Int J Clin Pharm (2014) 36:154–162 DOI 10.1007/s11096-013-9889-2
RESEARCH ARTICLE
Experiences of a community pharmacy service to support adherence and self-management in chronic heart failure Richard Lowrie • Lina Johansson • Paul Forsyth Stuart Lochhead Bryce • Susan McKellar • Niamh Fitzgerald
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Received: 21 June 2013 / Accepted: 17 November 2013 / Published online: 30 November 2013 Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2013
Abstract Background Heart failure (HF) is common, disabling and deadly. Patients with HF often have poor self-care and medicines non-adherence, which contributes to poor outcomes. Community pharmacy based cognitive services have the potential to help, but we do not know how patients view community-pharmacist-led services for patients with HF. Objective We aimed to explore and portray in detail, the perspectives of patients receiving, and pharmacists delivering an enhanced, pay for performance community pharmacy HF service. Setting Community pharmacies and community-based patients in Greater Glasgow and Clyde, Scotland. Methods Focus groups with pharmacists and semi-structured interviews with individual patients by telephone. Cross sectional thematic analysis of qualitative data used Normalization Process Theory to understand and describe patient’s reports. Main outcome measure Experiences of receiving and delivering an enhanced HF service. Results Pharmacists voiced their confidence in delivering the service and highlighted valued
aspects including the structured consultation and repeated contacts with patients enabling the opportunity to improve self care and medicines adherence. Discussing co-morbidities other than HF was difficult and persuading patients to modify behaviour was challenging. Patients were comfortable discussing symptoms and medicines with pharmacists; they identified pharmacists as fulfilling roles that were needed but not currently addressed. Patients reported the service helped them to enact HF medicines and HF self care management strategies. Conclusion Both patients receiving and pharmacists delivering a cognitive HF service felt that it addressed a shortfall in current care. There may be a clearly defined role for pharmacists in supporting patients to address the burden of understanding and managing their condition and treatment, leading to better self management and medicines adherence. This study may inform the development of strategies or policies to improve the process of care for patients with HF and has implications for the development of other extended role services. Keywords Adherence Community pharmacy Heart failure Patient views Scotland Self-care
Electronic supplementary material The online version of this article (doi:10.1007/s11096-013-9889-2) contains supplementary material, which is available to authorized users. R. Lowrie (&) P. Forsyth S. L. Bryce Research and Development, Pharmacy and Prescribing Support Unit, NHS Greater Glasgow and Clyde, Victoria Infirmary, Langside Road, Glasgow G42 9TT, UK e-mail: [email protected] L. Johansson S. McKellar Strathclyde Institute of Pharmacy and Biomedical Sciences, Strathclyde University, Glasgow, UK N. Fitzgerald Create Consultancy Ltd., Glasgow, UK
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Impacts on practice • •
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Patients with HF and other chronic illnesses struggle to cope with their medicines and manage their conditions. Governments across the world, and patients, are increasingly looking to pharmacists and other health professionals, for alternative models of care to improve self care and medicines management. Few qualitative data underpin service developments by community pharmacists aiming to help patients with HF.
Int J Clin Pharm (2014) 36:154–162
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Policy makers considering the introduction of community pharmacy services may be reassured by patients’ and pharmacists’ reports of acceptability and benefit from qualitative evidence.
Introduction Heart failure (HF) is disabling, costly and deadly, resulting in consistently poorer quality of life than in other long-term conditions, high rates of hospitalisation and mortality rates of 30 % over 5 years [1–3]. Evidence-based pharmacological therapy is the cornerstone of management of HF due to left ventricular systolic dysfunction (LVSD) [4].Patients with HF report a lack of understanding of their condition, symptoms, medicines and self-management. This accounts for excess HF hospitalisations [5–7].They are prone to generalised cognitive impairment [8], depression [9, 10] which together with polypharmacy [11] result in adherence [12, 13] and self-care [14] being persistently sub-optimal [15–20]. Individualised, repeated support by pharmacists may improve adherence, self-care and clinical outcomes [21–23] and collaborative, multidisciplinary involvement of pharmacists is recommended [24–26]. Despite this, there is an absence of research into patients’ and pharmacists’ experiences of community pharmacy based cognitive services for patients with HF. A community pharmacy based HF service has operated in NHS Greater Glasgow and Clyde (NHSGGC), Scotland (Europe’s largest Health Board area) since 2004. Approximately 1,250 patients have received the service from pharmacists who had received additional training, in one of 195 pharmacies.
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Pharmacists Ten pharmacists took part in two focus groups which used the schedule described in Table 2 (see Supplementary material). We selected the first 10 pharmacists to opt into the study, who had also delivered the service to at least five patients. In total, approximately 20 of those who consented had delivered the service to at least five patients. One hundred and six pharmacists were willing to participate in the research. All pharmacists provided written informed consent, and were employees of a range of pharmacy business models: independently owned single pharmacies, small chain (2–10 pharmacies) and a large multiple pharmacy businesses (more than 10 pharmacies). Pharmacists were a range of ages, background experience and years since qualification. Each group interview lasted about 1 h and was conducted jointly by LJ and SMcK, audio-recorded, transcribed and analysed thematically. Patients Sixty-five patients participated in semi-structured telephone interviews conducted by LJ. Sixty-three percent of patients were male. Patients’ mean age was 67 years. Almost 40 % lived in the most socioeconomically deprived Scottish areas with approximately equal proportions spread across other areas. Saturation was reached after 65 interviews were completed. Patients were identified by inviting the first 200 patients who received the service, to return a consent form. The interview schedule (Table 3: see Supplementary material) comprised eight initial questions followed, if necessary, by probes. Telephone interviews were audio-recorded and transcribed.
Aim of the study Analysis This study aimed to explore patients’ and pharmacists’ views of the NHSGG&C community pharmacy-based HF service.
Methods The study received NHSGGC Primary Care Local research ethics committee approval and was conducted in March 2006. Focus groups and interviews involved pharmacists and patients who were in the process of delivering and receiving the service respectively. Table 1 describes the service model and training received by participating pharmacists. Pharmacist focus groups (lasting about 1 h each) were conducted first; findings informed the design of patient interviews which lasted about 20 min each.
We used the framework analysis approach described by Ritchie and Lewis [27].An initial thematic framework was constructed from coded sections of transcripts [28–30].Data were then manually indexed and sorted. Emergent themes were grouped with quotations, and refined before abstracting and interpretation. Themes were considered in each discrete methodological stage (pharmacist focus groups or patient telephone interview) then subjected to cross-sectional analysis. We present quotations from a range of respondents. ‘Treatment burden’ describes the self care practices that patients with long term conditions need to conduct, in order to enact management strategies and respond to the demands of health care providers [31]. To enable understanding of the extent to which the service helped patients to overcome the burden of HF and treatment,
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123 Recording of care outcomes and referral to GP or HF Nurse where appropriate.
What it is for
Action planning to resolve any care issues/problems identified including referral to GP or HF Nurse where appropriate.
Any questions from the patient.
Smoking status and referral.
Role of weight monitoring.
Identification and scoring of HF symptoms.
Adherence issues. Patient’s perception and understanding of side effects.
Review of identified care issues/problems and action taken to address.
Monitoring of HF symptoms—scoring and comparison to previous score.
Systematic review of each medicine for HF including:
How it is taken
Follow-up consultation topic schedule
Initial consultation topic schedule
The community pharmacy was expected to deliver the service to the patient on a monthly or two–monthly basis. Topics covered during consultations are given below. The content of the consultation was shaped by a theoretical model of behavioural change which requires repetition of key messages, individualisation of advice, co-ordination of advice with other healthcare providers [48]. On submission of a completed consultation to the service organisers, the pharmacy receives a payment. Pharmacists are asked to send their completed documentation to practices for information.
Patient engagement and service delivery
Service delivery Step 2
All referrals were made into a service administrator (based in Greater Glasgow and Clyde Headquarters) who entered relevant data onto a database and forwarded relevant paperwork to the patient’s choice of community pharmacy.
Symptomatic patients with a primary diagnosis of HF due to LVSD were also identified and referred by specialist pharmacists based in doctor’s surgeries or by specialist nurses based in hospitals. These pharmacists and nurses had consulted with the patient as part of routine service provision, and had offered the service to patients, after agreeing on the need for it, during a consultation.
Inclusion in the service was through one of three routes: general practices, specialist pharmacists or specialist nurses. GPs maintained a register of all HF patients and in practices participating voluntarily permission was granted for specialist pharmacists to access the demographic, clinical and prescribing details of all patients on these registers. These patients (regardless of symptoms or duration of HF and without any objective assessment of their need for improved understanding or adherence) received a letter explaining the service and asking them to return a consent form including their nominated community pharmacy.
Patient identification and referral
Service delivery Step 1
Training received by each participating community pharmacist comprised 3 h of contact time with experienced pharmacists and nurses. Training covered the aetiology, epidemiology and treatment of HF. Under supervision, and using service documentation (standardised pro-formas), pharmacists conducted mock consultations with patients who had HF and received feedback from specialist pharmacists, nurses and patients.
Pharmacist training
Table 1 Greater Glasgow and Clyde Pharmacy HF service model
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we used Normalization Process Theory (NPT) [32] to conceptualise and interpret patients’ responses [33]. Results Focus groups with pharmacists Pharmacists’ confidence and competency Pharmacists expressed confidence in delivering the service and linked this to service design factors, including the structured consultation and encouragement for patients to refer themselves to their GP in the event of symptom deterioration. ‘‘The forms are good. They are easy to follow and because you’ve got somebody’s had an initial contact, like you said, we’re just following through with the guidelines that are there on the forms and they’re pretty straight-forward and easy to use.’’ ‘‘…you have…simple questions and you are asking them monthly and you are going to be able to…identify anybody that’s sort of going downhill quickly. And you can refer them back to the doctor before they necessarily would see the doctor.’’ In some cases, confidence in delivering the service appeared conditional on strong collaboration with GPs. ‘‘It depends on the relationship you’ve got with the doctors and if you’re quite happy to speak to the doctors yourself …But if you feel a bit, you know, how will the doctor take this, they might shout at me down the phone or tell me to mind my own business…’’ A majority felt that communication from practices, following a consultation, was sparse. ‘‘They could maybe give us more feedback on it because when we send things off we don’t get any response. We might suggest that the doctor does this or whatever but we don’t get any responses back.’’ Some voiced difficulties in their attempts to improve patients’ HF specific self-care. ‘‘And they say, ‘I’ll do it [weigh myself] for a week’. I say to them, ‘do it every week!’ you know. Every time they come to visit, just try to encourage them, for the importance of it. I think the message is getting on board.’’ Many pharmacists felt confident that patients’ ability to self-manage their medicines and condition had improved.
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‘‘They are being more proactive about their condition. It’s making them aware of their situation…they might be more inclined to think, I’d better go and see the doctor’’ ‘‘I think, as well, explaining to them about the diuretics that they don’t have to be taking them at the same time every day. That helps as well because they think that if it says one in the morning they have to take it in the morning and then they’re restricted from going out.’’ Challenges of other co-morbidities Pharmacists felt exposed when faced with patients who had pressing co-morbidities other than HF. ‘‘A big problem is as well that most of them have got other health problems along with their heart failure. They start talking about other medicines, and I’m like ‘to get back to your furosemide’’’. ‘‘Sometimes a lot of them have either asthma or COPD and you start talking and the first thing they say is; ‘I’m breathless all the time.’’’ Community pharmacy related factors Pharmacists thought patients perceived them as approachable and the timing of the consultation was seen as beneficial. ‘‘Even with the doctors, they’re maybe scared to ask them ‘what’s that for again?’ They think the doctor’s a ‘big person’, whereas we’re just normal!’’ ‘‘I think probably in hospital they would just be too frightened and overwhelmed by everything, so just going over the information again with them. They can understand it a bit better. They are not really scared to ask us questions, you know ‘What is that for?’ and ‘how does that work?’, just because we’re sitting down and chatting with them.’’ However, approachability came at a price, for pharmacists felt under increased pressure to manage their time amidst unpredictable fluctuations in pharmacy workload. ‘‘It’s difficult if they come in [for their monthly prescription] at a point when you’re really overly busy…and they can’t wait or they don’t really have time to come back. So you miss them that month. You know, it’s difficult to make sure you catch the person every month.’’
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Unmet need
Coherence: learning about HF and consequences
Pharmacists relished their new role, because they perceived it to address a gap in the healthcare system.
Some patients reported that pharmacists were the first to tell them they had HF and to explain it to them.
‘‘…a lot of them know what their tablets are for and they know it’s to help with their water retention. But for instance, the ACE-inhibitors, they didn’t know the importance of them and nobody had ever really explained to them so…Sometimes it took them some time, they didn’t take them because they didn’t feel it was important but now all of them know it’s important to take the ACE-inhibitors.’’
‘‘Well, I was surprised, you know, learning that that’s the name of what I had wrong with me. I knew that there was something wrong but I didn’t think it was called heart failure. You know, I thought that somebody who had heart failure had died.’’
Fragmentation of care Some pharmacists were wary of the professional tensions arising from encroaching on roles traditionally delivered by others. ‘‘It’s difficult when there’s so many people involved in the care of one patient. There are us and the heart failure nurses, GPs and the primary care pharmacists. To coordinate all that and to get everybody saying the same thing, that’s definitely…not easy.’’ Others thought duplication of effort was important and acceptable. ‘‘It takes a good few times, whether it’s their GP or nurse or pharmacist…it takes …everybody all reinforcing the same thing, if they’re going to be able to manage their own medicines.’’ Patient interviews Patients generally reported that the service had had a positive impact, it filled a gap in their care and the community pharmacy was an appropriate setting. Few patients perceived the service to be of no value, in the main because they felt they had already a good level of knowledge and understanding. ‘‘…my doctor has already given me that information so I already knew that.’’ Some also explained this in terms of the consultation appearing functional. ‘‘I don’t know if I know any more [as a result of the service], it’s just the same. I just answered the questions that were there, that the pharmacist asked.’’ Emergent themes were set in the context of NPT: coherence (sense-making work); cognitive participation (relationship work); collective action (enacting work) and reflexive monitoring (appraisal work) [32].
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‘Absolutely, I didn’t even know I had heart failure. The doctor hadn’t told me so until I got that letter from the surgery he had never even mentioned it to me. So I’m delighted with the service. It’s been very helpful.’ For some patients, this was met with a sense of denial: ‘‘Well, for a start I don’t think I’ve got heart failure but everybody else seems to think so. But the pharmacist is very good and very helpful. But I still don’t think I’ve got anything wrong with my heart.’’ ‘‘I never knew about my heart failure before, no one had ever told me. I had no symptoms of any kind.’’ In another case, the news was received well: ‘‘I didn’t even know I had heart failure. The doctor hadn’t told me so until I got that letter from the surgery he had never even mentioned it to me. So I’m delighted with the service. It’s been very helpful.’’ Many patients felt that the service had increased their understanding of their condition overall. ‘‘I think it’s excellent, just the way that the pharmacist went about explaining everything to me. You know, the pharmacist was very clear and very concise.’’ ‘‘The pharmacist has told me all the things, like breathlessness going up the stairs to my bedroom and swelling of my ankles. The pharmacist explained all that to me.’’ Cognitive participation: engaging with others Many patients reported that the service was needed as it fulfilled functions not currently offered elsewhere. ‘‘Your doctor is telling you about a heart condition and gives me tablets and just let me get on with it. But what I was explained by the chemist was the feed-back from all the rest of it and what’s going on and what the reasons for doses are and when they explain it it’s understandable.’’
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‘‘I think it’s good because your doctor doesn’t explain it. He just gives you the pills and that’s it, you know what I mean? You’re taking them and you don’t know nothing about them.’’ Some used the pharmacist as a first port of call, to help decide whether to self refer to a GP: ‘‘But if I have any queries…I usually ask the pharmacist first and then he suggests if I have to go to a doctor or a nurse or whatever, you know.’’ Others voiced the benefits of gaining support, advice and reassurance: ‘‘…I think probably also the psychological effect here that you can talk to somebody, you know. And even if you just get a confirmation of what the doctor has prescribed for you it’s a big help.’’ Many patients reflected on the unique accessibility, less regimented environment and approachability of the community pharmacist. ‘‘It’s always easier to ask again. Because sometimes you ask and get an answer and you’re not sure what the answer is. You can ask the pharmacist again.’’ ‘‘Well, to be honest with you, sometimes when I go to the doctor there are so many things you want to say to the doctor. But sometimes I feel as if you’re taking up too much of his time, you know…So when I go to the pharmacist I can get everything explained.’’ ‘And you know if you have any questions you could ask him/her. You know, there’s no awkwardness or no…you know…Yes, I think it’s an excellent service.’ ‘You know, sometimes when you ask questions you feel you’re holding the doctor up but you can go to the pharmacy and they can sit and explain everything and what it does and that, you know. You don’t want to take up too much of the doctor’s time so the pharmacist will take the time to explain it all to you.’ ‘Oh, I think it’s very good. It’s hard to say but first I think it brings you a lot closer, you know. Well, I mean the doctors, they’re fine but somehow or another you can’t talk to them the same as you can to the pharmacist.’
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‘‘Well, with all the different kinds of medication you don’t realise what everything’s for. The pharmacist explains what they are for and what they do, you know…about the water tablet and the beta-blocker and things like that.’’ Others reported improved linkage of medicines to outcomes, through reviewing their treatment in discussion with the pharmacist: ‘‘The pharmacist explains that what I take is essential, that the dosage is essential and when to take it and not to miss and what to do if it’s missed. And that if I do the right things I’ll get a proper result. And what to do if things go wrong.’’ Some participants said they would be more likely to take their medicines following the pharmacists’ support, or have gained a deeper understanding of the need: ‘Yes, I will take my medication more regularly.’ ‘The pharmacist told me different things about the medication that I didn’t know beforehand. And I feel better about taking the medication now.‘ A few reported that they ‘felt better’ about taking their medication and it had resulted in them changing their routine: ‘‘The pharmacist told me different things about the medication that I didn’t know beforehand. And I feel better about taking the medication now.’’ ‘‘I was on furosemide and I wasn’t taking them because I was going out, you know. So the pharmacist has put me on to a routine now that when I come in, say it’s 4 o’clock in the afternoon when I get back here again. I take it then, you know.’’ Some made reference to how the repeated visits to the pharmacy include monitoring of symptoms by the pharmacist. ‘‘The pharmacist asks me every…at least once a month when I have a chat to him. He asks me about my ankles to see if they’re swollen or if any other part of the body is swelling up.’’ Another patient reported subsequently feeling more confident speaking to their doctor about changes in symptoms.
Collective action (methods for managing symptoms and treatments) or reflexive monitoring (changing routine)
‘‘Well I can talk to the doctor more about it, you know. Now that the pharmacist tells me all these things, you know, I can talk to the doctor all better…’’
Most patients said the service had improved knowledge and understanding of medicines:
In response to the question ‘Has talking to the pharmacist made any difference to the likelihood of you telling
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the doctor or nurse if you notice those symptoms?’’, some indicated they felt empowered to discuss their condition or medicines: ‘Yes, I think that would be true enough because I think I would be more inclined to speak to the doctor about something I wasn’t very sure about asking before.’ Discussion Our results suggest community pharmacists with minimal additional training can support HF patients with symptom and medicines management and patients welcome such support. Expressed views indicate the service improves adherence for some patients, adding to our current understanding of how pharmacists may provide an integrated, multidisciplinary model of care [34, 35]. Reasons for pharmacists feeling comfortable with the service included the structured consultation pro-forma, but uncertainty was introduced if the consultation required them to deviate from this, as arose with co-morbidities and other medications. While structure may offer a acceptable introduction to involve pharmacists in delivering more clinical roles, it could detract from person-centred care in which practitioners are encouraged to let the patient set the agenda [36, 37]. Our finding that some pharmacists felt constrained by the structured consultation contrasted with patient reports suggesting they felt at ease to speak freely during the consultation. Further explanatory work is required to improve our understanding of this area. Pharmacists illustrated some discomfort on discussing other medicines or co-morbidities during the consultation. This suggests further training needs, as reported by other studies [38]. Alternatively, pharmacists, despite receiving additional remuneration for delivering this enhanced service, may have felt under pressure to return to routine dispensing business. Unmet need has been described previously by patients with HF [39].Community pharmacists and patients thought the service addressed unmet need, in a way that other healthcare professionals could not. Overcoming treatment burden can have an important positive impact on patient functioning, and key components of the burden can be analysed under a coding framework informed by NPT. Our analysis used the NPT framework because it enables understanding and description of everyday tasks undertaken by patients with long term conditions, [32] including HF [33, 40], and stroke [31]. The NPT framework includes domains of Coherence (learning about the illness and the consequences); Cognitive participation (engaging with others); Collective action (development and
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enactment of methods for managing symptoms and treatments) and Reflexive monitoring (monitoring the illness and treatments). In order to better understand, manage their condition, and get the most from their medicines, it is suggested that patients require to address these domains; failure to do so has been hypothesised to lead to treatment failure across a spectrum of long term conditions [41, 42]. Through repeated engagement with pharmacists (‘Cognitive participation’) to improve their understanding of their condition and ability or confidence to speak with doctors or take their medicines, patients’ reports were aligned with previous findings [39]. Patients welcomed the opportunity to engage with pharmacists repeatedly, and it is possible that the logistical, administrative or expert help perceived or received, contributed to favourable reports of the service. While we are uncertain whether these experiences led to improvements in adherence and self care practices, our findings begin to improve our understanding of how a community pharmacy based service can help patients overcome their ‘treatment burden’. [31] It is also possible to view these findings in the context of previous work describing dimensions of educational quality in the field of interventions to improve knowledge of long term conditions and medicine use. [43] Individualisation, relevance of information, the opportunity to provide feedback, reinforce advice and provide the means by which patients can change their medicines use and self care are key measures of quality, and were available to patients and pharmacists through the platform created by the HF service. In particular, the relationship between community pharmacist and patient, forged over several consultations, is likely to have led to the pharmacist individualising advice to the patient’s expressed needs and level of understanding. There are a number of limitations to this study including lack of involvement of GPs and specialist HF nurses as participants and a lack of detail in relation to patient characteristics. We involved patients with HF and are uncertain if the results would be similar for a group with another long term condition. Patients who were offered the service were taken from a community based cohort, with or without symptoms and therefore may or may not have required support to manage their condition and medicines. Nevertheless, the views expressed were generally positive, and the patient and community pharmacy population representative. A further limitation inherent in the qualitative methodological approach, is the lack of objective, quantifiable evidence of improvement in medicine adherence and self management. There is an attempted move away from payment by prescription volume, to more clinical and cognitive service models [44] including services such as ours which remunerate pharmacies for non-dispensing activity. Recent reports have described the public’s lack of trust in extended
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pharmacy services, and an inability of community pharmacists to improve outcomes [45–47]. In contrast, we found that patients valued pharmacists’ extended input and recognised their unique role, while appreciating the need to involve their GP in the event of symptom deterioration. Our work complements quantitative research showing benefit to patients with HF [22] and recent work demonstrating improved evidence based prescribing [49]. In comparison with published accounts of work in this area, our pragmatic, sustained, integrated model of care is one of the few examples of community pharmacists working within teams to support the delivery of collaborative care, [50, 51]and how to configure such services is of contemporary interest [35]. Together, this suggests there may be merit in further developing community pharmacy based services for patients with HF, at a time when alternative, more economical models of care are needed [52].
Conclusion Both patients receiving and pharmacists delivering a cognitive HF service felt that it addressed a shortfall in current care. Patients reported improved understanding of their condition and medicines. There appears to be an evolving role for pharmacists in supporting patients to address the burden of understanding and managing their condition and treatment, which may lead to better self management and medicines adherence. Acknowledgments Our friend and collaborator, Prof Steve Hudson, died during the course of this project. The authors are indebted to Steve for his general guidance, support and good humour. Conflicts of interest
There are no conflicts of interest to report.
Funding NHS Greater Glasgow and Clyde. The principal author’s time was funded by The National Research Scotland Fellowship Scheme.
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162 23. Bouvy ML, Heerdink ER, Urquhart J, Grobbee DE, Hoes AW, Leufkens HG. Effect of a pharmacist-led intervention on diuretic compliance in heart failure patients: a randomized controlled study. J Card Fail. 2003;9(5):404–11. 24. NHS Quality Improvement Scotland. The coronary heart disease (CHD) Improvement Management Programme. CHD Resource Pack version 1. Edinburgh: NHS QIS; 2009. ISBN 0-7559-4376-7. 25. Scottish Intercollegiate Guidelines Network. Management of Chronic Heart Failure: A national clinical guideline. SIGN 95. Edinburgh: SIGN;2007. ISBN 1899893946. 26. National Institute for Health and Care Excellence. Chronic heart failure: Management of chronic heart failure in adults in primary and secondary care. CG108. London: National Institute for Health and Care Excellence; 2008. ISBN 1-84257-323-3. 27. Ritchie J, Lewis J, editors. Qualitative Research Practice: A Guide for Social Science Students and Researchers. London: Sage; 2003 ISBN 0761971106. 28. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2008;3(2):77–101. 29. Daly J, Kellehear A, Gliksman M. The public health researcher: a methodological approach. Melbourne: Oxford University Press; 1997 ISBN 232324510. 30. Joffe H. Thematic Analysis. In: Harper D, Thompson AR, editors. Qualitative Research Methods in Mental Health and Psychotherapy: A Guide for Students and Practitioners Chichester: Wiley, 2011; ch15. doi: 10.1002/9781119973249. 31. Gallacher K, Morrison D, Jani B, MacDonald S, et al. Uncovering treatment burden as a key concept for stroke care: a systematic review of qualitative research. PLoS Med. 2013;10(6): e1001473. 32. May C, Finch T. Implementing, embedding, and integrating practices: an outline of Normalization Process Theory. Sociology. 2009;43(3):535–54. 33. Gallacher K, May CR, Montori VM, Mair FS. Understanding patients’ experiences of treatment burden in chronic heart failure using normalization process theory. Ann Fam Med. 2011;9(3): 235–43. 34. Molloy GJ, O’Carroll RE, Witham MD, McMurdo MET. Interventions to enhanced adherence to medications in patients with heart failure: a systematic review. Circ Heart Fail. 2012;5(1): 126–33. 35. Milfred-LaForest SK, Chow SL, DiDomenico RJ, Dracup K, Ensor CR, Gattis-Stough W, et al. Clinical pharmacy services in heart failure: an opinion paper from the Heart Failure Society of America and American College of Clinical Pharmacy Cardiology Practice and Research Network. J Card Fail. 2013;19(5):354–69. 36. Alston CL, Paget GC, Halvorson B, Novelli B, Guest J, McCabe P, et al. Communicating with patients on health care evidence. Discussion paper. 2012 [Accessed Nov 2nd 2013]. Washington DC: Institute of Medicines. Available at: http://www.iom.edu/*/ media/Files/Perspectives-Files/2012/Discussion-Papers/VSRTEvidence.pdf. 37. Sanders T, Harrison S, Ckeckland K. Evidence based medicine and patient choice: the case of heart failure care. J Health Serv Res Policy. 2008;13(2):103–8.
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Int J Clin Pharm (2014) 36:154–162 38. Greenhill N, et al. Analysis of pharmacist-patient communication using the Calgary-Cambridge guide. Patient Educ Couns. 2011; 83(3):423–31. 39. Clark AM, McMurray JJV, Morrison CE. A qualitative study of the contribution of pharmacists to heart failure management in Scotland. Pharm World Sci. 2005;27(6):453–8. 40. Jani B, Blane D, Brown S, Montori VM, et al. Identifying treatment burden as an important concept for end of life care in those with advanced heart failure. Curr Opin Support Palliat Care. 2013;7:3–7. 41. Chambers JA, O’Carrol RE, Hamilton B, Whittaker J, et al. Adherence to medication in stroke survivors: a qualitative comparison of low and high adherers. Br J Health Psychol. 2010;16: 592–609. 42. Bayliss EA, Steiner JF, Crane LA, Main DS. Descriptions of barriers to self care by persons with comorbid chronic diseases. Ann Fam Med. 2003;1:15–21. 43. Dolan-Mullen P, Green LW, Persinger GS. Clinical trials of patient education for chronic conditions: a comparative metaanalysis of intervention types. Prev Med. 1985;14:753–81. 44. Correspondent Scotland. New remuneration structure on the cards in Scotland. Pharm Journal. 2013;290:628. 45. Blalock SJ, Roberts AW, Lauffenburger JC, Thompson T, O’Connor SK. The effect of community pharmacy-based interventions on patient health outcomes: a systematic review. Med Care Res Rev. 2013;70(3):235–66. 46. Gidman W, Ward P, McGregor L. Understanding public trust in services provided by community pharmacists relative to those provided by general practitioners: a qualitative study. BMJ Open [online journal]. 2012;2(3):3000939 [Accessed 2nd Nov 2013]; 2(3). Available at: http://bmjopen.bmj.com/content/2/3/e000939. full. 47. Salter C, Holland R, Harvey I, Henwood K. ‘‘I haven’t even phoned my doctor yet’’. The advice giving role of the pharmacist during consultations for medication review with patients aged 80 or more: qualitative discourse analysis. BMJ. 2007;334:1101–4. 48. Mullen PD, Simons-Morton DG, Ramı´rez G, Frankowski RF, Green LW, Mains DA. A meta-analysis of trials evaluating patient education and counseling for three groups of preventive health behaviors. Patient Educ Couns. 1997;32(3):157–73. 49. Lowrie R, Mair F, Greenlaw N, Forsyth P, Jhund P, McConnachie A, Rae B, McMurray JJV. Pharmacist intervention in primary care to improve outcomes in patients with left ventricular systolic dysfunction. Eur Heart J. 2011;33(3):314–24. 50. McAlister FA, Stewart S, Ferrua S, McMurray JJV. Multidisciplinary strategies for the management of heart failure patients at high risk of admission: a systematic review of randomised trials. J Am Coll Cardiol. 2004;44(4):810–9. 51. Carter BL, Rogers M, Daly J, Zheng S, James PA. The potency of team based care interventions for hypertension: a meta analysis. Arch Intern Med. 2009;169:1748–55. 52. NHS Scotland. Building a Health Service Fit for the Future. A National Framework for Service Change in the NHS in Scotland. Edinburgh: Scottish Executive; 2005. ISBN 0755946693.
RESEARCH ARTICLE
Experiences of a community pharmacy service to support adherence and self-management in chronic heart failure Richard Lowrie • Lina Johansson • Paul Forsyth Stuart Lochhead Bryce • Susan McKellar • Niamh Fitzgerald
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Received: 21 June 2013 / Accepted: 17 November 2013 / Published online: 30 November 2013 Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2013
Abstract Background Heart failure (HF) is common, disabling and deadly. Patients with HF often have poor self-care and medicines non-adherence, which contributes to poor outcomes. Community pharmacy based cognitive services have the potential to help, but we do not know how patients view community-pharmacist-led services for patients with HF. Objective We aimed to explore and portray in detail, the perspectives of patients receiving, and pharmacists delivering an enhanced, pay for performance community pharmacy HF service. Setting Community pharmacies and community-based patients in Greater Glasgow and Clyde, Scotland. Methods Focus groups with pharmacists and semi-structured interviews with individual patients by telephone. Cross sectional thematic analysis of qualitative data used Normalization Process Theory to understand and describe patient’s reports. Main outcome measure Experiences of receiving and delivering an enhanced HF service. Results Pharmacists voiced their confidence in delivering the service and highlighted valued
aspects including the structured consultation and repeated contacts with patients enabling the opportunity to improve self care and medicines adherence. Discussing co-morbidities other than HF was difficult and persuading patients to modify behaviour was challenging. Patients were comfortable discussing symptoms and medicines with pharmacists; they identified pharmacists as fulfilling roles that were needed but not currently addressed. Patients reported the service helped them to enact HF medicines and HF self care management strategies. Conclusion Both patients receiving and pharmacists delivering a cognitive HF service felt that it addressed a shortfall in current care. There may be a clearly defined role for pharmacists in supporting patients to address the burden of understanding and managing their condition and treatment, leading to better self management and medicines adherence. This study may inform the development of strategies or policies to improve the process of care for patients with HF and has implications for the development of other extended role services. Keywords Adherence Community pharmacy Heart failure Patient views Scotland Self-care
Electronic supplementary material The online version of this article (doi:10.1007/s11096-013-9889-2) contains supplementary material, which is available to authorized users. R. Lowrie (&) P. Forsyth S. L. Bryce Research and Development, Pharmacy and Prescribing Support Unit, NHS Greater Glasgow and Clyde, Victoria Infirmary, Langside Road, Glasgow G42 9TT, UK e-mail: [email protected] L. Johansson S. McKellar Strathclyde Institute of Pharmacy and Biomedical Sciences, Strathclyde University, Glasgow, UK N. Fitzgerald Create Consultancy Ltd., Glasgow, UK
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Impacts on practice • •
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Patients with HF and other chronic illnesses struggle to cope with their medicines and manage their conditions. Governments across the world, and patients, are increasingly looking to pharmacists and other health professionals, for alternative models of care to improve self care and medicines management. Few qualitative data underpin service developments by community pharmacists aiming to help patients with HF.
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Policy makers considering the introduction of community pharmacy services may be reassured by patients’ and pharmacists’ reports of acceptability and benefit from qualitative evidence.
Introduction Heart failure (HF) is disabling, costly and deadly, resulting in consistently poorer quality of life than in other long-term conditions, high rates of hospitalisation and mortality rates of 30 % over 5 years [1–3]. Evidence-based pharmacological therapy is the cornerstone of management of HF due to left ventricular systolic dysfunction (LVSD) [4].Patients with HF report a lack of understanding of their condition, symptoms, medicines and self-management. This accounts for excess HF hospitalisations [5–7].They are prone to generalised cognitive impairment [8], depression [9, 10] which together with polypharmacy [11] result in adherence [12, 13] and self-care [14] being persistently sub-optimal [15–20]. Individualised, repeated support by pharmacists may improve adherence, self-care and clinical outcomes [21–23] and collaborative, multidisciplinary involvement of pharmacists is recommended [24–26]. Despite this, there is an absence of research into patients’ and pharmacists’ experiences of community pharmacy based cognitive services for patients with HF. A community pharmacy based HF service has operated in NHS Greater Glasgow and Clyde (NHSGGC), Scotland (Europe’s largest Health Board area) since 2004. Approximately 1,250 patients have received the service from pharmacists who had received additional training, in one of 195 pharmacies.
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Pharmacists Ten pharmacists took part in two focus groups which used the schedule described in Table 2 (see Supplementary material). We selected the first 10 pharmacists to opt into the study, who had also delivered the service to at least five patients. In total, approximately 20 of those who consented had delivered the service to at least five patients. One hundred and six pharmacists were willing to participate in the research. All pharmacists provided written informed consent, and were employees of a range of pharmacy business models: independently owned single pharmacies, small chain (2–10 pharmacies) and a large multiple pharmacy businesses (more than 10 pharmacies). Pharmacists were a range of ages, background experience and years since qualification. Each group interview lasted about 1 h and was conducted jointly by LJ and SMcK, audio-recorded, transcribed and analysed thematically. Patients Sixty-five patients participated in semi-structured telephone interviews conducted by LJ. Sixty-three percent of patients were male. Patients’ mean age was 67 years. Almost 40 % lived in the most socioeconomically deprived Scottish areas with approximately equal proportions spread across other areas. Saturation was reached after 65 interviews were completed. Patients were identified by inviting the first 200 patients who received the service, to return a consent form. The interview schedule (Table 3: see Supplementary material) comprised eight initial questions followed, if necessary, by probes. Telephone interviews were audio-recorded and transcribed.
Aim of the study Analysis This study aimed to explore patients’ and pharmacists’ views of the NHSGG&C community pharmacy-based HF service.
Methods The study received NHSGGC Primary Care Local research ethics committee approval and was conducted in March 2006. Focus groups and interviews involved pharmacists and patients who were in the process of delivering and receiving the service respectively. Table 1 describes the service model and training received by participating pharmacists. Pharmacist focus groups (lasting about 1 h each) were conducted first; findings informed the design of patient interviews which lasted about 20 min each.
We used the framework analysis approach described by Ritchie and Lewis [27].An initial thematic framework was constructed from coded sections of transcripts [28–30].Data were then manually indexed and sorted. Emergent themes were grouped with quotations, and refined before abstracting and interpretation. Themes were considered in each discrete methodological stage (pharmacist focus groups or patient telephone interview) then subjected to cross-sectional analysis. We present quotations from a range of respondents. ‘Treatment burden’ describes the self care practices that patients with long term conditions need to conduct, in order to enact management strategies and respond to the demands of health care providers [31]. To enable understanding of the extent to which the service helped patients to overcome the burden of HF and treatment,
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123 Recording of care outcomes and referral to GP or HF Nurse where appropriate.
What it is for
Action planning to resolve any care issues/problems identified including referral to GP or HF Nurse where appropriate.
Any questions from the patient.
Smoking status and referral.
Role of weight monitoring.
Identification and scoring of HF symptoms.
Adherence issues. Patient’s perception and understanding of side effects.
Review of identified care issues/problems and action taken to address.
Monitoring of HF symptoms—scoring and comparison to previous score.
Systematic review of each medicine for HF including:
How it is taken
Follow-up consultation topic schedule
Initial consultation topic schedule
The community pharmacy was expected to deliver the service to the patient on a monthly or two–monthly basis. Topics covered during consultations are given below. The content of the consultation was shaped by a theoretical model of behavioural change which requires repetition of key messages, individualisation of advice, co-ordination of advice with other healthcare providers [48]. On submission of a completed consultation to the service organisers, the pharmacy receives a payment. Pharmacists are asked to send their completed documentation to practices for information.
Patient engagement and service delivery
Service delivery Step 2
All referrals were made into a service administrator (based in Greater Glasgow and Clyde Headquarters) who entered relevant data onto a database and forwarded relevant paperwork to the patient’s choice of community pharmacy.
Symptomatic patients with a primary diagnosis of HF due to LVSD were also identified and referred by specialist pharmacists based in doctor’s surgeries or by specialist nurses based in hospitals. These pharmacists and nurses had consulted with the patient as part of routine service provision, and had offered the service to patients, after agreeing on the need for it, during a consultation.
Inclusion in the service was through one of three routes: general practices, specialist pharmacists or specialist nurses. GPs maintained a register of all HF patients and in practices participating voluntarily permission was granted for specialist pharmacists to access the demographic, clinical and prescribing details of all patients on these registers. These patients (regardless of symptoms or duration of HF and without any objective assessment of their need for improved understanding or adherence) received a letter explaining the service and asking them to return a consent form including their nominated community pharmacy.
Patient identification and referral
Service delivery Step 1
Training received by each participating community pharmacist comprised 3 h of contact time with experienced pharmacists and nurses. Training covered the aetiology, epidemiology and treatment of HF. Under supervision, and using service documentation (standardised pro-formas), pharmacists conducted mock consultations with patients who had HF and received feedback from specialist pharmacists, nurses and patients.
Pharmacist training
Table 1 Greater Glasgow and Clyde Pharmacy HF service model
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we used Normalization Process Theory (NPT) [32] to conceptualise and interpret patients’ responses [33]. Results Focus groups with pharmacists Pharmacists’ confidence and competency Pharmacists expressed confidence in delivering the service and linked this to service design factors, including the structured consultation and encouragement for patients to refer themselves to their GP in the event of symptom deterioration. ‘‘The forms are good. They are easy to follow and because you’ve got somebody’s had an initial contact, like you said, we’re just following through with the guidelines that are there on the forms and they’re pretty straight-forward and easy to use.’’ ‘‘…you have…simple questions and you are asking them monthly and you are going to be able to…identify anybody that’s sort of going downhill quickly. And you can refer them back to the doctor before they necessarily would see the doctor.’’ In some cases, confidence in delivering the service appeared conditional on strong collaboration with GPs. ‘‘It depends on the relationship you’ve got with the doctors and if you’re quite happy to speak to the doctors yourself …But if you feel a bit, you know, how will the doctor take this, they might shout at me down the phone or tell me to mind my own business…’’ A majority felt that communication from practices, following a consultation, was sparse. ‘‘They could maybe give us more feedback on it because when we send things off we don’t get any response. We might suggest that the doctor does this or whatever but we don’t get any responses back.’’ Some voiced difficulties in their attempts to improve patients’ HF specific self-care. ‘‘And they say, ‘I’ll do it [weigh myself] for a week’. I say to them, ‘do it every week!’ you know. Every time they come to visit, just try to encourage them, for the importance of it. I think the message is getting on board.’’ Many pharmacists felt confident that patients’ ability to self-manage their medicines and condition had improved.
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‘‘They are being more proactive about their condition. It’s making them aware of their situation…they might be more inclined to think, I’d better go and see the doctor’’ ‘‘I think, as well, explaining to them about the diuretics that they don’t have to be taking them at the same time every day. That helps as well because they think that if it says one in the morning they have to take it in the morning and then they’re restricted from going out.’’ Challenges of other co-morbidities Pharmacists felt exposed when faced with patients who had pressing co-morbidities other than HF. ‘‘A big problem is as well that most of them have got other health problems along with their heart failure. They start talking about other medicines, and I’m like ‘to get back to your furosemide’’’. ‘‘Sometimes a lot of them have either asthma or COPD and you start talking and the first thing they say is; ‘I’m breathless all the time.’’’ Community pharmacy related factors Pharmacists thought patients perceived them as approachable and the timing of the consultation was seen as beneficial. ‘‘Even with the doctors, they’re maybe scared to ask them ‘what’s that for again?’ They think the doctor’s a ‘big person’, whereas we’re just normal!’’ ‘‘I think probably in hospital they would just be too frightened and overwhelmed by everything, so just going over the information again with them. They can understand it a bit better. They are not really scared to ask us questions, you know ‘What is that for?’ and ‘how does that work?’, just because we’re sitting down and chatting with them.’’ However, approachability came at a price, for pharmacists felt under increased pressure to manage their time amidst unpredictable fluctuations in pharmacy workload. ‘‘It’s difficult if they come in [for their monthly prescription] at a point when you’re really overly busy…and they can’t wait or they don’t really have time to come back. So you miss them that month. You know, it’s difficult to make sure you catch the person every month.’’
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Unmet need
Coherence: learning about HF and consequences
Pharmacists relished their new role, because they perceived it to address a gap in the healthcare system.
Some patients reported that pharmacists were the first to tell them they had HF and to explain it to them.
‘‘…a lot of them know what their tablets are for and they know it’s to help with their water retention. But for instance, the ACE-inhibitors, they didn’t know the importance of them and nobody had ever really explained to them so…Sometimes it took them some time, they didn’t take them because they didn’t feel it was important but now all of them know it’s important to take the ACE-inhibitors.’’
‘‘Well, I was surprised, you know, learning that that’s the name of what I had wrong with me. I knew that there was something wrong but I didn’t think it was called heart failure. You know, I thought that somebody who had heart failure had died.’’
Fragmentation of care Some pharmacists were wary of the professional tensions arising from encroaching on roles traditionally delivered by others. ‘‘It’s difficult when there’s so many people involved in the care of one patient. There are us and the heart failure nurses, GPs and the primary care pharmacists. To coordinate all that and to get everybody saying the same thing, that’s definitely…not easy.’’ Others thought duplication of effort was important and acceptable. ‘‘It takes a good few times, whether it’s their GP or nurse or pharmacist…it takes …everybody all reinforcing the same thing, if they’re going to be able to manage their own medicines.’’ Patient interviews Patients generally reported that the service had had a positive impact, it filled a gap in their care and the community pharmacy was an appropriate setting. Few patients perceived the service to be of no value, in the main because they felt they had already a good level of knowledge and understanding. ‘‘…my doctor has already given me that information so I already knew that.’’ Some also explained this in terms of the consultation appearing functional. ‘‘I don’t know if I know any more [as a result of the service], it’s just the same. I just answered the questions that were there, that the pharmacist asked.’’ Emergent themes were set in the context of NPT: coherence (sense-making work); cognitive participation (relationship work); collective action (enacting work) and reflexive monitoring (appraisal work) [32].
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‘Absolutely, I didn’t even know I had heart failure. The doctor hadn’t told me so until I got that letter from the surgery he had never even mentioned it to me. So I’m delighted with the service. It’s been very helpful.’ For some patients, this was met with a sense of denial: ‘‘Well, for a start I don’t think I’ve got heart failure but everybody else seems to think so. But the pharmacist is very good and very helpful. But I still don’t think I’ve got anything wrong with my heart.’’ ‘‘I never knew about my heart failure before, no one had ever told me. I had no symptoms of any kind.’’ In another case, the news was received well: ‘‘I didn’t even know I had heart failure. The doctor hadn’t told me so until I got that letter from the surgery he had never even mentioned it to me. So I’m delighted with the service. It’s been very helpful.’’ Many patients felt that the service had increased their understanding of their condition overall. ‘‘I think it’s excellent, just the way that the pharmacist went about explaining everything to me. You know, the pharmacist was very clear and very concise.’’ ‘‘The pharmacist has told me all the things, like breathlessness going up the stairs to my bedroom and swelling of my ankles. The pharmacist explained all that to me.’’ Cognitive participation: engaging with others Many patients reported that the service was needed as it fulfilled functions not currently offered elsewhere. ‘‘Your doctor is telling you about a heart condition and gives me tablets and just let me get on with it. But what I was explained by the chemist was the feed-back from all the rest of it and what’s going on and what the reasons for doses are and when they explain it it’s understandable.’’
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‘‘I think it’s good because your doctor doesn’t explain it. He just gives you the pills and that’s it, you know what I mean? You’re taking them and you don’t know nothing about them.’’ Some used the pharmacist as a first port of call, to help decide whether to self refer to a GP: ‘‘But if I have any queries…I usually ask the pharmacist first and then he suggests if I have to go to a doctor or a nurse or whatever, you know.’’ Others voiced the benefits of gaining support, advice and reassurance: ‘‘…I think probably also the psychological effect here that you can talk to somebody, you know. And even if you just get a confirmation of what the doctor has prescribed for you it’s a big help.’’ Many patients reflected on the unique accessibility, less regimented environment and approachability of the community pharmacist. ‘‘It’s always easier to ask again. Because sometimes you ask and get an answer and you’re not sure what the answer is. You can ask the pharmacist again.’’ ‘‘Well, to be honest with you, sometimes when I go to the doctor there are so many things you want to say to the doctor. But sometimes I feel as if you’re taking up too much of his time, you know…So when I go to the pharmacist I can get everything explained.’’ ‘And you know if you have any questions you could ask him/her. You know, there’s no awkwardness or no…you know…Yes, I think it’s an excellent service.’ ‘You know, sometimes when you ask questions you feel you’re holding the doctor up but you can go to the pharmacy and they can sit and explain everything and what it does and that, you know. You don’t want to take up too much of the doctor’s time so the pharmacist will take the time to explain it all to you.’ ‘Oh, I think it’s very good. It’s hard to say but first I think it brings you a lot closer, you know. Well, I mean the doctors, they’re fine but somehow or another you can’t talk to them the same as you can to the pharmacist.’
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‘‘Well, with all the different kinds of medication you don’t realise what everything’s for. The pharmacist explains what they are for and what they do, you know…about the water tablet and the beta-blocker and things like that.’’ Others reported improved linkage of medicines to outcomes, through reviewing their treatment in discussion with the pharmacist: ‘‘The pharmacist explains that what I take is essential, that the dosage is essential and when to take it and not to miss and what to do if it’s missed. And that if I do the right things I’ll get a proper result. And what to do if things go wrong.’’ Some participants said they would be more likely to take their medicines following the pharmacists’ support, or have gained a deeper understanding of the need: ‘Yes, I will take my medication more regularly.’ ‘The pharmacist told me different things about the medication that I didn’t know beforehand. And I feel better about taking the medication now.‘ A few reported that they ‘felt better’ about taking their medication and it had resulted in them changing their routine: ‘‘The pharmacist told me different things about the medication that I didn’t know beforehand. And I feel better about taking the medication now.’’ ‘‘I was on furosemide and I wasn’t taking them because I was going out, you know. So the pharmacist has put me on to a routine now that when I come in, say it’s 4 o’clock in the afternoon when I get back here again. I take it then, you know.’’ Some made reference to how the repeated visits to the pharmacy include monitoring of symptoms by the pharmacist. ‘‘The pharmacist asks me every…at least once a month when I have a chat to him. He asks me about my ankles to see if they’re swollen or if any other part of the body is swelling up.’’ Another patient reported subsequently feeling more confident speaking to their doctor about changes in symptoms.
Collective action (methods for managing symptoms and treatments) or reflexive monitoring (changing routine)
‘‘Well I can talk to the doctor more about it, you know. Now that the pharmacist tells me all these things, you know, I can talk to the doctor all better…’’
Most patients said the service had improved knowledge and understanding of medicines:
In response to the question ‘Has talking to the pharmacist made any difference to the likelihood of you telling
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the doctor or nurse if you notice those symptoms?’’, some indicated they felt empowered to discuss their condition or medicines: ‘Yes, I think that would be true enough because I think I would be more inclined to speak to the doctor about something I wasn’t very sure about asking before.’ Discussion Our results suggest community pharmacists with minimal additional training can support HF patients with symptom and medicines management and patients welcome such support. Expressed views indicate the service improves adherence for some patients, adding to our current understanding of how pharmacists may provide an integrated, multidisciplinary model of care [34, 35]. Reasons for pharmacists feeling comfortable with the service included the structured consultation pro-forma, but uncertainty was introduced if the consultation required them to deviate from this, as arose with co-morbidities and other medications. While structure may offer a acceptable introduction to involve pharmacists in delivering more clinical roles, it could detract from person-centred care in which practitioners are encouraged to let the patient set the agenda [36, 37]. Our finding that some pharmacists felt constrained by the structured consultation contrasted with patient reports suggesting they felt at ease to speak freely during the consultation. Further explanatory work is required to improve our understanding of this area. Pharmacists illustrated some discomfort on discussing other medicines or co-morbidities during the consultation. This suggests further training needs, as reported by other studies [38]. Alternatively, pharmacists, despite receiving additional remuneration for delivering this enhanced service, may have felt under pressure to return to routine dispensing business. Unmet need has been described previously by patients with HF [39].Community pharmacists and patients thought the service addressed unmet need, in a way that other healthcare professionals could not. Overcoming treatment burden can have an important positive impact on patient functioning, and key components of the burden can be analysed under a coding framework informed by NPT. Our analysis used the NPT framework because it enables understanding and description of everyday tasks undertaken by patients with long term conditions, [32] including HF [33, 40], and stroke [31]. The NPT framework includes domains of Coherence (learning about the illness and the consequences); Cognitive participation (engaging with others); Collective action (development and
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enactment of methods for managing symptoms and treatments) and Reflexive monitoring (monitoring the illness and treatments). In order to better understand, manage their condition, and get the most from their medicines, it is suggested that patients require to address these domains; failure to do so has been hypothesised to lead to treatment failure across a spectrum of long term conditions [41, 42]. Through repeated engagement with pharmacists (‘Cognitive participation’) to improve their understanding of their condition and ability or confidence to speak with doctors or take their medicines, patients’ reports were aligned with previous findings [39]. Patients welcomed the opportunity to engage with pharmacists repeatedly, and it is possible that the logistical, administrative or expert help perceived or received, contributed to favourable reports of the service. While we are uncertain whether these experiences led to improvements in adherence and self care practices, our findings begin to improve our understanding of how a community pharmacy based service can help patients overcome their ‘treatment burden’. [31] It is also possible to view these findings in the context of previous work describing dimensions of educational quality in the field of interventions to improve knowledge of long term conditions and medicine use. [43] Individualisation, relevance of information, the opportunity to provide feedback, reinforce advice and provide the means by which patients can change their medicines use and self care are key measures of quality, and were available to patients and pharmacists through the platform created by the HF service. In particular, the relationship between community pharmacist and patient, forged over several consultations, is likely to have led to the pharmacist individualising advice to the patient’s expressed needs and level of understanding. There are a number of limitations to this study including lack of involvement of GPs and specialist HF nurses as participants and a lack of detail in relation to patient characteristics. We involved patients with HF and are uncertain if the results would be similar for a group with another long term condition. Patients who were offered the service were taken from a community based cohort, with or without symptoms and therefore may or may not have required support to manage their condition and medicines. Nevertheless, the views expressed were generally positive, and the patient and community pharmacy population representative. A further limitation inherent in the qualitative methodological approach, is the lack of objective, quantifiable evidence of improvement in medicine adherence and self management. There is an attempted move away from payment by prescription volume, to more clinical and cognitive service models [44] including services such as ours which remunerate pharmacies for non-dispensing activity. Recent reports have described the public’s lack of trust in extended
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pharmacy services, and an inability of community pharmacists to improve outcomes [45–47]. In contrast, we found that patients valued pharmacists’ extended input and recognised their unique role, while appreciating the need to involve their GP in the event of symptom deterioration. Our work complements quantitative research showing benefit to patients with HF [22] and recent work demonstrating improved evidence based prescribing [49]. In comparison with published accounts of work in this area, our pragmatic, sustained, integrated model of care is one of the few examples of community pharmacists working within teams to support the delivery of collaborative care, [50, 51]and how to configure such services is of contemporary interest [35]. Together, this suggests there may be merit in further developing community pharmacy based services for patients with HF, at a time when alternative, more economical models of care are needed [52].
Conclusion Both patients receiving and pharmacists delivering a cognitive HF service felt that it addressed a shortfall in current care. Patients reported improved understanding of their condition and medicines. There appears to be an evolving role for pharmacists in supporting patients to address the burden of understanding and managing their condition and treatment, which may lead to better self management and medicines adherence. Acknowledgments Our friend and collaborator, Prof Steve Hudson, died during the course of this project. The authors are indebted to Steve for his general guidance, support and good humour. Conflicts of interest
There are no conflicts of interest to report.
Funding NHS Greater Glasgow and Clyde. The principal author’s time was funded by The National Research Scotland Fellowship Scheme.
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