The implementation of pharmacogenomics into UK general practice: a qualitative study exploring barriers, challenges and opportunities.

Pharmacogenomics describes interpatient genetic variability in drug responses. Information based on whole genome sequencing will soon open up the field of pharmacogenomics and facilitate the use of genomic information relating to drug metabolism and drug responses. We undertook a qualitative study, aiming to explore the potential barriers, opportunities and challenges facing the implementation of pharmacogenomics into primary care. Semi-structured interviews were undertaken with 18 clinical participants (16 GPs and 2 other clinicians). All interviews were recorded and transcribed verbatim. Using a thematic analysis approach, data items were coded, ordered and themes constructed. Most participants were aged 55-60 years and worked as part-time clinical GPs with other clearly defined roles. The emerging themes covered several areas of concern, including the following: the utility of pharmacogenomics and the value of introducing such testing into primary care; how to educate the primary care workforce and 'mainstream' pharmacogenomics; the ethical, legal and social aspects of pharmacogenomics and its impact on patients; and potential impacts on the healthcare system particularly around economics and informatics. Most participants had concerns about pharmacogenomics and felt that there were a number of barriers and challenges to its implementation into routine primary care. Most striking were their concerns around the cost-effectiveness of using pharmacogenomics in primary care. At the same time most recognised the increasing availability of direct-to-consumer testing, and felt that this would drive the need to understand the ethical and social implications of using genomic information in primary care. This study has raised important issues that need to be considered when planning the implementation of pharmacogenomics into clinical practice. Prior to the implementation of genomic testing into day-to-day practice in UK primary care, it is important that considerations around education, cost-effectiveness and informatics are addressed, as well as the impact on patients.

Patient perspectives on multiple medications versus combined pills: a qualitative study.

BACKGROUND: A growing number of patients are taking multiple medications. Unfortunately, adherence may fall as drug numbers and procedural complexity increase. While there are plausible theoretical reasons why combining pills might improve non-adherence, patients' attitudes are unknown. AIM: To explore attitudes and practices to medication regimens among patients already in receipt of multiple medications, and to assess whether a combined tablet would be perceived as advantageous. DESIGN: Qualitative study. METHODS: Ninety-two men and women aged >40 years currently receiving both antihypertensive and cholesterol-lowering medications took part in 14 focus groups. RESULTS: Drugs were seen as unwelcome but necessary. Some took drugs flexibly by changing dose timing, thereby increasing the complexity of their regimen. A routine was seen as the key to coping with multiple medications, although it was sometimes threatened by changes in prescriptions and life circumstances. While some participants welcomed a combined pill, there was uncertainty about whether a combination that mirrored their current doses would be available. There were also concerns about tablet size, allergies, the attribution of side-effects, timing of tablets throughout the day, and the ability to alter dose levels. CONCLUSION: While some patients would be willing to try a combined pill and would appreciate the associated convenience, they are likely to have a number of concerns that prescribers should address. Willingness to move to combined therapy may be hindered if drug combinations that mirror personalized and trusted regimens are not available.

Clinical governance: the new NHS, new responsibilities?

The declared aim of the White Paper 'The New NHS: Modern, Dependable' is to restructure the NHS so that it is based on 'partnership and driven by performance' (Department of Health (DoH), 1997). The key organizing principles are those of efficiency and excellence. Establishing a framework for clinical governance is seen as central to establishing 'an environment in which excellence in clinical care can flourish' (DoH, 1998). These new arrangements will apply to the the practice of all clinical professionals, including nurses. Clinical governance offers a new opportunity for the nursing profession to raise standards of practice without being hamstrung by issues of patient throughput and price, as was the case under the last government. However, it also presents a challenge to the frameworks within which nursing has traditionally operated. In addition, clinical governance brings with it the potential for more direct involvement of non-clinicians in professional practice.

Impact of The Patient's Charter on A&E departments. 2: The emergency nurse practitioner.

This article is the second of a two-part study based upon the results of a national survey of senior nurses in accident and emergency (A&E) departments. It explores the development of the nurse practitioner role in A&E. In particular, the extent to which this expanded role has become a means by which patients with minor injuries can be 'fast-tracked', to the possible detriment of more holistic goals for care delivery.

Impact of The Patient's Charter on A&E departments: 1.

In the first of a two-part series presenting the results of a national survey of senior nurses in accident and emergency (A&E) departments, developments in the delivery of nursing care are examined within the context of the major organizational changes within the NHS since 1990; in particular, the requirements of meeting The Patient's Charter (Department of Health, 1991, 1995a) standards are discussed. The second article in this series will examine the developing role of the nurse practitioner in A&E departments.