Integrating community pharmacy with NHS Direct: evaluation of a pilot scheme

□ The National Health Service plan promised referral to pharmacy by NHS Direct by 2002 □ Evaluation of a pilot scheme showed that the initial referral rate to pharmacists fell markedly over a few months □ Pharmacists were positive about both NHS Direct and the pilot scheme but we found no evidence of added benefit in terms of callers' views of the service □ NHS Direct nurses supported the scheme in principle, but in practice had concerns about referring to pharmacists in the absence of a clear rationale     

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.     

Consumer attitudes towards community pharmacy services in Saudi Arabia

Objective The purpose of this study was to determine consumer attitudes towards community pharmacy and their preferences for the introduction of new services. Methods A self‐completion questionnaire was developed and 1,144 consumers in 55 community pharmacies were invited to complete it. The questionnaire covered consumers' choice of pharmacy; their perceptions of, and actual interactions with, community pharmacists; advice from pharmacists about general health and prescribed medicines; and privacy in the pharmacy. Respondents were asked for their views about five possible new services. Setting The study was based in community pharmacies in Riyadh City, Saudi Arabia. Key findings The response rate was 79.6%. Fifty‐nine per cent of respondents often or sometimes visited a particular pharmacy. One‐quarter of respondents perceived community pharmacists as having a good balance between health and business matters, while 56.1% thought pharmacists were more concerned with the business. The majority of respondents (69.7%) said they felt comfortable asking the pharmacist for advice. Just under half (44.8%) felt that pharmacists allowed them enough time to discuss their problem fully and listened well. In addition, 58.5% of respondents indicated that their pharmacists showed sensitivity to privacy by speaking more quietly across the counter. In 14.4% of situations pharmacists were reported to use a private area within the pharmacy when discussing personal or private matters. Most respondents (65.2%) indicated that their pharmacist was willing to discuss their health problems and tried to understand their feelings. Consumers' priorities for new services were: monitoring blood pressure; measuring weight, height and temperature; monitoring blood sugar; and monitoring cholesterol. Conclusion This study showed that most pharmacy customers feel comfortable seeking advice from their pharmacist. Although many pharmacists were reported to show sensitivity to a possible lack of privacy in the pharmacy, few respondents reported that their pharmacy had a private area for discussion. Customers' views on possible new services were generally positive, with the exception of patient medication records.     

Are customers requesting medicines by name less likely to be advised or referred? Provision of over‐the‐counter H2‐receptor antagonists and alginate products from pharmacies

Objectives To identify selected factors which may influence the provision of over‐the‐counter alginate and H₂‐receptor antagonist (H₂RA) products, advice and referral from community pharmacies, and to establish if referrals of customers with dyspepsia made by pharmacy staff were in line with published referral guidelines. Setting Customers supplied with over‐the‐counter alginates or H₂RAs by 39 community pharmacies in Scotland and Wales in a six‐month period. Method A structured questionnaire was issued to customers provided with an alginate or H₂RA from community pharmacies, with one reminder sent to non‐responders. Key findings A total of 608 completed questionnaires were returned (79 per cent response): 523 customers (86 per cent) stated they requested the product they were supplied with by name, with previous use being the most frequently cited reason. Customers who requested a product by name were less likely to receive advice about the supplied medicine, less likely to be referred to a medical practitioner (GP) and also less likely to receive lifestyle advice than customers who did not request a named product. Overall, only 30 per cent of patients who met criteria for referral to a GP were referred. Conclusion The findings of this study suggest that more emphasis should be placed on referrals by pharmacy staff and on the provision of lifestyle and product‐specific advice, particularly when products are requested by name. The acceptability of these actions to pharmacy customers is not known.     

我院药师在直接抗病毒药物相互作用管理中的实践

目的:评估药师在丙肝患者药物相互作用(drug-drug interaction, DDI)管理中的工作。方法:北京佑安医院建立直接抗病毒药物(direct-acting antiviral agent, DAA)治疗患者转诊流程,医师为丙肝患者开具DAA药物后转诊至药学门诊,由药师进行全面的药物审查,识别患者用药中存在的DDI。根据DDI的风险程度不同,药师采取不同的干预措施。结果:2020年5月至2021年4月期间药师为189名转诊患者提供药学服务,共确定108例次DDI。常与DAA发生DDI的药物是:中成药或中草药(38%)、胃肠用药(18.5%)、高血压用药(12%)。药师对患者提出的干预措施主要是:停用合并用药(42.6%)、调整服药时间(24.1%)和加强临床监测(17.6%)等。结论:药学门诊的专职药师可以通过评估DAA治疗的适当性、确定DDI并向患者推荐适当的干预措施来帮助患者优化治疗过程。     

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.     

Does community pharmacy offer women family‐friendly working conditions and equal opportunities? The accounts of female community pharmacists over the age of 30

Objective The sex mix of the pharmacy workforce has altered significantly over the last 60 years such that in 2005 54% of the practising pharmacy workforce was female. After the age of 30 years, part‐time working is common and it is often assumed that pharmacy working attracts and suits women because it is flexible and family friendly. This paper aims to explore to what extent that is true. Setting This study was based in the North West of England. Method Face‐to‐face interviews (n=30) were conducted with women over the age of 30 years who worked as community pharmacists. The interview schedule was designed to explore: interviewees' motivation for choosing pharmacy; employment history; motivation for choosing a particular pattern of working; views of recent changes in pharmacy; and future career plans. Key findings In line with previous studies this sample of female community pharmacists adopted heterogenous work patterns, and personal and extrinsic structural factors were found to influence work patterns. Importantly, there was evidence of a lack of family‐friendly practices, with antisocial hours, difficulties accommodating annual leave, and the restrictive legislative framework that necessitates that a pharmacist is always present in a store, all affecting work patterns. Conclusion Our study, in contrast to other studies, suggests that for about half of the women interviewed, community pharmacy working was difficult to combine with family commitments. This finding has implications for employers and workforce planners because an increasing proportion of the community pharmacy workforce is female.     

Patients' views of the value of “brown bag” medication reviews

Objective — To explore and describe patients' views of the value of brown bag medication reviews. Method — Semi‐structured, tape‐recorded interviews were conducted with 20 patients who had participated in a brown bag medication review scheme. Setting — A health authority area in south‐east inner London. Key findings — Patients perceived the following benefits from brown bag reviews: clinical problems resolved; better understanding of their medications, leading to increased confidence; and appreciation that an interest was being taken in their health care. Reviews had given patients a sense of empowerment, and had made them realise that they had a right to information about their medical treatment and medication. As a result they were likely to be more proactive in seeking information in future. Reviews had made patients realise that pharmacists were knowledgeable about medicines, where previously many had thought that only doctors had sufficient knowledge. Reviews had enhanced relationships between patients and pharmacists. However, some patients still perceived their doctor as the authoritative source of information about medicines. Patients' accounts indicated that much of the information provided by the pharmacist was new, raising the issue of what information was routinely being provided by pharmacists. Conclusions — Brown bag reviews were regarded by patients as beneficial and they wanted them to be available in the future. Patients' perceptions of pharmacists as health professionals and providers of information on medicines were enhanced by brown bag reviews.     

Schizophrenia care and the Dutch community pharmacy: the unmet needs

Background Schizophrenia is a severe psychiatric disease with a prevalence of 0.6% both worldwide and in the Netherlands. Without proper treatment, schizophrenia will be increasingly incapacitating for up to 70% of patients. Management consists of drug treatment and education and can include cognitive therapy. Information about antipsychotic drugs and the importance of treatment compliance are most often given to the patient by the treating psychiatrist. Method Structured postal questionnaires to patients and relatives ‐ 250 members of Anoiksis, a Dutch patients' association for people suffering from psychotic illnesses and 250 members of Ypsilon, a Dutch support network for relatives of patients suffering from schizophrenia or psychosis. Face to face, semi‐structured interviews with 25 community pharmacists randomly selected from different parts of the Netherlands. Key findings Patients and their relatives were unaware of the possible information‐giving and support roles of the community pharmacist. More than 60% of patients and relatives agreed that they would have liked to receive more information about drug treatment. Two‐thirds of patients and relatives thought that an active reminder to collect refill medication would be a valuable service. However, the community pharmacists were unaware of patients' unmet needs and of the support they could offer to patients with schizophrenia. Conclusion Patients and their relatives have needs for medication information and support that are not currently being met. Dutch community pharmacists do not currently perceive that they have a contribution to make to the care of patients with schizophrenia. As the first stage in developing future community pharmacy services, the findings of this study should be disseminated to pharmacists. Objective To investigate the role of the Dutch community pharmacist in schizophrenia care.     

Design of an algorithm to support community pharmacy dyspepsia management

Objectives To design a care pathway and referral documentation system to support dyspepsia management in the community pharmacy according to national guidelines. To explore attitudes of community pharmacists and general practitioners (GPs) towards the proposed model of care. Setting Focus group of four community pharmacists from one locality and one-to-one interviews with five GPs in each of their surgeries in different city localities. Method Literature review; design of a care pathway and referral system; qualitative analysis of focus group discussion and one-to-one interviews. Main outcome measure Modified design of documentation system; attitudes and barriers towards an extended role for pharmacists in a community pharmacy based model of individual care of patients with dyspepsia. Results The care pathway and documentation system was modified to make it simple to use and to assure appropriate referral and reporting to GPs. All participants agreed that the SIGN guideline for Dyspepsia and local dyspepsia guidelines provide an opportunity to extend the role of pharmacists to prescribe therapeutic doses of H₂ receptor antagonists, test for Helicobacter pylori in the pharmacy and prescribe eradication therapy. Perceived advantages to patients included better convenience and reduced waiting times for H. pylori testing. Current barriers to this model identified were: medico-legal issues, budgetary issues, limited access to patient data, lack of privacy to talk to patients, inadequate time and remuneration, no patient registration, patients describing vague symptoms and patient confidence in pharmacists. Conclusion The proposed model of care and documentation system for community pharmacy based dyspepsia management generated a favourable response and design contributions from community pharmacists and GPs. Barriers were identified which have to be overcome prior to implementation and evaluation of the model. This study was conducted by the lead author when based in NHS Lothian, Scotland to undertake an MSc in Clinical Pharmacy at University of Strathclyde, Glasgow.     

Community pharmacists' views and beliefs about the treatment of symptoms suggestive of vaginal thrush in community pharmacies

Objective: To investigate the views and beliefs of community pharmacists about the benefits and disadvantages to the customer, pharmacy and pharmacist of treating women with symptoms suggestive of vaginal thrush. Design: Semi‐structured interviews.Setting: Community pharmacists from within Grampian Primary Care NHS Trust.Outcome Measures: Pharmacists' views and beliefs analysed using content analysis.Results: Of the 26 pharmacists contacted, 19 (73%) pharmacists from 16 pharmacies completed interviews. The pharmacists were generally positive towards the treatment of women with vaginal symptoms and perceived few disadvantages. Immediate access to treatment and rapid symptom relief were perceived to be the greatest advantages to the customer. The main problems were customer embarrassment, cost and the risk of masking a serious condition. Customer embarrassment was perceived to be influenced by lack of privacy and the gender of the member of staff involved in the consultation. Five pharmacists perceived vaginal thrush to be an infection that could be spread by sexual transmission. Discussion: There is a need to make pharmacists aware of the current evidence regarding the treatment of vaginal thrush, particularly that sexual partners of women with acute, uncomplicated thrush do not require treatment with an anti‐fungal. The main difficulties that community pharmacists reported with the treatment of this condition were obtaining an accurate history and this was influenced by customer embarrassment. The gender of pharmacy staff and lack of private consultation facilities were suggested as factors that are associated with customer embarrassment and hence, the ability to obtain an accurate history.     

Political and legal aspects of pharmacist prescribing

The appropriateness of pharmacist prescribing is examined, and limits that should be incorporated into legislation are discussed. Arguments that support pharmacist prescribing are that (1) in current practice, pharmacist consultation has evolved into prescribing; (2) there is a need for pharmacists to prescribe; (3) nurse practitioners and physicians' assistants, whose training in clinical pharmacology is conducted by pharmacists, have authority to prescribe in many states; (4) as the need for dispensing functions decreases, new functions must be assumed; and (5) pharmacist prescribing in pilot studies has been safe, effective, and either equal or superior to physician prescribing. Negative aspects of pharmacist prescribing include (1) not all pharmacists are competent to prescribe, (2) pharmacists are not trained in diagnosis, (3) physicians oppose it, (4) it could increase patient-care costs, and (5) pharmacists' access to patient information is not adequate for competent prescribing. Based on these arguments, legislation regulating pharmacist prescribing should contain certain limits: (1) certification to prescribe should be based on demonstrated competence, (2) pharmacists who prescribe must have access to medical records, (3) pharmacists must prescribe within established working relationships with physicians, and (4) pharmacist prescribing should be limited to long-term therapy for chronic disease and therapy for acute self-limiting illnesses that are not diagnostically complex. These limitations have been incorporated into California law. A bill is pending that allows pharmacists, within specified guidelines, to initiate drug treatment.     

Pharmacist supplementary prescribing training: a study of pharmacists' perceptions and planned participation

Objective The aim of this research was to investigate in a national sample of pharmacists, who have not yet applied for a supplementary prescribing (SP) course, their planned participation in training, and attitudes towards pharmacist SP. Setting Great Britain. Method A postal questionnaire was sent to 4300 pharmacists (approximately 10% of all Great Britain registered pharmacists). The questionnaire had five sections: awareness of SP training; perceptions of aspects of SP training; actions taken relating to SP training based on ‘stage of change’ model; attitudes towards implementing SP into practice; and demographics. Within demographics, respondents were asked to denote themselves as innovators, early adopters, early majority, late majority and laggards, based on receptivity to change. Non‐respondents were mailed up to two reminders. Key findings The response rate was 55.1% (2371/4300). Of the 1707 with patient contact but who had not commenced training, almost all (1668, 97.7%) were aware of pharmacist SP. A minority had taken any significant SP training action, with most being at the precontemplation/contemplation stage of change. However, most respondents either strongly agreed/agreed that practising SP would improve patient care, but strongly disagreed/disagreed that they had sufficient pharmacist/technical support. Two‐hundred and forty‐three (73.0%) of the ‘venturesome’ pharmacists (the innovators) and 291 (79.5%) of the ‘role models’ (the role models) had either never thought about training or had not yet explored training options further. Following logistic regression, predictors of prescribing training actions were: awareness of local networks for SP; receptivity to change; knowledge of colleagues who had undertaken or were currently undertaking SP training; postgraduate qualifications; intrinsic (professional) factors such as professional duty to become a prescriber; and extrinsic (infrastructure) factors such as sufficient IT support. Conclusion We have demonstrated that pharmacists are aware of SP courses and that certain factors are associated with actions relating to prescribing training. However, the practice setting(s) require(s) attention to ensure readiness to support such innovations in areas such as IT and administrative support. These issues have implications for education providers, the NHS and policy makers; and the extension into independent prescribing. Issues based on receptivity to change and models of change require further investigation.     

Improved reporting of adverse drug reactions

A program using satellite pharmacists to improve adverse drug reaction (ADR) reporting in an 1100-bed teaching hospital is described. Because relying on physicians to report ADRs had met with little success (only six reports in seven years), the pharmacy department proposed that pharmacists in satellite pharmacies on patient-care units be called upon to identify and report ADRs. To begin this program, an ADR team composed of a physician, pharmacist, and nurse made weekly rounds of the satellite pharmacies to assist pharmacists in identifying potential ADRs. The FDA definition of an ADR was adopted. Also, inservice education programs about ADR reporting were conducted for pharmacists and nurses. Currently, suspected ADRs are reported to the satellite pharmacist, who forwards a completed drug reaction report form to the assistant director for clinical pharmacy services. Reports are discussed quarterly by the ADR subcommittee of the pharmacy and therapeutics committee; the sub-committee members determine whether any follow-up action is needed. In the first three years after implementation of this program, 306 ADRs were reported; 90% of the reports were filed by pharmacists. An ADR reporting system based on reporting by staff pharmacists has been effective in increasing the number of reported reactions and pharmacist involvement in monitoring patients for ADRs.     

Community pharmacy services for antidepressant users

Objective — To evaluate the communication and barriers to communication between community‐based pharmacists and antidepressant users. Method — A survey package designed to evaluate the communication between pharmacists and antidepressant users was distributed to 50 community pharmacies. Each package included one pharmacist survey and 10 sealed antidepressant user surveys to be distributed by the pharmacy staff. The survey addressed the components of communication, level of satisfaction and barriers to effective communication. Setting — Urban and rural community pharmacies in the Canadian Maritime provinces of Nova Scotia and New Brunswick. Key findings — Overall, pharmacists rated the value of their communication more highly than did antidepressant users, although the difference was not statistically significant. When beginning treatment, between one‐half and two‐thirds of antidepressant users recalled pharmacists inquiring about past use of the antidepressant and discussing information provided by the physician, time to onset of benefits and potential side effects. The purpose of the antidepressant, target symptoms, usual duration of therapy and risk of relapse with premature discontinuation were addressed less often according to antidepressant users, and monitoring of compliance was not a common activity. Antidepressant users estimated that initial communication with the pharmacist generally lasted less than five minutes, and often less than two minutes. However, pharmacists appeared to resolve misconceptions and concerns about antidepressant use efficiently. According to pharmacists, the major barrier to effective communication was a lack of privacy. Conclusion — Although compliance with antidepressants is low and treatment outcomes are sub‐optimal, pharmacists are not using their opportunities to minimise this problem through effective communication and follow‐up. Pharmacists, pharmacy administrators and regulators need to re‐assess their contribution to this problem and how they can lead to its resolution in the patient's best interest.     

“Mental mirrors” of pharmacists: How do pharmacists perceive their over-the-counter customers?

The aim of this study was to analyse how a sample of Finnish pharmacists perceived a number of video-taped customers requesting over-the-counter medicines. The conceptual basis of the study was cognitive psychology. Eleven female pharmacists took part in the study. In a questionnaire, each pharmacist was asked how she perceived each customer and to say what information she would have given the customer if time was available in the pharmacy. This was followed by a set of questions to which the pharmacist responded by using the ordinal scales provided. The data were analysed by a combination of qualitative and quantitative methods. The reaction to a specific situation was found to vary considerably among the pharmacists and was influenced by the cognitive structures of the pharmacist, the perceived personal qualities of the customer and the situation. The pharmacists indicated that they would give health information to complement information about the OTC preparation if time was available. Customers who were presumed to be independent would be given more information about side effects and alternative preparations than other customers.     

Attitudes of hospital pharmacists to adverse drug reactions and the “yellow card” scheme: a qualitative study

Objective — To elicit the views of hospital pharmacists towards adverse drug reaction (ADR) reporting. Method — Qualitative, semi-structured interviews were conducted on a face to face basis using a prepiloted questionnaire. Analysis was carried out using Winmax Pro, content analysis and comparison of interpretation by two independent reviewers. Setting — All major hospitals in one Committee on Safety of Medicines/Medicines Control Agency (CSM/MCA) regional monitoring centre in England. Key findings — It was considered that introduction of reporting had been poorly publicised and promoted. Only 42 per cent of those interviewed had submitted more than one “yellow card” report and a similar percentage had reported none. The CSM/MCA has a poor image in terms of accessibility and its perceived opinion of pharmacists' role in reporting. Feedback from the CSM/MCA was satisfactory and Current Problems in Pharmacovigilance was highly regarded. Several factors appear to be dissuading pharmacists from participation in the scheme, including lack of clinical knowledge, pressure of work and a lack of time. The absence of a fee did not appear to be a deterrent to reporting; in fact, a fee was considered inappropriate. Initial schemes for education and training were perceived as having been successful. However, ongoing training needs had not been fully addressed. Conclusion — While hospitals pharmacists acknowledge ADR reporting as part of their professional role, it is not yet considered as part of their daily practice and requires more vigorous promotion. Further investigation and quantitative work are required to investigate fully this aspect of pharmacy practice.