Adherence, compliance and concordance
Providing medicines adherence support to areas of high deprivation in England: community pharmacists’ experience
Introduction and aim: Pharmacists provide a range of services in the community to support the use of prescribed medicines, including the delivery and dispensing of medicines into multicompartment compliance aids (MCAs). However, there is little research exploring pharmacists’ experiences of providing these services, with existing literature focusing on patient outcomes or costs. This study explores community pharmacists’ experiences of providing interventions, products and services that support medicines adherence.
Methods: Between September 2016 and August 2018, a small sample of pharmacists with experience in the community sector were recruited from deprived areas in north east England (n=15) and London (n=5). Semi-structured interviews were completed using an interview schedule in these two areas. Thematic analysis was conducted by both authors using the qualitative anlaytical software NVivo (QSR International). Approval was obtained by the ethics approval committee in the Faculty of Medical Sciences, Newcastle University.
Results: A total of 20 interviews were conducted with 20 different participants from independent, small-to-medium and large-chain community pharmacies. Three themes were identified that described: 1) a variety of different interventions, products and services to support prescribed medicine use, including delivering medicines, packing medicines into MCAs and completing patient-facing consultations; 2) that participants identified medicines use reviews (MURs) and new medicine service (NMS) consultations as the most efficacious way to support treatment adherence; and 3) that participants reported that services, such as delivery and MCA dispensing, were often provided pro bono, based on pharmacists’ own assessment of clinical need. Most participants highlighted that pro bono services may have to be restricted in the future to support business sustainability, following changes to reimbursement in the ‘Community pharmacy contractual framework 2016–2018’.
Discussion: Current funding arrangements for community pharmacy services to support medicine use may create barriers to the provision of services to support medicines adherence. These findings should be interpreted with caution as the majority of pharmacists who took part were working in areas of high deprivation, so findings may not be transferable to areas of low deprivation.
Conclusion: Further work is needed to examine how funding structures could be redesigned to support the delivery of services that are currently provided pro bono by community pharmacists.
Keywords: Community pharmacy; compliance aid; medication adherence; medicines adherence; pharmacy contract; pharmacy payments; pharmacy services
Original submitted: 8 March 2019; Revised submitted: 8 June 2019; Accepted for publication: 2 July 2019; Published online: 31 March 2020; doi: 10.1211/PJ.2020.20207514
- Community pharmacists provide a variety of services to improve medication adherence as a routine part of their practice.
- Supporting medication adherence by delivering medication or supplying compliance aids is not recognised or reimbursed by current funding structures in community pharmacy.
- A lack of recognition and funding to support activities to promote medication adherence puts these services at risk.
- Many of the services to support medication adherence are provided by community pharmacists pro bono, which presents challenges to the sustainability of these services.
- Community pharmacists felt some people requested MCAs inappropriately, but they were unable to decline these requests.
- Some commissioned services were overly restrictive and prevented pharmacists using their judgement to deliver care where they felt it was needed most.
Historically, pharmacists have focused on the supply of pharmaceuticals, with more recent initiatives enabling pharmacists to support the most appropriate use of medicines by providing novel services, interventions and products. While there is a plethora of existing literature describing interventions to improve the quality use of medicines, little work has been conducted exploring pharmacists’ experiences, perspectives and decisions regarding these interventions,.
Non-adherence to medicine is sometimes intentional, representing an active decision made by the patient — for example, a patient choosing to skip a dose of furosemide in order to avoid needing to urinate. However, it is possible for non-adherence to be unintentional, such as when a patient actively chooses to use the prescribed treatment, but is inhibited by intrinsic or extrinsic barriers — for example, a patient who wants to take their furosemide, but is unable to open the blister pack or cannot remember to take their medicine.
Adherence can be supported by community pharmacists in several ways. For example, many pharmacies currently provide services that support medicines adherence, which include multicompartment compliance aids (MCAs) such as monitored dosage systems (MDSs), dosette boxes, MediPacks (MediPack), as well as other reminder devices and services. A 2019 report by the Academic Health Science Network North East and North Cumbria suggests that around 64 million MCAs are provided in England by community pharmacists and that, on average, a community pharmacy supplies 113 patients with MCAs per year. However, only 28% (n=14) of the community pharmacists sampled assessed patient need before initiating MCA provision, and only 11% (n=5) re-assessed patient need after one year. Non-adherence is estimated to contribute to around £500m per year of financial waste for the NHS,. The global burden of non-adherence on healthcare services is estimated to be far greater, with the latest literature suggesting a figure of US$52,341 per person per year.
Commissioned community pharmacy consultation services, such as medicines use reviews (MURs) and the new medicine service (NMS), have been demonstrated to be cost effective, although evidence of the efficacy of other non-commissioned interventions, such as MCA provision, is inconclusive,,. This suggests that although the evidence base for interventions is weak, there may still be demand for community pharmacists to provide them. Understanding the interventions community pharmacists provide, and their experience of providing them, is paramount in ensuring that medicines adherence can be supported in primary care.
However, there is limited literature describing the experiences of community pharmacists completing this work. The literature that does exist focuses on evaluation of specific interventions or contexts, rather than community pharmacists’ approaches to support medicines adherence more generally. As a result, there is little work exploring pharmacists’ decision-making process regarding which intervention, product or service is most appropriate for a patient. Understanding pharmacists’ perspectives, in terms of variation in opinion, availability, cost and knowledge, will enable the development of appropriate resources that can direct pharmacists to select the most appropriate service. This would also enable robust remuneration structures for pharmacist proprietors, and provide valuable insights for policy makers and professional bodies to support pharmacists in conducting this important work.
Therefore, the aim of this study was to explore community pharmacists’ experiences of providing interventions, products and services that support medicines adherence. The objectives of this study were to conduct semi-structured interviews with pharmacists to identify what interventions, products and services are available, and how pharmacists experience making decisions about providing these interventions, products and services.
This study used qualitative methods and adheres to the ‘Consolidated criteria for reporting qualitative research’ guidelines for publishing qualitative studies.
The research team was made up of a researcher, a clinical pharmacist and an undergraduate pharmacy student. In 2015, a medical sociologist and two senior pharmacy academics helped design the study. Researchers had some familiarity with participants through professional and academic networks, which this supported recruitment. Interviews were conducted by researchers with distinct sociodemographic differences to encourage participation in the research from across the sociodemographic spectrum.
Interviews were carried out between September 2016 and August 2018 in 20 community pharmacies in London and north east England. The majority of pharmacies (12/20) that took part were from areas of high deprivation, as defined by the English Indices of Deprivation 2017. Participants were able to choose where to hold the interview and most chose consultation rooms in their pharmacy of employment. Using a familiar space helped participants to be comfortable and the close proximity to the rest of the shop floor facilitated recruitment.
Convenience sampling was used to recruit participants through existing academic and professional networks, such as the North of Tyne and Tees local pharmaceutical committee via email, as well as advertising through online forums (such as Royal Pharmaceutical Society [RPS] Local Practice Forums, and specific forums for newly qualified and locum pharmacists) and walking into pharmacies that were local to the researchers and directly approaching pharmacies within 50-mile radius of the researchers’ office in Newcastle.
Participants had to be registered with the General Pharmaceutical Council (GPhC), be conversant in English and willing to share their experiences of medicines adherence interventions, products and services. Participant information leaflets were sent out via mail or email ahead of the interviews. Written consent was taken prior to participation using a standardised participant consent form (see Figure 1).
Figure 1: Participant consent form
Semi-structured interviews were carried out with pharmacists who have had experience working in community pharmacies. An interview used a schedule that asked questions about the participants’ experience of using, supplying and delivering medicines adherence interventions (see Figure 2). A total of 20 interviews were conducted with 20 different participants (see Table) and interviews ranged from 8 minutes 10 seconds to 55 minutes 18 seconds.
A combination of open and closed questions were asked to ensure that a variety of responses were obtained. The interview schedule included questions about demographics — including gender, employment status, years qualified, pharmacy setting, location and postcode — which were used to identify the deprivation decile using the Index of Multiple Deprivation.
Participants were encouraged to answer questions as they wished and were asked to elaborate on points that required further clarification. Interviews were recorded and participants were told prior to starting that they could pause the recording or end the interview at their own discretion. Transcripts of participants’ interviews were available to the participants to review on request, but no participant requested this. Repeat interviews were not carried out.
Data management and analysis
The data were anonymised during transcription, with participants being assigned a unique identification number. Interviews were transcribed by the researcher that conducted the interview and quality-checked by the other researcher. Transcribed interviews were stored electronically on a password-protected hard drive. Following transcription, audio files were deleted and data were loaded into the qualitative anlaytical software NVivo (QSR International), version 11.4.2. Thematic analysis was conducted using a conventional method of iterative inductive coding, where each interview was read and re-read with data coded into nodes and then clustered to establish themes. Analysis was conducted with themes agreed via consensus between both researchers.
This was obtained by the ethics approval committee in the Faculty of Medical Sciences, Newcastle University (ref ESC2/2016/3). Participants’ consent was asked verbally and in writing. Research approval was given by the Responsible Pharmacist at the time of the interview at each site.
A total of 42 potential participants from a range of deprivation indices were approached for this study; however, 22 pharmacists declined or did not reply to the invitation. Pharmacists that declined to partake did so owing to scheduling conflicts or concerns regarding senior management approval.
|Participant ID||Gender||Employment status||Years qualified||Pharmacy setting||Location||Deprivation decile|
|P1||Female||Large multiple||<2 years||Local pharmacy||North east England||Low|
|P2||Female||Independent owner||2–9 years||Local pharmacy||North east England||High|
|P3||Female||Large multiple||10–19 years||High street||North east England||Low|
|P4||Female||Independent owner||20–29 years||Local pharmacy||North east England||High|
|P5||Female||Large multiple||2–9 years||High street||North east England||Low|
|P6||Male||Independent owner||20–29 years||Local pharmacy||North east England||High|
|P7||Male||Large multiple||20–29 years||GP surgery||North east England||Low|
|P8||Female||Large mutiple||2–9 years||Supermarket||North east England||Intermediate|
|P9||Male||Independent owner||20–29 years||High street||North east England||Low|
|P10||Male||Large multiple||2–9 years||High street||North east England||Low|
|P11||Female||Small multiple||<2 years||Local pharmacy||North east England||High|
|P12||Male||Large multiple||>30 years||High street||North east England||High|
|P13||Male||Large multiple||<2 years||Local pharmacy||North east England||High|
|P14||Female||Locum||10–19 years||Local pharmacy||London||High|
|P15||Female||Locum||10–19 years||Local pharmacy||London||High|
|P16||Female||Independent owner||2–9 years||High street||London||Low|
|P17||Male||Independent owner||<2 years||High street||London||High|
|P18||Male||Independent owner||<2 years||Local pharmacy||London||High|
|P19||Female||Large multiple||10–19 years||High street||North east England||High|
|P20||Male||Large multiple||2–9 years||High street||North east England||High|
Themes are outlined below with supporting quotes presented verbatim in the text.
Theme 1: Availability of interventions
A wide range of products, services and interventions specific to supporting medicines adherence were experienced by community pharmacists. These included MURs and NMS consultations, as well as those provided outside of the ‘Community pharmacy contractual framework 2016–2018’, such as pill boxes, SMS text reminders, digital alarms and delivery services.
“We have a ‘safe and sound’ range just on the front counter. We offer some 7-day dosette trays; some kind of daily ones as well, that have four slots in it for four doses; and then we offer a weekly one as well. I think you can get a 28-day one as well, so we do offer those over the counter. In terms of medicines adherence, we also do placebos in branch so, if people are on inhalers, we can check their technique.” — P7
However, there was variation in the scale between participants from different parts of England. For example, community pharmacists in north east England reported preparing MCAs was a much larger part of their everyday work compared to community pharmacists in London.
“We provide a lot of [MDSs]. [That is what] we call them. A lot of people call them a lot of different things — dosette boxes, MDSs — I’m not sure what the generic name is for them.”— P19
Community pharmacists reported experiences with using delivery drivers to support the regular supply of medicine, although this was done more frequently in north east England than in London. Drivers acted not only to ensure that medicine was available for use by the patient, but also as a link between the pharmacy team and the patient to identify non-adherent patients and those who require additional support and intervention from the pharmacy team.
“My driver does a lot, because he’s seeing the patients. A lot of them are housebound so we don’t see them, so he’s seeing them [and telling us] they’ve got loads of medicines at home and they’re not taking them.” — P1
Commissioned consultations were also reported as an activity to support medicines adherence, such as MURs and NMS consultations, which were reported to be generally positive by pharmacists.
“During an MUR, you explain you know what time of day is best to take the medicine. We talk to people about missing doses and you try and get people to give ideas about how to get on top of things, give them new ideas. For example, it might be easier to take all their tablets in the morning, rather than at lunchtime or at night time. Keep your medicines next to your toothbrush in the bathroom cabinet so you know that’s when you’re taking your medicines. Every time you’re brushing your teeth, you’re going to remember to take your night time tablets and things like that.” — P11
Pharmacists also reported pseudo-services, which are brief interventions that support medicines adherence, but are not commissioned. They are provided free of charge for the professional satisfaction of the community pharmacist.
“I get a personal kind of buzz about it — kind of an achievement that you’ve provided that service for so many different patients and they’ve benefitted from that five-minute conversation they’ve had with you. You could tell them one simple, different routine way of using their medicines and it could make the world of difference to them, and that’s what I like about it.” — P2
Digital health technology interventions, such as text messages to prompt patients to collect prescriptions, were routinely used. Although not typically considered an intervention to promote adherence, one participant rationalised that if the patient does not collect their medicine, they cannot take it as prescribed. However, more advanced technology, such as those that report when a medicine is consumed, were described negatively owing to patient acceptability.
“It is very ‘Big Brother’. You know, watching over you, you’re not taking your medicines and a lot of patients would look at that as being told off — they wouldn’t look at it as it’s for my own good, and that it’s so I’m being looked after and getting the best care. It’s reporting back to my doctor and they’re going to tell me off for not taking my medicines. No — my patients wouldn’t go for it. My patients would hate it.” — P2
One participant also reported that patients at their pharmacy can submit queries on demand to support their medicine use via their pharmacy’s website and mobile app for free.
“They can submit queries online now too, through the website, so they send it in and we get an email to say we have a message.” — P20
Theme 2: Efficacy
Many pharmacists felt that MURs and NMS consultations were the most effective form of adherence support. Participants suggested that they still utilise skills and attributes from their early years of training, such that carrying out consultations felt natural to their practice.
Community pharmacists in this study believed that their consultations were generally thought to be more effective than consultations provided by other healthcare providers — although this may be subjective to bias it does suggest a high level of perceived self-efficacy.
“As pharmacists, we have an advantage over GPs in that we’re less formal, and the GPs that work here — and some of them come to our staff do and they’re really approachable and nice guys, and a couple of women who are lovely people — but they still have that aura that scares a lot of the public above the age of 30 [years], I think. I think we’re plugged into those people to a larger extent — I’m not going to say we’re the answer to everything, but we’ve definitely got better access.” — P9
However, some participants reported experiences of poor patient acceptability of some services, such as MURs and NMS consultations.
“Sometimes, I want to do them, but I’m not able to do them because people don’t want to come into the room for the chat, they’d rather just have a quick chat over-the-counter.” — P11
Some 13 participants felt the most effective interventions did not focus on scientific, evidence-based understanding of pharmaceuticals, and that more flexible skills and understanding about the patient were needed to adopt a holistic patient-centred approach.
“Can we shorten this to: “I think a lot of it isn’t about clinical knowledge or pharmacy knowledge; it’s about people knowledge and knowing it’s more of a psychology than anything else … it’s nothing to do with medicines” — P1
Other participants described identifying efficacious intervention through collaborating with other healthcare professionals and accessing guidelines.
“If I needed to look up something, I would probably go on the RPS [website] or something; I know they’ve got loads of different information on there — obviously the [ British National Formulary] would be your other source — but, the majority of the time, I would probably just link up with other healthcare professionals and try and see if we can get the best thing.” — P2
MCAs were considered an effective method of supporting medicines adherence in particular patient groups.
“If you have an elderly patient who maybe has early signs of dementia, Alzheimer’s [disease] or they’re with a carer or a partner, [MCAs take away] a little bit of that pressure of ‘How many tablets am I going to take in the morning’ or ‘How many am I going to take in the evening’. When it’s already set up, there, ready for them to take, I just think it’s a small thing that can make a huge difference, and also for people that have just come out of hospital and have just been discharged, or anybody that has undergone any cardiovascular surgery — it benefits them.” — P2
Drawbacks during the transfer of care were commonly reported with MCA interventions.
“Dosette boxes are hard work, like with hospital admissions and things like that because the communication between the hospital and the GP is not that great. They have a three-week lag. And people come out with medicine — a week’s supply they’re getting in hospital — but that stresses us out when we’re trying to sort out a prescription at the GP and they don’t have that information, but I think that communication should be better.” — P3
One participant reported concerns regarding the use of patient-filled MCAs and the dangers these pose.
“Yeah we sell those and I mean they’re OK, but the onus is on the patient to get the medicine right, and sometimes I think that can be quite dangerous if they’re not 100% savvy with what they’re taking. I’ve done it myself — I’ve put too many thyroxine in one day, and I’ve thought no, and I think if you’re just popping them out quickly, they’re easy to fall into the wrong compartment, and they’re quite small — some of these boxes — like the little box for that day, and if they’re on a lot of medicine, then the patients can sometimes have to shove them in. If they’re [modified release] or something, then they are damaging the coating on them or something. Also, storage as well — you’ve got to think about. I mean, at least we know when we’re doing Mediboxes in here. It’s in a pharmacy setting, but if they’re making them at home and they leave it next to the radiator or something. I mean I think they’re all right, but I think you have to be relatively sensible to use one.”— P8
Reminder services and technologies, such as SMS alerts and digital alarms were not considered very effective; however, they could often be automated and so were not considered to get in the way of other pharmacy work. Delivery drivers were described favourably by pharmacists as they could provide additional information about patients that may prompt the pharmacist to invite the patient in for review. However, delivery was costly and, at times, was taken on by the pharmacist or technical staff in addition to their regular duties. Essentially, these findings indicate that participants favoured face-to-face consultations and semi-automated digital interventions, over packing down medicines into MCAs.
Theme 3: Assessing clinical need and maintaining business viability
Participants did not report a standardised approach for identifying patients that required an intervention by assessing need. The necessity of an intervention was experienced as a careful balance of patient parameters (e.g. the patient’s age, disease status and number of prescribed medicines), people parameters (e.g. requests from patients, healthcare professionals or care givers) and maintaining business viability (e.g. being able to afford staff to deliver the service).
What was not apparent in the participants’ assessment was the need for the medicine, the appropriateness of the prescription or the patient’s desire to continue treatment. The results suggested that pharmacists negotiated the provision of services to support medicines adherence in a complex, multifaceted way. Rather than being directly linked to reimbursement, pharmacists continued to provide services as part of their everyday practice.
Assessing clinical need
Need for MCAs was assessed based on age, living status and cognitive function. For example, geriatric patients in care homes and patients living with dementia or with Alzheimer’s disease were considered as needing support services.
“You’d think about their age, what condition they have and how many medicines they’re taking. Obviously, if they’re [taking] a huge number of medicines, fair enough, and [if] they’re quite elderly it can get quite confusing for them, so they are the patients that we would try and help out. For example, if they ask for a MediPack, we wouldn’t question that, we wouldn’t think twice about it. We’d just help them out, we’d just do it. And then there are some other patients that have mental health issues — they’re quite young but they’ve got mental health issues that need a bit more support and we’ve got MediPacks in place for them too.”— P11
However, others reported that need was assessed using criteria linked to payment. For example, MURs and NMS consultations were routinely offered to patients who met specific eligibility criteria that would result in a payment (e.g. patients with asthma or diabetes), rather than offered to patients who demonstrated a specific clinical need. Consultations offered to patients based on the pharmacist’s assessment of clinical need or professional referral — which were outside the scope of commissioned services and would not result in payment — were less likely to be provided.
“I wouldn’t really be able to say I use an evidence base, it’s normally based on if I think it’s clinically appropriate. For the services, there are medicines that can be targeted and criteria that have to be met before you can do them. So for the MURs, there are high-risk medicines; if they’re not high-risk, then you need to be on a certain number of medicines before you can do one. For the NMS [consultations], it’s only for some medicines that you can target it to, so I suppose it’s within those. If you think people will benefit, you can do ones outside of that if you think it’s clinically appropriate, or if the hospital calls you after a discharge, but they’re less likely.”— P7
Two participants provided an example of how they assessed need and how they reported their assessment based on computer-generated prompts, company targets, and local or national commissioned services.
“So we get notifications from our computer system to say if they’re target MURs or annual MURs, depending on the medicines … We’re not target-driven here; I know other companies that are driven to meet their 400 [MUR] target, but here we try and base it just on the patient’s needs. So, there is no pressure for us to hit targets here.” — P19
Some participants reported that assessing need was difficult.
“It is difficult to find out if people are having difficulties with their medicines until you actually sit down and start talking to them about it during the MUR.” — P20
Many products and services that were not commissioned were provided to patients on request, without further assessment of necessity or adaption to specific patient groups.
“If they specifically ask for a dossette box, then yes, we put them on it. We don’t question it.”— P15
For example, SMS reminders to patients were rarely tailored to specific patients’ needs — for example, for patients that did not routinely collect their prescriptions — but rather were provided to any patient collecting repeat prescriptions that opted in to the service.
“We send text messages to tell them that their prescription is ready to collect; we do not remind them to [take their] medicine. We remind them to tell them to pick it up and that works, because people do sometimes forget to pick their medicine up, and then they think they’ve got a lot of it, and then they miss them if they haven’t got it … It’s a company thing” — P3
For patients that required an intervention, but did not meet eligibility criteria of commissioned services, pseudo-services were offered free of charge. For example, one participant described their process for supporting medicine use in patients that were ineligible for an ‘official’ MUR, so were offered a consultation similar to an MUR.
“I would have a look at what medicines they take, discover what the problem is and why [they’re experiencing it], and have a sit-down conversation, do a medicines use review, go through their medicines, establish what problems there are, if it’s memory and they forget to take them. If there are problems with that formulation, I would substitute it and think of something that would work better for them, and that’s the first thing that comes to my head. To sit down and do some form of MUR — I mean, whether I put it through as an MUR is a different thing, to kind of be processed and paid for in that way. I would still sit down and go through that whole process with them.” — P12
Providing services without assessment or that did not fit within remuneration structures drew on resources from the pharmacy business and threatened business viability. However, novel approaches to obtaining slight increases in payment were made to maintain the provision of additional pseudo-services — particularly MCAs. For example, one pharmacist reported requesting weekly rather than monthly prescriptions, despite highlighting that this would not provide sufficient payment to cover the service completely.
“We don’t get paid extra to do [MCAs]. We get paid, in [a] way, [because normally] we would get paid for 28 tablets for a prescription [charge], whereas in a dosette tray, they’d be weekly, so we’d get four prescription [charges] instead of one. So in terms of that, we do get marginally more payment, but they do take quite a lot of time to do.”— P7
Despite difficulties faced by the business when providing services without formal assessment of need, some community pharmacists still provided these as an option for patients struggling with medicine use.
“We give [the patient] the option and its totally down to them, although it’s not entirely cost effective for us sometimes.” — P14
Some pharmacists reported concern that some services, such as MCAs and delivery, had become expected by many patients and that some patients exploited the goodwill of community pharmacies.
“The patients that are coming to us for MediPacks that are completely able. There is nothing wrong with them — they just need to put a little bit more effort to take control of their lives, rather than having everything done for them. I think some people do abuse it.” — P11
However, in some instances, pharmacists in particularly busy community pharmacies refused to provide services free of charge, such as taking on new MCA patients, unless they could secure small amounts of additional funding.
“We only take them on if the GP agrees to it, because we have so many, we couldn’t actually afford to do any more unless the GP agrees to change the scripts to weekly ones, so we get a little bit more money from dispensing them.” — P19
Of concern were two participants that reported difficult experiences of obtaining additional funding, suggesting it may not always be possible to provide services where funding is not forthcoming.
“We have tried to get some patients using dosette boxes if they’re on a lot of medicine. For example, there is one lady who is acutely confused and I think she struggles with her medicine. [We’ve contacted the surgery] and they’ve put their foot down and refused, because of the money aspect of it. There is a lady who has cancer and I think it’s palliative … she has a lot of medicines and [the carers have] asked us if she can [have an MCA] and [surgery] said no to that.” — P8
One pharmacist compared remuneration strategies with other countries, supporting the notion of an alternative payment system that would facilitate the provision of care to all patients, rather than restricting the provision of services to particular patient groups.
“Going back to MURs, I think that we’re not paid for them in an appropriate way. If patients had to be registered with us and we knew who it was, and we could care from them properly and then be paid based on that. I think they have this system in Scotland called the chronic care system [formerly ‘chronic medication service’ and renamed to ‘medication care and review’] and people that pay the pharmacists do so on a sort of capitation basis, so they get paid almost to look after people’s health rather than being based on [how many consultations are done]. You know it doesn’t have to be so formalised because the way we work isn’t, everything has to be fitted onto the MUR system, and you’re just being channeled in to do one particular thing, which isn’t always appropriate, I don’t think. I tend to take a wider sort of view of things, where you get to know people, you get to know their problems and then solve their issues that way, rather than just being paid to do it once a year on a limited number of people. These big companies, they just want people to do it as a tick-box exercise in order to get remuneration, basically. I’m not saying it happens here, but other places I’ve worked it does, but I think the MUR system is functionally flawed, as I see it.” — P12
Unremunerated costs involved in providing some services and the impact this had on the business did not appear to inhibit pharmacists’ appetite to develop new methods of supporting medicine use.
“We currently text them when their prescriptions are ready and we’re looking at texting them when they’ve got to take a particular tablet. It’s complicated at the moment because that would have to be a voluntary arrangement and I’m certainly not interested in being paid for it necessarily, although there is a cost involved in sending the text.” — P9
Pharmacists reported experiences of providing a wide variety of interventions, services and products to support medicines adherence, with varying rates of efficacy. Experiences were dominated by assessing the clinical need of a particular product or intervention, and maintaining business viability.
Community pharmacists reported experiences of providing many services, such as MCAs, delivery of medicines, brief interventions and unofficial MURs pro bono. In some cases, the provision of these services was restricted if small amounts of additional funding could not be secured. Although pharmacists reported trying to provide services based on assessment of patient need, their experiences indicate that commissioned services were provided readily without individual patient assessment; in particular, based on predefined patient groups.
Free services, however, were provided based on an assessment of business needs, as well as patient need. In both cases, patient-centred care is restricted by community pharmacists’ responsibility to maintain business viability and adhere to predefined payment structures.
Comparison to existing literature
These findings highlight the difficult negotiations pharmacists must make to provide interventions, services and products to support medicines adherence, despite existing evidence on the efficacy of interventions often being inconclusive. The findings suggest that in the absence of an evidence base, interventions, services and products are supplied ad hoc, with decisions informed by pharmacists’ unstructured assessment of patient needs balanced with the economic needs of the business.
This raises new issues around products, such as MCAs. Although pharmacists reported some areas of concern around transfer of care and patient-filled dispensing devices, broader experiences and consideration of efficacy, risks and benefit did not appear important. What was conspicuous by absence was the participants’ experiences of supporting medicines adherence by assessing the need of a medicine and other initiatives, such as deprescribing.
Changes in policies, cuts in funding and continuing development of novel interventions being introduced to the market have left in-house services, such as consultations like MURs and NMS consultations, as the most reliable option for supporting patients who take prescribed medicines. Existing literature comparing attitudes to different interventions further supports the findings that pharmacists factor in external influences and accessibility issues when choosing adherence interventions. Although patients and other healthcare professionals also input into the decision making, an intervention cannot be provided if additional staff and time are required to maintain it, but are not appropriately resourced.
In the Netherlands, assessment of need is based on broad eligibility criteria that mean that providing drug assessment services (a service akin to MURs) is not feasible under current remuneration packages. A significant reason for this is the lack of dependability on resources and the decline in their availability, which hinders pharmacists’ ability to carry out additional services, such as MCAs or digital health interventions. The view that better remuneration structures were needed was persistent among participants, despite differences in reported levels of provision of services for those in London and north east England. This difference may be owing to local variation in commissioning.
The financial remuneration associated with interventions to improve medicine use was considered insufficient, particularly regarding MURs and NMS consultations. While participants did not report that they stopped trying to carry out consultations once they had reached a nationally set target, some participants found that their aim was reaching that target, rather than carrying out consultations based on necessity,.
In-house services such as these are entirely dependent on pharmacists, and what they are taught throughout their education and careers. This study highlights that community pharmacists feel they have the correct communication skills to improve adherence, but funding structures do not currently enable them to practice these skills routinely. Checking for adherence is a routine procedure that is not necessarily outlined for pharmacists by any official body, but the results of this study show that pharmacists consider talking to patients about their medicines and investigating potential issues to be standard pharmacy practice. Guidelines on how to conduct these investigations and how to choose adherence interventions are outlined in the Professional Attributes Framework, as well as publications from the RPS,.
However, participants in this study reported they did not use these resources often. Financial resources were needed that would enable them to practise their communication skills and shared decision-making, rather than chasing contracted or commissioned services to meet the economic needs of the business.
Impact on practice and policy
Community pharmacies are dependent on commissioning by NHS England and local clinical commissioning groups (CCGs). As CCGs are responsible for the NHS services in their local area, service provision will naturally vary across the UK. Depending on what their local populations need, the CCGs assess what needs to be planned, prioritised and purchased to improve overall health in their designated area.
As part of the NHS England ‘Five-year forward view’, published in October 2014, there has been an increased effort to conduct research on how patient care can be improved and medicines use can be optimised. The findings from this study suggest that quality medicine use may be supported through the provision of suitable remuneration packages, such as payments based on patient registration that recognise the routine services that pharmacists offer in their practice, rather than being based on restrictive, criteria-based systems.
Strengths of the study
The approach that was taken to ensure the confidentiality of pharmacists’ identities is considered to be a strength of this study, as gaining access to community pharmacists that work for large community multiples can be difficult. The study was successful in including pharmacists from large multiples, as well as independent pharmacy proprietors, ensuring a range of views were captured.
Carrying out this study in two parts of the country reflected how experiences with medicines adherence varies depending on demographic context. Furthermore, theoretical data saturation was reached after 18 interviews, when the researchers felt no new findings were being reported, and decided by consensus after two follow-up interviews confirmed that this was the case.
Limitations and further research
A major limitation of the study is that findings may be different if sampling had included other areas of the UK, such as Wales and Scotland, which have alternative remuneration arrangements for community pharmacies. The differences reported between London and north east England in the provision of services have shown that further work is required to explore the resilience of services across regions in England, given changes to local and national commissioning agendas. Further work is also needed to support the claims made by participants in this qualitative study, to provide quantitative evidence that community pharmacists provide additional MCA services in the north east of England compared to London.
Additional work should be carried out by professional bodies and researchers to explore the decision-making process involved in supporting and maintaining the quality use of medicines through interventions, services and products. Further educational interventions are needed so that community pharmacists can appraise products, services and interventions to improve adherence, such that the right patient receives the right intervention to support adherence in the correct way.
There is also potential to explore how pharmacists can rationalise the assessment of adherence interventions, services and products to include shared decision making, deprescribing and reviewing the appropriateness of prescribed therapy, which may prevent the unnecessary provision of services and liberate resources to be directed elsewhere.
This study did not explore patient views. As such, there is scope for further research to explore patients’ views of products, services and interventions provided by community pharmacies to ensure that local and nationally commissioned services reflect patient demand.
Community pharmacies are attempting to support and maintain the quality use of medicines by their patients. While many interventions are on the market, the most preferred method of supporting medicines adherence were MUR consultations, which require face-to-face interaction with the patient. Commissioning by the CCG in each area determines how much a pharmacy can spend on implementing services and which services can be provided by the pharmacy pro bono. To ensure services can be maintained and medicine use optimised, commissioners and policy makers should seek to develop a remuneration structure that provides stability for community pharmacists to continue to practice and provide adherence interventions, services and products.
The authors would like to thank Kimberly Jamie, Adam Todd and Andrew Husband for supporting the design of a preliminary study in 2015.
The Harold and Marjorie Moss Charitable Trust Fund and the George Henderson and George Brown endowment fund provided financial funding via the Newcastle University Vacation Scholarships Programme to facilitate this work.
Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2020.20207514
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