Background
Method
Study design
Study setting
Participants’ recruitment
Data collection
Demographic data, n (%) | |
---|---|
Gender | |
Female | 9 (39%) |
Male | 14 (61%) |
Age | mean age = 42.5 years, range = 24–56 years |
21–30 | 4 (17%) |
31–40 | 5 (22%) |
41–50 | 8 (35%) |
51–60 | 6 (26%) |
> 60 | 0 (0%) |
The interview topic guide
Data analysis and reporting
Ethical consideration
Results
Theme | Subtheme (s) |
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Services and limitations of patient support | Services provided to respiratory patients Barriers to patient support |
Fragmented primary care | Lack of communication with other HCPs Lack of access to patients’ records |
The need and acceptability of new technologies to support respiratory patients | Relative advantage Compatibility Complexity Trialability and observability |
The need to promote the clinical role of community pharmacists | |
Professional identity |
Theme/ Subtheme | Respondents’ Quotations |
---|---|
Theme 1: Services and Limitations of patient support | |
Subtheme: Services provided to respiratory patients | “We do MURs or NMS for these patients…. We also do flu vaccination and smoking cessation.” (CP10) “MURs, we are targeting respiratory MURs, smoking cessation my colleague does…. We do NMS… We do flu vaccines at the moment” (CP13) “Usually NMS and Smoking cessation service, MUR, flu vaccination.” (CP14) |
Subtheme: Barriers to patient support |
“I think biggest barrier would be time, resources. It is basically, I think we need to think about rearranging our time table so it would mean that we would have to have a little bit of extra resources, the only time I bring people in the consultation room when I have a locum”. (CP6)
“Lack of training probably and again yea not having placebo inhalers, these two things” (CP7)
Patients’ attitudes and cooperation to have the service, the ability to recruit patients, the willingness to participate, and the time we have to spend with patients (CP16).
“Time, because it can take 10–15 min each intervention especially when you want to check technique. Correct reimbursement, because it comes out of our time. Barriers would be mainly time and reimbursement. If we got to have tools supplied on a regular basis like my placebos go back to while ago so I have to keep asking the reps, we do not see the reps any more so we don’t get placebos unless we ring the manufacturer.” (CP10) |
Theme 2: Fragmented primary care | |
Subtheme: Lack of communication with other HCPs | “And there is also I feel lack of information coming from the prescriber, for example: with the preventer steroid inhalers they don’t say to them (the patients) use it regularly… so they (the patients) just use the reliever whenever they need, and with the other one (preventer) they end up in trouble because they don’t realise it is far better to manage.” (CP11) “There is a bit of resistance from patients because they are saying we are repeating what the practice nurses may have done. The practice nurse may have gone through all this with them and then they are wondering why is the pharmacist doing it as well”.(CP17) “…even we can’t access the GP surgery, communication is so bad, telephones are always busy, receptionists get the doctor to call back…” (CP3) |
Subtheme: Lack of access to patients’ records | “I think what is a barrier at the moment and what would help us and I think it is for the future, they are going to allow us clinical access with our smart card for us to know so with our smart card not only we will be able to look at the drug history of the patient but we should be able to look at the clinical history.” (CP4) |
Theme 3: The need and acceptability of new technologies to support respiratory patients | |
Subtheme: Relative advantage | “it shows they are using their device properly, using it on timely basis because unlike when I am talking to them, I am trusting them to say yes I am using my inhaler. I am depending on the trust; I am using my inhaler twice a day without fail. Whereas, this device would say you don’t use your device twice a day, you are telling me that you use it. It allows us to actually say here you are to proof that sometimes you are not using the device properly, sometimes you are not taking enough drug, sometimes you are missing it totally, you are not using it enough etc…so yea I am for that technology” (CP12) “yea definitely, I think it will be good for some patients because at least this way even doctors will be able to get feedback about this. The information you are getting/creating here gets referred back essentially to a prescribing body about usage and about the technique being used correctly. There is no point of prescribing something and then not assessing the patients, there is a gap between usage and compliance and being used properly. I mean you need to make sure the drug is being used effectively so then assess the patient thereafter so this information should be good for the doctor to get back.”(CP18) |
Subtheme: Compatibility | “Sometimes it is easier with technology, isn’t it? It can make things easy for you.” (CP10) “We see the information gathering from technology tends to be more useful so information gathering in old ways tends to be difficult to actually utilise whereas it tends to be easier analysed with that technology to benefit the patient. Easier to analyse and use.” (CP13) |
Subtheme: Complexity | “I mean as long as it is efficient, as long as it does not affect therapy then I will be happy to and as long as it is easy to use.” (CP14) “It has some beneficial factor (2b) and easy to use (2c). Going with the time. Sometimes it is easier, isn’t it? It can make things easy for you.” (CP10) |
Subtheme: Trialability and observability | “By collecting preliminary data, if something new or new sort of advice come up that would bring benefit to the patient so obviously yes.” (CP15) “If I am offering something that I tried and I know works, they (patients) are advised that it works and if they use it and find it works then they are more likely to be happy.” (CP11) |
Theme 4: The need to promote the clinical role of community pharmacists | |
“In MUR we will find out whether or not the product is working, if we see that the product is not actually doing what is supposed to do then we have to refer them back to the GP, it is not for us to say, we can’t make clinical recommendations.” (CP16) | |
Theme 5: Professional identity | |
“We would like to have the funded COPD service back when we were actually caring for the patients before when we were providing the COPD service….But you have to value the pharmacist time then, at the moment nobody is valuing the pharmacist time. If I was providing all these services and not getting paid for it then there is no value to my service yea, there is no value to my establishment, where I am going to get the money for to provide all this, right?” (CP3)
“You can spend 10 min with the patient but you can’t spend half an hour unless it is properly funded you know that’s the only thing, it is easier to spend 10 mins that’s fine but if you are going into a lot of details with the patient then you need an extra funding to do all the extra services. It’s like an extra service, then we can spend half an hour with the patient and go through all the queries and all the problems.” (CP21) |
Services and limitations of patient support
Services provided to respiratory patients
“We do respiratory MURs as part of targeted MUR group, we do NMS enhanced service for new patients starting on a different inhaler whether asthma or COPD, we also do flu vaccination and smoking cessation.” (CP19).
Barriers to patient support
“MUR is an annual thing but it all depends that if we get the patient again the following year so they may have one off or it might be every two or three years, it just depends on the catchment.” (CP12)
Other barriers for services provision included: pharmacists’ time and workload, lack of training, lack of incentives/re-imbursement, financial barriers, lack of resources (placebo inhalers, manpower), patients’ time in addition to patients’ health beliefs and attitudes.“…even just for the yearly MURs people are not willing to take part and that is only once a year” (CP3)
“It is basically more about time, time regarding you are busy dispensing medication, you do not have time unless there is another pharmacist working at the same time.” (CP4)
Therefore, patient support is patchy and opportunistic depending on several factors related to either patients or pharmacists.“A lot of people don’t want to do it (the MUR service), not every year. Like I said before people’s attitudes and people’s adherence is human nature, their beliefs.” (CP3)
Fragmented primary care
Lack of communication with other HCPs
“I think the other thing which could be viewed as a problem is the multiple approach from different parts of the NHS …so you are having different things which are not talking to each other...” (CP13)
“You know I tried the surgeries, I spoke to all the nurses and GPs and said if any patient comes to you, you can get them come to me. I am quite happy I am not going to charge anything and I will refer anybody up to you if there are any issues. No one.” (CP11)
Lack of access to patients’ records
“If you are coming to me first time I know nothing about you but if I had access to your clinical history….it is easier for us to help you...” (CP3)
The need and acceptability of new technologies to support respiratory patients
“…it is difficult to know really. Obviously you can go through it from the PMR and you can see the frequency of dispensing....” (CP17)
“….you ask them about their adherence but what they tell you whether it is true or not you do not know. Most of the time they say they are pretty good, I mean they admit one odd missed dose but usually they say they take them regularly.” (CP1)
“… just from what they say and to see how often I get prescriptions for the blue inhaler, if I know it has been over prescribed then they are not using their preventer often, and I just ask, there is no other real way to assess adherence”. (CP9)
“…. each MUR we find there is something in the technique that needs correction….” (CP6)
“….there are a lot of patients they can’t use these turbo devices because it is just too difficult for them to make the device work, whereas, the easier is the press device but then likewise you get dexterity problems. Older people can’t actually synchronise, they can’t press”. (CP12)
Therefore, when INCATM technology was discussed as an example with the interviewees, they were receptive and open to the idea. The interviews highlighted no pre-use of technology apart from YouTube videos for education.“…there are quite a lot who make mistakes and who don’t really know what they are doing which is why I think they are targeting them as MUR subjects.” (CP13)
“During MURs, I advise them to watch some videos on Youtube. Otherwise, nothing related to technology” (CP11)
The analysis revealed certain pre-requisites as essential for adopting any technological innovation, such as the INCATM device. The five attributes of innovation mentioned by DOI theory [29] were depicted in the CPs’ responses.“No tools related to technology.” (CP15)
Relative advantage
“It will be a bonus definitely, because if you can get the results on adherence and technique…... Having the results of that particular piece telling me that the evidence level is this, then I can investigate why, whereas now in the consultation room I will be spending time to find out about that adherence level and still not get it right whereas with this I have evidence.” (CP19)
Compatibility
However, the technology needs to be compatible with time pressure and funding available for CPs.“If it makes it easier for patients to understand, then why not.” (CP 9)
“I think it is the way forward where we should be developing the services and the advice we give and be paid for it…..Well any new service you do you need to be paid for it, you can’t just do it for free. It’s time, isn’t it?” (CP20)
Complexity
Pharmacists proposed the need for proper training to ensure ease of use.“As long-as it is easy to use, so patient friendly…” (CP13)
“Yes, I will do it, but we need training” (CP5)
“Yea, as long as there is training, I like technology; I have an interest in it.” (CP11)
Trialability and observability
“There is no harm in trying, if after at the first 10-15 patients does not seem there is any benefit then we can always revert back to just old kind of normal way ….” (CP9)
The need to promote the clinical role of community pharmacists
Three CPs did not feel that a clinical role within MUR provision is within their remit, while others (n = 3) highlighted the need to develop such a clinical role to improve patients’ outcomes.“You check how they use their medication that’s all, there is no clinical input or anything else, and it’s just the usage, it is not review really”. (CP1)
“Yes (referring to discussing the condition treatment during MUR), but we can’t get involved clinically because it is not our remit that’s down to the surgery…” (CP12)
“I think when we get it (the services) right, it definitely improves the patient’s view of us as professionals…We do have quite a lot of patient contact but we want to make that a bit more clinical if we can….” (CP13)
“There is a lot of stuff that can be done by support staff, it does not have to be a pharmacist…… Is it inhaler technique? Do you need a pharmacist to check the inhaler technique or can use one of your support staff, where the pharmacist has to intervene is when you are looking at therapy and it is not working and then either increase or decrease, it is the clinical aspect we need to develop, our clinical role better. Flu jabs, why do you need a pharmacist to do flu jab? Why can’t support staff do it? If they are appropriately trained…” (CP20)
Professional identity
“…if there are any ways of making this sort of thing “COPD management” a part of mainstream community pharmacy services that will be a lot easier ….This is more of a sort of an administrative and reimbursement…” (CP23)
“I am sure the government will save money if they included that in one of our services we get reimbursed for…The money they save from hospital admissions will be well worth it. I mean how many COPD patients keep going into hospital and if we keep an eye on them but get paid for it I will make the effort to, you know, staying on the top of their treatments. Incentives, I guess are always going to be financial in some ways, isn’t it?” (CP10)
“…we should have remuneration for it not just as part of the service. GPs get paid for just measuring blood pressure which should be really the job anyway…so it is things like this, that mentality has come through now to the pharmacists: if there is no money involved they do not want to do, remuneration.” (CP8)
“If we get paid for it. It is brilliant. I would say it is an enhanced service so if you want me to do that you got to pay me to recruit the patients and also monitor the patient, make sure they are compliant etc.…. it is got to be some sort of incentives. At the moment you can just give the inhaler out but if you want to see improvements and see if they are compliant and you want me to put a device on it (the inhaler) then I need to monitor and I have to call the patient in.” (CP20)