Integration and impact of pharmacists in general practice internationally: A rapid review.

OBJECTIVE: English general practices have been facing ongoing pressures, arising from complicated health care needs and the recent pandemic. To overcome these pressures and reduce the workload of general practitioners, there have been extensive attempts to integrate pharmacists into general practices. A number of literature reviews, often systematic, have partially explored the topic of general practice-based pharmacists (GPBPs) internationally. Our aim was to further explore the employment/integration models of GPBPs and their actual activities and impact, concepts that have not been thoroughly investigated by previous reviews. METHODS: Two databases were searched from inception to June 2021 for studies published in the English language. Results were independently screened by two reviewers to establish eligibility for inclusion. Original research studies, or protocols where results had not been released at the time of search, that reported on services provided by pharmacists with some sort of integration into general practices were included. The studies were analysed using narrative synthesis. RESULTS: Searches identified 3206 studies in total, of which 75 met the inclusion criteria. The included studies were highly heterogeneous in terms of participants involved and methodologies employed. Integration of pharmacists into general practices has occurred in several countries, with funds originating from multiple sources. Several employment models for GPBPs were described - for example, part-time and full-time work and/or coverage of multiple or single practices. GPBP activities, with some exceptions, were comparable between different countries, with medication reviews being the most common task globally. GPBP impact was identified through both observational and/or interventional research methods, by pursuing a large variety of measures (e.g. activity volume, contact with patients, perceptions/experiences, and patient outcomes). Independent, quantifiable outcomes from GPBP activities were all positive but were of varying statistical significance. CONCLUSIONS: Our findings suggest that GPBP services can lead to positive, quantifiable outcomes, mainly in relation to medication use. This shows the usefulness of GPBP services. The findings of this review can help policy makers decide how best to implement and fund GPBP services, and how to identify and measure GPBP impact.

Patients' experiences of pharmacists in general practice: an exploratory qualitative study.

BACKGROUND: Since 2015, pharmacists have been integrating into English general practices and more recently into primary care networks. General practice-based pharmacists provide a range of patient-facing services, such as medication reviews, management of long-term conditions and minor ailments, prescribing duties and answering queries over the telephone. Literature reports patients' satisfaction with general practice-based pharmacists' services, however, previous research captured only limited experiences. The aim of the current study was to pursue an extensive exploration of patients' experiences of pharmacists in general practice. METHODS: General practice-based pharmacists, working in practices in West London, Surrey and Berkshire, handed invitation packs to patients seen during consultations. Patients that wanted to take part in the study were invited to undertake a qualitative, in-depth, face-to-face, semi-structured interview within the practice with which each patient was registered. Interviews lasted from 15 min to more than 1 h and were audio-recorded. Recruitment continued until data saturation. Audio-recordings were transcribed verbatim and transcripts analysed thematically. RESULTS: Twenty participants were interviewed. Four themes were discerned: awareness ("I had been coming to this practice for 24 years and I didn't know that there was a pharmacist"); accessibility ("People ring for a GP [general practitioner] appointment … it's Monday and they [receptionist] tells you 'We can slot you in on Friday' … with a pharmacist on board, they can [instantly] look at you"); interactions ("I've always had a really good interaction with them [pharmacists] and they listen and they take on board what I'm trying to say"); and feedback ("It's easier [to collect feedback instantly] because I could have forgotten half of what they [pharmacists] have told me in an hour or so's time"). CONCLUSIONS: Findings indicate that pharmacists' integration into general practices could improve accessibility to, and the quality of, care received. The findings will assist policy development to provide general practice-based pharmacists' services as per patients' needs.

Community pharmacy teams' experiences of general practice-based pharmacists: an exploratory qualitative study.

BACKGROUND: In England, since 2015, there has been a formal drive to integrate pharmacists into general practice as a new healthcare service. Research efforts have offered insights into how general practice-based professionals and patients view the service, however, they took no account of community pharmacy teams' opinions. There have been anecdotal statements about opposition from community pharmacies to the service, due to fears of losing business. The aim of the current study was to identify the experiences and perceptions of community pharmacy teams regarding pharmacists' presence in general practice. METHODS: The National Health Service Choices website was used to identify community pharmacies within a radius of two miles from eight West London general practices. The search resulted in 104 community pharmacies which were all contacted via telephone. Pharmacy staff who verbally expressed their interest to participate were then provided with the study's documents. Qualitative, face-to-face, semi-structured interviews were conducted inside the pharmacy from which each participant was recruited. Interviews lasted 30 to 45 min and were audio-recorded. Audio-recordings were transcribed verbatim and transcripts analysed thematically. RESULTS: Forty-eight community pharmacy staff participated. Four themes were discerned: awareness ("I knew that [pharmacists] have already been implemented [in general practice] but I haven't really followed it … where does the pharmacist role come?"); interactions ("I'm just so pleased that there's a pharmacist professional in the general practice … because we speak the same language!"); patient care ("if I was a patient knowing that there is a general practitioner and a pharmacist [in general practice], I would … think 'nothing can go wrong at the moment'"); and funding challenges ("if general practices take on the extra responsibility of stop smoking or flu vaccination campaigns … financially, this would affect this pharmacy"). CONCLUSIONS: The current study revealed the perceived impact of general practice-based pharmacists on community pharmacies would be improved communication between pharmacies and practices. Findings will inform policy so that any future framing of pharmacists' presence in general practice considers the needs of community pharmacies.

Capturing pharmacists' impact in general practice: an e-Delphi study to attempt to reach consensus amongst experts about what activities to record.

BACKGROUND: In the UK, there is ongoing integration of pharmacists into general practice as a new healthcare service in primary care. Evaluation of the service involves national measures that require pharmacists to record their work, on the general practice clinical computer systems, using electronic activity codes. No national agreement, however, has been established on what activities to record. The purpose of this study was to attempt to reach consensus on what activities general practice-based pharmacists should record. METHODS: The e-Delphi method was chosen as it is an excellent technique for achieving consensus. The study began with an initial stage in which screening of a general practice clinical computer system and discussion groups with pharmacists from two 'pharmacists in general practice' sites identified 81 codes potentially relevant to general practice-based pharmacists' work. Twenty-nine experts (pharmacists and pharmacy technicians from the two sites along with experts recruited through national committees) were then invited by e-mail to participate as a panel in three e-Delphi questionnaire rounds. In each round, panellists were asked to grade or rank codes and justify their choices. In every round, panellists were provided with anonymised feedback from the previous round which included their individual choices along with their co-panellists' views. Final consensus (in Round 3) was defined as at least 80% agreement. Commentaries on the codes from all e-Delphi rounds were pooled together and analysed thematically. RESULTS: Twenty-one individual panellists took part in the study (there were 12 responses in Round 1, 18 in Round 2 and 16 in Round 3). Commentaries on the codes included three themes: challenges and facilitators; level of detail; and activities related to funding. Consensus was achieved for ten codes, eight of which related to activities (general and disease specific medication reviews, monitoring of high-risk drugs and medicines reconciliation) and two to patient outcomes (presence of side effects and satisfactory understanding of medication). CONCLUSIONS: A formal consensus method revealed general practice-based pharmacists' preferences for activity coding. Findings will inform policy so that any future shaping of activity coding for general practice-based pharmacists takes account of pharmacists' actual needs and preferences.

How do pharmacists in English general practices identify their impact? An exploratory qualitative study of measurement problems.

BACKGROUND: In England, there is an ongoing national pilot to expand pharmacists' presence in general practice. Evaluation of the pilot includes numerical and survey-based Key Performance Indicators (KPIs) and requires pharmacists to electronically record their activities, possibly by using activity codes. At the time of the study (2016), no national evaluation of pharmacists' impact in this environment had been formally announced. The aim of this qualitative study was to identify problems that English pharmacists face when measuring and recording their impact in general practice. METHODS: All pharmacists, general practitioners (GPs) and practice managers working across two West London pilot sites were invited, via e-mail, to participate in a focus group study. Appropriately trained facilitators conducted two audio-recorded, semi-structured focus groups, each lasting approximately 1 h, to explore experiences and perceptions associated with the KPIs. Audio-recordings were transcribed verbatim and the data analysed thematically. RESULTS: In total, 13 pharmacists, one GP and one practice manager took part in the study. Four major themes were discerned: inappropriateness of the numerical national KPIs ("whether or not we actually have positive impact on KPIs is beyond our control"); depth and breadth of pharmacists' activity ("we see a huge plethora of different patients and go through this holistic approach - everything is looked at"); awareness of practice-based pharmacists' roles ("I think the really important [thing] is that everyone knows what pharmacists in general practice are doing"); and central evaluation versus local initiatives ("the KPIs will be measured by National Health Service England regardless of what we think" versus "what I think is more pertinent, are there some local things we're going to measure?"). CONCLUSIONS: Measures that will effectively capture pharmacists' impact in general practice should be developed, along with a set of codes reflecting the whole spectrum of pharmacists' activities. Our study also points out the significance of a transparent, robust national evaluation, including exploring the needs/expectations of practice staff and patients regarding pharmacists' presence in general practice.

Pharmacists in general practice: a qualitative interview case study of stakeholders' experiences in a West London GP federation.

BACKGROUND: Increased patient demand for healthcare services coupled with a shortage of general practitioners necessitates changes in professional roles and service delivery. In 2016, NHS England began a 3-year- pilot study of pharmacists in general practice, however, this is not an entirely new initiative. There is limited, current, evidence-based, UK research to inform the pilot so studies of pre-existing services must suffice until findings from a formal national evaluation are available. METHODS: The aim of this exploratory, descriptive interview study was to explore the experiences of stakeholders in eight general practices in the Ealing GP Federation, West London, where pharmacy services have been provided for several years. Forty-seven participants, including pharmacy team members (pre-registration and clinical pharmacists, independent prescribers and pharmacy technicians), general practitioners, patients, practice managers, practice nurses and receptionists took part in semi-structured, audio-recorded qualitative interviews which were transcribed verbatim, coded and analysed thematically to extract the issues raised by participants and the practicalities of providing pharmacy services in general practice. RESULTS: Findings are reported under the themes of Complementarity (incorporating roles, skills, education and workloads); Integration (incorporating relationships, trust and communication) and Practicalities (incorporating location and space, access, and costs). Participants reported the need for time to develop and understand the various roles, develop communication processes and build inter-professional trust. Once these were established, however, experiences were positive and included decreased workloads, increased patient safety, improved job satisfaction, improved patient relationships, and enhanced cost savings. Areas for improvement included patients' awareness of services; pharmacists' training; and regular, onsite access for practice staff to the pharmacy team. CONCLUSIONS: Recommendations are made for the development of clear role definitions, identification of training needs, dedication of time for team building, production of educational materials for practice staff members and patients, and provision of on-site, full-time pharmacy services. Future work should focus on evaluation of various models of employing pharmacy teams in general practice; integration of pharmacists and pharmacy technicians into multidisciplinary general practice teams; relationships between local community pharmacy and general practice personnel; and patients' service and information needs. A formal national evaluation of the pilot scheme is overdue.