Service provision in the wake of a new funding model for community pharmacy

This study is largely quantitative with responses elicited through a national survey. Qualitative data was also collected through the option to free text answers for several questions in the survey.

A list of pharmacies in New Zealand was collated using publically available records, including the New Zealand Pharmacy Guild membership list (New Zealand Pharmacy Guild is a pharmacy owner’s organisation, membership is not compulsory), Google™ and the Yellow Pages Telephone Directory. A total sample of 1007 pharmacies was created from these sources. It was found that 49 pharmacies had closed, leaving a final survey sample of 958 pharmacies. Email addresses were available for 690 pharmacies representing close to three quarters (72%).

The survey instrument was developed through literature review and consideration of the research question and objectives. Developed by the authors over several months it consisted of the following sections; pharmacist and pharmacy demographic information [24], workforce and service provision, and barriers to undertaking services. To ensure face validity, the survey was piloted with 80 pharmacies from a geographically clustered sample, using electronic and postal methods [25]. A small number of changes were made to the structure and wording of the survey based on respondent’s feedback. Additional services were also included in the list of questions relating to service provision.

The survey was developed in SurveyMonkey® and the link was emailed in August 2014 to all community pharmacies with an email address (n = 690). All non-responders (n = 598) to the emailed survey and those without an email address (n = 268) were mailed a paper copy of the survey 2 weeks after the initial email, giving a total sample size of 958 pharmacies. A reminder email and postal drop was completed at both 5 and 7 weeks after the first email respectively. A third postal reminder was posted 11 weeks after the first email to all non-responders. A fourth and final email reminder was sent 5 months after the first email. The survey was promoted through the Pharmacy Guild of New Zealand newsletter (regular newsletter for pharmacy owners) and in Pharmacy Today - a sector-wide trade publication.

Data entry was undertaken by a single individual (AS). If a survey had more than 20% of missing data, it was excluded from the data set. Data were analysed using SPSS (IBM analytics, version 23).

Demographic variables are presented as proportions of valid responses. Likert scale responses to opinions about barriers were coded as 1 = Strongly Agree (SA) to 5 = Strongly Disagree (SD). Responses were recoded into a 3-point ordinal variable (Strongly Agree (SA) + Agree (A), neutral, and Strongly Disagree (SD) + Disagree (D)) to compare agreement/disagreement while accounting for neutral responses. [26]. Comparisons between pharmacy location (rural vs metro) and types (banner vs non-banner) were undertaken using the chi-square test. [26] Statistical significance was assumed where p < 0.05. Services were ranked, with the service that is provided by the most pharmacies ranked as 1.

Nearly two thirds (n = 329, 62.3%) of respondents were pharmacy owners, had worked for > 20 years (n = 249, 47%) and worked between 41 and 50 h per week (n = 246, 47%). Over 40% of respondents were from major cities and just under this number identified as being located on a main street (39%). Interestingly, the large majority of respondents did not identify with belonging to a banner group (Independent pharmacies that are affiliated with a central office and pay fees for the right to use a recognized name and to participate in centralized buying, marketing, professional programs) (57%). There was a wide range (< 100–700+) in the number of prescriptions dispensed daily and over two-thirds (68%) of pharmacies supplied residential aged care facilities or community residential villages (Table 2).

A large majority (96%) of pharmacies had patients enrolled in the LTC program, with the number of registrants ranging from 1 to 600.

Table 3 shows the number and proportion of pharmacies that undertake various services and the funding stream for the service. The service’s rank is also listed.

There were no significant differences in service provision between pharmacy location type except that rural pharmacies were more likely to provide prescription depot services (p < 0.01) and provincial towns were more likely to provide education and advice to community groups and needle exchange services compared to major and provincial cities (p < 0.01).

One hundred and seventy four pharmacies (33%) stated they were ‘considering introducing a new service or screening/monitoring process’. The top five services that these pharmacies were considering were; Community Pharmacy Anticoagulation Management (n = 36), vaccinations (n = 35), blood glucose monitoring (n = 20), blood pressure monitoring (n = 18) and erectile dysfunction treatment (n = 17).

Eighty eight pharmacies (17%) had discontinued services, with blood cholesterol (n = 21) and zinc testing (n = 9) the most commonly stopped services due to them being too expensive.

Overall core service provision had the least barriers and DHB funded services the most. Across all funding streams, on average, staff availability was the most common barrier followed by cost to the pharmacy to undertake the services (Fig. 1). There were a number of free text comments around these, some examples are shown below;

‘I would love to introduce new services. I find myself stretched very thin. Whilst the 'concept' of this new pharmacy services contract is great, execution is difficult. What I mean by that is there are so many elements to the work required that adding more services require more staff that require more $ to provide for. We are fortunate that our retail sales (esp. OTC) are strong. This in turn keeps the store going so that we can provide the few services that we do!’ (Participant 170)

Many respondents commented about the extensive amount of time taken to complete an LTC patient review including the necessary paperwork and that the remuneration was not adequate.

‘LTC is a waste of time because too much time spent form filling. The $20 payment only covers 8 minutes of a pharmacist’s time so not possible to do it in this time’ (Participant 40)

‘LTC , documentation -time taken to do this is biggest drawback, talking to customers is not an issue’ (Participant 49)

Banner pharmacies were significantly more likely to take undergraduate and intern students and dispense a high number of prescriptions a day (> 700), and be situated in a major city and a mall, than non-banner groups (p < 0.01). However there were no significant differences in the barriers to service provision between banner and non-banner pharmacies (p > 0.05).

According to this study there is a range of pharmacy types in New Zealand but the most representative (labelled “typical”) is a non-banner pharmacy near a medical centre in a major city which is open for 5.5 days, has a pharmacist who speaks two languages, dispenses 101–200 prescriptions a day, uses Facebook, trains undergraduate students and provides services to residential aged care facilities. Despite the ‘city’ pharmacy being the most common, there is large variation in the types of pharmacies operating in New Zealand ranging from internet only pharmacies to rural and supermarket based pharmacies. The types of services offered were found to vary but only small dependence on the pharmacy type existed in this study. Interestingly a high proportion of respondents (approximately 70%) were from independent pharmacies.

Internationally, pharmacists are increasingly providing an extended range of accessible, high-quality, coordinated services that focus on patient care and population health and this study has found that New Zealand is no exception [29].

The vast majority of pharmacies are providing traditional pharmacy services; dispensing medicines and providing education/advice on medicines and health conditions, pharmacy staff also spend the majority of their day undertaking these services. There has been strong uptake of prescribing services (Emergency Contraceptive Pill (ECP) and trimethoprim provision for urinary tract infection (UTI)) but less on screening and health prevention activities at the time of this study. Whilst this aligns with the government’s goals of ‘care closer to home’ (improved access to medicines) it does not support the push to help people to make healthy choices and stay well, including; services for smoking cessation, weight management, sexual health and alcohol screening. A UK study of health professionals and consumers found less support for public health services undertaken through pharmacy compared to medicine services and minor ailments. This could also be true for the New Zealand setting, and therefore patient demand may be important in the implementation of these services [30‐32].

Location had little effect on service provision with rural pharmacies providing similar services to that of their metro counterparts; however banner pharmacies were significantly more likely to provide patient-funded services than non-banner pharmacies. One study suggests that corporatisation (chain pharmacies) may influence the degree to which services are provided in a negative way but that was not seen in this study [33]. What is not known is whether the provision of these services are being driven by patient demand, as banner pharmacies are more likely to be situated in major cities or by the business model and/or the organisation structure and support from their banner group. If the later, it provides evidence that more support and assistance may be needed for independent pharmacies to enable equivalent extension of services and therefore increased patient access to services especially in rural areas.

Internationally there has been little work done on differences between independent and banner pharmacies. An Australian study found pharmacies with a high financial turn-over or younger owners were more likely to provide more enhanced pharmacy services [21]. Banner groups in Canada have higher turnover and lower running costs compared with independents [34].

There has been extensive uptake of the long-term conditions service with 95% of pharmacies having patients enrolled in the service. This is not unexpected as in-order to gain a dispensing contract, pharmacists need to provide LTC under the new CPSA funding arrangement. Unlike in other countries this is not an “opt-in” situation where the pharmacist decides whether or not to participate. There are limited quality assurance processes in place to ensure consistency across the service, pharmacists are required to complete a standardised registration form however it is then their choice how they record patient interactions in their Pharmacy Management Software [17]. Nationally there has been a lot of publicity and feedback from the sector around the inadequacy of the funding for this service and the extent of bureaucratic and cumbersome paperwork [16]. This study confirms media anecdote with staff availability and cost of providing the service being cited as significant barriers to carrying out these services by more than half of the respondents. This is consistent with findings from another recent NZ study where a perceived lack of remuneration and the required compliance around work pharmacists believe they were already doing, emerged as significant issues [27].

The staged rollout of the CPSA funding formula and the subsequent adjustments have attempted to alleviate these issues, however this study suggests that these issues are still seen by pharmacists as being the major barrier to optimal implementation of this service agreement. Remuneration for the provision of clinical services has been a long-time issue within the New Zealand community pharmacy sector and perceptions seem to have changed little within the sector over the past dozen years [27, 35, 36].

Whilst all but a few pharmacies have patients enrolled in the LTC service it is unknown if the patient-centric ethos is being upheld by all, especially those pharmacies who have enrolled in excess of 500 patients. It is also unknown if this model is providing different or better care and outcomes for patients than the previous volume based funding for dispensing. The present study did not aim to investigate this but it would be valuable to understand this further, this service is not offered in this way internationally therefore we are unable to learn lessons from other countries. To enable this to be investigated an LTC patient ‘flag’ within the administrative pharmacy claims database would help to evaluate this program by measuring hospitalisations and/or morbidity and mortality, through linked administrative databases.

There is a significant international literature reporting on the implementation of cognitive services but few studies which outline the broader pharmacy service provision following such a radical change in the funding model.

Core services had the least barriers for provision compared to all other types. On average, across the range of services provided, cost and staff availability are seen as the most significant barriers. This is consistent with international studies where it is known the presence of a remuneration scheme is not sufficient to guarantee uptake and sustainability of services of new cognitive services [10, 18, 19, 21, 27, 29, 35‐40].

This is the first NZ study to report pharmacy demographics and service provision following the introduction of the new community pharmacy funding model (CPSA). The findings of this study are useful in informing policy-makers and pharmacy professional organisations what is required to further advance the profession. This is especially the case with the new health strategy and pharmacy action plan being implemented by the Ministry of Health [11]. This study provides a baseline for the current levels of service provision upon which future studies can compare to and evaluate any changes in service provision with the CPSA going forward. From this study it seems that community pharmacists are providing a wide range of services. This study could be used by pharmacists to “speak up” take an advocacy platform and highlight not only the “what we do” but also the “how we do it” and the benefits to the community [41].

A small number of pharmacies may have been missed in the sample due to the use of publicly available records which may not be up to date. However, our final sample corresponds very closely to that of Central Technical Advisory Services [22] and so we feel that our sample is largely representative. The response rate of 55% is comparable with another large NZ study [36] and although the findings of this study should not be generalised the response rate is acceptable within this field. Non-responder demographics are unknown and therefore the potential for non-responder bias warrants consideration.

This study provides a descriptive analysis of what services are being provided by community pharmacies, but not how well they are being provided. Further work is needed to understand how pharmacy is performing against other national health strategies e.g. becoming part of an integrated team to provide shared care or promoting optimal use of antimicrobial agents. The finding that there were no significant differences in service provision between pharmacy location and type is interesting. This breaks down stigma that mall pharmacies are “more retail” and observational research is required to explore this further. The finding that banner pharmacies provided a wider range of services than independent pharmacies warrants increased research around the corporatization of community pharmacy in New Zealand. There were no significant differences in the barriers to service provision between banner and non-banner pharmacies and so does this suggest that the sector is largely a homogeneous culture regardless of location or business model. More organisational culture studies are required to understand this further [42].