How do organisational configuration and context influence the quantity and quality of NHS services provided by English community pharmacies? A qualitative investigation

Abstract

Community pharmacies are expanding their role into medicines-related healthcare and public health services, previously the domain of physicians and nurses, driven by policies to improve healthcare access for patients and to address problems of increasing demands and rising costs in primary and urgent care services. Understanding the organisational context into which this expansion is taking place is necessary given concerns over the extent to which pharmacies prioritise service volume over the quality of service provision. As part of a larger programme of work, this paper aims to explore stakeholder perceptions of the organisational and extra-organisational factors associated with service quality and quantity in community pharmacy as an established exemplar of private sector organisations providing publicly-funded healthcare. With ethics committee approval, forty semi-structured interviews were conducted with service commissioners, superintendent and front-line pharmacists, purposively selected from across nine geographical areas and a range of community pharmacy organisational types in England. Interviews were audio-recorded, transcribed verbatim and thematically analysed. Findings highlight the perceived importance of appropriate staffing and skill-mix for promoting service quantity and quality in community pharmacy. Organisational cultures which supported team development were viewed as facilitatory whereas those prioritising business targets over service quality seen to be inhibitive. Older local populations and low patient expectations were thought to limit service uptake as was poor integration with wider primary care services. The contractual framework and commissioning processes were also seen as a barrier to increasing service quality, quantity and integration in this sector. These findings suggest that healthcare administrations should take account of organisational and extra-organisational drivers and barriers when commissioning services from private sector providers such as community pharmacies to ensure that the quality of service provision is incentivised in addition to service quantity. Additionally, collaborative working should be encouraged through integrated commissioning mechanisms.

A national survey of pharmacists and interns in Aotearoa New Zealand: provision and views of extended services in community pharmacies

“…Many of the barriers to service delivery identified in the present study have been widely reported over many years in the international literature. Lack of time, staff and funding are issues that are regularly cited [ 33 – 38 ] and were also found in this study. With respect to time and staffing, pharmacists offered more services if they had sufficient technicians or other support staff.…”

“…The impact that an owner can have on the time available to support extended services by pharmacist employees has been recently reported in the context of the delivery of primary mental health care [ 60 ]; this is very likely to also hold true for the delivery of any extended service. The “culture” within a pharmacy undoubtedly has an important role to play [ 36 , 38 ].…”

“…Lack of time, staff and remuneration are regularly cited in the literature by pharmacists as barriers to extended care [ 34 – 38 ], while a private consultation space is often identified as a facilitator of extended care [ 34 , 36 ]. Variation in the availability and quality of service provision has also been noted [ 35 , 37 , 38 ].…”

Applying a whole systems lens to the general practice crisis: cross-sectional survey looking at usage of community pharmacy services in England by patients with long-term respiratory conditions

“…This study also suggests that publicising community pharmacy services has limited influence on patients if they are not endorsed by GPs and pharmacists are not proactively offering them. Policymakers should be aware it is unlikely pharmacists will prioritise healthcare services over dispensing or that GPs will refer patients to community pharmacies under current reimbursement models 47. Thus, incentivising joint working between community pharmacists and GPs should be a key priority for policymakers seeking to lessen the burden on GP practices by enhancing patient demand and uptake of community pharmacy services 47 48…”

To be or not to be: The identity work of pharmacists as clinicians

“…Moreover, pharmacists are working in different settings, mostly in hospitals and communities and only recently in primary care; hence the ability to practice at an advanced level varies widely and is dependent on organisational support, opportunities and contractual incentives (Hann et al, 2017;Willis et al, 2019) In community pharmacy, the 2005 NHS Community Pharmacy Contractual Framework for England (Pharmaceutical Services Negotiating Committee, 2005) introduced, for the first time, incentives and indeed mechanisms to commission medicines, clinical and public health services. However, medicine sales and supply (dispensing) remained the main source of income for community pharmacies, and most services attracted fee-per-service payments, which led to a focus on service quantity (with performance targets set) over quality, particularly by larger chains (Hann et al, 2017;Jacobs et al, 2018Jacobs et al, , 2020. The 2008 White Paper (Department of Health, 2008), which was seen as a landmark in the development of new roles for community pharmacists (Murray, 2016a), claimed that clinical services in community pharmacies, such as treatment of minor ailments (such as coughs, colds, skin problems), could deliver outcomes such as safer care and more clinical and cost-effective treatment (Watson et al, 2015).…”