Investigating the organisational factors associated with variation in clinical productivity in community pharmacies: a mixed-methods study

Stage 1

The first stage of the study was purely quantitative, combining analysis of existing data sets with primary data collection to examine variation in levels of service delivery across community pharmacies (objective i) and to investigate associations between organisational characteristics and levels of service delivery (objective ii).

Stage 2

The second stage of data collection incorporated both quantitative and qualitative elements. Quantitative methods examined the inter-relationships between organisational characteristics, levels of service delivery and service quality (objective iii). Qualitative methods explored issues around levels of service delivery and service quality in community pharmacies, their relationship and the mechanisms by which they are influenced by organisational characteristics (objective iv).

Integration of stage 1 and stage 2 findings

Integration of the findings from the different stages and methodologies employed by the study was an important final step to building a rounded picture of the factors associated with variation in clinical productivity in community pharmacies. Methods of synthesis incorporated elements of triangulation of the data and also illustration and explanation of one set of findings by another. 66 For example, when findings from the survey indicated a significant association between particular organisational characteristics and productivity in terms of quantity of service provided, the qualitative data from interviews with stakeholders were interrogated to obtain information on the mechanisms of that association. We also looked for alternative explanations when findings from different stages of data collection diverged. This process of integration formed the basis of the discussion (see Chapter 8) and will provide the basis for any recommendations we make to service commissioners regarding commissioning processes, to community pharmacy organisations regarding their provision of NHS pharmaceutical services and to patient/public audiences regarding medicines usage.

Commissioners’ workshop and toolkit development

The final objective (v) of the study was to develop a toolkit informed by the study findings to help service commissioners improve their contracting processes with community pharmacies to promote clinical productivity (both quality and quantity) and, hence, value for money. To do this, a half-day workshop was organised in July 2015, in partnership with NHS Primary Care Commissioning (PCC), to which commissioners from the new NHS commissioning structures (NHS England and CCGs) from across the North West of England and further afield were invited. In addition, a number of community pharmacy representatives were invited, including from the PSNC, Pharmacy Voice (umbrella organisation incorporating the CCA, Association of Independent Multiple Pharmacies and National Pharmacy Association) and community pharmacy multiples, together with four members of the public.

The workshop was used to present the findings from the study and invite discussion and feedback in small mixed-group sessions, facilitated by the PCC (see Appendix 4 for the programme). The groups each recorded key discussion points on flipcharts and these were brought back to the larger group for final discussion. The PCC collated the findings of the discussions and these directly informed the first draft of the toolkit to which the research team added supporting summaries of the research evidence from the study. The toolkit (see Appendix 5), which will be made available electronically to service commissioners nationally through PCC channels, links to the six stages in the NHS commissioning cycle67 and provides guidance and supporting evidence for commissioners at each stage.

Dispensing volume

The full findings of the univariable and subsequent multivariable linear regressions of annual dispensing volume for stage 1 pharmacy survey respondents can be found in Appendix 6: a summarised version is presented in Table 5.

Staffing levels and skill mix had important associations with dispensing volume: pharmacies with higher dispensing volumes were significantly more likely to employ two or more pharmacists, have a registered pharmacy technician or an accuracy checker; a univariate analysis also demonstrated a positive association with the overall staff number (however, this was correlated with skill mix and, as we were more interested in skill mix, this variable was dropped from the multivariable analyses). The organisational culture of the pharmacy (measured using the PSO tool) also proved to be significantly associated with dispensing volume: pharmacies with higher dispensing volumes were assessed as having a greater focus on quantity, technical work and medicine than on quality, professional work and the patient. Pharmacies that had been open for ≥ 3 years also had significantly higher dispensing volumes. Dispensing volume was not associated with pharmacy ownership type.

As expected, the level of deprivation in the local population (IMD score) was significantly associated with dispensing volume. Although the local prevalence of a number of health-related variables was also significantly associated with dispensing volume (univariable analyses), some of these variables were dropped from the final multivariable model as a result of collinearity with IMD score and intercorrelation; those that were tested were not significantly associated with dispensing volume.

Volume of medicines use reviews conducted

The full findings of the univariable and subsequent multivariable ordered logistic regressions of annual volume of MURs conducted by the stage 1 pharmacy survey respondents can be found in Appendix 6: a summarised version is presented in Table 6.

The volume of MURs conducted by these pharmacies was strongly associated with annual dispensing volume. Controlling for this in the multivariable regression, pharmacy ownership type had the strongest association of the organisational variables with volume of MUR provision, with multiples, particularly large multiples and supermarkets, conducting significantly more MURs annually than independent pharmacies. Although a number of organisational factors were univariably associated with volume of MURs (HLPs, 100-hour pharmacies, those with more staff or employing a pharmacy technician or accuracy checker all conducted higher volumes of MURs), the only other organisational factor remaining in the final multivariable model was opening hours; pharmacies with longer opening hours conducted more MURs.

Unlike dispensing volume, the volume of MURs conducted was not related to the level of deprivation in the local population (IMD score). A significant association was seen, however, with the prevalence of asthma – although this was a negative association – with higher numbers of MURs being conducted in pharmacies with lower proportions of asthma in the local population. This significant association was seen in both univariable and multivariable models. There were no other significant associations with any demographic or socioeconomic variables.

Volume of new medicines service interventions

The full findings of the univariable and subsequent multivariable ordered logistic regressions of annual volume of NMS interventions conducted by the stage 1 pharmacy survey respondents can be found in Appendix 6: a summarised version is presented in Table 7.

Similar to MURs, pharmacy ownership type had one of the strongest associations with annual volume of NMS interventions with multiples, particularly large multiples and supermarkets, again conducting significantly more NMS interventions annually than independent pharmacies. Although dispensing volume was significantly positively associated with NMS volume in the univariable models, this relationship was found to be non-significant in the multivariable analysis. Another organisational characteristic strongly associated with annual volume of NMS interventions conducted was the number of pharmacists employed on a typical day, with those employing two or more conducting significantly more NMS interventions annually. Although overall staffing levels, weekly opening hours, the working pattern of the main pharmacist and HLP status were also significantly associated with NMS provision in the univariable analysis, none of these associations remained in the final multivariable model.

Unlike dispensing volume and MUR provision, both the geographical location of the pharmacy and the strength of its relationship with the local GP surgery were significantly associated with the volume of NMS interventions conducted annually. In particular, pharmacies located in city centres conducted significantly fewer NMS interventions than pharmacies in other locations and those unable to identify a local GP surgery with which they had a working relationship conducted significantly fewer than those indicating very good working relationships with their nearest GP surgery.

There were no significant associations found between annual volume of NMS interventions conducted and any demographic or socioeconomic variables.

Dispensing volume

The findings of the univariable and subsequent multivariable linear regressions of annual dispensing volume of pharmacies in the national data set are presented in Table 9.

There was a significant association between pharmacy ownership type and dispensing volume with large multiples dispensing significantly more and supermarkets significantly fewer items than independents.

Dispensing volume was significantly and positively associated with local population deprivation scores, the proportion of older people and the local prevalence of some long-term conditions (CHD, depression). Although univariably associated with dispensing volume, the local prevalence of asthma did not remain so in the multivariable analysis. The prevalence of MH problems in the local population was significantly but negatively associated with pharmacy dispensing volume.

Volume of medicines use reviews conducted

The findings of the univariable and subsequent multivariable ordered logistic regressions of the volume of MURs conducted by pharmacies in the national data set are presented in Table 10.

There was a strong association between pharmacy ownership type and the volume of MURs conducted, with pharmacy multiples, particularly large multiples and supermarkets, conducting significantly more MURs than independent pharmacies. There was also a strong positive association between the volume of MURs conducted and a pharmacy’s dispensing volume.

As in the pharmacy survey data analysis, the volume of MURs conducted was negatively associated with the prevalence of asthma in the local population. Local prevalence of MH problems was also univariably associated with the volume of MURs conducted but did not remain so in the multivariable analysis. The volume of MURs conducted was negatively associated with local population deprivation score and the proportion of young children in the local population. Although more MURs were conducted in pharmacies situated in areas with a higher proportion of older people, this association did not persist in the multivariable analysis controlling for the stronger effects of dispensing volume and pharmacy ownership type.

Volume of new medicines service interventions

The findings of the univariable and subsequent multivariable ordered logistic regressions of the volume of NMS interventions conducted by pharmacies in the national data set are presented in Table 11.

As with MURs, there was a significant association between the numbers of NMS interventions conducted, dispensing volume and pharmacy ownership type with all multiples, particularly large multiples, conducting significantly more NMS interventions than independent pharmacies.

Again, similar to MUR provision, the volume of NMS interventions conducted was inversely related to a number of markers of ‘need’ (deprivation score, local prevalence of MH conditions and asthma prevalence). Although the age of the local population showed significant associations with the volume of NMS interventions conducted in the univariable analysis, these relationships did not persist in the multivariable model controlling for the stronger effects of dispensing volume and pharmacy ownership type.

Satisfaction with pharmacy visit

The full findings of the univariable and subsequent multivariable linear regressions of overall satisfaction with pharmacy visit for stage 2 patient survey respondents can be found in Appendix 6: a summarised version is presented in Table 15.

Patients who had chosen to visit a pharmacy for reasons that spanned a greater number of categories than just one (access, service, products) were significantly more satisfied with their visit. Patients who had received information from either the pharmacist or another member of staff were more satisfied with their visit than those who had not received any information. Furthermore, those who usually received advice from the same person were more satisfied than those who did not. Patients with higher scores on the ‘overuse of medication’ scale of the BMQ – indicating that they believed more strongly that medicines were overused – were significantly less satisfied with their pharmacy visit. Number of long-term conditions was positively associated with patient satisfaction in the univariable but not the multivariable analysis.

Significantly higher levels of patient satisfaction with their pharmacy visit were measured in patients who had visited pharmacies holding an ‘other’ type of contract (e.g. essential small pharmacy or local pharmaceutical services compared with a standard 40-hour contract) and those employing a registered pharmacy technician. Patients were also more satisfied following a visit to a pharmacy with an organisational culture more closely aligned to the patient, quality and professional work than to the medicine, quantity and technical work (univariable regression). However, this significant association did not persist in the multivariable model. Patient satisfaction was not significantly associated with pharmacy ownership type.

Overall patient satisfaction was not significantly associated with the annual dispensing volume of the pharmacy. However, patients were significantly more satisfied if they had visited a pharmacy that conducted over 365 MURs per year compared with those who had visited a pharmacy conducting fewer than 12. It should be noted, however, that only one pharmacy in the stage 2 sample conducted fewer than 12 MURs per year. Above 12 MURs per year, there was no indication that volume of MURs was significantly associated with overall patient satisfaction.

Although the geographical location of the pharmacy and a small number of socioeconomic and demographic indicators were associated with patient satisfaction in the univariable analyses, they did not remain so in the final multivariable model.

Satisfaction with information received about medicines

The full findings of the univariable and subsequent multivariable ordered logistic regressions of SIMS score for stage 2 patient survey respondents can be found in Appendix 6: a summarised version is presented in Table 16.

Patients who usually received advice from the same person at their pharmacy were more satisfied with the information that they had received about medicines. Younger patients, and those with higher scores on the ‘overuse of medication’ scale of the BMQ, had significantly lower SIMS scores. Patients who had chosen to visit their pharmacy for reasons that spanned a greater number of domains (access, service, products) had significantly higher SIMS scores in the univariable analysis, but not in the final multivariable model. Although patients receiving their medication for the first time were significantly less satisfied with the information received (univariable analysis), this association also did not persist in the multivariable analysis.

Satisfaction with Information about Medicines Scale scores were significantly associated with pharmacy type, being significantly higher in small and medium multiples than in independent pharmacies. Although two other organisational characteristics (100-hour pharmacies and those with longer opening hours) were associated with higher SIMS scores in the univariable analysis, neither remained in the final multivariable model.

Other than the mean age of the local population, which was positively associated with SIMS score, no other socioeconomic or demographic variables were significantly associated with patient satisfaction with information received about medicines.

There was again no indication that the magnitude of this outcome was associated with the dispensing volume of the pharmacy. However, as for overall satisfaction, SIMS scores were significantly higher for patients visiting pharmacies that conducted more than 365 MURs per year than for those visiting pharmacies conducting fewer than 12 MURs per year. However, it should again be noted that only one pharmacy in the stage 2 sample conducted fewer than 12 MURs per year. Above 12 MURs per year, there was no indication that volume of MURs was significantly associated with patient satisfaction with information received about their medication.

Self-reported medication adherence

The full findings of the univariable and subsequent multivariable binary logistic regressions of MARS score for stage 2 patient survey respondents can be found in Appendix 6: a summarised version is presented in Table 17.

Patients who did not usually receive information or advice from the same person were significantly (weak association) more likely to be classified as ‘low adherers’ than either those who did or those who could not identify who they received their information from or for whom this question was not applicable (had not received any information or advice). As with SIMS scores, younger patients, and those with higher scores on the ‘overuse of medication’ scale of the BMQ, were significantly more likely to be classified as ‘low adherers’. Other patient characteristics shown to be associated with self-reported adherence in the unvariable analyses (receiving medicine for the first time, member of staff information was received from, number of long-term conditions, SIMS score) did not remain so in the multivariable analysis.

The only organisational characteristic significantly associated with self-reported adherence was use of locums; patients who had visited pharmacies who regularly (on a daily/weekly basis) used locums were significantly more likely to be classified as ‘low adherers’ according to their MARS score. There was no association with pharmacy ownership type.

Other than the mean age of the local population, which was weakly associated with MARS classification in the unvariable analysis, no socioeconomic or demographic variables were significantly associated with self-reported adherence in the multivariable model. There was no indication that self-reported adherence was significantly associated with the volume of services (dispensing or MURs) provided by the pharmacy.

Quality of dispensing services

In relation to dispensing, speed and accuracy were the most commonly described elements of service quality. Most pharmacists and superintendent pharmacists believed that speed of dispensing was valued by patients above anything else:

. . . often it’s public expectation, I mean people expect you to just basically . . . have a prescription within 2 minutes or whatever. The fact that whatever is on that prescription, they’d say, ‘oh, you can just pick it off a shelf and put its label on’; their expectation is for speed, but not always for quality or for anything else.

Pharmacist 35

Although speed was also felt to be important by pharmacists themselves, more often accuracy was described as being paramount to service quality and many expressed the need to balance speed with accuracy. A number of commissioners also highlighted the importance of accuracy in the dispensing process:

So, the waiting times are important to the patient, I suppose, it’s important to us as well in the pharmacy, but I suppose it’s more important to us to make sure that it’s right.

Pharmacist 29

A number of pharmacists and commissioners believed that, alongside speed and accuracy, the clinical input of the pharmacist was an important element of the quality of dispensing. This could either be about the provision of counselling or advice-giving alongside dispensing or else interventions made as a result of the clinical check:

So there is the accuracy, and then there is our role as pharmacists, to check the prescribing and the clinical side of the thing, just to make sure that it is right for the patient, and challenge a little bit, GPs, if necessary.

Pharmacist 1

I would want a really strong cognitive element at the beginning in terms of the clinical check so people really thinking about what they’re doing rather than necessarily looking at prescriptions thinking ‘have we got this in stock?’. Thinking critically about that prescription and at the end of the process making sure that patients know what they’re taking and why they’re taking it and recognising that there is somebody that they can call upon should they have any problems. So there’s the whole of the patient counselling piece at the end which I think is often forgotten about in the spirit of getting prescriptions done as quickly as possible to meet customer demand.

Superintendent pharmacist 3

Although sometimes not perceived as being as important as speed and accuracy, most interviewees also felt that a full supply of medication to enable every prescription to be filled when first presented was another aspect of a high-quality dispensing service. This prevented prolonged waits for medication or patients having to return to the pharmacy for ‘owings’:

And having a good level of stock as well . . . if people keep coming in and every month you’re having to owe them the same tablet then they’re sort of thinking, ‘Well, they never have my tablets in stock’. So having the right stock levels is important as well.

Pharmacist 32

Having a patient-centred approach and offering good customer service were also mentioned by several pharmacists as important elements of a high-quality dispensing service:

I think [patients] think it’s high quality when we’re genuinely interested in them, their medication, and helping them with their medication.

Pharmacist 21

Quality of medicines use reviews

For the majority of interviewees, a high-quality MUR was one that had made an impact on the patient. The types of impact described included increasing the patient’s knowledge or understanding of their medication and why it had been prescribed; improving patients’ adherence to their medication, ensuring that they take it, at the right times and in the right way; identifying and addressing side effects; improving clinical outcomes and quality of life; and providing reassurance to the patient:

I guess it’s still reassuring for the patient to know that they’re taking everything properly and everything’s fine and it’s just like a quick check. But I only find them worthwhile when you have an outcome at the end of it. So if, say for example, they’ve been experiencing a side effect and they haven’t linked it to a particular drug, or you’ve actually offered something more to them to either improve their regime, or to resolve a problem that they’ve been having, or there’s been some kind of positive outcome where they either feel more reassured about taking the medication or there’s been some kind of change, or something else that you have to offer which has helped in any kind of way – then I find them worthwhile.

Pharmacist 38

However, a number of interviewees were keen to highlight that a high-quality MUR stopped short of being a full clinical medication review and that MURs should be about the patient’s use of existing prescribed medications and not a review of what they should or should not be prescribed:

. . . I think there still is a misconception around what actually we should do in a medicines use review and then what would then tip into being a clinical medication review. I’ve seen MURs where it’s come back and said, ‘This patient’s got heart disease, so you should really put them on a statin’. Whereas I’ve seen some really good quality ones . . . [saying] ‘I’m a bit concerned because this lady takes a diuretic and only . . . in the morning, because she worries about going to the . . . ’, so . . . she wasn’t taking her diuretic properly . . . for fear of she had to run to the toilet.

Commissioner 8

Several respondents suggested that a high-quality MUR service was one that was targeted at the people most likely to benefit: those taking a larger number of medicines or those in particular patient groups, for example those with long-term respiratory conditions or those with cardiovascular disease:

I bet you get a lot of MURs that are just . . . two or three item ones where they’re not really making much difference to the patient. Someone who’s in their forties who’s on two blood pressure medications, they know what they’re doing with it, probably. But then still an MUR because you check to see that they’re happy and they know what they’re doing. And I don’t think that’s the point of MURs. I think it’s to make an impact on people.

Pharmacist 23

At the moment the ones where I feel that we do something is respiratory MURs, because we can use them to test their inhaler technique, that’s something quite quick and quite simple and you can tell that providing they then comply and carry on with the technique you’ve shown them, you feel, yes, well, that’s benefited the patient.

Pharmacist 35

There was a perception among many interviewees that a MUR should be patient centred to be of high quality. This involved effective listening and communication skills, and tailoring the consultation to the individual patient rather than sticking rigidly to a set of questions that risked restricting the consultation to a tick-box exercise. It was suggested that a patient-centred MUR would be more likely to affect positive outcomes for the patient:

I always find that having a relaxed less formal approach to the MUR, people are more likely to open up to you and it’s like a conversation rather than a step-by-step going through each of their medicines . . . I often find that I’ll ask them about something and they say, ‘Oh well, no one’s ever said that to me’. So it’s more having a relaxed conversation about all their medicines and how the medicines are fitting into lifestyles . . . I would say, for them, [that] is a high-quality MUR.

Pharmacist 19

The length of the consultation was another important element of a high-quality MUR for some interviewees. Devoting adequate time to a MUR prevented the consultation being rushed, provided sufficient time for patients to air their concerns about their medication and facilitated a patient-centred approach:

It’s a balance between getting patients when there’s plenty of time for you to actually sit with them and make sure it’s going to be a good MUR, rather just coming in and rushing through . . . we’ve got 5 minutes to rush through this while someone waits outside and they get the script done, and then you’re dashing in and out all the time. So that’s the main thing, to make sure the quality is there and make sure that patients . . . the other customers aren’t waiting because you are sat for 20 minutes doing an MUR.

Pharmacist 26

Less frequently, interviewees mentioned the opportunities for added value that contributed to the quality of a MUR consultation. These included the provision of healthy living advice, signposting to or integration with other pharmacy services and integration with GP services:

. . . as part of MUR you don’t always cover that sort of thing [healthy living advice]. There’s normally a tick box, ‘yes, I have covered it’, but with the time space you get it’s . . . we do really push it here and make sure the patients understand lifestyle advice, things like diet, exercise, smoking, obesity, that sort of thing . . . and we have a stand outside . . . lots of leaflets and things. So we’ll always show people, ‘have a read about your condition’, so they’ve obviously got something to take home with them as well.

Pharmacist 40

I think we’ve got a pretty good one [relationship with local GPs], which is unusual, because we’re not located in the surgery, or we haven’t got a surgery nearby. But we do work with surgeries across the city, and generally, we have a very good relationship with GPs. And we’ve had some really positive feedback about our MURs, especially where we’ve been able to solve a problem as part of the MUR, rather than just write to them with a list of problems. We’ve been able to actually do something. Then I think we’ve been very well received.

Pharmacist 2

Finally, although less within the control of the pharmacist, a number of interviewees suggested that a high-quality MUR was one in which the patient was engaged with the process:

Some patients don’t want to spend 2 minutes with you, and I don’t call that an MUR. You’ll get those patients who, ‘I know what I’m doing, don’t worry about it’. Even trying to get something out of them it’s just like talking to a brick wall. Everything you fire just comes back to you. So those aren’t high-quality MURs.

Pharmacist 15

Staffing and skill mix

All of the pharmacist and superintendent pharmacists and most of the service commissioners we interviewed mentioned aspects of staffing and skill mix as important, if not the most important, organisational factors determining the level of clinical productivity achieved by community pharmacies (both the quantity and quality of services provided). This was in relation to overall staffing levels, skill mix (including second pharmacists, dispensers, accuracy checkers, pharmacy technicians, counter staff, pre-registration pharmacists, locum pharmacists, drivers), training, teamwork, delegation and continuity of staff.

Management of workload

Organisational culture

Many of these interviews highlighted the role of organisational culture in determining a pharmacy’s clinical productivity. Organisational culture, or ‘the way things get done around here’, was described in terms of the value the organisation (head office, the superintendent pharmacist or pharmacy owner) placed on investing in staffing and skill mix, the extent to which business targets or quantity was prioritised over quality of service, and management style and structure:

How things get done around here . . . I think that’s really key, actually. The organisational culture, because you get some people who are really positive and really want to make things work and really want to succeed and they normally have more staff than other people, to be fair, and others who are just kind of . . . they can only just about get through the day job and they just haven’t got the energy. They don’t have the vision, they don’t have the understanding of their importance or the fact that they’re part of a much bigger NHS family and they’re just part of one of the jigsaw pieces in that family of providing services to patients.

Commissioner 6

Ownership type

A number of opportunities and barriers to clinical productivity were identified by interviewees in relation to the type of organisation a pharmacy belonged to (e.g. large multiple, supermarket, smaller chains and independents). These often related to the organisational cultures associated with these different ownership types. However, they also related to organisational size and infrastructure, pharmacy staffing and skill mix, pharmacists’ autonomy and the relationship with the customer.

Healthy living pharmacies

The HLP concept was not one that was discussed widely by interviewees in relation to clinical productivity, even though 13 pharmacies selected for stage 2 of the study were either accredited HLPs or else working towards HLP accreditation. For those that did, there were mixed views about the impact HLP status had on a pharmacy’s clinical productivity, ranging from commitment and buy-in to scepticism. Service commissioners were similarly ambivalent:

In terms of healthy living pharmacy, well it is quality; it’s a quality framework around healthy living services. So it’s a quality framework which we’re very much committed to, so that’s a good thing.

Superintendent pharmacist 4

I think we do HLP, we’re just doing it a different way . . . and that’s the way we’ve done our business for the last 10 years or so. So we’ve trialled HLP but we’ve seen no benefit in terms of the stores I’ve operated, but we’ve kind of been doing it for 10 years anyway.

Superintendent pharmacist 2

What we were finding was healthy living pharmacy in [locality] was different to healthy living pharmacy in [other localities]. There’s not a standardised approach and that’s a shame. We need a standard national kite mark so that people know that when you’re in a healthy living pharmacy you’re going to have a certain standard and certain information of messages being given out.

Commissioner 1

Some believed that the quality of service delivery was improved by the knowledge and skills gained by staff from the HLP accreditation process:

We are a healthy living pharmacy and I think that has been useful, in terms of staff member engagement and perhaps the increase in the added value. So before, when we might have just sold a bottle of Gaviscon [Gaviscon^®, Reckitt Benckiser, Slough, UK] with some advice on how to take it that might now include, for example, alcohol use, other lifestyle things, in terms of diet and perhaps change mind sets in the team, around other advice we give.

Pharmacist 2

Others, however, considered that providing healthy living advice was already part of their role and that HLP status conferred no additional advantage:

To be honest, I think all pharmacies whether they’re branded ‘healthy living’ or not should be offering the healthy living advice. I don’t think you can be a pharmacy without offering healthy living advice.

Pharmacist 40

In terms of the advantage HLP status may or may not give pharmacies in the commissioning process, one superintendent pharmacist believed it gave them additional negotiating power with service commissioners, whereas others felt that this was limited:

I think what it’s done very well is branded a type of service delivery, especially to commissioners, and it’s given people a concept that they can wrap their heads round, which is quite important in negotiation.

Superintendent pharmacist 2

I don’t think the benefits have quite kicked in yet. What the CCG thought, and what we thought we were going to get from health living pharmacy hasn’t quite been the case . . . we thought we’d get . . . them pushing more stuff towards us and then we would have a campaign around that.

Pharmacist 3

Although HLPs could be seen as a way of increasing the skills of the pharmacy team and alleviating some of the pressure on the pharmacist for delivering services through effective use of skill mix, this was not always successful and some felt that further investment in training was required to deliver the model successfully:

. . . We were at some point nominated by our manager, to work towards the healthy living pharmacies, but then it just sort of flopped . . . we were too busy doing the basic things and trying to get that right . . . You need to have people that are properly trained to do things, so it’s investing in training, not only pharmacists, but the staff, for us to get more involved in healthy living advice . . . at the moment we’re struggling with just being able to dispense normally . . . and do MURs and those few services that we do.

Pharmacist 1

Patient and population factors

Community pharmacy/general practice relationships

The nature of the pharmacy’s relationship with local GP surgeries was cited by a large number of pharmacist and superintendent pharmacist interviewees as a factor influencing clinical productivity. The overarching finding was that positive relationships with GPs and practice staff helped to nurture interdisciplinary practice, fostering greater co-operation and working together for patients, increasing effective signposting and opening channels of communication. Respondents were fairly evenly split between those who described relationships with local practices in positive terms and those who described those relationships as being more problematic or strained.

All of the commissioners interviewed also spoke about the importance of good pharmacist–GP relationships for improved clinical productivity. Several aspects of the relationship were mentioned, including the need for clear and direct communication channels between the pharmacist and the GP to enable prescription queries to be resolved efficiently and swiftly, thus ensuring that the patient receives the appropriate medication promptly without impacting on both the pharmacist and GPs’ workload and affecting clinical productivity.

I also think that good communications and relationships . . . makes a huge, huge difference to the working lives of pharmacists and GPs . . . if you have those relationships in your working day in itself, it will be so much smoother, and so reduced in terms of hassle, then you can only use that to your benefit to get the work through and get the work done at a quality that you wish to produce. So the wider working relationships are as important as the staff to underpin that service, I think.

Commissioner 5

Many pharmacists believed that good relationships with local practices enabled prompt resolution of issues, for example problems with prescriptions and repeat prescriptions, clinical interventions and stock shortages. This had a positive effect on the quality of the pharmacy service as experienced by the patient.

If there was something that I was concerned about or needed changing . . . if I have a good rapport with the surgery then I’m more likely to pick up the phone and say ‘can I sort this out this afternoon?’ . . . Whereas if the surgery you don’t have a good rapport with . . . you’re less likely to be able to . . . do that or it might take longer to do . . . So the better rapport you have with them the easier it is to sort things out for patients, it will always impact on the quality of the service.

Pharmacist 19

Conversely, when poorer relationships existed, this could be perceived as a barrier to the timely resolution of problems, adversely affecting the quality of the dispensing service.

Sometime we have problems, you know, with the GP . . . the receptionist, but I suppose that everybody’s got the same problem. The way you’re to trying to help a situation, they will hinder it basically. That causes a massive problem with the flow of things, but there’s no way round that. It just seems to have always been the way.

Pharmacist 28

One commissioner mentioned that in her area there had been a number of reports of pharmacists being blocked from directly speaking to GPs; however, some progress had been made with encouragement from the area team:

We encourage pharmacies to foster that good relationship . . . There is still this reluctance although the barriers are being broken down a little bit . . . pharmacists talk about being blocked; not being able to speak to the GP when they’ve got a query on a prescription and that happens a lot. I’ve been in meetings certainly with GPs and I’ve thrown that back to them and they’ve said, ‘Oh, right, well, we hadn’t realised that . . . we have our own special numbers’ and I said, ‘But you’re not releasing them to pharmacists’ . . . one particular very forward GP . . . he said, ‘This is ridiculous!’ . . . when I saw him again recently he said, ‘I’ve made sure that local pharmacies round me have got that number now that they ring up if they need to speak to me or send me an e-mail or whatever.

Commissioner 1

A number of pharmacists felt that positive relationships encouraged GPs to initiate contact with pharmacists, for example, to request advice and follow up recommendations from MURs. Indeed, some perceived that effective working relationships were optimised when local GPs had developed a certain level of trust in the pharmacist. Good working relationships with local practices could therefore help to increase the volume and range of services pharmacies were able to deliver through referral or signposting of patients to pharmacy services:

And to be honest ever since that my relationship with the surgery has skyrocketed. I think they actually appreciate you looking out for things . . . now I get . . . one [doctor] especially keeps phoning me up asking what he should prescribe.

Pharmacist 23

We sometimes get a letter from the GP saying, ‘Dear pharmacist, we would be grateful if you could provide an MUR to this patient, she’s having the following difficulties with taking her medicines’. Or it might be just via the patient, ‘Go and see the pharmacist and they’ll provide you with some help with medicines taking’. So it varies from formal to informal. It’s mainly informal, but it would be much better if there was a proper commissioning pathway for this. So if it was formalised it would be better.

Superintendent pharmacist 4

Commissioners also spoke about the importance of GP endorsement of pharmacy services, to increase patient participation and, thus, clinical productivity. Commissioners felt that if the GP and pharmacist had a good relationship, the GP or practice staff were more likely to signpost patients to a pharmacy for consultation:

If a GP said to a patient, ‘Oh, by the way the pharmacy down the road offers this really good service called an MUR and I think it’s really important that you go and talk to them about your inhaler technique’, the patient is far more likely to do that . . . if you get that endorsement from GPs around pharmacy services I think that carries a lot of weight with patients.

Commissioner 6

However, for some pharmacists, referral or signposting to pharmacy was believed to be, at best, selective for some services, with competition between pharmacies and general practices to provide some services encouraging silo behaviours and acting as a barrier to service uptake by patients from community pharmacies. The seasonal influenza vaccination service, which at the time of these interviews was yet to be introduced as an ‘advanced’ service, was provided as an example of when competition between GPs and pharmacists was straining relationships as a result of traditional income streams for GPs being challenged:

. . . pharmacy/GP integration is something that needs to be focused upon . . . The problem is . . . they’re two competing businesses . . . there is certain cross-over areas, such as flu vaccinations and things like that . . . If we work together . . . pharmacists can help the GPs to achieve their targets . . . [and] at the same time . . . also enable the pharmacist to provide another service.

Pharmacist 3

Finally, some believed that patient perceptions were another barrier to pharmacist–GP integration and any subsequent benefits for clinical productivity in community pharmacies. Some pharmacists perceived that patients objected to pharmacists encroaching on GPs’ territory or, given the general lack of patient awareness of the pharmacist’s extended role described above and an absence of signposting or referral by GPs to pharmacy services, that patients chose GP service provision over pharmacy service provision:

I think a lot of it is a culture shock to them . . . in terms of . . . ’My doctor does that, I go to the doctor for this’ . . . If pharmacy is going to take on all these new roles, and new services, that’s something that needs to be broken down, I suppose. Or, the patients informed that actually we’re better placed than the doctors’ service, and . . . you don’t have to wait to see us.

Pharmacist 29

A number of possible solutions to improving pharmacist–GP integration was suggested by interviewees including pharmacists themselves being proactive in establishing and maintaining good working relationships with GPs through regular communication and face-to-face meetings; the interprofessional education of trainee doctors; GP endorsement of pharmacy services with increased signposting and referral to pharmacies; and closer alignment of the general medical and general pharmaceutical services contracts:

Once in a while I go and sit with the doctors and have coffee and just discuss, ‘OK, these are the difficulties, I think you guys should do this, this way . . . If you are prescribing batch prescriptions these are the kind of people that should be on batch’. They hear from me and I hear also their struggles. The surgery next door is also educational because they get student doctors there . . . [who] come here once in a while to see how things are and we can also explain to them how prescribing should be done, pack sizes. So it’s a good combination for us and them . . . it’s a good relationship and one that I want to keep and maintain.

Pharmacist 20

I do think that if there was closer alignment of the two contracts, so there was a shared and common interest in how both clinicians are then delivering their services to the patient, that we might get more effective targeting of MURs to those patients that are not taking their medicines appropriately, and that we might then be able to improve their use of medicines and . . . help inform some of the prescribing decisions that GPs might make in the future as a result of both their own clinical reviews of medicines, and also the medicine use review . . . [they are] different, but they’re highly complementary and both really inform each other.

Commissioner 4

At a more strategic level, some commissioners felt that clinical productivity generally could be improved by having more community pharmacy representation in CCGs, which would foster greater GP–pharmacist integration:

A lot of CCGs are still coming across as representing the GPs rather than actually representing the patients, and we said right at the beginning that they missed a trick, the government, by not insisting on having a community pharmacy representative on the board of every CCG who could . . . encourage working together, because community pharmacy and GPs are so interlinked.

Commissioner 2

One commissioner from a CCG that did have community pharmacy representation stated that having this input had been useful in terms of reducing wastage and providing valuable information to the CCG about drug switches and supplier problems, to ensure that both GP practices and pharmacies could plan and accommodate these.

Commissioning structures and processes

This study was conducted at a time of significant reorganisation within the NHS, which had a marked impact on the commissioning landscape for community pharmacy services. PCTs were dissolved in 2012 and replaced by CCGs. However, the commissioning of community pharmacy services became fragmented between the new area teams of NHS England (primarily for essential and advanced services but including some enhanced services), CCGs (for locally commissioned medicines-related health-care services – previously enhanced services) and, for the first time, local authorities (for locally commissioned public health services – previously enhanced services). It is therefore unsurprising that many interviewees discussed commissioning as a factor influencing clinical productivity – particularly in terms of the reorganisation, the geographical variation and a new GP dominance of local NHS commissioning processes.

The reorganisation of commissioning caused confusion among many pharmacy interviewees about the sources of remuneration and the commissioning process for different services. The resulting increase in the variety of commissioners (NHS England, CCGs, local authorities) caused further confusion and increased the bureaucratic process to bid for services. In addition, some perceived that as services transferred from PCTs to the new CCGs and local authorities, there had been a degree of decommissioning of services. As a consequence, the quantity of service provision was reduced following the reorganisation, reducing pharmacies’ sources of income, threatening the viability of some businesses and investment in staffing in others. This reduction in service provision, by reducing service accessibility to patients, was also seen as lowering the quality of NHS services.

There was almost a false sense of security, I think, initially, because services were just rolled over because it was probably too much as part of the changes that were going on to do anything about them . . . over the last probably 12 months, there’s been quite a lot of recommissioning . . . Most of the public health initiative-type services, have gone onto the local authority tendering format which has put a much increased burden bureaucratically on community pharmacies . . . there are a number of pharmacies that have said, . . . ’That’s too much like hard work to complete all of that paperwork and maybe I will and maybe I won’t be successful at the end of it. Actually I’m busy enough as it is; I’m not going to bother.’ . . . That leads to poorer quality of service because there’ll probably be fewer pharmacies delivering certain services and therefore you haven’t got the accessibility for the service that was previously available.

Superintendent pharmacist 5

There were conflicting views about the way in which individual pharmacies or pharmacy chains were commissioned to provide different services in different localities. Some believed that selective commissioning within a geographical area meant that their pharmacy’s income and viability was challenged, especially when training had been undertaken to deliver a service. It also influenced the pharmacy’s ability to compete with other pharmacies.

I worked in an area . . . the teen pregnancy rate was just off the scale like the highest in the country. And we commissioned and commissioned and I did months of training to get the emergency contraceptive and they just said, ‘it’s in five pharmacies already . . . we’re not giving it to any more’ . . . We said ‘look we’ve sent people up to [large multiple] in [location], and there’s no pharmacist on board who’s trained so they’ve had to come back and buy it or we’ve had to refer it to the GPs’. We’ve got a pharmacist here 6 days a week and who’s willing to provide the service, he’s totally trained, I’ve done all the child protection stuff . . . and they just said ‘No funding . . . we’re not commissioning it in your pharmacy’. That’s the thing that we worked on with the LPC was commissioning on all services for any pharmacy that wants to do it. So if you want emergency contraceptive, if you can provide the training to us now, you can provide the certificates, if you can say look this is what we’ve got, this is our opening hours then every pharmacy should be able to provide every service.

Pharmacist 26

Conversely, one pharmacist believed that uniform commissioning of all pharmacies across a geographical area could be inappropriate as local population need could vary drastically. This could lead to an underutilisation of the skills of the pharmacy workforce and could reduce the quality of the service delivered.

Variation in commissioning activity between commissioners caused disruption to the remuneration process in one pharmacy located on the border of different commissioning areas, which led to reduced quantity of services provided. Variation in commissioning arrangements across commissioning borders was also seen as a barrier to clinical productivity when service delivery required local accreditation for the pharmacist, the requirements of which differed between commissioners. Pharmacy chains with branches in different commissioning areas were also affected by variation in service commissioning between different CCGs and local authorities, some of which were seen to be more proactive in commissioning from community pharmacies than others. This could be seen as a threat to that pharmacy chain’s income and the investment that they were able to make in staffing and infrastructure.

So unfortunately in [county] because there’s very little commissioning we’re really constrained by the lack of any commissioning that we can engage with . . . in [adjacent county], where there’s a lot more imaginative commissioning we’re also doing MDS . . . weight management and we do a much broader sexual health service . . . and we’ve got a huge warfarin service including home visiting . . . it’s a massive service . . . where you’ve got . . . a consistent credible reliable additional income stream you can make an investment in more ACTs, second pharmacists a lot more IT, because you get a return. Where you’ve just got like we have here a few sporadic services none of which are really economic to provide it’s impossible to make the investment.

Superintendent pharmacist 4

The commissioners we spoke to were themselves still learning about the new commissioning structures and processes. Some NHS England commissioners had commissioned a pharmacy-enhanced service on behalf of their local CCG, meaning that the CCG held responsibility for managing the service but NHS England held overall accountability. This arrangement had arisen as a result of the service previously having been commissioned as an enhanced service by the PCT and, to minimise administrative work, had remained as an enhanced service rather than transferring to a CCG locally commissioned service. Many commissioners engaged with LPCs to design services and to gain endorsement to attract providers. Input from LPCs was seen as a way of helping to improve the quality of commissioning.

Last year’s flu campaign . . . it was probably commissioned a bit rushed . . . it probably wasn’t the highest quality commissioning cycle. As a result, the uptake through pharmacies was really poor . . . this year it was different, we set about it earlier, we engaged with the LPC. We used the LPC to advertise and roll out the service, and somebody within the LPC who was well known was the point of contact and everything. And as a result, we got loads of pharmacies signed up and they really got behind it . . . within about 4 weeks of the service start, we’d done 1000 flu jabs in pharmacies.

Commissioner 3

Contractual framework and remuneration

The nature of the community pharmacy contractual framework and the levels of remuneration available for essential, advanced and enhanced/locally commissioned services were seen by many to have both a direct and indirect impact on clinical productivity.

As private businesses, community pharmacies are required to make a profit. Many pharmacists and superintendent pharmacists interviewed perceived that the level of remuneration for services was insufficient for the pharmacy to invest in the levels of staffing (number of pharmacists and/or other pharmacy staff) and infrastructure (consultation rooms/IT) necessary to be able to deliver these services at high enough quality and to still make a profit. This perceived insufficiency of remuneration could have the effect of minimising investment in the number and skill mix of staff employed by pharmacies, limiting the range of services taken up by pharmacies, and/or reducing the volume of those services delivered. One superintendent used the MUR service as an example of this.

To enable you to do MURs you have to invest in a consultation room . . . Then you need . . . a second PMR [patient medication record] system to use in that room. In order to free the pharmacist up you need a team of better-trained counter staff and dispensary assistants. When you add up all those costs you would be much better off to forget the MURs . . . it just doesn’t work, the economics don’t work.

Superintendent pharmacist 4

Overall, remuneration by the NHS was seen by many pharmacists not to have increased in line with increasing workloads and expectations. Although the contract was still weighted towards dispensing (essential services), remuneration for these services was seen to have been cut, with the overall global sum redistributed towards payments for advanced services (MURs and NMS interventions). Although one respondent believed that the redistribution of funding away from dispensing and towards services had a positive effect on the clinical impact of community pharmacy, the majority felt that, together with Category M (of the Drug Tariff, which relates to reimbursement prices set for over 500 generic medicines, subject to regular review and negotiation between the PSNC and Department of Health) ‘clawbacks’, this had led to a perceived squeeze overall on profit margins leading to cuts in staffing and the consequent threat to clinical productivity (described in more detail in Staffing and skill mix):

I think number one [barrier to maximising clinical productivity] is definitely the income we get . . . it’s just being eroded year after year. So it is hard sometimes to keep upping your game when they keep reducing your dispensing fees . . . you can’t employ more staff and it just filters down from there.

Pharmacist 7

Other contract-related issues having a detrimental effect on clinical productivity included the short commissioning cycle operated by NHS commissioners, seen as a barrier to investment in staffing and training of staff, remuneration on the basis of service volume rather than service quality and the cap on the provision of MURs at 400 per year:

. . . the financial outlook is, in the NHS and in pharmacy with the various contracts, can be quite . . . [Pharmacies] don’t know whether it’s worthwhile doing [services] because 2 years down the line they mightn’t get paid for it, or they might be expected to do it without the same reimbursement.

Pharmacist 35

Obviously when we get to the limit for the year then we don’t do any more after that really. Once we’ve done the 400 we don’t provide any more.

Pharmacist 32

Suggestions made by interviewees for counteracting these financial constraints included increasing the overall global sum; increasing the levels of remuneration for advanced and enhanced/locally commissioned services to more accurately reflect the cost of delivery; an increase in the level of local commissioning of pharmacy services; and changing the basis of remuneration from fee-for-service to one reflecting aspects of service quality or outcome, for example having a pharmacy QOF in line with general practice. The perceived benefits of such changes included not only increased investment in staffing, which could lead to an increase in the quantity and quality of services a community pharmacy was able to deliver, but also an alleviation of pressure on general practice workloads:

. . . if they were to commission more services here then obviously we can work our way around that . . . [if] they are viable in this area and I can make them successful then obviously I would get in the staff, I would go out of my way to get an ACT, so I wouldn’t have to worry about other things.

Pharmacist 15

They need to be thinking about the contract in a very different way. So a QOF for pharmacy would be good . . . [The pharmacy contract] doesn’t appear to be aligned particularly well to the GP contract so we’ve not necessarily got two professions working in the best interests of patients. I think a route and branch review of the pharmacy contract would be a good start and start to recognise the clinical value that pharmacists add through their interaction with patients.

Superintendent pharmacist 3

Legal and regulatory constraints

Some legal and regulatory constraints to maximising clinical productivity in community pharmacy were identified by interviewees, most notably around the existing consideration of dispensing errors as ‘strict liability’ or criminal offences and the Medicines (Pharmacies) (Responsible Pharmacist) Regulations 200871 and associated provisions for supervision under the Medicines Act 196872 and the National Health Service (Pharmaceutical and Local Pharmaceutical Services) Regulations 201373 (under review at the time of writing and likely to change in the near future).

A number of interviewees identified the existing consideration of dispensing errors as criminal offences as a barrier to clinical productivity because it deterred the effective deployment of skill mix within the pharmacy:

They need to deregulate the criminal aspect of dispensing errors; that needs to not be an offence . . . and the dispensers . . . you should have a team of them, one dispensing it, one checking it . . . and one labelling it and it all gets done by three different people . . . and I could join in as well, but I’m not solely responsible for any cock-ups. So that then frees me up and them up as well to do things.

Pharmacist 34

Others felt that the existing responsible pharmacist regulations and associated supervision arrangements were unclear, not only leading to suboptimal utilisation of skill mix, thereby lowering the quantity and quality of service provision (as described in Skill mix), but also making it difficult to nurture effective relationships with local GPs and preventing pharmacists from providing services such as MURs to those who may benefit most, for example the housebound elderly:

. . . in order to free up pharmacists’ time, there’s probably going to have to be a change as far as the supervision regulations . . . there might be the possibility of remote supervision, which already . . . occurs in a number of other countries.

Pharmacist 3

. . . as a responsible pharmacist we can disappear off. I’m not sure how many of us do that, because we’re all worried about lack of business from a commercial point of view, and pressure, but we need to talk more and practice meetings at surgeries should probably involve the local pharmacies more.

Pharmacist 35

A small number of pharmacists believed that increases in staffing and improved skill mix could overcome these regulatory constraints, but that this would require increased levels of remuneration or else result in a drop in profit for the pharmacy. Two pharmacists believed that only a two-pharmacist model would provide a solution and allow pharmacies to increase their clinical productivity:

I think over 50 per cent of potential MURs we can’t do because they’re either deliveries or they’re collection by a relative, not the patient . . . I know you can apply to go off site and do them but maybe it’s something that . . . NHS England . . . look at making that sort of service easier to provide. But that would require a second pharmacist . . . which again would have to be extra payment. I suppose you could argue the extra MURs would pay for a second pharmacist. Maybe it’s an area that they need to look at, because there probably is those patients that are housebound or don’t get out very often.

Pharmacist 41

Supply chain problems

The importance of having well-managed stock to the delivery of a high-quality dispensing service has been described above (see Quality of dispensing services). It is therefore unsurprising that many pharmacists interviewed reported that supply chain problems were a barrier to clinical productivity in community pharmacy. Stock shortages, fluctuating prices, perceived quotas imposed by wholesalers, ‘direct-to-pharmacy’ schemes and perceived wholesaler preference or ties to larger pharmacy multiples all contributed to the difficulties reported by pharmacists in obtaining stock.

Supply chain problems were believed to be detrimental to service quality – sometimes forcing patients to revisit the pharmacy when the full prescribed order was not readily available – and on the pharmacy’s relationship with the patient. It was also seen to have an adverse effect on the workload of the pharmacy, increasing the time spent by pharmacists sourcing products, finding alternatives with prescribers, dispensing ‘owings’ and tying up dispensing staff restocking the dispensary. The volume or quantity of service provision was therefore also affected:

This is where I think as a pharmacist I waste a lot of my time, chasing stock and chasing prices.

Pharmacist 15

We’re spending hours just sourcing products now. Nobody takes into account the sheer workload involved in making sure you’ve got the drug for the patient which used to just be a given. Direct-to-pharmacy schemes [in which manufacturers supply pharmacies directly] have made it harder and harder to obtain products. It places huge constraints because if you’re spending an hour on the phone trying to get Mrs Smith’s products you haven’t got an hour to spend with her doing an MUR.

Superintendent pharmacist 4

Approaches to the management of supply chain problems described by interviewees included having good working relationships with local GPs, prescription collection services, having good working relationships with other local pharmacies and building relationships with trusted suppliers:

But [the local practice] are nice enough to, if we tell them that it’s not something that we can get hold of, with all these shortage issues with stock, then they try and change it to something else sometimes the doctors will call me and ask me if there is anything else I can think of.

Pharmacist 1

We have excellent relationships with both competitors . . . if I ever don’t have an item they’ll loan it to me . . . In other places where I’ve worked, if you requested that off another pharmacy they would tell you to simply send the prescription to them . . . that means that I’m never owing an item or I’m never owing an item for any longer than I should do for a patient, so we manage to process the prescription fairly quickly and the end result is that the patient is happy.

Pharmacist 31

Current monitoring arrangements for clinical productivity

Benefits and drawbacks to monitoring clinical productivity

A number of benefits to monitoring both the quantity and quality of community pharmacy services was identified by respondents. For example, it was suggested that monitoring service activity levels by community pharmacies allowed benchmarking against other pharmacies, helped pharmacies to reach targets to maximise income, and generally increased the volume of service delivery and the number of patients reached:

[The pharmacy owner] wanted to firstly make sure that we’re on target . . . with MURs . . . he wants to make sure that we’re going to be getting the 400 a year, and if we’re starting to do like 10, 15 a month regularly he’ll say, ‘Well, you need to increase that’ . . . and items as well, I think he will quite often look at items and say, ‘You’ve had a busy month’, or he can quickly spot if we have 1 month which is far lower than normal and, again, he’ll say, ‘Well, what’s happened there?’.

Pharmacist 32

For commissioners, a reduction in service activity levels could be an indicator of wider problems within a pharmacy and a prompt for further investigation. It was also suggested that contract monitoring procedures, by improving record-keeping, ultimately led to improvements in service quality:

All I can say is that the monitoring, I believe, then leads to better record-keeping . . . I’m hoping that by improving the record-keeping and making pharmacies more aware of what it is that they should be doing in the service, will then lead, in turn, to improve the quality.

Commissioner 4

Monitoring and reviewing patient safety incidents (dispensing errors and near misses) was perceived as an opportunity for organisational learning – sometimes shared learning across pharmacies within a chain – and a way of improving patient safety within community pharmacies:

. . . if I feel that it’s linked to any particular person at any particular time then I like to get to the bottom of why that’s happening . . . I think sometimes people don’t necessarily assess themselves about how many errors they’re making unless it’s kind of pointed out to them, but it seems to have worked and it’s reduced the number of errors that are going to the patients.

Pharmacist 38

Monitoring quality, for example through the annual patient survey, was seen by some as a way of increasing service quality by identifying weaknesses and developing action plans for improvement. However, often the benefits of the patient survey were seen to be limited. It was recognised that pharmacies could ‘cherry pick’ those patients who received a questionnaire, that responses were generally very positive with little opportunity for making improvements and that commissioners did not review the findings, limiting opportunities for benchmarking or monitoring change in quality over time:

I suppose if there was negative feedback you would perhaps look into it and see how can we do things better. But it’s usually quite positive . . . I think we just use it as a tool and it’s something we have to put on the wall anyway to show people.

Pharmacist 17

Respondents also identified a number of drawbacks to monitoring clinical productivity in community pharmacies. These included pharmacies being overburdened with monitoring and inspection requirements, and the excessive bureaucracy involved in some of these processes; the fact that sometimes neither pharmacies nor commissioners reviewed or acted on the information obtained through monitoring processes; and the focus on quantity and business targets rather than the quality or clinical outcomes of services:

Inevitably the danger here is we then try and measure and monitor everything and you spend so much time recording things that you don’t actually have time to care.

Superintendent pharmacist 3

Opportunities and barriers to monitoring clinical productivity

Many interviewees recognised the difficulties inherent in measuring the quality of community pharmacy services that created a significant barrier to monitoring clinical productivity. A number indicated that there were no existing markers for quality or that they would not know what to measure. It was also suggested that the dissonance between a patient’s view of a quality dispensing service (speed) and one that was clinically of high quality was an additional hurdle to developing appropriate measures. Moreover, with few pharmacy services offering a follow-up of patients, it was difficult to measure their impact on the patient or wider health service:

[Quality] is enormously difficult to measure . . . because you’re not aware of anything bad, you’re hoping that the quality is going to be good. I suppose for us if you were looking at it more widely we would be looking from a commissioner’s point of view, the sort of stuff is, what about hospital admissions? . . . Is the level of disease going down in an area? . . . How on earth are we going to measure that? I don’t know.

Commissioner 1

When measures of quality did exist (e.g. patient surveys, records of errors and near misses, or records of pharmacist interventions) a number of barriers was identified to their effectiveness as tools with which to monitor clinical productivity. Community pharmacies did not always record interventions, sometimes because of a lack of time or because this was not supported by existing IT systems:

I think one of the major stumbling blocks that we’re finding, when we’re going out and doing our contract monitoring visits, is the poor level of support that most, if not all of, our pharmacies have, from their IT system . . . one of the prerequisites of the contractual framework is that pharmacies should be recording any interventions that they make around dispensing, around signposting, around support for self-care, and for support around public health initiatives, and yet, what we’re seeing is very, very low levels of interventions being recorded.

Commissioner 4

So if we’ve had to speak to a doctor or if there’s been an issue we are supposed to record interventions. But it’s finding the time to record them, it’s difficult, especially when you’ve got a high volume, you’re doing quite a lot of interventions. It’s difficult to find the time to do that.

Pharmacist 23

The barriers to monitoring clinical productivity faced by service commissioners also included the fragmentation of community pharmacy commissioning following the dissolution of PCTs. This not only meant that no one commissioning body had oversight of all elements of pharmacy service provision, but it also resulted in a significant reduction in the resources available to commissioners to monitor services. This fragmentation of commissioning responsibilities was compounded by barriers to data sharing and poor communication between pharmacies and commissioners, and between different commissioning bodies, sometimes in relation to data protection restrictions and terms of service:

. . . we don’t have the resource any more in the CCG to monitor pharmacies, because we lost all that resource when it went to NHS England . . . In PCT days, we had a programme of pharmacy visits . . . we had a pharmacy quality scheme . . . So we had a very good knowledge on the ground of what was happening . . . and we have a lot less confidence about the quality of what’s happening than we did . . . When we had our commitment to quality pharmacy scheme, with three levels of quality . . . we had a grid and we could have told you pretty much any pharmacy in [area], we could have given you chapter and verse about the quality of work, the number of indicators . . . We can’t do that anymore.

Commissioner 7

Nonetheless, there were some reports of opportunities taken by service commissioners to monitor clinical productivity. These included joint visits and data sharing with the local General Pharmaceutical Council inspectorate, use of the number of targeted MURs as a quality indicator, and the triangulation of existing data and intelligence to give an indication of clinical productivity in community pharmacies:

I think what we need to build on is working together with the GPhC [General Pharmaceutical Council] inspectors . . . when there was an issue that was both performance related and contractual related we did a joint visit to a pharmacist.

Commissioner 2

Future monitoring of clinical productivity

When asked if there should be more monitoring of clinical productivity in community pharmacies, the majority of respondents believed that there should be, with only a small number expressing ambivalence or disagreeing. In particular, it was suggested that there was a need to measure service quality or to be able to demonstrate the outcomes or benefits of pharmacy services. A number of aims of such monitoring was proposed, including ensuring accountability for spending taxpayers’ money, being able to demonstrate the benefits or value of community pharmacy services, improving quality and identifying areas of concern:

But if the regulations say that we’re going to pay them for 400 MURs every year, it’s public money, we should be getting value for money out of those MURs. And we don’t know that at the moment. It’s public money so we have a right to ensure, like anything, we are answerable to all of us.

Commissioner 3

The purported need for additional monitoring varied according to the type of service. For some services, for example influenza vaccinations, numbers and activity levels were thought to be sufficient. However, there was a consensus that services such as MURs and NMS interventions should have more quality markers:

But, yeah, I do think it’s important to get the patient’s reflection on things like MURs and NMS, and look at the information that they’re giving and see whether it’s actually worthwhile doing, whether they found them beneficial or not. I suppose that’s the only way you’re going to be able to measure [it].

Pharmacist 40

However, even among those who perceived monitoring as a good thing, there was some recognition that both commissioners and community pharmacies were already overstretched and had little capacity to undertake further monitoring activities. Other respondents questioned what further monitoring of clinical productivity would achieve, some seeing it as a tick-box exercise having no impact on quality improvement:

If you look at the wider NHS, what does monitoring achieve? . . . not in just the NHS, look at teaching, looking at Ofsted. Does it genuinely achieve long-term gain in quality or does it achieve a short-term gain in quality for the purpose of passing the inspection? . . . whereas if you get the structure and the management and the ethos within an organisation right, that will always lead to better quality.

Commissioner 3

Face validity of study findings

There was general agreement in the room that the study findings had high face validity. However, some surprise was voiced regarding the inverse relationship between annual volume of MURs and indicators of local population need. The reasons for this inverse relationship were discussed with suggestions raised that it might relate to less complex cases being targeted for MURs in some instances because of either time constraints or pressure to reach targets, or that it may be related to public perceptions of the role of the pharmacist and that people do not ask for MURs. There was further discussion around the public perceptions of pharmacy presented in the qualitative findings and the need for the sector to obtain a better understanding of what patients want and need from medicines optimisation services. Finally, the role of HLP status on clinical productivity was discussed with the suggestion that it was probably more important for enhancing service quality than service quantity.

Implications for patients

There was some discussion about the role of the pharmacist in relation to other health-care providers, and patients’ perceptions and preferences around this. It was suggested that services should be designed around patient needs and expectations, and that patient experience should be monitored. This would, in turn, provide added value to any medicines optimisation service and patients would return, by choice, to the pharmacy. There was also a suggestion that pharmacists should become the primary contact for patients in relation to medicines and the need to manage patient expectations around this, and to obtain buy-in from other health-care professionals. It was also recognised that medicines optimisation should occur during the dispensing process (through the provision of counselling and advice) as well as through dedicated services such as MURs. The positive outcomes identified by groups from a well-designed medicines optimisation service included greater choice, flexibility and access to services for patients, informed patient decision-making, better health outcomes, improved trust, and partnerships between patients and pharmacists and between pharmacists and other health-care providers.

Implications for community pharmacies

Much of the discussion on the implications for pharmacies was around skill mix and the role of the whole pharmacy team in helping to free up the pharmacist to be able to deliver medicines optimisation services. To support this, there was a perceived need for services to be commissioned on a longer-term basis than annually to allow pharmacies to make the necessary investment in staffing and skill mix. Finally, it was recognised that all new services commissioned should have robust evaluations built into them to be able to demonstrate benefit and secure ongoing commissioning.

Implications for service commissioners

A number of themes arose from the small group discussions around what actions commissioners needed to take in relation to the study findings. First, there was a necessity for commissioners to identify the need for a particular medicines optimisation service and to define the cohort of patients for whom the service should be designed. Second, commissioners needed to consider the role of community pharmacy in relation to the other elements of the health-care system to help ensure integrated care pathways and remove competition between pharmacy and general practice. Suggestions were made here around incentivising GPs to refer patients to pharmacies, and aligning the GP and community pharmacy contracts. In designing the service, the views and needs of all stakeholders should be considered, particularly the patient’s, but including pharmacy providers (enlisting the help of LPCs) and other health-care providers. Delegates also identified the need for commissioners to take into account the organisation of community pharmacies, particularly making best use of the available skill mix (not just the pharmacist) and the capacity of pharmacies to deliver additional services within existing resources. In relation to this, the issues of funding and sustainability were discussed to facilitate pharmacies with making any necessary investment to deliver new services. It was also suggested that commissioners include the newly introduced Declaration of Competence system within service specifications. The need to build evaluation into the design of any new services was raised as was the marketing or advertising of services to patients to generate demand.

Content of commissioning toolkit

The final topic discussed during the workshop was the required content of a commissioning toolkit for medicines optimisation services. A number of suggestions was made in relation to content, starting with background information about pharmacies and how they operate, definitions of medicine optimisation, and local and national statistics around hospital admissions and GP data to support the commissioning of a new service. Contextual information about where medicines optimisation services fit into the wider commissioning landscape and contractual framework for community pharmacy, and with health-care services more widely, was similarly considered important. Guidance on developing a business case, possibly a template, was suggested as useful content, considering any potential cost savings and/or value for money. Advice around early stakeholder involvement, particularly PPI, in service design was suggested. Content around designing the service specification was discussed, taking into account any necessary training and the Declaration of Competence. Consideration should also be given in the toolkit to measuring and monitoring outcomes, data sharing and data protection, and the evaluation of services. Finally, it was suggested that the toolkit should cover funding and the sustainability of services.

Organisational factors associated with clinical productivity in community pharmacies

Pharmacy ownership type was strongly associated with the volume of services provided by pharmacies, particularly the volume of MURs and NMS interventions, with large multiples and supermarkets providing a significantly greater volume of these services than independent pharmacies (although dispensing volumes in supermarkets were significantly lower than in other types of pharmacy).

Although the perception existed among some stakeholders that the greater volume of services provided by large multiples was associated with a poorer quality of service provision, there was little evidence from the quantitative study that ownership type was associated with service quality.

Pharmacies with higher dispensing volumes provided more MURs and NMS interventions; however, there was no association between dispensing volume and service quality. Pharmacies conducting the fewest MURs per year had significantly lower patient satisfaction and SIMS scores than those conducting close to the annual maximum of 400 per year. There was no other significant association between service volume and service quality.

Stakeholder interviews also suggested that ownership type influenced clinical productivity through variation in organisational culture, staffing and skill mix, the quality of the customer relationship and ease of commissioning.

Organisational culture was perceived by many stakeholders to be important in relation to the drive to reach business targets and the degree to which that was prioritised above service quality, as well as the importance placed on investment in staffing and staff and team development. The measure of organisational culture used in the pharmacy survey was strongly associated with higher dispensing volumes and with safety climate. Specifically, pharmacies with a culture more closely aligned to ‘quantity’, the ‘medicine’ and ‘technical’ work than to ‘quality’, the ‘patient’ and ‘professional’ work had higher dispensing volumes but a significantly less favourable safety climate. However, no association was demonstrated with any other measure of service quality or quantity.

Overall staffing levels and also the skill mix deployed in the pharmacy were identified by most stakeholders as crucial to the level of clinical productivity achieved. Although staffing levels were perceived to have been reduced, limiting both the quantity and the quality of services delivered, the availability of a trusted and competent team with appropriately trained pharmacy technicians, dispensers and medicines counter assistants was viewed as necessary to support the pharmacist to take on an effective clinical role. The value of accuracy checkers and a two-pharmacist staffing model was also discussed, as were the pros and cons of locum pharmacists.

In the quantitative study also, associations were demonstrated between staffing and skill mix, and service quantity and quality. Pharmacies with a higher dispensing volume were more likely to have longer pharmacist daily working hours or to employ a second pharmacist, pharmacy technicians or accuracy checkers. Pharmacies employing more than one pharmacist also conducted a greater volume of NMS interventions. Pharmacies in which the main pharmacist worked longer hours were associated with a less favourable safety climate. Unexpectedly, however, pharmacies with an accuracy checker were also associated with a less favourable safety climate. The employment of a pharmacy technician was associated with higher levels of patient satisfaction. Regular use of locums was associated with poorer patient self-reported medicines adherence.

Some ambivalence was shown by stakeholders over the value of HLP status to the clinical productivity of the pharmacy. Some believed that it might improve service quality in terms of the added value offered and that it was beneficial for staff development and skill mix. However, it was not perceived to increase the quantity of services delivered or to attract the commissioning of new or additional services. HLP status was not seen to be associated with any measures of service quantity or quality in the quantitative study.

Pharmacy–GP relationships were perceived by some stakeholders to have a bearing on the clinical productivity of the pharmacy. Good working relationships were seen to improve the quality of services provision, for example by allowing prompt resolution of prescribing or dispensing issues, or by ensuring GP follow-up of the pharmacist’s recommendations following a MUR. Good working relationships were also thought to help boost the quantity of service provision through increased signposting and referral to pharmacy services by the GP. The quantitative study demonstrated a significant positive association between the strength of the pharmacist–GP relationship and the volume of NMS interventions conducted.

Extraorganisational factors associated with clinical productivity in community pharmacies

Increasing levels of local area deprivation were associated with higher dispensing volumes but a lower volume of MURs and NMS interventions. In the qualitative interviews, however, stakeholders identified the level of local deprivation as either an opportunity or a barrier to clinical productivity. For example, in more affluent areas where the population was better educated, customers or patients were sometimes perceived to be less receptive to pharmacy services or advice. More deprived areas, on the other hand, offered opportunities to deliver some services (e.g. needle exchange or minor ailments) but the level of deprivation was a barrier to others (e.g. private services).

The age profile of the local population was also associated with dispensing volumes, with higher proportions of both older people (aged ≥ 75 years) and young children (aged 0–4 years) in the local population associated with higher dispensing volumes in the national data. A number of pharmacists interviewed also suggested that an older customer base limited the number of MURs and other services they could offer as a result of them either being housebound or receiving services for long-term conditions from their GP. Of those responding to the patient survey, older patients were significantly more satisfied with the information they received about medicines and were more likely to be self-reported adherers.

Local disease prevalence relating to a number of long-term conditions was positively associated with dispensing volumes but for asthma was negatively associated with the volume of MURs and NMS interventions conducted.

The location of the pharmacy was seen from both the qualitative and quantitative study to provide either opportunities or barriers to the volume of pharmacy service provision. NMS provision was significantly lower in city centre pharmacies than in pharmacies in other locations; city centre pharmacies being seen by stakeholders to cater for a different customer base than local or suburban pharmacies.

Public perceptions and expectations of the pharmacist’s role and the services available from pharmacies were described in the stakeholder interviews as influencing the clinical productivity of the pharmacy. A lack of understanding by patients of the complexity of the dispensing process and the clinical input of the pharmacist was thought to contribute to pharmacists’ prioritisation of speed over other aspects of quality and of dispensing over other services provided. Moreover, a lack of awareness of the range of services available from the pharmacy limited public demand and receptiveness to being offered information or advice. However, from the patient survey, when patients had more reasons for choosing to visit a particular pharmacy, this was significantly associated with greater patient satisfaction, as was continuity of advice-giving from the same member of pharmacy staff.

Supply chain problems were reported by many of the stakeholders interviewed to be a barrier to both the quantity and quality of pharmacy services provided. These could be caused by stock shortages, fluctuating prices, wholesaler quotas, direct-to-pharmacy schemes and a perceived wholesaler preference for some large multiples. Difficulties in obtaining stock could be detrimental to the patient experience and could also increase the pharmacist’s workload, reducing the time available to provide other services.

Since the 2013 NHS reorganisation, the commissioning structures and processes for pharmacy had become fragmented between NHS England, CCGs and local authorities. This caused confusion for some pharmacies, a perceived increase in commissioning-related bureaucracy and some decommissioning of services. Many interviewees viewed this as a threat to clinical productivity. Variation in commissioning, both between geographical areas and within the same locality was seen as a barrier to clinical productivity by others. The short commissioning cycle operated by many CCGs was also seen to hamper longer-term planning and the investment required for pharmacies to be able to deliver new services.

The existing contractual framework and associated levels of remuneration were seen by many pharmacists and superintendent pharmacists to have both a direct and an indirect negative impact on clinical productivity. Investment in staffing and infrastructure was reported to be limited by current levels of remuneration, which were perceived to be decreasing.

Finally, legal and regulatory constraints to maximising clinical productivity were reported by many stakeholders, including the continued consideration of dispensing errors as a criminal offence and the responsible pharmacist regulations and related supervision arrangements, all of which are under review at the time of writing.

Monitoring clinical productivity in community pharmacies

Arrangements for monitoring clinical productivity that already existed in community pharmacy organisations primarily focused on the quantity of service provision but also looked at quality in terms of obtaining informal customer feedback, patient survey returns, monitoring and analysing errors, and near misses and monitoring complaints.

Arrangements for monitoring clinical productivity by NHS commissioners were almost exclusively focused on the quantity of service provision. When quality was monitored, this was usually through self-assessment by the pharmacy or following reported incidents or complaints from patients.

A number of benefits and drawbacks to monitoring clinical productivity in community pharmacy were suggested by stakeholders including the ability to benchmark activity, helping to improve quality and safety, providing an indicator of underlying problems and the bureaucracy involved.

The barriers to monitoring clinical productivity identified by stakeholders included the inherent difficulty in measuring quality, poor recording by pharmacies, findings not being monitored by pharmacies or commissioners, a lack of resources and manpower, the fragmentation of commissioning and responsibilities for monitoring. However, some opportunities were highlighted through pockets of good practice.

Most stakeholders agreed that there should be more monitoring of clinical productivity in the future but highlighted the need for more quality markers to be developed and the additional regulatory burden that would entail.

How can service quality best be measured in community pharmacy?

The qualitative evidence from this study provides valuable insights into definitions of quality in relation to dispensing and MUR services in community pharmacy. Further research is needed to help develop reliable and validated quantitative tools to measure community pharmacy service quality over and above patient satisfaction. As interview respondents described, there are inherent difficulties in measuring patient outcomes that can link directly to community pharmacy services. However, there is a growing body of knowledge in this area that, if expanded, could provide both researchers and commissioners with the tools necessary to monitor and improve service quality. The development of such tools should draw on qualitative investigations of patient views and experiences of pharmacy services as well as those of pharmacists and GPs.

How cost-effective are different models of skill mix in community pharmacy?

To support the development of cost-effective models of skill mix in community pharmacy, research is needed to describe and evaluate existing developments in this area (including in hospital pharmacy where such developments have already been successfully implemented) to examine how they affect clinical productivity. This should include, but not be limited to, investigating the costs and effects of implementing a two-pharmacist model, different configurations and levels of support staff, and the implementation of different dispensing cascade models (i.e. conducting the clinical check at the beginning vs. at the end of the dispensing process), all of which aim to free up pharmacists to deliver more clinical, patient-centred services.

How are community pharmacy services commissioned and how does this relate to local need?

Research is also needed into the way in which services are commissioned locally from community pharmacies by CCGs, local authorities and NHS England, and the extent to which local needs are met. The evidence from this study suggests that, for MURs at least, services are not targeted at areas with greatest need. This may not be the case for locally commissioned services but, without the evidence, improvements cannot be made to the commissioning process to ensure that community pharmacy services are targeted at those in greatest need and integrated with other services around patient pathways.

1. Quantity

Thinking about the quantity of services provided by your pharmacy – and by quantity I mean both the number or range, and volume of different services provided by your pharmacy (essential, advanced and locally commissioned) – would you say that this level of activity is high (above average), about average, or low?

• What aspects of the way your pharmacy operates do you think helps you to maximise this level of service delivery? (Probe: which organisational factors and how they help – PROMPT SHEET)

• What aspects of the way your pharmacy operates do you think gets in the way of you maximising the quantity of the different services you deliver? (Probe: which organisational factors and how they get in the way – PROMPT SHEET)

2. Quality

I would now like to ask you about the quality of the services your pharmacy provides.

Thinking first of all about dispensing, what for you characterises a ‘high-quality’ dispensing service provided by a pharmacy?

• What does a high quality dispensing service look like? (Probe: pharmacy team perspective, patient perspective)

How often do you feel the dispensing service provided by your pharmacy achieves this level of quality? (Probe: level of quality actually achieved, how this deviates from ‘high quality’)

• Thinking about how this pharmacy operates, what aspects do you think help you to provide a high-quality dispensing service? (Probe: which organisational factors and how they help – PROMPT SHEET)

• What aspects do you think get in the way of you providing a high-quality dispensing service? (Probe: which organisational factors and how they get in the way – PROMPT SHEET)

Thinking now about MURs, what for you characterises a ‘high-quality’ service provided by a pharmacy?

• What does a high-quality MUR look like? (Probe: pharmacy team perspective, patient perspective)

How often do you feel that the MURs provided by your pharmacy achieve this level of quality? (Probe: level of quality actually achieved, how this deviates from ‘high quality’)

• Thinking about how this pharmacy operates, what aspects do you think help you to provide high-quality MURs? (Probe: which organisational factors and how they help – PROMPT SHEET)

• What aspects do you think get in the way of you providing high-quality MURs? (Probe: which organisational factors and how they get in the way – PROMPT SHEET)