Integration of a clinical pharmacist workforce into newly forming primary care networks: a qualitatively driven, complex systems analysis

Abstract

ObjectiveThe introduction of a new clinical pharmacist workforce via Primary Care Networks (PCNs) is a recent national policy development in the National Health Service in England. This study elicits the perspectives of people with responsibility for local implementation of this national policy package. Attention to local delivery is necessary to understand the contextual factors shaping the integration of the new clinical pharmacy workforce, and thus can be expected to influence future role development.DesignA qualitative, interview studySetting and participantsPCN Clinical Directors and senior pharmacists across 17 PCNs in England (n=28)AnalysisInterviews were transcribed, coded and organised using the framework method. Thematic analysis and complex systems modelling were then undertaken iteratively to develop the themes.ResultsFindings were organised into two overarching themes: (1) local organisational innovations of a national policy under conditions of uncertainty; and (2) local multiprofessional decision-making on clinical pharmacy workforce integration and initial task assignment. Although a phased implementation of the PCN package was planned, the findings suggest that processes of PCN formation and clinical pharmacist workforce integration were closely intertwined, with underpinning decisions taking place under conditions of considerable uncertainty and workforce pressures.ConclusionsNational policy decisions that required General Practitioners to form PCNs at the same time as they integrated a new workforce risked undermining the potential of both PCNs and the new workforce. PCNs require time and support to fully form and integrate clinical pharmacists if successful role development is to occur. Efforts to incentivise delivery of PCN pharmacy services in future must be responsive to local capacity.

Consultation skills development in general practice: findings from a qualitative study of newly recruited and more experienced clinical pharmacists during the COVID-19 pandemic

“…An ARRS interviewee coming from hospital pharmacy wanted more 'clinical information', categorising material on interaction with patients as 'non-clinical' and better learnt in practice: I just…wanted…what you need to know for general practice, here's how you deal with…X disease, here's how you deal with this medicine…because I feel quite confident on how to interact with patients and all the non-clinical things…I learned more by just having practise of it rather than reading models. (8).…”

“…One of the pharmacists she said, oh no, you sounded a bit harsh…I thought…I worded it really well…And only when that pharmacist said that did, I think, oh what if they're thinking that?…it's the patient that you need to engage with…and that can only be done by getting patient feedback. (7) Some ARRS pharmacists thought shared decisionmaking was more relevant for medications like statins but not for others where there was 'no choice' about treatment recommendations (5), or more relevant for initial prescribing rather than reviewing medication (8). In contrast, an ARRS pharmacist more advanced in doing SMRs spoke about her experience of its importance for deprescribing: I think approaching it in the right way is key to depre-scribing…And people scoff at it…oh it's just woolly pharmacy practice stuff but actually, shared decisionmaking makes my life easier as a pharmacist, and it puts the patient in control as well.…”

“…4 Building on this earlier clinical pharmacy pilot, 5 a clinical patient-facing pharmacist role has been introduced into GP practices in England while new primary care network (PCN) structures were forming. [6][7][8] This coincided with the COVID-19 pandemic. PCNs comprised a group of GP practices collaborating locally, which allowed them to access additional funding distributed at PCN level for extra staff under the NHS Additional Roles Reimbursement Scheme (ARRS).…”

“…8 As unincorporated networks of practices, PCNs were not legal entities and so could not employ staff themselves. 8 This resulted in a range of operational models; some ARRS pharmacists were working in teams shared across practices in a PCN, some were based solely in individual GP practices while others were contracted through third-party agencies. 8 New ARRS PCN clinical pharmacists must enrol in or have qualified from an accredited training pathway, a revised version of the training provided on the 'General Practice Pharmacist Training Pathway' (GPPTP) in the 2015 pilot scheme.…”

“…8 This resulted in a range of operational models; some ARRS pharmacists were working in teams shared across practices in a PCN, some were based solely in individual GP practices while others were contracted through third-party agencies. 8 New ARRS PCN clinical pharmacists must enrol in or have qualified from an accredited training pathway, a revised version of the training provided on the 'General Practice Pharmacist Training Pathway' (GPPTP) in the 2015 pilot scheme. 12 The 18 month 'Primary Care Pharmacy Education Pathway' (PCPEP), run by the Centre for Pharmacy Postgraduate Education (CPPE), provides a combination of 28 study days, peer learning sets, assessments and access to three support functions-an education supervisor (offering individualised educational support), a GP clinical supervisor (based in practice, offering day-to-day clinical support) and a clinical mentor (an experienced clinical pharmacist).…”