Positioning pharmacists’ roles in primary health care: a discourse analysis of the compensation plan in Alberta, Canada

In many parts of the world, pharmacy practice is undergoing a paradigm shift that highlights new roles and responsibilities in the provision of patient care. Pharmacists, as the first point of contact for the public, are becoming increasingly involved in primary health care, providing access to medications and chronic disease management services [1, 2]. They are also involved in public health through delivery of smoking cessation, cardiovascular screening, and immunization programs [3]. Most studies examining the shift to a patient care-focused practice indicate a willingness amongst community pharmacists to provide more clinical services [4, 5]. In a study of pharmacists’ intentions to provide new medication therapy management services reimbursed under Medicare in the United States, the results were, overall, positive, and most agreed they had sufficient training [6]. However, lack of remuneration is often recognized as a significant barrier to expansion of new services provided by pharmacists [7‐9]. In addition to poor collaboration with other health care professionals and a shortage of shared vision about the various services provided by pharmacists, lack of remuneration has been identified as a major contributor to the underutilization of pharmacists’ services [10]. Remuneration, among other strategies, may advance the profession and enhance the role of community pharmacists as primary health care providers [9, 11].

In Canada, momentum for primary health care reform was established in the late 1990’s, precipitated in part due to growing concern about access to and quality of health care [12] as well as findings from reports on the publicly funded Canadian health care system [13]. Membership of pharmacists on health care teams, and collaboration between health care professionals, was deemed important for primary health care reform [13]. In order to align pharmacy practice with the health care needs of Canadian patients, the Task Force on a Blueprint for Pharmacy developed a vision for pharmacy practice in Canada [14]. As part of the vision for pharmacy, pharmacists would practice to the full extent of their knowledge and skills and manage drug therapy in collaboration with patients and other health care providers [14]. The Blueprint for Pharmacy also stated pharmacists’ services should be compensated based on expertise and complexity of care [14]. Over the past decade, legislative changes have facilitated expansion of the scope of pharmacy practice in Canada, although approaches have differed by province or territory [15, 16].

In the province of Alberta, with its population of approximately four million, incremental changes have occurred over time to support increased involvement of pharmacists in the delivery of patient-centred services. Pharmacists were permitted access to provincial electronic health records in 2006, including laboratory tests and records of dispensed medications [17]. This was followed in 2007 by enactment of regulations that allow pharmacists to prescribe and administer drugs by injection [18]. A framework for pharmacist prescribing that includes initial access prescribing was developed by the Alberta College of Pharmacists, the regulatory organization responsible for the quality of pharmacy practice [19]. In July 2012, a government-funded Compensation Plan for Pharmacy Services provided by community pharmacists (Compensation Plan hereafter) was introduced following negotiations with the Alberta Pharmacists’ Association, the advocacy organization for pharmacists. The Plan is complementary to the scope of practice in Alberta and is commonly referred to by pharmacists as the Pharmacy Services Framework [20, 21]. Prior to introduction of the Compensation Plan, pharmacies were remunerated based on government negotiated dispensing fees. While pharmacies continue to receive dispensing fees, expanded services covered by the Compensation Plan include: care planning services and patient follow-up; prescribing services that require patient assessment such as trial prescriptions, refusal to fill a prescription, adapting or renewing a prescription, and independent prescribing to initiate or manage ongoing therapy; and administering drugs or publicly-funded vaccines by injection. The services covered by the Compensation Plan were revised in 2014 to include payment for additional services. A full description of the development of the Compensation Plan, services covered as well as associated fees, has been previously published [22]. The Compensation Plan is one of the most comprehensive fee schedules available for remuneration of clinical pharmacy services in Canada [15]. Alberta Blue Cross administers payment for pharmacy services on behalf of the government.

In addition to Canada, remuneration models to pay for pharmacy services have been implemented in other parts of the world including the United States, United Kingdom (UK), Australia, and New Zealand [23]. A systematic review by Houle et al. found that the most common remunerated service was medication reviews with or without development of a care plan, and that evaluation data for remunerated services was limited [23]. The UK was one of the first countries to expand the scope of pharmacist practice, and in 2005 introduced a new contractual framework for community pharmacy [24]. Within this framework, there are three different types of services: essential (e.g. dispensing, disposal of unwanted medicines), enhanced (e.g. minor ailment prescribing, smoking cessation programs) and advanced (e.g. medication use review). Research has shown that in many cases these pharmacy services are effective [25]. Services such as medication use reviews are generally positively viewed by patients and pharmacists [26, 27]; however research has shown less positive views by general practitioners, in part due to perceptions regarding duplication of work [28]. Observational studies that have explored patient-pharmacist interactions as part of medication use review consultations have noted challenges integrating these services into routine workload, and lack of patient awareness about the consultation [29].

Given legislative changes to enable expanded scope of pharmacist practice and introduction of a Compensation Plan in Alberta, research is needed to evaluate how pharmacists are providing patient care services as well as the perceived value of these services to patients, pharmacists, and other healthcare providers. The current study is part of a larger project looking at how pharmacists are providing care planning services in Alberta. Documents such as government communications and trade and newspaper articles are important sources of data when examining the context and implementation of government policy. Governments write policy with a certain target audience in mind; however, this information is also available to other, non-target audiences [30, 31]. For instance, documents written about the Compensation Plan provide pharmacists with important information about the clinical pharmacy services for which they can be compensated; at the same time, it informs pharmacists and the general public about expectations for and changes in pharmacists’ professional roles.

Language constructs the social world because it influences perceptions and actions [32]. Various text-based analytical approaches have been used to examine how government policies affect patient care, the effect of the media on how government policies are understood by the general public, and how pharmacists’ professional roles are conceptualized by both pharmacists and the general public [33‐40]. The objective of this study is to examine the positioning of pharmacists’ roles in documents used in the communication of the Compensation Plan to Albertan pharmacists and other audiences. Understanding how the Compensation Plan was framed and communicated provides insight into pharmacists’ roles and helps to identify factors that influence implementation of the Compensation Plan by Albertan pharmacists.

Our study examined documents used to communicate information about the Compensation Plan for Pharmacy Services to Albertan pharmacists and other audiences. Social positioning theory provided a lens through which to carry out our analysis; it is about “how people use words to locate themselves and others” [65]. Our findings provide insight into the dynamic and evolving roles of pharmacists. Three inter-related positioning themes highlighted pharmacists’ present and emerging roles in the context of the Compensation Plan within a storyline of primary health care. The discourse associated with the Compensation Plan positioned pharmacists’ roles as: (1) expanding to include services such as medication management for chronic diseases, (2) contributing to primary health care by providing access to services such as prescription renewals and immunizations, and (3) collaborating with other health care team members to improve patient outcomes. Pharmacists’ changing roles were positioned in alignment with the aims of primary health care, including access to services, quality and safety of care, coordination of services, prevention and management of chronic diseases, and cost of services [12].

Expansion of community pharmacists’ roles beyond dispensing and compounding of medications has gradually occurred over the past 20–30 years, starting with the introduction of pharmaceutical care in the early 1990’s [66]. The shift from a product focus to patient-care related services has occurred in Alberta through a series of incremental legislative changes starting with increased access to patient information through health records and progressing to the ability to order laboratory tests, administer drugs by injection, and prescribe in a range of situations (including renewing and adapting prescriptions, prescribing in an emergency, and prescribing on initial access) [19, 22]. The importance of incremental changes to legitimize changes in nursing practice was reported by Goodrick and Reay [67]. They found that legitimization of new roles required incremental development of an argument over time and a simultaneous effort to retain the legitimacy of former roles. By focusing on pharmacists’ educational backgrounds, professional experiences, and previously established professional frameworks, such as codes of ethics and Standards of Practice, the Compensation Plan contributed to this incremental change in pharmacists’ roles and the services they offer and reinforced the importance of their former roles as dispensers of drugs. To pharmacists, the Compensation Plan was presented as a means of supporting evolution of pharmacists’ practices whereas for the public communication focused on access to primary health care services associated with pharmacists’ expanded roles.

Community pharmacists have been viewed as one of the most accessible health care providers, but lack of clinical autonomy and remuneration based on dispensing a product have been historical challenges in utilizing pharmacists more effectively in the delivery of primary care. The Compensation Plan helped position pharmacists as providers of primary health care delivery with overall goals of improving access to services, and offering choice and convenience for patients. Communications highlighted that pharmacist services covered by the Compensation Plan complemented those of physicians. The repositioning of pharmacists’ roles in primary care is similar to what has occurred in other countries. For example, in the UK, pharmacy organizations were the main actors in promoting the reprofessionalization of pharmacy over the past couple of decades, including redefining community pharmacy’s role in the primary health care team [68]. The government in the UK was supportive of expansion of community pharmacists’ roles through a series of reports that highlighted the need for community pharmacists to become more involved in primary care [68‐70]. Legislative changes to enable expanded scope of practice and remuneration of clinical pharmacy services have been important steps in both the UK and Canada in positioning pharmacists to take on a bigger role in the primary care arena.

Collaboration is a prominent theme in pharmacy and primary health care services research and is closely associated with safety [71‐73]. The documents positioned the Compensation Plan as facilitating collaboration between pharmacists and physicians. For example, the comprehensive annual care plans compensated by the Plan were intended to be complementary to care plans developed by physicians in order to facilitate collaboration among providers. Collaborative medication reviews provided by pharmacists and primary care physicians are reported to improve prescribing and may reduce costs associated with health care services [10]. Previous research has found that collaboration is associated with improved patient care [74], new clinical services provided by prescribing pharmacists [75, 76], and legitimizing pharmacists’ prescribing [77]. However, researchers have also found that collaboration is not a routine part of practice [74]. Tannenbaum and Tsuyuki [78] called attention to the importance of physician–pharmacist communication in contexts where pharmacists provide expanded clinical services, such as prescribing. Barriers to communication due to location make conditions for collaboration between community pharmacists and physicians less than optimal [79]. Donald and colleagues [80] evaluated community pharmacists’ care of patients with cardiovascular disease. They concluded that efforts must be made to optimize communication between pharmacists and physicians and to clarify roles. Beginning in 2014, Albertan physicians were compensated for communication with pharmacists related to patient services covered by the Compensation Plan [81]. Lack of compensation is recognized as a barrier to implementing new practices for physicians, such as ordering routine tests, and to interprofessional collaboration [9, 82]. The new Compensation Plan positioned pharmacists as supporting information sharing and collaboration. To determine the effects of paying physicians, pharmacists, or other health care team members for communications in support of collaborative practice, additional research is required.

Based on the social constructionist view of language, our study demonstrated that expansion of pharmacists’ roles and scope of practice was supported by legislation and in the documents communicated by the pharmacy profession. Professional organizations, such as the Alberta Pharmacists’ Association and the Alberta College of Pharmacists, play an important part in legitimizing professional change, supporting practice innovation and facilitating acceptance of new practices [83]. With the introduction of the Compensation Plan in Alberta, pharmacists may become more actively involved in providing clinical pharmacy services and exercising their full scope of practice. Since pharmacists’ roles were positioned as expanding, contributing to primary health care, and facilitating collaboration among health care team members, pharmacists may be expected to alter their practice accordingly. Available data suggests that positioning of pharmacists’ roles through communications may have impacted changes in pharmacist practice. As an example, following introduction of the Compensation Plan in 2012, the number of Alberta pharmacists with Additional Prescribing Authorization increased dramatically from 167 to 1654 pharmacists; currently, 31% of Albertan pharmacists have this authorization [84]. Since implementation of the Compensation Plan, the most frequently provided services were those highlighted in the documents used in this study: prescription renewals, influenza immunizations, and prescription adaptations [22].

The context of this study, the unique practice environment of Albertan pharmacists, is one of its limitations. However, our findings illustrate how social positioning theory can contribute to understanding the relationship between communications and pharmacists’ professional roles. Strengths of this work include the research team’s involvement in the selection of documents and in the analysis itself, which lend credence to the trustworthiness of the results of this study [85]. The analysis involved reflexive discussions of views on compensation, interpretation of data, and co-construction of thematic categories related to pharmacists’ roles in primary health care. This work may be helpful to researchers, policy makers, and professional organizations interested in expanded roles for pharmacists or other health professionals.

This study provides insight into how communications around the Compensation Plan in Alberta, Canada positioned pharmacists’ roles. Our findings draw attention to the role of compensation in recognizing the expanding roles of pharmacists, pharmacists’ contributions to primary health care, and collaborative patient care. The Compensation Plan was positioned as supporting further shifts in pharmacy practice. For the public, the Plan was framed as supporting access to primary health care services such as prescription renewals and administering injections. Using the framework of social positioning theory, we conducted an analysis of the Compensation Plan within the practice context in Alberta that provides valuable information for pharmacists. It may also inform other jurisdictions considering implementation or expansion of remunerated clinical services provided by pharmacists. The findings of this study provide a foundation for future research on how language influences practice and how clinical pharmacy services compensated by the Plan are interpreted and implemented by pharmacists.