Are pharmacists suitable to work in a general practice setting? – Views of community pharmacists.
- Findings from literature search
- Aims and Objective
- Focus group format
- Study sample
- Data analysis
- Interview guide
- Participant invitation letter
- Participant information leaflet
- Participant consent form
- Ethics approval
- List of figures
- List of tables
A systemic review article predicted that around 600,000 people visit community pharmacies in Scotland each day.  Primary healthcare and community pharmacies are the main access point for healthcare services.  A collaboration between general practitioner (GP) and community pharmacist (CP) improves the effectiveness by bringing a better, user-friendly healthcare system to the public. [2,14] There are several factors that need to be considered in order to provide such collaboration including shared access to patient notes and strong inter-professional communication. Other barriers to a collaboration between GP and CP are the geographical separation of a community pharmacy and general practice surgery, limited access to patient information and time restriction for inter-professional communication.
Pharmacists being integrated into GP practice provides a solution to all the factors mentioned above. . It provides a better inter-professional communication collaboration. [4,5]Practice pharmacists (pharmacists based in GP practice) provide administrative services – clinical wise. These includes providing additional help in managing long-term conditions, giving advice to patient with more than one medication and better access to health check, medication review, medication education and patient counselling, health promotion and disease management clinic. [3,6] Alongside with the other services provided by the practice pharmacist (PP), the PP also manage medicine review, assist in managing patient’s hospital discharge and identifying patient who need extra support in their medication.
The integration of a clinical pharmacist into the general practice setting will allow the GP to focus more on their expertise in diagnosing and treating patient with complex conditions. Clinical pharmacists in general practice (CP-GP) pilot was launched in July 2015 to enhance patient care by integrating clinical pharmacist into the general practice team.  As part of the pilot, over four hundred ninety clinical pharmacists were placed in GP practice. The General Practice Forward View dedicated over £100m in the investment to assign additional one thousand five hundred clinical pharmacists to work in a GP practice by the year 2020/21.
A literature search was conducted in November 2016 to obtain current evidence regarding the attitudes of community pharmacist on the suitability of pharmacists to work in general practice. The electronic database DISCOVER was searched using a combination of keywords related to pharmacy (pharmacist) and general practice (general practitioner or GP or family doctor or primary care). The search was limited to English language articles. Using the keywords above, an advanced search was carried out. The search parameters were restricted to papers from year 1990-2017. I’ve chosen this parameter in order to obtain the relevant studies only. The topic ‘pharmacists’ was chosen in order to remove irrelevant journals. After removing duplicates, there were one hundred and forty-seven journals.
Relevant studies were picked after reading the abstract, method and conclusion. Inclusion criteria inclusion of both general practitioner and pharmacist and a relative depth to the working relationship between general practitioner and pharmacist. The studies that includes the perception of GPs or pharmacists (either PP or CP) were included. Any studies which include any medical conditions were excluded. Studies that only included the collaboration of GP with nurses were also excluded. From the total number of papers, thirteen journals were found relevant to the literature review topic.
11,210 records identified through discover database search
10,935 records identified after English language was chosen
156 records eligible after subject ‘pharmacy’ was chosen.
127 studies left after duplicates removed
Titles and abstracts did not relate to the topic.
(100 titles and abstracts)
27 studies (full text) were found chosen after reading abstract, introduction and conclusion.
Assessment of the full texts lead to the exclusion of 14 papers since it did not meet the inclusion criteria.
A total of 13 studies were chosen
Figure 1: PRISMA flowchart on the methodology for database ‘Discover’
- Findings from literature search
Qualitative studies have been conducted to discuss the perceptions of the GPs, pharmacists, and healthcare consumers on the collaboration with general practitioners. [2,5,8-10] These qualitative studies highlighted the consistency in the results where it discusses the importance of mutual knowledge and the knowledge on each professional’s role.
In a study conducted in Spain, GPs and CPs were interviewed to discuss the perception of collaboration.  Another study was done in Australia that discussed the attitudes of CPs towards collaboration with GPs. A questionnaire was designed based on a collaboration model – Attitudes towards Collaboration Instrument for Pharmacists (ATCI-P) to measure the collaborative behaviours.  Based on the results, the CPs who worked in the near vicinity to the GP surgery were found to have greater collaborative practice. The CPs also believed that determinants for effective collaborations were communication, mutual trust, willingness to work together and recognition of roles.  The willingness of a GP and pharmacist to accept each other roles in providing better healthcare for the public is important to form a good relationship between the GP and pharmacist. Both studies showed similar results indicating that GPs and CPs with collaborative experience believe that on a health system level, collaboration would improve the quality of service and efficacy in providing better quality of prescription.
In this study conducted in New Zealand, CPs felt that they had a role in monitoring of non-concordance, adverse drug reactions and the effectiveness of medications.  A study was conducted in Australia to explore the perspective of healthcare consumers on the integration of a pharmacist into GP setting. In this study, majority of the GPs agreed with that CPs have a role in monitoring of non-concordance and adverse drug reaction. However, only 11% of the GPs have accepted that CPs have a role in the monitoring of the effectiveness of medicine.  The integration of a pharmacist in a GP setting provided access to the patient medical file and also the increase of communication with GPs was seen as a potential benefit. Barriers of the integration of the pharmacist in GP setting was the hesitation of GPs’ and perception of GPs on physical space. 
A systemic review was done in order to assess the roles of pharmacists co-located with other healthcare professionals within GP clinics.  Most pharmacy reported at least one positive outcomes measures. The positive effects were mostly seen in studies where a pharmacist deliver an intervention with a patient follow-up, instead of delivering medication review, drug information separately. Studies that were included in this study also showed that pharmacist service in management of chronic condition such as cardiovascular disease and diabetes achieved the therapeutic health goals more often that the ones in usual care. Pharmacist co-located in the GP clinic is able to provide various types of interventions, showing favours in areas of chronic disease management and medicines optimisation.
Previous studies that was conducted in the United Kingdom suggest that the inter-professional collaboration between GPs and pharmacies rely on a relationship based on trust. [4,10] Those pharmacies with trust-based relationships with the GPs have an advantageous position in meeting the aims of the studies. The first model, the local pharmaceutical services (LPS) pilot showed that to extent the role of pharmacists, a good and working relationship with the GPs should be establish.  The collaboration between GPs and community pharmacists in this study was reliant on mutual and voluntary agreement.  It was identified that certain GPs expressed lack of acknowledgement towards the extent of knowledge and skills of pharmacists. A more challenging barrier to overcome is the negative attitude of GPs towards the ability and skills of pharmacists. This study suggest co-location of healthcare professionals provides a higher level of integration of the primary health care team. It offers professionals an opportunity to learn and improve awareness of individual health care professional’s ability and skills. 
The Pharmacists in Practice study (PIPS) was conducted in Malbourne, Australia in December 2011 and January 2013 to assess the effectiveness of a pharmacists located within a primary care setting.  A prospective, before-after intervention study was conducted at two general practice clinics. Participants in this study were patients with one or more risk factors for medication related problems. Based on the definition, a MRP is “an event of circumstance involving mediation therapy that potentially interferes with an optimum outcome for a specific patient”. The most common type of MRP identified in this study is non-adherence. The practice pharmacist correct this issue by patient education and counselling. Through these actions, the patient’s adherence towards their medication regimen increased significantly according to Morisky (P=0.013) and Tools for Adherence Behaviour Screening (TABS) scale (P=0.019). Other MRPs identified were failure to receive medication, untreated indication, inappropriate medication, adverse drug reaction, drug interaction, incorrect dose and improper storage. This study suggests that pharmacists placed in the general practice setting reduces patient’s MRPs. The pharmacist’s role was well received and supported by other members of staff in the clinic as well as the patients.
A new collaboration model, Family Health Teams (FHTs) involves GPs, nurses, nurse practitioners, pharmacists, dietitians and social workers to improve access, linking patients to the community setting, optimization prevention care and chronic illness management.  Ethnographic methods were used in this study to collect data from six newly formed FHTs in Ontario, Canada. The study aim was to investigate how pharmacist routine evolves around FHTs and how other perceived their role. It shows that the role of a pharmacist has made a significant shift in pharmacy profession for the last 20 years. The Canadian pharmacy profession identified the need for additional continual education for pharmacist to practice effectively in primary healthcare. It is vital to the pharmaceutical care that pharmacist forms relationship with their patients and take responsible for outcome related to drug therapy. The importance of communication was emphasized in this study in order to develop collaborative relationship.
In a separate Australia study, semi-structured interviews and focus group was conducted with GPs, pharmacists and consumers on their perceptions around concordance.  Concordance is an agreement between patient and healthcare professionals such as GP or pharmacist on providing the best treatment compatible with the patient. All three groups voiced out the need for improvement in the information sharing system is important for the future healthcare system. Consumers in this study felt that they need more specific and accurate information on their medications and medical conditions.
Previous work was done in Malaysia to explore the perception of the integration of pharmacists into private GP practice.  The results showed that the participants were supportive of the idea of integrating a pharmacist into a GP clinic. Although the idea was well received, some of the participants were worried with the GPs’ perception in the integration of a new healthcare professional into the GP team. It may be due to the fact that GPs’ feel threatened by this new role. Potential barriers to this study was GPs’ resistance and potential increase in health care cost.
- AIMS AND OBJECTIVES
- To establish the attitudes of community pharmacists regarding the appropriateness of pharmacists to work in the general practice setting
- To identify the perceived training, skills and experience that community pharmacists believe pharmacists require to work in general practice.
A focus group will be conducted including community pharmacists and data will be thematically analysed.
This is a qualitative study exploring the suitability of a pharmacist to work in a general practice setting from the perspective of a community pharmacist. A focus group session was held with five community pharmacists in February 2017 in Sunderland, United Kingdom.
- Focus Group Format
The focus group was facilitated by a team of three researchers and supervisor. The main role of a facilitator was to reassure the participants to have a calm discussion, keeping the discussion relevant, and probe into areas which needed clarification.  An interview guide (appendix 1) was used as starter questions to direct the discussion, but it was largely free-flowing. Participants were highlighted in the participant consent form and reminded at the beginning of the focus group. Prior to the focus group, participants were asked to
- Study Sample
Purposive and convenience sampling were used in this study. Purposive sampling involved participants who have experience related to the topic and match the inclusive criteria. The inclusion criteria for recruiting of participants were participants must be a registered pharmacist working in community pharmacy setting located in Sunderland. The participants must be registered with the general pharmaceutical council for at least three years with or without experience working in a general practice setting. Purposive sampling was used to recruit participants with community pharmacy background and experience with or without experience in general practice Participant invitation letter (appendix 8.4) along with participant information leaflet (appendix 8.2) were handed out personally or emailed personally by researcher to any community pharmacist located in Sunderland. Purposive sampling did not successfully recruit any participants due to the time pressures of this project. Convenience sampling was used to any academics who have community pharmacy background with or without experience of collaboration.
Table 1 : Experience and background of the participants.
|CP1||Worked as community pharmacist, hospital pharmacist and practice support pharmacist in GP practice.|
|CP2||Business owner – community pharmacy|
|CP3||Works in GP practice and have previous community pharmacy background|
|CP4||Community pharmacy background|
|CP5||Worked in community pharmacy and is shifting to GP practice|
- Data Analysis
The focus group discussion was audio recorded with the consent of the participants. The recording was transcribed verbatim. Data was thematically analysed independently.
All participants provided written consent and the study was self-certified by the project supervisor in accordance to the University of Sunderland Reach and Ethics Committee.
A total of five participants (four male, one female) were involved in the focus group. Four major themes were found from the focus group interview and were reinforced by the quotes from the participants. I think the big themes can be broken down further
Reducing the workload of the general practitioner
Better services in medicine use review and medicine optimisation
Positive impact to the patients
Are pharmacists suitable to work in general practice?
Perceived benefit to the collaboration
Better services in chronic disease management
Addition training and skills needed
Access to patient information
Figure 1: The figure showing the key themes identified
Advantages of the Collaboration
All participants feel that the integration of pharmacists would benefit the GP team. A positive perception of the collaboration was needed in order for the collaboration to start. At healthcare system level, the participants believed that a practice pharmacist will reduce workload of a general practitioner allowing them to focus diagnosing patients whilst a pharmacist focus the patient’s medication. The CPs interviewed considered that collaboration would increase the pharmacists’ involvement in improving patient healthcare and bringing benefit to the public. Pharmacists and their expertise in medicines in GP setting would provide a great opportunity for the pharmacists to educate other healthcare professionals in GP team as well as the public.
Positive Impact to the patients
We are in a great position to educate the public on public health. So, things like smoking, obesity, healthy eating, and also other associated activities. (CP2)
They are getting an expert in terms of their medicine sitting down perhaps and really reviewing them and spending time and having access to all these resources and a team working together to impact that patient. (CP3)
Reducing the workload of the general practitioner
I think as a profession that we don’t end to just being there to ease the work load of GPs. (CP2)
It does maybe allow them to spend more time with patients and diagnosing and maybe passing over management to the pharmacist. (CP3)
Some of the participants express that the collaboration between the pharmacist and GP in the same GP surgery would provide a better service on medication reviews, patient safety and chronic illness. Hence, improving the outcomes and safety.
Perceived benefit to the collaboration
I think pharmacist is in a great position to educate other members of healthcare team all the way. Right the way through to GPs, all the way down to practice nurses and that’s a good positive thing about being in that setting. (CP2)
They should have big involvement in patient safety related things, so making sure practice has got appropriate policies in place around, say DMARD prescribing, or high risk drugs. Making sure they are looked after and monitor regularly. (CP3)
I think there’s potential a better quality in GP surgery. So, anything around monitoring of medicines, safety of medicines, kind of educating other staff members That’s needs to be what we kind of own really (CP5)
One of the pharmacists feel that with some community pharmacy training background, a pharmacist would be able to detect any pattern and would react if the situation comes up in the GP practice.
You will have notice if you have worked in community pharmacy in the past, probably you noticed patterns and things like can be problem, so be more aware of them and therefore look for them. (CP1)
Negative impact on community pharmacy
Although there is some perceived benefit with the collaboration, there are some issues that the participants have concern about. Some participants felt that the connection lines between the GPs and the CPs will be lost.
There is a bit of a worry that the communication line might be damage as well with a pharmacist working in a GP practice. (CP2)
I just wonder where that leaves us in terms of community pharmacists and pharmacies and what is left over for most and that’s my biggest concern. (CP4)
Participants were concerned how the collaboration would negatively impact the community pharmacies. There is a potential of deskilling the community pharmacists.
I think the disadvantage is the potential of deskilling the pharmacy and cutting funding to community pharmacist to support the new role. (CP3)
I think we have got to be careful as a profession we don’t negatively impact. (CP3)
My concern is the negative effect that would have on community pharmacist coming from a community pharmacist background (CP4)
Yeah, there’s a potential for the opportunity to review medicines, taken away from the community pharmacy. (CP5)
We don’t want with the deskilling the community pharmacists. (CP1)
We got to be careful not to deskilled the community pharmacist and damage those relationships. (CP3)
All participants were concern on the wellbeing of the patients. Participants were concern that if there is a negative impact on the community pharmacies, there would closure of community pharmacies.
I think convenience is really important. So, the disadvantage is that if they have the appointment but they don’t actually attend because it’s too far travel they would have gone to the local pharmacy. (CP2)
The disadvantage is that if they have the appointment but they don’t actually attend because it’s too far travel they would have gone to the local pharmacy. (CP2)
If the pharmacy closes and that GP surgery is farther away than the pharmacy and now they’re going through the same rapport is that going to get the best service to that patient and if there’s not a lot of pharmacist close that would be my concern. (CP4)
Better Quality of Service
Participants fully recognise the roles and expertise of a pharmacist and what can be done to improve the quality of service. Medication review, medication optimization, chronic illness management and cost saving are considered to be roles of pharmacists to perform within a GP surgery.
Long term management
There is no reason why pharmacists can’t be the one who is titrating all that dose and monitoring going forward. So, I think the longer-term management. (CP3)
It might be easier to manage sort of chronic health problems in that setting. (CP2)
Safety and monitoring of medication
I think there’s potential a better quality in GP surgery. So, anything around monitoring of medicines, safety of medicines, kind of educating other staff members. (CP5)
Medicine use review and medication optimisation
Services like MUR and medicines optimisation, the pharmacists within the GP surgery, there is the commercial kind of pressure taking away from you (CP5)
The traditional role of a practice pharmacist; they were employed to help with things like cost and money saving, they would be making changes to things like that and the formulary and other things. So there was definitely cost savings there.
Some of the participants considered that if communication were in place between GPs and pharmacist, sharing of information to be important. Previously, services such as medication use review, community pharmacists were unable to do review properly due to limited information access.
I think it’s great doing all these services but we need to share the information. (CP5)
If we had that communication in place and ways of accessing information about an individual patient and also more information about what this patient needs where am I going to send them who am I going to send them to that would work better. (CP1)
Because if we have the information shared we know who has had the review at the doctor’s, we know what happen, what was being said, are we bringing them for an MUR, are we repeating what was just being said. (CP1)
Training and Skills Needed for Pharmacist to work in GP surgery
Most participants that trainings and clinical skills are quite important for a pharmacist to exert their role in GP practice. Participants agree that the specific training and skills set needed depends on what the role of the pharmacist in that particular GP setting.
I think it’s very specific to each individual GP practice what the role of pharmacist employ there will be. (CP4)
More advance consultation skills, and prescribing skills, and perhaps clinical skills is quite important for that which pharmacists. (CP3)
I think it would be advantages to have the prescribing qualification definitely. So, I don’t think it is an essential thing to have, but obviously, it is an advantage thing to have. (CP1)
I know a lot of pharmacists who do work in doctor’s surgery and some of them do not have any prescribing qualification (CP1)
I do feel that even without prescribing qualification there is still a lot what the pharmacist could bring to the practice (CP4)
Traditionally, the role of community pharmacists only allows them to work isolated from other healthcare professional with minimal contact on routine matters.  The focus group above gave an understanding into the views of community pharmacists around the integrating pharmacists into general practice team. When participants were asked to discuss on the suitability of pharmacists working in general practice setting, our results showed that all participants were supportive of the concept of having pharmacists in a general practice setting. Participants strongly agree that there are definite benefits in this collaboration to the GPs, the GP team and the patients.
In all healthcare systems, general practice is recognised as a vital element by all health care providers. In the United Kingdom, general practice was always a key aspect of healthcare provision since the inception of the National Health Service in 1948.  A General Practitioner is your family doctor and is the main contact point for the healthcare for patients. The roles of GPs are to assess, diagnose, treat and manage illness. GPs assess, diagnose, treat  Between year 1995 to 2008, the demand for GP appointments rose slightly higher from 3.0 to 3.4 patient year. Collaboration of a practice pharmacists into the GP team allows to focus on their role and allow the practice pharmacists to manage the medications. Hence, removing some of GPs workload. Although government aims for pharmacy in the UK to reducing GP workload, study showed that GPs did not notice a reduction in their workload. A reduction in workload may be felt if the practice pharmacist had more experience and the service had been running longer period of time. 
The results from this study indicate that the co-location of pharmacist within GP practice would provide a better quality of service. Amongst the many services provided by pharmacists, the participants felt that PP can do a better with medicines use review and medicines optimisation. One study indicate that collaboration of healthcare professionals supports the results, indicates that the services quality and efficiency would improve.  The participants believed that pharmacists would better manage chronic conditions. Previous studies seen this pharmacist service as a positive role of practice pharmacist. [3,9] The involvement of pharmacists in managing chronic conditions in primary care speciality clinic showed improvement in managing blood pressure and cholesterol level.  A previous study showed the potential role for a practice pharmacist are medication dosage adjustment and vaccination.  Another study indicate that pharmacists co-located in the GP practice would improve medication outcomes, thus reducing medication errors.
Participants acknowledge information sharing was acknowledged is one of the important aspect in order for the collaboration to be successful. Previous studies showed information sharing between healthcare professionals would increase information exchange and smooths communications.  Results from this study also mentioned the need for access to patient information to allow healthcare professionals to work together Previous study also showed similar result. [8,14] Information sharing is essential in improving and providing a better service quality. Previous study which have explore this issue showed similar result, indicating that the collaboration of GPs and pharmacists would improve the quality of prescriptions.  One study mentioned that trust is an important factor to facilitate practice pharmacist to have access to GPs patient’s records and cooperation. 
The results of this study suggested that practice pharmacist could extend their role in GP setting. Participants indicates that the roles of a pharmacist could further improve medication optimization, medication use review and medication safety. The result also indicate that pharmacists placed in GP practice have a better opportunity to educate the public. In order to further expand their role, participants support the idea of doing extra training to improve the roles of a pharmacist.
Participants indicated the intention of pharmacists to have prescribing qualification. Prescribing qualifications allows practice pharmacist to prescribe medications within general practice. Our result indicates pharmacists with prescribing qualification have an advantage but it is not an essential qualification to have. A previous study reported benefits from health care consumers in pharmacist prescribing medication within GP practice provided great accessibility and a reduction of costs. [8,9]
Although there are perceived benefits of the collaboration, participants also showed concern in the collaboration. The result showed the concern of practice pharmacist taking over role of community pharmacists and potentially deskilling the community pharmacists. The presence of a pharmacists in the GP practice would imply that patients could be intercept in the GP practice, hence deskilling community pharmacy. Since practice pharmacist have access to patient information, practice pharmacist would be able to do a better-quality service such as medicines use review.
Strengths and Limitations
Focus group discussion provided an opportunity for a researcher to gain an insight and understanding how people think on a specific subject. It also provides an opening for a group of people to share their ideas, thoughts and experience that wouldn’t come up during an individual interview.
Several limitations were identified in this study. The participants in this study only includes five community pharmacists / academics. The small sample size limits the extent of our ability to explore the opinion or perception of community pharmacists in this study. The participants were also recruited from the same area. Since it is a relatively small sample size, the results obtained won’t be able to represent the general population. The full focus group did not focus mainly on the perception of community pharmacists on the suitability of pharmacists to work in general practice setting. Although the sample size was small, several themes were identified and explored. All participants have experience working in community pharmacy hence were able to give an insight on the topic. There was only one focus group conducted. The limit number of focus group conducted would prevent any additional data to be collected and further analyse.
Comparison with existing literature
Result from this study are consistent with
Implication for practice and future research
Focus group conducted with community pharmacists / academics have highlighted the significant benefits in the integration of pharmacists into general practice setting. Better relationship between general practitioner and practice pharmacist would improve the quality of service and improve the effectiveness of the collaboration. The collaboration would definitely provide benefits to the patients and general practitioners. Further investigation is needed to study the effect of the collaboration of general practitioners and pharmacists to the community pharmacy.
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- Appendix 1 interview guide
- Participant information Leaflet
PARTICIPANT INFORMATION LEAFLET
Project Title: What are community pharmacists’ attitudes about the suitability of pharmacists to work in general practice?
Before you decide to participant, you need to understand why this research is being carried out and what it may involve. Please take your time to read the following information carefully before deciding whether or not to take part in this research.
Why am I doing this project?
This study aims to determine the perceptions of community pharmacists regarding the suitability of pharmacists to work in general practice. Through this project, I am hoping to be able to gain an insight into the perceived training, skills and experience that community pharmacists believe pharmacists require to work in general practice.
What will you have to do if you agree to take part?
If you agree to participate in this research, you are required to sign the attached consent form and return it to me by email. This research will be conducted in the form of a focus group interview, which will take around thirty minutes to complete. The focus group will consist of up to six participants (community pharmacists). If you agree to take part, we will arrange a mutual time to meet. There will be one, single focus group session with a supervisor and myself. The focus group session will be audio recorded and transcribed verbatim.
What are the risks of participating in this research?
We do not anticipate any risks other than the interview will take up to thirty minutes of your time.
What are the benefits of this research?
The information that we get from this study will help provide insight into the attitudes of community pharmacists about the suitability of pharmacists to work in general practice. This is a chance for you to share your thoughts and perceptions as a community pharmacist.
Do I have to take part in this research?
Your participation is completely voluntary. You have the right to withdraw at any time without giving a reason. There will be no consequence if you do so.
Right to Withdraw
At any point if you wish to withdraw, you may do so without any penalty. You may withdraw by informing me or my supervisor in writing that you no longer wish to participate in this project. Upon withdrawal from this research, you have the right to choose whether to include any data collected from you in the study.
Will the information gathered be kept confidential?
Yes, all the information will be kept confidential and anonymised. Data will be shared with my supervisor. I will write a report and the results may be published. At that point, no research participant will be identifiable from any publications. All participants will be asked to sign a confidentiality agreement during the focus group.
Who has reviewed this project?
This project has been self-certified by the project supervisor in accordance to the Reach and Ethics Committee.
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