Pharmacist‐led medication review clinics in general practice: the views of Greater Glasgow GPs

Objectives To ascertain general practitioners' views of a pharmacist‐led medication review (PLMR) service. In particular, to quantify the percentage of GPs who perceived PLMR to be a useful service to their practices; to explore key service benefits, problems and areas for future improvement; and to quantify the percentage of GPs who believed service benefits outweighed problems. Method Semi‐structured interviews with a purposive sample of six GPs informed the development of a self‐completion postal questionnaire. The questionnaire was sent to all 258 GPs in the 82 practices where PLMR clinics were held. GP views on aspects of the PLMR process were elicited using a Likert scale. Closed questions sought views on overall service value. Free‐text responses were sought on benefits, problems and areas for future improvement. Key findings The response rate was 84% for GPs (93% of practices were represented). Ninety‐five per cent of respondents considered PLMR to be a useful service. Key perceived benefits (improved prescribing practice, raised standards of patient care and satisfaction, and increased GP knowledge and confidence) outweighed problems (space and time constraints, limited GP‐pharmacist contact, occasional patient dissatisfaction). Only a minority of GPs felt that the written pharmacy referrals relating to specific patients were inappropriate. Views were divided as to whether PLMR increased or decreased practice workload. Suggestions for future improvements included increased GP‐pharmacist communication and extended pharmacist roles. Conclusion The Glasgow model of PLMR deployed across a large Primary Care Trust by a team of pharmacists was viewed by those GPs who had received input as a useful service. The majority of GPs exposed to the service believed benefits outweighed problems.     

Contribution of a ward‐based technician service to delivering effective patient health care and reducing dispensary workload

Objective — To determine whether introduction of a ward‐based technician service reduces medication administration errors and decreases pharmacy workload. Method — Information on the incidence of unavailable medication administration errors (U‐MAEs), number of calls to pharmacy, volume of weekend medicine supply and workload of the non‐stock supply (NSS) pharmacist was compared during a two‐week period prior to the implementation of a ward‐based technician service (control period) and a two‐week period after the introduction of the service (study period). Setting — Five wards (two acute admission wards and three care of the elderly medical wards) at Bristol Royal Infirmary with a perceived high workload. Key findings — When a ward‐based technician service was implemented the number of U‐MAEs was almost halved (46 per cent reduction), and there was a 60 per cent reduction in the number of telephone calls from the five pilot wards to the dispensary. Overall, there was a decrease in the number of item requests during the weekend; however, the number of items requested from the non stock supply pharmacist increased from 51 to 58 (14 per cent). Conclusion — Following the introduction of the ward‐based technician service, patient care has improved as medicines are available more reliably, and the work life of the pharmacy team has benefited.     

Consumer perspectives of pharmacist‐delivered healtn information and screening services

Objective — Community pharmacy has been increasing its involvement in health promotion, especially information provision and screening, over the past decade. Little is known about how consumers view these services and there is a need to evaluate the level of consumer endorsement of this role. The aim of this study was to evaluate consumer attitudes towards pharmacist‐delivered health information and screening services over time and with personal experiences of these services, as part of a standardised pharmacy programme. Method — A validated instrument was administered in 1994 (n=98) and 2000 (n=58) to consumers who had not experienced a pharmacist health information and screening programme, and to a population in 2000 (n=159) who had received such a service. Comparisons of consumer attitudes were made between the unexposed 1994 and 2000 populations to test for the influence of time, and between the exposed and unexposed samples in 2000 to test for the effect of personal experience of the service. Setting — Data were collected in seven community pharmacies in various non‐metropolitan regions of New South Wales, Australia. Key findings — Even after accounting for demographic variation between cohorts, consumers had a more positive attitude towards pharmacist screening over time, and towards both health information and screening after personal experience of these services. Conclusion — Community pharmacists should be encouraged to participate more in health information provision and screening in order to take advantage of and further promote consumer endorsement of these pharmacist services.     

Referrals made by different health care professionals to community pharmacists for domiciliary visits

Objective — To examine the suitability of referrals made by health professionals to a pharmacist for a domiciliary visiting service. Method — General practitioners (GPs), district nurses and social services carers were contacted to request that they refer patients who they thought might benefit from a home visit by a pharmacist, using a referral form agreed by an expert panel. Information gathered by the visiting pharmacist during the patient interview was compared with the reason for referral by the health care worker. Setting — All GPs, district nurses and social services carers who cared for housebound patients in the Kenton and Stanmore areas of the London Borough of Harrow. Key findings — Ninety patients were visited. Of these, 47 had been referred by GPs, 29 by nurses and 14 by social services. The highest level of incorrectly stated referrals (22 per cent of their referrals) came from nurses. Nurses tended to refer patients for an explanation of the purpose of their medicines, and GPs because patients were taking more than three medications. Six patients, five of whom were referred by GPs, appeared not to have any problems that could be helped by a visit. Conclusion — There may be a need to raise awareness among social services carers about potential medication problems and the role that could be played by community pharmacists in helping these patients. When GPs make referrals, the criterion of patients taking more than three medications may not be sufficiently sensitive; this should be expanded to ensure that the GP has additional clinically related suspicions that there are adherence issues. Generally, little difference was found between the appropriateness of referrals from the three agencies.     

Community pharmacy as a performance: a participant observer's account of a day in the life of a locum

Objective — To understand, from a dramaturgical viewpoint, the performance of “community pharmacy.” Method — Participant observation supported by focus groups and semistructured interviews; the study adopted a grounded theory approach. Setting — Fieldwork was conducted within 21 community pharmacies in East Anglia, England. Key findings — Pharmacists identify with their setting and stage props. On the stage of community pharmacy, the pharmacist crucially converts the drug into medicine, during a complex and well‐rehearsed performance. There are sometimes distractions, which make the performance sub‐optimal. Other insights included what counts as error, how to manage stress, and the fact that the trust on which professional practice rests is at stake when expressive performance fails. Conclusion — It is possible to conduct ethnography of community pharmacy and this is among the first such studies of British community pharmacy. Were the pharmacist to leave the stage and its props (the drugs), only to advise patients on medicines, the performance of community pharmacy, as we know it, might disappear.     

A pharmacist-led intervention to improve the management of opioids in a general practice: a qualitative evaluation of participant interviews

Background Opioid prescribing has escalated, particularly long-term in chronic noncancer pain. Innovative models of care have been recommended to augment regulatory and harm-minimisation strategies and to review the safety and benefits of opioids for the individual patient. Medication stewardship and pharmacist integration are evolving approaches for general practice. Aim To explore enablers, barriers, and outcomes of a pharmacist-led intervention to improve opioid management in general practice, from the perspectives of general practitioners (GPs) and practice personnel. Method The study was part of a mixed-methods investigation into a general practice pharmacist pilot. Qualitative data relevant to opioids were analysed. Data from 13 semi-structured interviews were coded, analysed iteratively and thematically, and interpreted conceptually through the framework of Opioid Stewardship fundamentals proposed by the National Quality Forum. Results Seven themes and 14 subthemes aligned with stewardship fundamentals. Participants considered organisational policy, supported by leadership and education, fostered collaboration and consistency and improved practice safety. Patient engagement with individualised resources, ‘agreements’ and ‘having the conversation’ with the pharmacist enabled person-centred opioid review and weaning. GPs reported greater accountability and reflection in their practices, in the broader context of opioid prescribing and dilemmas in managing patients transitioning through care. Receiving feedback on practice deprescribing outcomes encouraged participants’ ongoing commitment. Patient communication was deemed an early barrier; however, learnings were applied when transferring the model to other high-risk medicines. Conclusion Improved opioid management was enabled through implementing pharmacist-led coordinated stewardship. The findings offer a practical application of guideline advice to individualise opioid deprescribing.

     

Pharmacists and their customers: a personal or anonymous service?

Aims — To explore the existence and nature of the pharmacist‐customer relationship. Methods — A qualitative approach was adopted. Semi‐structured interviews were conducted with 20 customers recruited from two pharmacies differing in type and location: Pharmacy A, a multiple chain pharmacy in a more affluent area, and pharmacy B, a small chain pharmacy. Key findings — Customers' views differed according to the pharmacy from which they were recruited. Pharmacy B customers had a personal relationship with the pharmacist and used the pharmacy as a health care resource, while pharmacy A customers did not have a personal relationship with the pharmacist and used the pharmacy simply for medicine supply. Several pharmacy A customers had their own different local pharmacist whom they used for more personal advice and counselling. Both groups described disadvantages of multiple chain pharmacies. Consumerist behaviour was identified among customers whereby they preferred to control the provision of advice, assess it and act upon it. However, lack of information was mentioned by several interviewees, which suggested that different types of customers have different needs from the pharmacy. The pharmacist has therefore to recognise these different needs and to meet them accordingly to provide services, whether anonymous or personal, within their “extended role.” While most customers viewed pharmacists as drug experts and considered managing minor ailments to be part of their job, they were less supportive of a more extended role in the therapeutic monitoring of drug therapy. This presents a serious barrier to pharmacists wishing to extend their role into a more patient‐oriented and clinical domain. Conclusion — This study reinforces the importance of considering customers' views when policies and strategies concerning the development of the “extended role” are considered. Recognising customers' views helps the profession to adapt and respond to changing consumer behaviour. Issues identified through this in‐depth exploration of public perceptions of pharmacists have implications for the extension of pharmacists' roles into areas favoured and appreciated by customers.     

Analysis of the information and support needs generated by a community pharmacy‐based methadone treatment programme

Background — Methadone treatment has been provided in Ireland since 1998 under the methadone protocol scheme. Two liaison pharmacists were employed by the Eastern Health Board to interface between pharmacists dispensing methadone in primary and tertiary care. Objective — To analyse and review the inquiries received and addressed by one liaison pharmacist in the first year of operation of a community pharmacy‐based methadone treatment scheme. Method — Inquiries received were recorded by the pharmacist using a standard data collection form. Using content analysis, key themes were identified and each inquiry was classified. Data were analysed using standard computer software. Key findings — Two primary categories of liaison inquiry were addressed: “patient‐related” inquiries, requiring the organisation of community pharmacy‐based methadone dispensing services for patients, and “pharmacy‐related” inquiries, which were requests from community pharmacists for information or support. Two thirds of the inquiries were “patient‐related.” The primary users of the liaison service were prescribers employed by the addiction services and community pharmacists. Conclusion — The liaison pharmacy service handled diverse inquiries, with an emphasis on the facilitation of the provision of pharmaceutical care for patients requiring community pharmacy‐based methadone dispensing services. The liaison service had a significant secondary role in the provision of support and information for community pharmacists. The study findings are of relevance to those involved in developing and introducing primary care‐based services for drug misusers.     

Pharmaceutical needs assessment in general practice

Objective — To develop a method of prioritising the need for pharmaceutical input into a general practice. Method — An adaptation of health needs assessment methodology was used to study areas of potential pharmacist input into a practice. Prescribing data, information from the practice's computer system and medical records were used to identify the practice's needs for pharmacist input and changes to practice. Interviews with practice staff and direct observation were used to obtain information on current systems and suggestions for change. A summary of the needs identified and suggestions for change were used in a prioritisation process. Setting — One UK general medical practice. Key findings — The study identified the need for improvements to the repeat prescribing system, a greater agreement between practice partners on the use of a practice formulary and treatment protocols, and regular review and improved monitoring of patients taking long‐term medication. Among patients taking repeat medication, those aged 45 or over and those taking four or more medicines were found to be at greatest risk of having potential pharmaceutical care issues which needed to be addressed. The prioritisation process resulted in pharmacist input into maintaining registers of patients taking drugs with narrow therapeutic indexes, reviewing the practice's computer‐based formulary and undertaking medication review being considered of highest priority by medical staff. Conclusion — The method enabled the identification of many areas which could benefit from pharmacist input and the prioritisation of these to plan future work.     

Exploring the gap: community pharmacists' perceptions of their current role compared with their aspirations

Objective — To investigate community pharmacy managers' perceptions of their role in providing health care to patients and to compare these with their aspirations for the future. Method — Fourteen pharmacist managers from one regional area of a UK national multiple pharmacy chain participated in two focus groups. Key findings — Participants voiced a shared vision of wanting to play a more integral part in the health care of patients. Strategies put forward to embrace a more participative role included delegation of health screening and minor illness clinics from the prescriber to the pharmacist, having more formalised and open channels of communication with prescribers and moving away from performing technical duties, such as the physical assembly of medicines. Participants in both groups showed awareness that apathy and inaction would result in potential opportunities for pharmacy to be lost or passed over to another profession within the primary health care team (PHCT). Two key external obstacles that currently prevented attainment of desired roles were identified: first, a lack of awareness among other health care professionals and the general public about the pharmacist's skills and attributes and, secondly, current UK legislation that limits the potential for community pharmacists to expand their role away from the pharmacy premises. Conclusions — Participants believed that they could provide a more comprehensive pharmaceutical service if given the chance. However, they believed that implementation of change would be difficult considering the obstacles that needed to be surmounted for change to occur.     

Opportunity or threat? General practitioner perceptions of pharmacist prescribing

Objective In recent years prescribing rights have been extended beyond doctors and dentists in the UK, first to nurses and subsequently to pharmacists. The aim of the study was to explore general practitioner (GP) perceptions of the advantages and disadvantages of pharmacist supplementary prescribing and the future introduction of independent prescribing. Method A qualitative study was conducted with GPs from three practices, in each of which a pharmacist prescriber was regularly working. Key findings The prescribing pharmacists, all of whom were already working in the practice when they qualified as prescribers, had negotiated new areas of work. Not all GPs in the practices referred patients to the prescribing pharmacists. Those GPs who did refer patients generally described benefits from the service, with some ambivalence. There was evidence that the GPs had, to some extent, redefined their professional boundaries, and delegated some routine work which involved no diagnosis and only limited decision making. In this way the GPs exercised control over the interprofessional boundaries. Conclusion The study findings indicate selective acceptance of pharmacist prescribing by GPs.     

The pharmacist as prescriber: A discourse analysis of newspaper media in Canada

BackgroundLegislation to expand the scope of practice for pharmacists to include authority to independently prescribe medications in Alberta, Canada was announced in 2006 and enacted in April 2007. To date, very little research has explored public views of pharmacist prescribing.ObjectiveThis study analyzes newspaper media coverage of pharmacist prescribing 1 year before and 2 years after prescribing was implemented.MethodsNews items related to pharmacist prescribing were retrieved from 2 national, Canadian newspapers and 5 local newspapers in Alberta over a 3-year period after the announcement of pharmacist prescribing. A purposive sample of 66 texts including news items, editorials, and letters were retrieved electronically from 2 databases, Newscan and Canadian Newsstand. This study uses social positioning theory as a lens for analyzing the discourse of pharmacist prescribing.ResultsThe results demonstrate a binary positioning of the debate on pharmacist prescribing rights. Using social positioning theory as a lens for analysis, the results illustrate self- and other-positioning of pharmacists' expected roles as prescribers. Themes related to the discourse on pharmacist prescribing include qualifications, diagnosis, patient safety, physician support, and conflict of interest. Media representations of pharmacist prescribing point to polarized views that may serve to shape public, pharmacist, physician, and others' opinions of the issue.ConclusionsMultiple and contradictory views of pharmacist prescribing coexist. Pharmacists and pharmacy organizations are challenged to bring clarity and consistency about pharmacist prescribing to better serve the public interest in understanding options for health care services.     

Work patterns and uptake of continuing education in a two-year cohort of New Zealand pharmacy technicians

Objective — To investigate the current practice, continuing education uptake and future work intentions of pharmacy technicians in New Zealand. Method — Postal questionnaire survey of all 148 technicians certificated through the Open Polytechnic of New Zealand who started training in 1991 and 1992. Responses were obtained from 83 (56 per cent) of the target population. Key findings — While most technicians regularly performed the duties for which they had been trained, some were also performing more demanding tasks, such as unit dose dispensing and deliveries for rest homes. A smaller number were engaged in more managerial tasks while fewer still were working beyond the confines of their legally defined role by undertaking extemporaneous compounding and preparing Controlled Drugs. Many felt restricted within their current role and wished to see it extended. Perhaps for that reason, most had undertaken some form of continuing education/professional development, not all of them with the support of their pharmacist employer(s). Conclusions — While pharmacy technicians' aspirations and activities might be perceived by some as threatening the traditional role of pharmacists, technicians could also assist pharmacists to move further from the dispensary into the new age of counselling and other forms of patient management and care.     

How effective are pharmacists who work with medical practitioners? A study of interventions intended to influence prescribing

Objective — This study was designed to describe the interventions made by pharmacists working within different therapeutic areas in medical practices in primary care and to estimate the effects on prescribing. Method — All medical practices and community pharmacists in one health authority area in England were invited to participate. Pharmacists were allocated to work with specific practices and training was provided in musculoskeletal, respiratory and anxiolytic/hypnotic (sedative) prescribing. Pharmacists negotiated and agreed with their medical practice the type of interventions which would meet the practice's needs. Pharmacists were remunerated to provide a maximum of eight three‐hour sessions in each medical practice on each therapeutic area over a 12‐month period. Details of all interventions were recorded by each pharmacist and countersigned by a practice GP. A summary form was then sent to the health authority. Analysis of prescribing data before and after intervention in all practices was carried out using a predictive model to calculate estimated costs. Key findings — Twenty‐seven pharmacists working with 39 medical practices participated in the study. Pharmacist interventions resulted in 165 dose changes, 368 drug changes, 470 drug discontinuations and 1,042 patient reviews. On average, £3.99 was saved for each musculoskeletal intervention made. This compared with an additional cost of £15.50 and £17.92 for each intervention in sedative and respiratory prescribing, respectively. Analysis of prescribing data showed that the total spend in musculoskeletal and sedative prescribing in participating practices one year after intervention was lower than that predicted. Conclusion — Accurate recording of individual interventions with reasons, outcomes and direct cost consequences allows purchasers to make more informed decisions about the potential benefits of practice pharmacists. This method may, however, underestimate the pharmacist's indirect impact on prescribing since it does not take into account any educational effect on prescribers.