey.

OBJECTIVES: The Community Pharmacist Consultation Service launched in England in 2019. Patients requiring urgent care were referred from National Health Service-based telephone/digital triage or general practice to a community pharmacist, who provided a consultation, which could include a physical examination. The aim of the study was to evaluate the effectiveness of a learning programme to prepare community pharmacists for the service. METHODS: Learning programme participants were invited to complete an online survey shortly after the workshop and another survey 3 months later. The survey collected opinions on aspects of the programme, including Likert-type statements and free text questions. The 3-month follow-up survey explored how the programme had helped pharmacists change their practice. Data were analysed in SPSS (v.25; IBM) with inferential statistics used to compare subgroups. Open comments were analysed qualitatively. KEY FINDINGS: The learning programme addressed participants' learning needs including history-taking, clinically observing the patient, performing physical examinations, structuring a consultation, safety-netting, and documenting consultations. Barriers to using skills acquired included low service uptake and a lack of equipment to perform physical examinations. While many participants recognised the importance of skills to provide person-centred care, some participants did not appear to recognise the shift in policy to a more clinical role. CONCLUSIONS: The learning programme resulted in increased confidence and a recognition of a shift in the policy vision for community pharmacist roles. Although some pharmacists appeared to embrace this, others have yet to fully appreciate the need to adapt to be ready for the opportunities that this service can provide.

A Systematic Review of Pharmacovigilance Systems in Developing Countries Using the WHO Pharmacovigilance Indicators.

BACKGROUND: In the context of the growth of pharmacovigilance (PV) among developing countries, this systematic review aims to synthesise current research evaluating developing countries' PV systems' performance. METHODS: EMBASE, MEDLINE, CINAHL Plus and Web of Science were searched for peer-reviewed studies published in English between 2012 and 2021. Reference lists of included studies were screened. Included studies were quality assessed using Hawker et al.'s nine-item checklist; data were extracted using the WHO PV indicators checklist. Scores were assigned to each group of indicators and used to compare countries' PV performance. RESULTS: Twenty-one unique studies from 51 countries were included. Of a total possible quality score of 36, most studies were rated medium (n = 7 studies) or high (n = 14 studies). Studies obtained an average score of 17.2 out of a possible 63 of the WHO PV indicators. PV system performance in all 51 countries was low (14.86/63; range: 0-26). Higher average scores were obtained in the 'Core' (9.27/27) compared to 'Complementary' (5.59/36) indicators. Overall performance for 'Process' and 'Outcome' indicators was lower than that of 'Structural'. CONCLUSION: This first systematic review of studies evaluating PV performance in developing countries provides an in-depth understanding of factors affecting PV system performance.

The development, feasibility and acceptability of a coach-led intervention to ease novice community pharmacists' transition to practice.

BACKGROUND: Despite reported benefits of transition support programmes for other healthcare professionals, no evidence-based support interventions exist to ease newly-registered novice community pharmacists' (NCPs) transition into practice. OBJECTIVES: To develop an intervention to provide psychosocial support, support the development of professional behaviours and skills of novice pharmacists in community pharmacy and conduct an evaluation. METHODS: The Medical Research Council (MRC) guidance for developing complex interventions was applied to develop a 17-week, pharmacist coach-led intervention, using a social media group, a face-to-face introductory workshop, two webinars, weekly case studies, portfolios (reflective logs and development plans) and a handbook. Twelve newly-registered NCPs participated. A coach log and semi-structured interviews collected data on feasibility, acceptability and perceived impact. RESULTS: Findings suggest the intervention was feasible and highly acceptable to NCPs, who perceived the coach and social media group to be the most valuable components. The coach was described as non-judgemental, approachable and collaborative. Provision of guided one-to-one reflection was viewed as useful for debriefing, feedback and meaningful reflection, and supported development of reflection-in-action. The face-to-face workshop was considered important for establishing rapport and trust. The social media group was most valued for providing an accessible, confidential and responsive support network, in which NCPs felt psychologically safe to learn. This component was reported to present opportunities for developmental discourse and shared reflection with peers, thus reducing the sense of professional isolation. NCPs reported that the intervention led to increases in meaningful learning, confidence, critical reasoning, self-awareness and self-reflection. The webinars and handbook were identified as the least valuable components. CONCLUSIONS: A transition-support intervention using an experienced pharmacist coach, delivered within a safe, supportive, albeit online facilitated learning environment, appeared feasible and valuable in supporting guided reflection and developmental discourse. This facilitates transformative learning, and supports NCPs to gain proficiency and become independent reflective practitioners.

Cross-sector pre-registration trainee pharmacist placements in general practice across England: A qualitative study exploring the views of pre-registration trainees and education supervisors.

The Pharmacy Integration Fund commissioned 95 cross-sector pre-registration trainee pharmacist placements across England, which incorporated trainees spending 3-6 months in general practice (GP), whilst employed in hospital or community pharmacy. Delivery models varied (blocks or split weeks/days); trainees had pharmacist tutors at the employing/base (hospital/community pharmacy) organisation and in GP. This study aimed to evaluate implementation of cross-sector pre-registration placements, and to identify barriers and enablers of a "successful" placement that achieved its intended outcomes. A qualitative study was undertaken, using semi-structured interviews with triads/dyads of trainee and pharmacist tutors at base and/or GP site. Interviews explored trainees' and tutors' GP placement experiences, and the contribution of GP placements to achieving intended learning outcomes. Data were thematically analysed. Thirty-four interviews (14 trainees, 11 base tutors, 9 GP tutors) were completed in 11 study sites (5 GP/hospital; 6 GP/community pharmacy). GP placements were perceived as valuable and producing well-rounded pre-registration trainees with a good understanding of two settings. Key benefits of GP placements were trainees' ability to work within multidisciplinary teams, and improved clinical and consultation skills. Contingency planning/flexibility was important when setting up cross-sector placements. GP tutor supervision which supported a gradual transition from shadowing to more independent clinical practice with feedback was perceived as valuable. Good collaboration between tutors at the base and GP site ensured joined-up learning across settings. All participants considered 13 weeks in GP an appropriate minimum duration; community trainees preferred longer duration (26 weeks) for more opportunities for clinical and consultation skills learning. Base and GP tutors would welcome clarity on which pre-registration competencies should be achieved in GP placements, which would also aid quality and consistency across providers. Findings from this study identified key attributes of a successful pre-registration cross-sector training experience. These findings can inform policy reforms including changes to initial education and training of pharmacists.

Community Pharmacist Consultation Service: A Survey Exploring Factors Facilitating or Hindering Community Pharmacists' Ability to Apply Learnt Skills in Practice.

BACKGROUND: The NHS Community Pharmacist Consultation Service (CPCS) offers patients requiring urgent care a consultation with a community pharmacist, following referral from general practice or urgent care. The study explored the impact of undertaking a Centre for Pharmacy Postgraduate Education (CPPE) CPCS learning programme, and barriers and enablers to CPCS delivery. METHODS: CPPE distributed an online survey to those who had undertaken their CPCS learning. The survey explored participants' knowledge, confidence and application of taught skills/tools, including clinical history-taking, clinical assessment, record keeping, transfer of care, and Calgary-Cambridge, L(ICE)F and SBARD communication tools. Details on barriers and enablers to CPCS delivery were also included. RESULTS: One-hundred-and-fifty-nine responses were received (response rate 5.6%). Knowledge of, and confidence in, taught skills were high and respondents reported applying skills in CPCS consultations and wider practice. Barriers to CPCS included a lack of general practice referrals, staffing levels, workload, and GP attitudes. Enablers included a clear understanding of what was expected, minimal concerns over indemnity cover and privacy, and positive patient attitudes towards pharmacy. CONCLUSION: This study demonstrates that community pharmacists can extend their practice and contribute to the enhanced provision of urgent care in England. This study identified barriers, both interpersonal and infrastructural, that may hinder service implementation.

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.

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

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

Internationally trained pharmacists in Great Britain: what do registration data tell us about their recruitment?

BACKGROUND: Internationally trained health professionals are an important part of the domestic workforce, but little is known about pharmacists who come to work in Great Britain. Recent changes in the registration routes onto the Register of Pharmacists of the Royal Pharmaceutical Society of Great Britain may have affected entries from overseas: reciprocal arrangements for pharmacists from Australia and New Zealand ended in June 2006; 10 new states joined the European Union in 2004 and a further two in 2007, allowing straightforward registration. AIMS: The aims of the paper are to extend our knowledge about the extent to which Great Britain is relying on the contribution of internationally trained pharmacists and to explore their routes of entry and demographic characteristics and compare them to those of pharmacists trained in Great Britain. METHODS: The August 2007 Register of Pharmacists provided the main data for analysis. Register extracts between 2002 and 2005 were also explored, allowing longitudinal comparison, and work pattern data from the 2005 Pharmacist Workforce Census were included. RESULTS: In 2007, internationally trained pharmacists represented 8.8% of the 43,262 registered pharmacists domiciled in Great Britain. The majority (40.6%) had joined the Register from Europe; 33.6% and 25.8% joined via adjudication and reciprocal arrangements. Until this entry route ended for pharmacists from Australia and New Zealand in 2006, annual numbers of reciprocal pharmacists increased. European pharmacists are younger (mean age 31.7) than reciprocal (40.0) or adjudication pharmacists (43.0), and the percentage of women among European-trained pharmacists is much higher (68%) when compared with British-trained pharmacists (56%). While only 7.1% of pharmacists registered in Great Britain have a London address, this proportion is much higher for European (13.9%), adjudication (19.5%) and reciprocal pharmacists (28.9%). The latter are more likely to work in hospitals than in community pharmacies, and all groups of internationally trained pharmacist are more likely to work full-time than British-trained ones. Adjudication pharmacists appear to stay on the Register longer than their reciprocal and European colleagues. CONCLUSION: Analysis of the Register of Pharmacists provides novel insights into the origins, composition and destinations of internationally trained pharmacists. They represent a notable proportion of the Register, indicating that British employers are relying on their contribution for the delivery of pharmacy services. With the increasing mobility of health care professionals across geographical borders, it will be important to undertake primary research to gain a better understanding of the expectations, plans and experiences of pharmacists entering from outside Great Britain.

The impact of prescription charges on asthma patients is uneven and unpredictable: evidence from qualitative interviews.

AIM: To explore whether, and how, prescription charges affect asthma patients' disease management behaviour. METHOD: Thirty qualitative interviews. RESULTS: Interviewees were aged between 21 and 59, 21 were women, 24 were paying individual prescription charges, and six had prepayment certificates (PPCs). Most had a beta2-agonist 'reliever' and a steroid 'preventer' inhaler. Prescription charges posed affordability issues for some, and for two patients cost-related reduction in 'preventer' use affected asthma control negatively. Many described various ways of keeping medication cost down. Affordability issues, negative views on paying charges, and whether interviewees viewed their asthma medication as essential, were influential factors. Steroid inhalers were viewed more commonly as being less essential and affected by cost. The episodic nature of asthma meant that predicting benefit from PPCs was difficult. CONCLUSION: This study strengthens existing evidence that medication cost is a factor in asthma patients' management decisions, with a potential cost-related impact on asthma control.

The impact of nonreferral outpatient co-payment on medical care utilization and expenditures in Taiwan.

BACKGROUND: Taiwan's National Health Insurance's (NHI) generous coverage and patients' freedom to access different tiers of medical facilities have resulted in accelerating outpatient care utilization and costs. To deter nonessential visits and encourage initial contact in primary care (physician clinics), a differential co-payment was introduced on 15th July 2005. Under this, patients pay more for outpatient consultations at "higher tiers" of medical facilities (local community hospitals, regional hospitals, medical centers), particularly if accessed without referral. OBJECTIVES: This study explored the impact of this policy on outpatient medical activities and expenditures, different co-payment groups, and tiers of medical facilities. METHODS: A segmented time-series analysis on regional weekly outpatient medical claims (January 2004 to July 2006) was conducted. Outcome variables (number of visits, number of outpatients, total cost of outpatient care) and variables for cost structure were stratified by tiers of medical facilities and co-payment groups. Analysis used the auto-regressive integrated moving-average model in STATA 9.0. RESULTS: The overall number of outpatient visits significantly decreased after policy implementation due to a reduction in the number of patients using outpatient facilities, but total costs of care remained unchanged. The policy had its greatest impact on the number of visits to regional and local community hospitals but had no influence on those to the medical centers. Medical utilization in physician clinics decreased due to an audit of reimbursement declarations. Overall, the policy failed to encourage referrals from primary care to higher tiers because there was no obvious shifting of medical utilization and costs reversely. CONCLUSIONS: Differential co-payment policy decreased total medication utilization but not costs to NHI. The results suggest that the increased level of co-payment charge and the strategy of a single cost-sharing policy are not sufficient to promote referrals within the system. To achieve an effective co-payment policy, further research is needed to explore how patients' out-of-pocket payment affects medical utilization and which forces (not susceptible to co-payment) act in tertiary facilities.

Workload pressure among recently qualified pharmacists: an exploratory study of intentions to leave the profession.

OBJECTIVES: To explore the reasons why recently qualified pharmacists had chosen to follow non-standard career paths, or were thinking of doing so. METHODS: Participants in a nationwide longitudinal cohort study examining pharmacy careers who were either working in non-standard roles (i.e. not primarily employed in community, primary care or hospital pharmacy), or who had expressed a likelihood of leaving the profession in the near future, were invited to participate in a follow-up qualitative study. After pilot work to inform the design of a semi-structured interview schedule 12 telephone interviews were conducted with pharmacists who had qualified within the last 5 years. KEY FINDINGS: Regardless of the sector in which these early career pharmacists had gained work experience, there was a common occurrence of workload pressures influencing career decisions. Pressures in community pharmacy were often related to the need to meet certain targets in a business environment. Community pharmacists also bemoaned a lack of resources, such as support staff, which often meant that their day-to-day routines became monotonous and unfulfilling. A feeling of being undervalued and underutilised was the main concern voiced by all pharmacists and represented the views of those with experience of working in both the community and hospital sectors. This situation arose because participants felt that they had been highly trained to deliver new pharmaceutical services yet the opportunities to use their skills did not materialise, partly due to the nature of their workloads. CONCLUSIONS: Early career pharmacists can become disillusioned because the pressure to perform routine tasks often results in a lack of time to provide new pharmaceutical services. Increased job satisfaction levels are seen when more opportunities for clinical input are afforded to pharmacists. This could be achieved through the use of clear guidelines on staffing levels and, more importantly, the provision of adequate support staff.

Solidarity or dissonance? A systematic review of pharmacist and GP views on community pharmacy services in the UK.

There has been a strong policy emphasis over the past decade on optimising patient-centred care and reducing general practitioners' (GPs') workload by extending community pharmacy services and collaboration between pharmacists and GPs. Our aim was to review current evidence of pharmacists' and GPs' views of extended community pharmacy services and pharmacists' roles in the United Kingdom (UK). A systematic review was undertaken looking at UK studies investigating pharmacists' and/or GPs' views of community pharmacy services or roles from 2005 to 2017. A range of databases were searched including EMBASE, PubMed, Scopus, Web of Science, International Pharmaceutical Abstracts (IPA), PsycINFO, Science Direct and The Cumulative Index to Nursing and Allied Health Literature (CINAHL). In addition, reference lists of included studies were screened and grey literature was searched. Following the application of inclusion/exclusion criteria, the quality of papers was critically analysed, findings were extracted into a grid and subjected to narrative synthesis following thematic analysis. The search strategy yielded a total of 4,066 unique papers from which 60 were included. Forty-seven papers covered pharmacists' views, nine combined both pharmacists' and GPs' views and four covered GPs' views. Study designs included interviews (n = 31, 52%), questionnaire surveys (n = 17, 28%) and focus groups (n = 7, 12%). Three main themes emerged from the data: "attitudes towards services/roles", "community pharmacy organisations" and "external influences". Pharmacists and GPs perceived a number of barriers to successful implementation and integration of pharmacy services. Moreover, collaboration between pharmacists and GPs remains poor despite the introduction of extended services. Overall, extending community pharmacy services require quality-driven incentives and joint working between community pharmacists and GPs to achieve better integration within the patient's primary care pathway.

A qualitative exploration of Bahrain and Kuwait herbal medicine registration systems: policy implementation and readiness to change.

BACKGROUND: The Kuwaiti drug regulatory authority (DRA) lack a structured classification system for the assessment of imported herbal medicines (HMs), which leads to ambiguity in the registration process. This study aimed to examine the policy development and implementation process in an established HM registration system (Bahrain) and harness lessons to inform recommendations for a suitable HM classification system and explore implementation readiness in Kuwait. METHODS: A sequential study design was chosen, with data collected in Bahrain (case 1), recommendations formed and readiness for implementation explored subsequently in Kuwait (case 2). With ethics and DRA approval in place, data sources were documentary review of regulatory policies, direct observations of HMs registration processes, and semi-structured interviews with twenty three key officials involved in the HMs registration processes. Data from all three sources were analysed thematically and findings triangulated. RESULTS: The classification policy in Bahrain was found to be based on evidence and extensive stakeholder engagement, resulting in a clear and organised HM registration process. The availability of HMs classification policies in other DRAs, officials' dedication and teamwork, and support by higher authority, were identified as the main facilitators in policy development and successful implementation. Barriers were the diversity of HM classifications worldwide, a lack of staff and resultant workload, and lack of training. Proposed recommendations for Kuwait were to adopt a clear definition of what constituted HMs, and to introduce a Traditional Herbal Registration based on this definition and the product's characteristics. Interviews in Kuwait showed that almost all participants were in favour of the proposed recommendations and were in support of timely implementation. Interviewees anticipated that consistency in the HM registration process would be the main benefit, increasing reviewer's confidence in making regulatory decisions. Interviewees also identified potential challenges which may impede successful implementation, including staff shortages, resistance to change by internal and external stakeholders, and the impact of cultural and traditional ways of working. CONCLUSIONS: Insights into the HM policy development and implementation process in Bahrain, and exploration of Kuwait's readiness to implement resultant recommendations informed an effective implementation process for a well-designed HMs policy for Kuwait and other Arab countries.