AIM - To identify the lessons learnt from a shared care approach for patients with asthma and to make recommendations for similar activities and projects in the future.
DESIGN - Evaluation of joint training workshop for participants, review of project results and performance, telephone interview of GP participants and focus group of community pharmacist, GP and tutor participants.
SUBJECTS AND SETTING - Community pharmacists and GPs within East Sussex, Brighton and Hove health authority.
OUTCOME MEASURES - Joint workshop participants' perceptions, community pharmacists' and GPs' opinions and perceptions, patient recruitment.
RESULTS - Learning objectives were met for workshop participants. 103 patients out of an expected 300 were recruited. GPs who had patients referred to them felt that the referrals were justified. GP and community pharmacist support for the project was generally good. Community pharmacists were able to practise effectively in a new, patient-centred model if provided with the correct training and support. A systematic approach for assessment and intervention in asthmatic patients enabled pharmacists to identify and address a considerable number of practical issues. However, these interventions were made in the pharmacy without recourse to other members of the primary health care team. Negative aspects were identified, including pharmacists' time, movement of employee pharmacists from study pharmacies and using prescription presentation as a "cue" for an extended, patient-centred, pharmaceutical care activity.
CONCLUSION - When setting up new, patient-centred projects or pharmaceutical care activities in community pharmacy, although pharmacists can practise effectively in that model a range of issues must be addressed to achieve optimal benefit.
Over the past few years a number of bodies and groups both nationally and locally have recognised that the expertise, knowledge and skills of the community pharmacist are frequently under-utilised.1-3 In East Sussex, the primary care development strategy recognised this fact2 and called for a greater involvement of pharmacists in primary care teams, particularly in specific disease areas such as asthma care. Furthermore, the pharmaceutical services strategy3 has an overall aim of maximising the skills and resources of community pharmacists in delivering primary health care.
This change in direction and philosophy in the role of the community pharmacist requires both leadership from national groups and professional bodies and innovative action at local level. The Royal Pharmaceutical Society's "Pharmacy in a New Age" initiative has identified that one of the four main areas where pharmacists can make a vital contribution to health outcome is in the management of chronic conditions.4
Asthma is a disease where it is felt that optimal control and management has not yet been achieved,5 despite major initiatives nationally and locally. Therefore, there may be scope for community pharmacists to contribute to improving patient management further. Most patients who have a repeat prescription for asthma medication collect their medicines from a pharmacy. This interaction between pharmacist and patient could be used as a cue for an additional intervention in the management of the patient. There is also an opportunity for pharmacists to reinforce information, instructions and education that have been provided by the general practitioner, the practice nurse or the asthma nurse. Experience in Sweden,6 the United Kingdom7 and the United States8 has already shown that community pharmacists can have a positive impact on the care of patients with asthma.
A pilot study was set up in East Sussex to investigate whether community pharmacists and general practices working together more closely could improve medication compliance and effective use of inhalers in asthmatic patients and hence lead to improved control of symptoms. In addition, potential benefit may also occur as a result of improved working relationships between community pharmacists and general practitioners and their staff.
However, this was a novel approach for community pharmacists and their staff. First, it was an activity that differed from their traditional dispensing role in that the process was active and required the pharmacist to carry out a patient assessment. Secondly, the work was done in close liaison with GPs and practice nurses. Finally, the activity was asthma patient-centred rather than medicine-centred. The pharmacist's role included monitoring disease and treatment, reinforcing information and advice given at the practice and referring patients with problems back to the practice.
Therefore, a number of new concepts and activities were introduced not only for the pharmacists but also for doctors, practice nurses and patients. This paper outlines some of the lessons learnt from carrying out the project and makes some recommendations for similar activities and projects in the future.
Full details of the operation of the project and evaluation have been published elsewhere9 and the following is a synopsis. Participant pharmacists and GPs were selected as "pairs" from responses following a health authority-wide invitation to participate. As the ethos of joint working was core to the project, GPs and community pharmacists were encouraged to apply jointly.
The original intention was that patients would be enrolled into the project by the community pharmacist on presentation of a prescription for asthma medication. After confirming that they had asthma, patients were asked if they would be prepared to take part in the study. The pharmacist carried out an assessment in accordance with the protocol agreed during the project. A series of actions was then put in place to address any issues identified in the assessment. These could include patient education, counselling (both general or specific, for example inhaler technique), and referral back to the practice. The documentation used for the assessment process was also used for the collection of data for the evaluation.
All pharmacists participating in the project were confident that they had at least 30 patients who would be suitable for the project. A modest sum of £10 per patient was provided as remuneration.
Joint training workshop for participants A one-day training session was set up. The morning consisted of an update training session covering current aspects of asthma therapy and the use of devices for the all participating community pharmacists. In the afternoon, the pharmacists were joined by representatives of each general practice to develop project activity and documentation. Local guidelines for clinical management of asthma following those of the British Thoracic Society (BTS)10 were also agreed. The session was attended by 27 individuals, consisting of 11 pharmacists, 10 GPs, four practice nurses and two Centre for Pharmacy Postgraduate Education (CPPE) tutors. All GP practices were represented by at least one member of the practice staff and with one exception, at least one GP participated from each practice.
A number of learning outcomes were set for the afternoon session, namely, to:
The session was evaluated using the evaluation criteria commonly used for both medicine (postgraduate education allowance) and community pharmacy (CPPE).
Pharmacists, GPs and practice staff used the session to develop a local protocol for identification of patients for review in the pharmacy. This protocol also outlined the process by which the pharmacist should carry out the intervention. The data collection form for the study was also developed in this protocol development session and formed the basis for the collection of both clinical records and research data.
Review of project results and performance A multidisciplinary steering group was constituted to oversee the project. The group consisted of a community pharmacist, a GP, a GP postgraduate tutor, two CPPE tutors, an academic pharmacist and the HA nurse adviser. In addition, they were also available for direct contact with any clinician (doctor, pharmacist, nurse, etc) who wanted an informal but confidential perspective on any project issue. A formal review was carried out by the steering group on two occasions and this was supported by informal links throughout the project.
Data collected and recorded by the community pharmacists and the GPs were analysed by an independent researcher using an Epi Info version 6.0 database.
Telephone interview of GP participants Participating GPs were interviewed over the telephone by an independent researcher to canvass their opinions and perceptions on the value of the project, outcomes and the quality of pharmacist intervention. There were 10 respondents out of the 11 practices participating. All the respondents were GPs except for one, who was an asthma nurse. The interview was short and consisted of a number of open and closed questions, which were analysed using Epi Info version 6.0 for both the quantitative and qualitative data.
Focus group The experiences of pharmacists and GPs were obtained at a facilitated focus group meeting to which all participating pharmacists and GPs were invited. In the event, the participants were four community pharmacists, two GPs and a pharmacist and nurse adviser from the health authority. The focus group was smaller than ideal but all four pharmacists and one GP had patients in the study.
Three objectives for the meeting were set and used to guide the discussion, namely:
The focus group was facilitated by an independent research pharmacist.
Joint training workshop Returned evaluation forms revealed that all participants felt that the learning objectives had been met, the session had been informative and adequate time had been given to all aspects required for the project.
Some individual responses revealed areas where the process could have been further improved. Three pharmacists felt more time should have been given to discuss the project with GPs informally, and two GPs thought there should have been more time on clinical management of children. Another two GPs thought it would have been helpful for the pharmacist to have visited the practice before the workshop. The clear value of this workshop, particularly the aspect of training together, was frequently mentioned in both the telephone interviews and focus group.
Project review The number of patients enrolled (103) was far short of the expected 300. At the initial meeting, all 10 pharmacists were confident of recruiting at least 30 patients each. In reality, there was a wide variation in patient numbers per pharmacy. Two pharmacies recruited none, and the rest varied from two to 29.
The evaluation of patient management has been described fully elsewhere.9 This provided, for example, evidence of patient benefit, in terms of deficiencies in inhaler technique addressed, patient education to redress dosage regimen misunderstanding, and referral of patients with poor symptom control back to the practice. However, much of it was carried out by the pharmacist alone and did not require referral to the practice. Fifteen patients did require referral to the GP or practice nurse for review or alteration of their therapy.
An interesting finding that created a problem in the recruitment of patients was that some employee pharmacists (four out of the 11 pharmacists in the project) were transferred by their company to other pharmacies not involved in the project and so were lost to the project.
GP interviews Five GPs had patients referred to them and all felt that the referrals were justified. When asked whether they had detected any error of judgment on the pharmacist's part, the seven GPs who felt able to respond, said that they had seen no errors of judgment. The remaining respondents felt unable to comment because they had no patients referred to them. A similar question used for cross-validation later in the interview, about whether they had seen any examples of a patient's condition worsening because of a pharmacist's action, elicited a negative response from all six respondents to the question.
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Pharmacist/GP focus group This session raised a range of issues. Some were responses to specific questions and some were general comments and points. In general, there was consensus from the majority of participants on most matters.
Specific questions raised (and the responses) were as follows:
At the original meeting (the joint training meeting) before the project commenced it was felt that pharmacists would be overwhelmed by the number of asthma patients. Why do you think that did not occur?
Why do you think there was such a variation in the number of patients between pharmacies?
How did you choose the patients to be included in the project?
Has any similar research been carried out?
How could we attract greater participation in a project such as this?
Why do you think that no pharmacists withdrew from the project after the training (except the four pharmacist managers who were transferred)?
Do you think that the form was alienating?
Was the form too long?
Would training in face-to-face interviews help?
Were patients asked if they self-referred to the GP?
Were pharmacists asked things that were unfair to them?
Which patients had self-management plans (SMPs)?
General comments were as follows:
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The focus group also identified 10 key points that should be actioned in the case of a future project and two points to avoid (see Panel). Discussion
The Pharmacy in a New Age and New Horizons initiatives1,4 called for an expansion in the role of pharmacists, particularly in the community. It is now many years since the Nuffield report called for research to be carried out to provide the evidence to underpin change in professional practice. Work has been published on the attitudes of community pharmacists towards practice research,11,12 tools that can be used in the community,13 their limitations14 and reliability.15,16
Professional relationships Most GPs reported that the study had probably not improved their relationship with the community pharmacist as they already had a good one. This is probably a result of the group being self-selecting and expressing willingness to co-operate. A truly random sample, which would include practices and pharmacies that did not have such good initial relationships, may show a different pattern. Although there was some isolated criticism of the project, most GPs were supportive of the pharmacists' contributions.
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Things to do and things to avoidThings to do
Things to avoid
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Organisation of the study The relatively low patient numbers compared with that expected is a matter for concern. All pharmacist were confident at the beginning of the study that they would be able to recruit at least 30 patients as their asthma prescription throughput was considerably in excess of this figure. In retrospect there are a number of factors that led to this. Although the presentation of a prescription, in this case for preparations for asthma treatment, may seem an ideal cue for an intervention in the community pharmacy, this in reality was not the case.
Presentation of prescriptions at a community pharmacy follows an extreme cyclical pattern, with peaks occurring around surgery times. As the priority for the patient and the pharmacist is to process these prescriptions through the pharmacy in a timely and safe manner, the opportunity for an extended intervention is lost. In many pharmacies there are periods in the day when the prescription-led demand is very low and the pharmacist would have ample time to carry out an extended intervention. Unfortunately, if few prescriptions arrive there is little opportunity for enhanced patient intervention.
One way of dealing with this is to use some form of appointment system or ask the patients to return at a later, less busy time. These two initiatives, which were used successfully by participants in the study, do however detract from both the concept of prescription presentation as a cue for intervention and the philosophy of the ever-accessible and available pharmacist. This does not mean that this type of activity should be avoided as the benefits of increased and structured pharmaceutical input may be greater than the loss of convenient access.
The second main factor is related to the inclusion of pharmacies from a major multiple. Although the pharmacists were enthusiastic about participating, the professional and business needs of the organisation created a number of problems. A number of the study pharmacists were transferred out of their pharmacies to other pharmacies in the company, and these were not in study localities. As the study had been designed around individual pharmacists and GPs this created "holes" in the sample.
In addition, no one informed any member of the steering group that this had occurred, so no rectifying action was possible. Moreover, the steering group's liaison with the organisation was through a professional liaison pharmacist, and she, too, was unaware of these transfers. To compound matters further the transferred pharmacists neither informed the project co-ordinator nor passed on information or instructions to their successor.
As pharmacy multiples make up a large proportion of community pharmacies in the UK, it is not possible to carry out this type of work without involving them. In general, systems should be put in place at the beginning of the project to ensure that this eventuality is allowed for and rectifying action possible.
A simple process would be to make pharmacists responsible for making the study co-ordinator aware of their transfer and of who their successors were. The study co-ordinator could then brief the new pharmacist on the study and ensure continuity. This is not without potential problems as it assumes that the successor can be adequately briefed and trained in such a manner, once the project is under way. It also assumes that the successor is willing to take part in the study.
A further barrier was the fact that, as previously outlined, the participants were specific pharmacists and if a pharmacist individually was unable to enrol and assess patients for whatever reason, no patients were recruited. In addition to pharmacist transfers, pharmacists taking on more management roles, sickness, holiday and the general busy nature of community pharmacies prevented them from enrolling patients. A better model may be to centre the project on the pharmacy and encourage the pharmacist to devolve some of the patient-centred activity to a second pharmacist or preregistration trainee. If that was done, it would be important to ensure that these individuals were fully briefed and involved in training if necessary.
Pharmacists were paid a modest fee on a patient contact basis so it is unlikely that remuneration was an issue in the low patient recruitment rate. This suggests that finance alone will not necessarily ensure adequate patient recruitment.
The self-selecting sample meant that the range of issues addressed in the study was limited and no knowledge has been gained on the effect of such activity when pharmacist/doctor relationships are less well evolved or absent. Also the patient-related outcomes cannot be generalised to other situations, such as where the GP or pharmacist has no special interest in asthma or in the absence of an asthma nurse. As discussed earlier, a health authority-wide random or stratified sample would be better.
Comments so far have been rather negative but should be considered in a constructive manner. There were, however, a number of positive aspects to the study which were reported by both the pharmacists and the GPs. The joint training meeting and the drawing up of the study protocols and guidelines was found to be of considerable benefit and was commented on by a number of GPs unsolicited.
This process gave total ownership of the protocol to the study participants. In addition to the fact that there was no confusion over the responsibilities and actions of the pharmacists and GPs, there were no recorded disputes or disagreements. If second pharmacists or preregistration trainees, or both, are to be involved in the study, which may be desirable, consideration should be given as to how they can be incorporated into the training process.
Although community pharmacists and GPs have worked closely together for many years there is little in the literature which describes this complex relationship. One piece of research17 demonstrated, among other findings, that GPs hold pharmacists in a higher regard than pharmacists think they are held, which shows how complex this area is.
The GPs involved in the East Sussex study almost all agreed that a closer working relationship with the community pharmacist was of benefit to the patient group involved in the study, ie, patients with asthma. However, they were less equivocal on whether this improved liaison had knock-on benefits for other patient groups. Whether this is the case or an incorrect perception is difficult to establish. The working relationships between the pharmacist and GP were already felt to be good by the GPs in most cases.
If activity in other patient groups is similar to that in asthmatic patients, ie, the pharmacist intervenes in the pharmacy and refers few patients on to the GP, then, although useful, much of this role of the pharmacist will be unseen to others in the health care team. A similar study of this type should probably include some element of evaluation from a patient perspective, through patient interviews or focus groups, for example.
Community pharmacists are able to practise effectively in a new patient-centred model if provided with the correct training and support. Most interventions are made in the pharmacy by the pharmacist without recourse to other members of the primary health care team. This means that the value of these interventions may go unrecognised by others. Pharmacists in the study had good working relationships with the GPs - relationships that were felt to be of benefit in patient care.
A number of lessons have been learned which should be considered when setting up future joint working projects.
Joint working projects are useful methods of developing closer working relationships between community pharmacists and other members of the primary care team. However, the value is limited in this respect if the participants already have a close working relationship.
The presentation of a prescription is frequently not a good cue for an extended patient centred pharmaceutical care activity.
Ways of making the best use of pharmacists time for this type of role should be pursued.
If a similar project is planned or the service developed into this type of model a number of processes and systems should be put in place. These should include:
If community pharmacists are to be involved in this type of project there is need for training in research methodology and support in the basic principles of research and development as distinct from professional development.
Acknowledgments Thanks are due to all of the community pharmacists, general practitioners, asthma nurses and practice nurses who participated in this project. This study was funded by an educational grant from Zeneca Pharma and independently managed by East Sussex, Brighton and Hove health authority.
Mr Cairns is director of pharmacy and dietetics at University Hospital Lewisham, London SE13 6LH. At the time of writing he was director, pharmacy academic practice unit, St George's hospital, London. Ms Eveleigh is nurse adviser, primary care and public health, East Sussex, Brighton and Hove health authority, Lewes. Correspondence to Mr Cairns