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Research Paper International Journal of
Pharmacy Practice International Journal of Pharmacy Practice 2015, 23, pp. 121–130
Pharmaceutical care of older people: what do older people want from community pharmacy? Kathryn Wooda, Fiona Gibsonb, Andrew Radleyc and Brian Williamsd a
Pharmacy Service, NHS Tayside, Arbroath, bSafety, Clinical Governance and Risk Team, East Day Home and cPublic Health Department, Kings Cross
Hospital, NHS Tayside, Dundee and dNursing, Midwifery and Allied Health Professionals Research Unit, University of Stirling, Stirling, UK
Keywords community pharmacy; needs assessment Correspondence Mrs Kathryn Wood, Pharmacy Service, Arbroath Infirmary, Rosemount Road, Arbroath DD11 2AT, UK. E-mail: [email protected] Received November 23, 2011 Accepted April 20, 2014 doi: 10.1111/ijpp.12127
Abstract Objectives To explore older people’s opinions of current community pharmacy provision and identify potential areas for improvement. Methods A pilot focus group was conducted to finalise the topic areas for discussion. Three focus groups and three small group interviews were held with a total of 25 people aged over 65 years. A purposive sampling approach was used to maximise variation in likely responses. All focus group discussions were transcribed and analysed for emerging themes. Data collection continued until saturation was reached. Finally, the themes were taken to a further five community groups to discuss and confirm the findings. Key findings Two main interlinked themes emerged around ‘personal and relational factors’ and ‘service factors’. The participants valued continuity of personalised pharmaceutical care and described receiving this care in small community pharmacies. The ability to build a trusting relationship over time was important to the people in this study. There was a lack of awareness of services already available from community pharmacies. Ongoing disruption in the supply of medicines caused problems for this client group, and the complexity of prescription ordering, collection and delivery systems presented challenges for participants. Good communication from the community pharmacy helped to improve the experience. Conclusion This study contributes some qualitative data on the opinions of older people about community pharmacies. There may be planning implications for the size of future community pharmacies and the range of services provided. Community pharmacies may need to take a more proactive role in promoting innovative services to older people who may benefit from these services.
Introduction Almost half of the medicines prescribed in the UK are for people aged 65 and over; furthermore, 36% of those aged over 75 take four or more prescribed drugs daily.[1] Consequently, effective prescribing, acceptable distribution and appropriate adherence may enhance quality of life. Conversely, inappropriate prescribing or use can lead to reduced quality of life and place older people at increased risk of drug-related harm.[2] Despite the importance of medicines to older people’s well-being, there is substantial evidence to suggest that © 2014 Royal Pharmaceutical Society
suboptimal medicine use is common. For example, as many as 50% of older people on prescribed medication may not take this medication in accordance with the intentions of the prescriber.[3] Approximately half of this nonadherence is intentional, an active ‘resistance’,[4] while the remainder occurs because patients are unaware that they are not taking medication as prescribed or because the regimen is just too complex.[5] Evidence suggests that improving the degree to which medicines are prescribed and distributed in a person-centred International Journal of Pharmacy Practice 2015, 23, pp. 121–130
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way increases the likelihood that quality of life as valued by the patient will be maximised.[6] Indeed, improving a patient’s quality of life using medication may be less dependent on the efficacy of the medicines than was previously thought and more dependent on patients’ preferences and actions, on relationship factors and on issues created by the health-care system that provides the care.[1,7] Patients value health-care professionals who listen to them and respect the patient’s own knowledge.[8] In addition, participation in decisions about all aspects of care is important and gives a sense of dignity.[9–12] Community pharmacies in Scotland contract with the NHS to provide pharmaceutical care. Pharmacy contractors are organised in different ways: independent pharmacies (generally one or two pharmacies owned and run by an individual or a partnership), small chains of pharmacies (generally up to 10 or so pharmacies owned by an organisation, usually in a small geographical area) and large national pharmacy chains with many pharmacies covering the whole of the UK and in some instances other countries. In any given rural or urban setting in Scotland, there may be a mixture of different kinds of pharmacy contractor. In 2002, the Scottish Government published ‘The Right Medicine’. This strategy acknowledged the central role of pharmacists in health care processes and outlined a commitment to pharmacists’ skills to improve the experience of patient care and outcomes. It established a person-centred approach to pharmaceutical care.[13] The redesign of community pharmacy services in Scotland was delivered by the introduction of a new Community Pharmacy Contract. The contract has four elements: an Acute Medication Service; a Chronic Medication Service to treat long-term conditions; a Minor Ailments Service; and a Public Health Service. The essential characteristics of the redesign were delivered by an essentially ‘top-down’ approach. However, it was recognised that the development of person-centred pharmacy services required consultation and a more ‘bottom-up’ approach. This study was therefore carried out to address the question ‘What do older people feel they need from community pharmacies and medication?’
Method The open, exploratory and consultative focus of the project, along with the aim to identify the range of opinions and experiences of pharmacy clients, indicated that a qualitative method was most appropriate.[14] A steering group was set up to plan the study, review progress and inform writing of the final report. A wider reference group was also set up to review methods and comment on design issues. The study was approved by the Tayside Committee on Medical Research Ethics (Reference 08/S1401/3). © 2014 Royal Pharmaceutical Society
Older people’s opinions of community pharmacy
Sampling and recruitment Individuals were eligible for inclusion if they were over 65 years old with capacity to consent to participation. People in care homes were excluded from the study, as the pharmaceutical care needs of people in care homes are met via different mechanisms. The study used a purposive sampling strategy to ensure a diversity of likely views were identified.[15] Recruitment therefore focused on five variables: • Gender – a mix of male and female • Level of medical need – including housebound people • Rurality – people from both rural and urban populations across Tayside • Diagnosis – those living with the most common long-term illnesses • Social support – those who have little or no social support Potential participants were identified through nursing staff at NHS day hospitals, through the manager at a voluntary agency day care centre for older people, and through the co-ordinators of two charities’ local support groups. Potential participants were given or posted an information sheet about the study at least a week before the focus group and invited to attend. All focus groups were held in the relevant setting the participants were attending, except for the two held with the charities’ support groups, which were held in health board premises. The participants in each focus group were drawn only from one organisation. A total of 25 people participated. We had intended to conduct six focus groups. However, recruitment and attendance meant that three groups consisted of two people only. The main benefit of a focus group approach is the freedom afforded to participants to talk directly to one another (rather than just to the facilitator alone) and thus comment on other participants’ views and experiences. Despite the small numbers in three of the focus groups, such interactions were clearly evident, and therefore data relevant to the study were identified and included in the final analysis. All participants completed a consent form prior to taking part in the focus group. Following analysis, the key findings were then taken to five community groups to discuss and confirm the findings. A further 25 people were involved in this stage of the research. This method was chosen in preference to respondent validation, as the findings from the series of focus groups would not always reflect an individual participant’s opinion.[16] The Health Board’s public involvement manager facilitated the identification of the community groups. Groups were recruited and consent obtained verbally through the co-ordinators or secretaries of the groups. The groups included healthy community collaborative lunch clubs and older people’s discussion groups supported by local council or voluntary organisation employees. No direct use was made of the data from these community groups, but the exercise allowed assessment of face validity of the findings from the International Journal of Pharmacy Practice 2015, 23, pp. 121–130
Kathryn Wood et al.
Table 1 • • • • •
Topic areas for focus groups
Actions taken to prevent illness/promote well-being Support given to prevent illness (informal and formal) Role of the community pharmacies Experiences of using community pharmacies How current services could be improved/developed to meet needs of older people
focus groups. In this way we tested and confirmed that the findings from the relatively frail population in the focus groups were as important to a healthier older population.
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that as themes and ideas emerged, we sought deviant cases to falsify theory. Where this occurred, themes and interpretation were modified accordingly. Secondly, analysis and data collection were conducted iteratively in order to ensure that emergent findings were pursued and explored in more detail. Thirdly, validation was undertaken within interviews through regular checking of interpretation and through final confirmation with five community groups. Finally, analysis was conducted by more than one member of the team. KW and FG analysed data; AR and BW then further checked interpretation and coding.[16]
Results Data collection A pilot focus group was conducted prior to the study. Data from the pilot group were not audio-recorded and were not included in the analysis. Field notes were used to ensure that the proposed schedule generated relevant discussion. The focus groups were facilitated by one of the researchers (FG), who was experienced in focus group moderation. All focus groups were digitally recorded; in addition, KW scribed notes to aid transcription and recorded nonverbal behaviours to supplement the transcription. The use of a nonpharmacist to facilitate the group aimed to reduce bias, allowing freer expression of opinions about pharmacy services by participants. Focus groups lasted between 45 min and 60 min and covered a number of topics as summarised in Table 1. The topics were derived from a literature search of previous community pharmacy services that have been shown to be of benefit to older people. The results of each focus group were analysed before the next was conducted. This allowed themes that had already been thoroughly discussed to be covered more briefly in subsequent groups, whereas emerging themes could be explored more fully.
Analysis Following the focus group, each transcript was checked against the original recording by two of the researchers (KW and FG). The transcripts were read independently by KW and FG and analysed using a generic qualitative approach utilising thematic analysis.[17] Recurrent themes were identified and coded independently, then discussed to reach consensus and coherent analysis. By the sixth group, no further themes were being identified, and it was judged that data saturation had been reached. Following this, final analysis was undertaken and key findings identified (Figure 1).
Rigour and trustworthiness Four strategies were employed to enhance the rigour and thus trustworthiness of the study findings. Firstly, analysis ensured © 2014 Royal Pharmaceutical Society
Table 2 describes the participants who attended the six focus groups. As potential participants were identified by staff in the organizations, the number who were approached to participate is unknown. Three groups had two participants each, one had five participants, one had six and one had eight. Analysis revealed the emergence of two overarching themes: ‘personal and relational factors’ and ‘service awareness’, each with their own subthemes. The relationship with the community pharmacy staff and the size of the pharmacy influenced opinions of community pharmacy as a whole, as did the awareness of the services available from the pharmacy and any previous experiences regarding availability of medicines.
Personal and relational factors Relationship Positive opinions were expressed of patients’ experiences of community pharmacy services and the relationships that they had with pharmacists within them. Central to the positive nature of these relationships were issues of confidence/ trust (Table 3, quotes 1 and 2). The issue of confidence and trust in the relationship was supported or undermined by a range of other experiences. These were of value in themselves but also provided the foundation for confidence and trust. These included the degree to which they were known by staff, whether a noncommercial approach to selling was being used, whether the staff showed respect, and the degree to which provision was personalised. Participants particularly valued a sense of being known by pharmacy staff, and this helped provide assurance of continuity of care (Table 3, quotes 3 and 4). The value of the relationship and the trust and confidence imbued in it appeared to be supported by pharmacists’ behaving in a reasonably noncommercial manner by explicitly putting patient interest first before profit despite their commercial basis. For example, a number of participants indicated that they valued pharmacists who do not try to sell International Journal of Pharmacy Practice 2015, 23, pp. 121–130
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Older people’s opinions of community pharmacy
Pilot focus group
Steering group
Focus group 1
Wider reference group
Recorded and transcribed. Analysed to identify themes.
Focus group 2 Focus group 3
Themes explored further in next group.
Focus group 4 Focus group 5 Focus group 6
Final themes identified Five community groups
Further discussion and confirmation with five community groups. Field notes taken. Final analysis conducted.
Figure 1 Table 2
Study methodology. Sample description
Sampling criteria
Sample description (n = 25)
Gender Medical need
10 men and 15 women 10 people had a high level of medical need (attendance at day hospital, MacMillan input) 6 people lived in rural communities, 14 lived in urban settings, residence of 5 was undefined 17 people described experiences of living with common long-term conditions (chronic obstructive pulmonary disease, Alzheimer’s disease, Parkinson’s disease, heart conditions) 14 people expressed feelings of little or no social support, although most acknowledged that they have some family involvement and/or family carers; 7 people described themselves as caring for another older person (one of these was under 65 years old)
Rurality Diagnosis
Social support
the most expensive product, or who do not try to sell anything at all (Table 3, quotes 5 and 6). Participants described pharmacists as having positive attitudes and viewed respect towards older people by community pharmacy staff as a valued part of the service provided (Table 3, quote 7). Participants gave examples of the types of personal service they particularly valued, including delivering other necessary items alongside medication for those with poor mobility and making home visits to those who are housebound (Table 3, quotes 8 and 9). © 2014 Royal Pharmaceutical Society
Many participants were not aware of the communication between community pharmacists and general practices. Those who were aware expressed satisfaction with the communication, recognising the importance of this in ensuring that contra-indicated or interacting medicines were not prescribed (Table 3, quotes 10 and 11). Small versus large stores Participants voiced a perception of different levels of service provided by independent pharmacies and larger national chains. Independents were perceived to provide more personalised service and advice (Table 3, quotes 12 and 13). In particular, big queues in large national pharmacy chains were off-putting (Table 3, quote 14). Some participants valued the opportunity to buy products within pharmacies, e.g. toiletries and cosmetics, while others felt this detracted from the role of the service (Table 3, quotes 15 and 16).
Service factors The structure of service provision and the range of services available appeared to be important to many participants. This included awareness of services, stock availability, and pick-up and delivery service. Awareness of services There was a general lack of awareness of the range of services available within community pharmacies, with some participants only recognising the dispensing role (Table 4, quote 1). International Journal of Pharmacy Practice 2015, 23, pp. 121–130
Kathryn Wood et al.
Table 3
Personal and relational factors
Quote number 1
2
3 4
5 6 7
8 9
10
11
12
13
14
15 16
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Quote E1: ‘They go all the way through to the young girl who’s just started.’ E2: ‘They’re all very good.’ E1: ‘When I go to the chemist, I go to my chemist with confidence that I’m going to get looked after by confident people.’ F5: ‘When that rash started like spots, it was like bites . . . so I says “We’ll go and have a wee chat to the chemist,” right, and they . . . had a look and have a wee talk to you, right, then gave you whatever and “Come back” they’ll say, and if it doesna clear up then you can go to your GP. So it’s really reassuring, isn’t it?’ E1: ‘The other thing is you go in and they know your name – it’s not a pub, it’s the place where they know your name and that’s my chemist.’ B1: ‘It’s the personal touch as well.’ B3:‘ I think if you go to the same one all the time it helps.’ B1: ‘Definitely helps but there are three different pharmacists in the one I use. The service is the same . . . whether it’s the owner or [the] two employees the service is still the same. They still know who you are and they know to phone you, I’m very impressed with it anyway.’ B1: ‘In spite of the fact their shop is there to sell things they don’t try to sell you the expensive things . . . and in fact they can recommend something cheaper for you, for long-term ointments, say.’ E2: ‘You know they weren’t trying to sell you something.’ E1: ‘They’re very friendly about it, and on those occasions when I made mistakes I left the place feeling reasonably happy. I didn’t feel . . .’ E2: ‘Stupid.’ E1:‘Stupid or guilty.’ E2: (laughs) E1: ‘Not more than usual but . . . I wasn’t paraded in front of everybody and made a fool of . . . I realise I’m a mature man, an old man now, but they’re very good.’ A1: ‘Every Thursday she comes with a bolster pack, you know, for your pills, and if you need anything you can phone when she’s coming up, like toothpaste or anything, and she brings it up.’ E2: ‘At one point . . . [my sister] had . . . new medicines she had prescribed and she felt very ill after it and the chemist . . . went down to my sister’s and spoke to her about the medicine and stuff . . . and gave her a wee bit of confidence to try it for a couple of days.’ B1: ‘There was a mistake made with my prescription at the doctor’s end and I pointed it out at the surgery, nothing happened; it was wrong the next time, told the pharmacist . . . it was fixed. The wrong strength of tablets, which was very important. . . . Most of us are sort of independent. I never thought for one minute of saying to the pharmacist, you sort it out with . . . the doctors. . . . That’s quite useful now’ E2: ‘My sister, she has . . . very bad stomach problems and she is allowed to take Gaviscon . . . and there was one time they sent down, is it a . . . generic . . . and she felt quite ill after it. . . . But I don’t know if the chemist can say to the doctor, “Look, I’m sorry, this patient isn’t happy with this at all.” ’ E2: ‘I went into [national pharmacy chain] and asked and the girl said “Well, that’s all we’ve got over there,” sort of thing.’ Fac: ‘So it’s not the same level of service?’ E2: ‘Oh, no.’ Fac: ‘If the [national chain] that you mentioned was closer to home, do you think you would go in there or would you maybe look for a kind of local chemist?’ E2: ‘I think actually I would look for a chemist, a chemist chemist.’ E1 :‘I’d go for a local one.’ E1: ‘But . . . at one time or another . . . I went into [national chain] with a prescription, and I’ve never been back because I hated the size of the queues.’ E2: ‘Yes.’ E1: ‘And it wasn’t very sympathetic, so I prefer to go back to my local chemist.’ E1: ‘Well . . . going into other chemist shop you feel that, “Oh, this is a cosmetic shop, this is something different, it’s not geared up for me as a patient.” ’ F6: ‘I love all the chemist shops. I like . . . the hair products and body lotions . . . and things for the skin. I could spend ages in the chemist, ages and ages.’
For presentation of results, the focus groups have been randomly assigned the letters A to F. Within the focus group respondents have been randomly assigned a number. ‘F6’ represents the sixth person in focus group F, for example. Note on language: ‘Chemist’ is used throughout interchangeably with ‘pharmacist’ or ‘pharmacy.’ ‘Bolster’/‘blister’, a monitored dosage system. Scots ‘wee’, English ‘small’ or ‘quick’. Scots ‘doesna’, English ‘does not’. Fac, facilitator.
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Table 4
Older people’s opinions of community pharmacy
Service factors
Quote number 1 2
3
4
5
6 7
8 9 10
11 12
13
14 15 16
17
18 19
Quote A2: ‘No, no, the chemist is only the pills.’ E1: ‘The sort of thing just now is my voice is going and I’m getting . . . chesty, so I can go to the chemist and say “This is what’s happening,” and he would recommend something to me, which means I don’t have to go to the doctor’s for that, but if it were to go on for a longer time then I could go to the doctor’s . . . a person with different qualifications.’ F4: ‘Sometimes you feel that whatever it is, you can’t really bother the doctor with it.’ F5: ‘That’s right, it’s, you feel it’s just a wee thing.’ F6: ‘Go and ask the chemist.’ F4:‘If you should be bothering the doctor then he’ll [the chemist] tell you to.’ F4: ‘[Yeah], I’ve used that.’ F6: ‘No, never used that.’ F5: ‘How do you get that, like, what do you do?’ Fac: ‘Just usually a form you’ve got to fill out, usually ask at the desk and fill out a form.’ F5: ‘Where do you get that form then?’ Fac: ‘Usually just the chemist’s.’ F6: ‘That’ll be one of the bigger ones.’ Fac: ‘I think they all do that, I think.’ F5: ‘And they’ll tell you what they can do, what’s available, like what they can. . .’ Fac: ‘They’ve got a list of medicines that they’re allowed to give without having to go through a doctor.’ B1: ‘I think it’s fine . . . The dentist told me what to use and when I went into the chemist to buy this, he said “. . .You can get that in from [Minor] Ailments”, and . . . I’ve used it a couple of times since quite successfully . . . Essentially I mean some of these things that you’re buying across the counter 5 or 6 pounds at a time, when you’re entitled to free prescriptions you . . . don’t want to go to the doctor, you know what you need or the chemist can tell you what you need, and I found it useful . . . The service is good.’ F6: ‘You get the Zantac and in [national pharmacy chain] they said to me one day, they said, “Our own make . . . is the same thing and they’re so, and they’re a lot cheaper than what the actual Zantac are”, you know, and that’s good.’ C1: ‘One bad thing that happened to me last winter, I went for my usual prescription, which is . . . forget the name of it now (pause), just the usual thing for my chesty cough, and one of the pharmacists served me . . . She says “Oh, you can’t take that with your drugs”, so she told me what I had to take.’ B2: ‘If I’ve got the cold or flu there is some things that I can’t take because of the medication that I do take. I can’t get the information in [supermarket]. Therefore I go to, I’ve got to go to a chemist to get advice.’ B1: ‘I think it should be handled by the pharmacist. If that means the pharmacists have to open additional hours, so be it.’ E1: ‘If they had a bigger shop, yes, they could provide bigger services. I would not feel happy about (sighs) going to a chemist for a health check. I wouldn’t mind vaccinations or inoculations. Blood tests (long pause), not sure about that. I feel that if I go to a doctor’s surgery and the nurse takes my blood everything is spot on for cleanliness and procedures. Whereas I think if you go to a chemist shop or pharmacy and there is something else happening in there, it’s just another service, I don’t know whether I’d get the same standard.’ E1: ‘I don’t think the chemist has facilities for giving me a health check. . . . The shop is a bit too crowded, I think, for that sort of thing. Also I would be very conscious of people that are able to hear what you’re saying.’ Fac: ‘If you thought [health checks were] being offered . . . at your local chemist, would you take it up?’ F5: ‘Yeah I would, saves you going into the doctor and waiting to get an appointment and phoning at eight o’clock in the morning to see if you can get one and . . . I would, I would definitely, just walk in and get it done.’ B4: ‘I went in last Friday, and I actually felt the pharmacist was quite rude and abrupt. “Come back tomorrow for one”, and I said, “Well, can I take the others today?” and he turned and said to the girl beside him, “Can’t she come back this afternoon for it?”, which would have been a six-mile trip into town again in the afternoon and then again the next day for any others.’ B1: ‘I know they’ve done that in the past, borrow from [national pharmacy chain] across the road or something like that.’ B1:‘Sometimes they don’t have the total quantity. They give me part quantity and immediately offer to deliver the others and phone me if there’s any problem.’ B4:‘I don’t have to order it, but as it’s prescriptions he’s getting on a regular basis you would think that they would.’ B5: ‘They would hae them in stock and they didnae hae them in stock.’ B4: ‘But even just a phone call, you know, to say they’re not ready so . . . save you a journey.’ D4: ‘If you’re not in, he’ll, well, I’ve got a wider letterbox so he puts it through the door.’ D6: ‘Well you see they wouldnae . . . put that through the door, you know what I mean. So you were having to phone up and say you were gonna [going to] be in . . . and at that time I’d had both my eyes cataract and there was nurses . . . coming four times a day putting drops in eyes.’ D8: ‘Aye, I know what you mean.’ D6: ‘But . . . it seems that you’ve got . . . to collect it and you’ve got to be the one that. . .’ E1: ‘Well, they collect my prescriptions demands and they deliver the prescriptions at their shop so that they are virtually missing out my visits to the surgery.’ B1: ‘With the prescription (eh) they have offered to deliver them permanently so that I don’t need to go for them at all, but I don’t want that ’cause that keeps me willing to go out, so it’s matter of choice that I go. It’s actually a mile and a half from the chemist but (eh) I must say (eh) the service I get is impeccable, it really is.’
For presentation of results, the focus groups have been randomly assigned the letters A to F. Within the focus group respondents have been randomly assigned a number. ‘F6’ represents the sixth person in focus group F, for example. Note on language: ‘Chemist’ is used throughout interchangeably with ‘pharmacist’ or ‘pharmacy.’ ‘Bolster’/‘blister’, a monitored dosage system. Scots ‘wee’, English ‘small’ or ‘quick’. Scots ‘doesna’, English ‘does not’. Fac, facilitator.
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The services that were discussed and valued most frequently by the participants were the provision of advice about medicines and minor ailments, counter-prescribing and functioning as a point of first contact before the GP (Table 4, quotes 2 and 3). Only a small proportion of the participants had heard of the Minor Ailments Service (a service that allows specific groups of patients, including older people, access to a range of medicines for minor ailments free of charge from community pharmacies) (Table 4, quote 4). Those who had heard of it had become aware through the suggestion from pharmacy staff. The service was described as a service that allowed them to avoid GP appointments while minimising cost (Table 4, quote 5). Some participants highlighted that pharmacy staff could also assist in minimising cost by providing advice on cheaper generics when they were self-medicating (Table 4, quote 6). Examples were given of the types of advice given by community pharmacists, including advice on over-the-counter medicines and their potential interactions with prescribed medicines (Table 4, quote 7). Despite acknowledging the convenience of being able to purchase over-the-counter medication in other locations, e.g. supermarkets, some people expressed a preference for pharmacies to be allowed to sell all medicines so that advice is available (Table 4, quote 8). However, it was recognised that this might require review of opening times at weekends and evenings (Table 4, quote 9). People expressed some ambivalence in attitudes towards potential new (or in some cases existing) services such as health checks or vaccinations. Specific concerns included cleanliness and privacy (Table 4, quotes 10 and 11). However, the ability to walk in without making an appointment sounded appealing to others (Table 4, quote 12). Stock availability Participants highlighted issues around stock supplies, resulting in them having to make repeat journeys to complete their prescription. This was often compounded by the distance between home and the pharmacy (Table 4, quote 13). It was recognised that some pharmacies tried different solutions to limit inconvenience, e.g. borrowing from another pharmacy or arranging for the items out of stock to be delivered (Table 4, quotes 14 and 15). However, participants found it harder to understand stock supply issues relating to regular repeat prescriptions, regarding which they felt that pharmacies should be aware how much is required every month (Table 4, quote 16). Pick-up/delivery There was much discussion within the groups regarding variation in the ordering, collecting and delivery services © 2014 Royal Pharmaceutical Society
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provided by community pharmacies (Table 4, quote 17). Participants wanted different options for collection of prescriptions and delivery of medicines. Some people chose to keep walking to the community pharmacy to keep them active. Others valued being able to get medication delivered to their home (Table 4, quotes 18 and 19).
Discussion The study participants emphasised personal and relational factors, such as being treated with respect and continuity of service provision, as important aspects of using a pharmacy. These factors were felt to contribute to building trust in the services provided, and the lack of this kind of relationship adversely affected the experience of using large stores compared to the experience of using smaller pharmacies. These data do not suggest that there are marked differences in the experiences of people living in rural areas compared with those in urban areas, although large stores are more likely to be found in town centres. Participants also demonstrated a lack of awareness of existing services available from community pharmacies. Systems of prescription ordering, collection and delivery caused much discussion, and a lack of availability of common medicines led to negative experiences being described. Participants wished to maintain their independence as far as possible, and this extended to activities around medicines management. The purposive sampling resulted in a cross-section of the local population participating in the focus groups. Representation was gained of rural and urban population, as well as housebound and independent-living people with common long-term conditions. The use of day hospitals and day centres allowed access to hard-to-reach people who would not have been able to attend without ambulance transport. The sample size was relatively small, and the original aim was to include at least 30 people in the focus groups. We experienced poor recruitment to three focus groups. However, the small numbers did not appear to inhibit freeflowing conversation and interaction. A larger number of participants may have revealed new issues. However, it was felt that as no new themes were emerging by the final focus group, data saturation had been reached by this point. Field notes taken at further public consultation events allowed ratification of the themes with a wider group of people. Participants from minority ethnic groups did not attend the groups. This is a reflection of the local population of older people, and further work is required to ascertain the opinions of older people of minority groups. The people who attended the groups generally were already prescribed repeat medicines. The results therefore may not reflect the views of older people who do not take repeat medicines but who use community pharmacies for other services such as health promotion. The opinions of some carers and a International Journal of Pharmacy Practice 2015, 23, pp. 121–130
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wider range of people were included through involvement in the public consultation events. A larger proportion of respondents lived in urban settings than in rural, reflecting the local demography. However, analysis of the data does not suggest that the level of rurality affected the experience of community pharmacy other than the cost involved in accessing services (e.g. in time taken) when repeated journeys to the community pharmacy were required. The type of pharmacy (independent, large national chain, etc.) utilised by the participant was more a determinant of the experience. Continued participation in everyday activities, such as using local community facilities, and the maintenance of good physical health are known to be important for reducing isolation, increasing self-esteem and maintaining good mental health for older people.[18] Community pharmacies in Scotland provide a range of services, including health promotion and advice and treatment for minor ailments, and are integral to many local communities.[13] In the context of current European strategies to empower communities,[19] community pharmacies can also be seen as part of the infrastructure necessary to ‘allow others to discover their ability and competencies to manage their own lives’ by the provision of technical expertise.[20] Indirect age discrimination has been defined as any ‘apparently neutral practice that disadvantages older people’.[21] In these terms, a large store that is easily utilised by younger people but is not as easily utilised by older people could be seen as discriminatory. It is interesting to note that this finding relates to the customer service within a large pharmacy store rather than the geography of the store itself. People in the study described enjoying the shopping experience; however, when continuity of pharmaceutical care and personalised service were being discussed, the experiences of using large stores were more negative. ‘The Right Medicine’[13] described the need for effective strategies to empower and inform patients and carers about medicines. The strategy recognised the important role of pharmacists in promoting independence and working to improve the quality of life of vulnerable groups, such as older people. The Chronic Medication Service provides a contractual methodology through which community pharmacists can assess the pharmaceutical care needs of patients with long-term conditions and work to improve the outcomes achieved from their medicines. The lack of awareness of services by some people in each focus group demonstrates issues with access to services from which older people may benefit. Similar results were also found in a recent study in the UK.[22] Communicating information about services in a format that reaches older people is necessary if the potential benefit to older people is to be realised. The current system of advertising services on posters and leaflets within the pharmacy seemed ineffective © 2014 Royal Pharmaceutical Society
Older people’s opinions of community pharmacy
in informing the people in this study. Participants in this study would be happy to be offered services that might benefit them; word of mouth seemed to be a frequent way of finding out about existing services. This finding has important consequences for pharmacists, who should make the patient their first concern.[23] In order to provide the best care to older people, pharmacists need to take on an active role in promoting nationally contracted services to this age group. Pharmacies offer services that collect prescriptions from general practices and deliver the dispensed medicines to the patient’s home. Different pharmacies devise different systems to achieve a similar service outcome. The complexity of the diverse systems for collection and delivery of prescriptions was worked around by the people in this study rather than understood. A similar result was found in a recent study,[22] which concluded that people adapt to the systems available. People expressed different preferences for collection and delivery services. In general, where good communication was common practice, people had more satisfactory experiences of these services. The lack of availability of common medicines for immediate dispensing led to much discussion in the groups, and generally negative opinions and experiences were expressed. Older people who took multiple medicines were more likely to experience this problem. The lack of availability of stock for the major consumers of medicines has implications for the perception of the whole community pharmacy service, especially where the view of community pharmacy is encompassed by ‘The chemist is only the pills’. Better solutions to the ongoing problems of medicines supply in community pharmacy are needed. The two themes of personal and relational factors and service factors interlink. Good services build trust, and good relationships mean that the service is perceived to be good. Pharmacies that meet the needs of older people have a community focus. They provide a personalised service; help with cost minimisation for patients, including not selling medicines if they are not needed; and provide good advice. This is their unique selling point. A recent white paper from the Department of Health in England highlights that a potential overemphasis on the business side of community pharmacy needs to be balanced by a contractual framework that rewards clinical activity.[24] The perceptions of people in this study were that some large pharmacy stores did not provide continuity of care or personalised services. Although these pharmacies might offer lower-cost medicines, the benefits of this cost minimisation were offset by the need to queue for services. This has implications for both rural and urban areas, as large pharmacies are widely distributed. Recent legislation in the UK emphasises that the need for new or relocated pharmacy services should be determined by the assessed need for pharmaceutical care within the local population.[25,26] In this International Journal of Pharmacy Practice 2015, 23, pp. 121–130
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context, the local demographics are an important factor for future decision-making, as smaller pharmacies in this study were perceived to provide better service. The WHO Health 2020 strategy for Europe states that ‘building the individual and community strengths that protect and promote health’ is a priority for reducing health inequalities.[19] There were some examples of community pharmacies already contributing to this in this study, as in the case of a housebound patient requesting toiletries as part of the prescription delivery service. This can be seen as a personalised service contributing to self-care. It would be interesting to see how much community pharmacy delivery services already contribute to self-care and support. The Reshaping Care for Older People in Scotland agenda emphasises that ‘growing community capacity that focuses on preventative and anticipatory support’ will improve outcomes for older people.[27] Participants expressed a wish to remain independent for as long as possible, and this extended to medicines management, with one particular participant declining offers of prescription delivery services in order to maintain his walks to the pharmacy as a regular activity. There is a growing recognition within the health and social care system that re-enablement is a necessity rather than a luxury for the future due to demographic changes.[27] The percentage of older people in the population is expected to rise, while the percentage of working-age people in the population (from which carers have traditionally been drawn) is expected to fall.[27] Maintaining independence in medicine-taking may well become even more important in the future as services have to evolve to work with people to enable them to do for themselves what is currently being done ‘to’ or ‘for’ them. Assets-based approaches to support medicines management by older people are a required practice development. Within NHS Scotland, the launch of the Healthcare Quality Strategy has committed all NHS Services to develop mutually beneficial partnerships with patients and their families that respect individual needs and values, demonstrating compassion, continuity, clear communication and shared decision-making.[28] It is clear from the results of this study that some community pharmacies are already achieving this in terms of personal and relational factors.
References 1. Department of Health (UK). Medicines and older people: implementing the medicines-related aspects of the NSF for older people. London: Department of Health, 2001. © 2014 Royal Pharmaceutical Society
Conclusion This study provides a reference point to inform what is ‘reasonable and adequate’ provision of community pharmacy services for older people. The study enabled some insights into what older people value about community pharmacy services, what creates problems and confusion for them, and how these services might contribute to delivering policy initiatives of the Scottish Government. In particular, pharmacies can work towards maintaining independence in medicinestaking for older people through building relationships and having a community focus. The prominent issues surrounding out-of-stock medicines and collection and delivery services were important factors perceived as decreasing the value achieved from community pharmacy. Participants described a preference for ‘smaller pharmacies’ where continuity of the relationship with the pharmacist was achieved. Pharmacies situated close to where people live were perceived to offer more desirable standards of service.
Declarations Conflict of interest The Author(s) declare(s) that they have no conflicts of interest to disclose.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Acknowledgements We would like to acknowledge the work of Lorna MacRae in the transcription of the data. We would also like to thank all the staff and charities who helped organise the groups and the participants for their time.
Authors’ contributions All authors designed the study. KW and FG conducted the focus groups and undertook initial analysis of the data. AR and BW then further checked interpretation and coding. KW drafted the paper.
2. Pirmohamed M et al. Adverse drug reactions as cause of admission to hospital: prospective analysis of 18 820 patients. BMJ 2004; 329: 15– 19. 3. Social Care Institute for Excellence. Helping older people to take prescribed
medicine in their own home – what works? London: Social Care Institute for Excellence, 2005 www.scie.org.uk/ publications/briefings/briefing15/ index.asp (accessed 2 June 2014). 4. Pound P et al. Resisting medicines: a synthesis of qualitative studies of
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medicine taking. Soc Sci Med 2005; 61: 133–155. Ley P. Communicating with Patients: Improving Communication, Satisfaction and Compliance. Cheltenham: Stanley Thornes Pub Ltd., 1997. Williams B, Dowell J. Decision making and the patient’s voice: the therapeutic decision model. In: Dowell JS et al., eds. Patient-Centred Prescribing. Abingdon: Radcliffe, 2007; 65–79. Haynes RB et al. Physicians’ and patients’ choices in evidence based practice. Evidence does not make decisions; people do (editorial). BMJ 2002; 324: 1350. Lehane E et al. Medication-taking for coronary artery disease – patient’s perspectives. Eur J Cardiovasc Nurs 2008; 7: 133–139. Staand J, Sandvik H. Stopping longterm drug therapy in general practice: how well do physicians and patients agree? Fam Pract 2001; 18: 597–601. Hasler G et al. Patient satisfaction with outpatient psychiatric treatment: the role of diagnosis, pharmacotherapy, and perceived therapeutic change. Can J Psychiatry 2004; 49: 315–321. Laine C et al. Important elements of outpatient care: a comparison of patients’ and physicians’ opinions. Ann Intern Med 1996; 125: 640–645. Woolhead G et al. ‘Tu’ or ‘Vous?’ A European qualitative study of dignity and communication with older people in health and social care settings. Patient Educ Couns 2006; 61: 363–371. Scottish Executive. The right medicine: a strategy for pharmaceutical care in
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Scotland. Edinburgh: Scottish Executive, 2002. Pope C, Mays N. Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research. BMJ 1995; 311: 42–45. Strauss AL, Corbin J. Basics of Qualitative Research: Grounded Theory Procedure and Techniques. Thousand Oaks, CA: Sage, 1990. Mays N, Pope C. Assessing quality in qualitative research. BMJ 2000; 320: 50–52. Caelli K et al. ‘Clear as mud’: toward greater clarity in generic qualitative research. Int J Qual Methods 2003; 2: 1–13. Lee M. Promoting mental health and well-being in later life: a first report from the UK Inquiry into Mental Health and Well-Being in Later Life. London: Age Concern and the Mental Health Foundation, 2006. World Health Organization Europe. Health 2020: a European policy framework and strategy for the 21st century. Geneva: World Health Organization, 2013. Laverack G. An identification and interpretation of the organizational aspects of community empowerment. Community Dev J 2001; 35: 134–145. Lee M. Improving services and support for older people with mental health problems: the second report from the UK Inquiry into Mental Health and Well-Being in Later Life. London: Age Concern England, 2007.
22. Farmer J, Munoz S-A. Rural community pharmacy models: an exploration of community perceptions. Aberdeen: UHI Millennium Institute and University of Aberdeen Centre for Rural Health Research and Policy, 2009. www.abdn.ac.uk (accessed 2 June 2014). 23. General Pharmaceutical Council (UK). Standards of conduct, ethics and performance. London: General Pharmaceutical Council, 2010. 24. Department of Health (UK). Pharmacy in England – building on strengths, delivering the future. London: Department of Health, 2008. 25. Scottish Government. NHS Circular PCA (P) 7 (2011) – NHS (Pharmaceutical Services) (Scotland) Amendment Regulations 2011 (SSI 2011/32) – Provision on Control of Entry to Pharmaceutical Lists. Edinburgh: Scottish Government, 2011. 26. Department of Health (UK). The National Health Service (Pharmaceutical Services) Regulations 2012. London: Department of Health, 2012. 27. Scottish Government; Convention on Scottish Local Authorities; National Health Service Scotland. Reshaping care for older people: a programme for change 2011–2021. Edinburgh: Scottish Government, 2011. 28. Scottish Government. The healthcare quality strategy for NHS Scotland. Edinburgh: Scottish Government, 2010.
International Journal of Pharmacy Practice 2015, 23, pp. 121–130
Research Paper International Journal of
Pharmacy Practice International Journal of Pharmacy Practice 2015, 23, pp. 121–130
Pharmaceutical care of older people: what do older people want from community pharmacy? Kathryn Wooda, Fiona Gibsonb, Andrew Radleyc and Brian Williamsd a
Pharmacy Service, NHS Tayside, Arbroath, bSafety, Clinical Governance and Risk Team, East Day Home and cPublic Health Department, Kings Cross
Hospital, NHS Tayside, Dundee and dNursing, Midwifery and Allied Health Professionals Research Unit, University of Stirling, Stirling, UK
Keywords community pharmacy; needs assessment Correspondence Mrs Kathryn Wood, Pharmacy Service, Arbroath Infirmary, Rosemount Road, Arbroath DD11 2AT, UK. E-mail: [email protected] Received November 23, 2011 Accepted April 20, 2014 doi: 10.1111/ijpp.12127
Abstract Objectives To explore older people’s opinions of current community pharmacy provision and identify potential areas for improvement. Methods A pilot focus group was conducted to finalise the topic areas for discussion. Three focus groups and three small group interviews were held with a total of 25 people aged over 65 years. A purposive sampling approach was used to maximise variation in likely responses. All focus group discussions were transcribed and analysed for emerging themes. Data collection continued until saturation was reached. Finally, the themes were taken to a further five community groups to discuss and confirm the findings. Key findings Two main interlinked themes emerged around ‘personal and relational factors’ and ‘service factors’. The participants valued continuity of personalised pharmaceutical care and described receiving this care in small community pharmacies. The ability to build a trusting relationship over time was important to the people in this study. There was a lack of awareness of services already available from community pharmacies. Ongoing disruption in the supply of medicines caused problems for this client group, and the complexity of prescription ordering, collection and delivery systems presented challenges for participants. Good communication from the community pharmacy helped to improve the experience. Conclusion This study contributes some qualitative data on the opinions of older people about community pharmacies. There may be planning implications for the size of future community pharmacies and the range of services provided. Community pharmacies may need to take a more proactive role in promoting innovative services to older people who may benefit from these services.
Introduction Almost half of the medicines prescribed in the UK are for people aged 65 and over; furthermore, 36% of those aged over 75 take four or more prescribed drugs daily.[1] Consequently, effective prescribing, acceptable distribution and appropriate adherence may enhance quality of life. Conversely, inappropriate prescribing or use can lead to reduced quality of life and place older people at increased risk of drug-related harm.[2] Despite the importance of medicines to older people’s well-being, there is substantial evidence to suggest that © 2014 Royal Pharmaceutical Society
suboptimal medicine use is common. For example, as many as 50% of older people on prescribed medication may not take this medication in accordance with the intentions of the prescriber.[3] Approximately half of this nonadherence is intentional, an active ‘resistance’,[4] while the remainder occurs because patients are unaware that they are not taking medication as prescribed or because the regimen is just too complex.[5] Evidence suggests that improving the degree to which medicines are prescribed and distributed in a person-centred International Journal of Pharmacy Practice 2015, 23, pp. 121–130
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way increases the likelihood that quality of life as valued by the patient will be maximised.[6] Indeed, improving a patient’s quality of life using medication may be less dependent on the efficacy of the medicines than was previously thought and more dependent on patients’ preferences and actions, on relationship factors and on issues created by the health-care system that provides the care.[1,7] Patients value health-care professionals who listen to them and respect the patient’s own knowledge.[8] In addition, participation in decisions about all aspects of care is important and gives a sense of dignity.[9–12] Community pharmacies in Scotland contract with the NHS to provide pharmaceutical care. Pharmacy contractors are organised in different ways: independent pharmacies (generally one or two pharmacies owned and run by an individual or a partnership), small chains of pharmacies (generally up to 10 or so pharmacies owned by an organisation, usually in a small geographical area) and large national pharmacy chains with many pharmacies covering the whole of the UK and in some instances other countries. In any given rural or urban setting in Scotland, there may be a mixture of different kinds of pharmacy contractor. In 2002, the Scottish Government published ‘The Right Medicine’. This strategy acknowledged the central role of pharmacists in health care processes and outlined a commitment to pharmacists’ skills to improve the experience of patient care and outcomes. It established a person-centred approach to pharmaceutical care.[13] The redesign of community pharmacy services in Scotland was delivered by the introduction of a new Community Pharmacy Contract. The contract has four elements: an Acute Medication Service; a Chronic Medication Service to treat long-term conditions; a Minor Ailments Service; and a Public Health Service. The essential characteristics of the redesign were delivered by an essentially ‘top-down’ approach. However, it was recognised that the development of person-centred pharmacy services required consultation and a more ‘bottom-up’ approach. This study was therefore carried out to address the question ‘What do older people feel they need from community pharmacies and medication?’
Method The open, exploratory and consultative focus of the project, along with the aim to identify the range of opinions and experiences of pharmacy clients, indicated that a qualitative method was most appropriate.[14] A steering group was set up to plan the study, review progress and inform writing of the final report. A wider reference group was also set up to review methods and comment on design issues. The study was approved by the Tayside Committee on Medical Research Ethics (Reference 08/S1401/3). © 2014 Royal Pharmaceutical Society
Older people’s opinions of community pharmacy
Sampling and recruitment Individuals were eligible for inclusion if they were over 65 years old with capacity to consent to participation. People in care homes were excluded from the study, as the pharmaceutical care needs of people in care homes are met via different mechanisms. The study used a purposive sampling strategy to ensure a diversity of likely views were identified.[15] Recruitment therefore focused on five variables: • Gender – a mix of male and female • Level of medical need – including housebound people • Rurality – people from both rural and urban populations across Tayside • Diagnosis – those living with the most common long-term illnesses • Social support – those who have little or no social support Potential participants were identified through nursing staff at NHS day hospitals, through the manager at a voluntary agency day care centre for older people, and through the co-ordinators of two charities’ local support groups. Potential participants were given or posted an information sheet about the study at least a week before the focus group and invited to attend. All focus groups were held in the relevant setting the participants were attending, except for the two held with the charities’ support groups, which were held in health board premises. The participants in each focus group were drawn only from one organisation. A total of 25 people participated. We had intended to conduct six focus groups. However, recruitment and attendance meant that three groups consisted of two people only. The main benefit of a focus group approach is the freedom afforded to participants to talk directly to one another (rather than just to the facilitator alone) and thus comment on other participants’ views and experiences. Despite the small numbers in three of the focus groups, such interactions were clearly evident, and therefore data relevant to the study were identified and included in the final analysis. All participants completed a consent form prior to taking part in the focus group. Following analysis, the key findings were then taken to five community groups to discuss and confirm the findings. A further 25 people were involved in this stage of the research. This method was chosen in preference to respondent validation, as the findings from the series of focus groups would not always reflect an individual participant’s opinion.[16] The Health Board’s public involvement manager facilitated the identification of the community groups. Groups were recruited and consent obtained verbally through the co-ordinators or secretaries of the groups. The groups included healthy community collaborative lunch clubs and older people’s discussion groups supported by local council or voluntary organisation employees. No direct use was made of the data from these community groups, but the exercise allowed assessment of face validity of the findings from the International Journal of Pharmacy Practice 2015, 23, pp. 121–130
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Table 1 • • • • •
Topic areas for focus groups
Actions taken to prevent illness/promote well-being Support given to prevent illness (informal and formal) Role of the community pharmacies Experiences of using community pharmacies How current services could be improved/developed to meet needs of older people
focus groups. In this way we tested and confirmed that the findings from the relatively frail population in the focus groups were as important to a healthier older population.
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that as themes and ideas emerged, we sought deviant cases to falsify theory. Where this occurred, themes and interpretation were modified accordingly. Secondly, analysis and data collection were conducted iteratively in order to ensure that emergent findings were pursued and explored in more detail. Thirdly, validation was undertaken within interviews through regular checking of interpretation and through final confirmation with five community groups. Finally, analysis was conducted by more than one member of the team. KW and FG analysed data; AR and BW then further checked interpretation and coding.[16]
Results Data collection A pilot focus group was conducted prior to the study. Data from the pilot group were not audio-recorded and were not included in the analysis. Field notes were used to ensure that the proposed schedule generated relevant discussion. The focus groups were facilitated by one of the researchers (FG), who was experienced in focus group moderation. All focus groups were digitally recorded; in addition, KW scribed notes to aid transcription and recorded nonverbal behaviours to supplement the transcription. The use of a nonpharmacist to facilitate the group aimed to reduce bias, allowing freer expression of opinions about pharmacy services by participants. Focus groups lasted between 45 min and 60 min and covered a number of topics as summarised in Table 1. The topics were derived from a literature search of previous community pharmacy services that have been shown to be of benefit to older people. The results of each focus group were analysed before the next was conducted. This allowed themes that had already been thoroughly discussed to be covered more briefly in subsequent groups, whereas emerging themes could be explored more fully.
Analysis Following the focus group, each transcript was checked against the original recording by two of the researchers (KW and FG). The transcripts were read independently by KW and FG and analysed using a generic qualitative approach utilising thematic analysis.[17] Recurrent themes were identified and coded independently, then discussed to reach consensus and coherent analysis. By the sixth group, no further themes were being identified, and it was judged that data saturation had been reached. Following this, final analysis was undertaken and key findings identified (Figure 1).
Rigour and trustworthiness Four strategies were employed to enhance the rigour and thus trustworthiness of the study findings. Firstly, analysis ensured © 2014 Royal Pharmaceutical Society
Table 2 describes the participants who attended the six focus groups. As potential participants were identified by staff in the organizations, the number who were approached to participate is unknown. Three groups had two participants each, one had five participants, one had six and one had eight. Analysis revealed the emergence of two overarching themes: ‘personal and relational factors’ and ‘service awareness’, each with their own subthemes. The relationship with the community pharmacy staff and the size of the pharmacy influenced opinions of community pharmacy as a whole, as did the awareness of the services available from the pharmacy and any previous experiences regarding availability of medicines.
Personal and relational factors Relationship Positive opinions were expressed of patients’ experiences of community pharmacy services and the relationships that they had with pharmacists within them. Central to the positive nature of these relationships were issues of confidence/ trust (Table 3, quotes 1 and 2). The issue of confidence and trust in the relationship was supported or undermined by a range of other experiences. These were of value in themselves but also provided the foundation for confidence and trust. These included the degree to which they were known by staff, whether a noncommercial approach to selling was being used, whether the staff showed respect, and the degree to which provision was personalised. Participants particularly valued a sense of being known by pharmacy staff, and this helped provide assurance of continuity of care (Table 3, quotes 3 and 4). The value of the relationship and the trust and confidence imbued in it appeared to be supported by pharmacists’ behaving in a reasonably noncommercial manner by explicitly putting patient interest first before profit despite their commercial basis. For example, a number of participants indicated that they valued pharmacists who do not try to sell International Journal of Pharmacy Practice 2015, 23, pp. 121–130
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Older people’s opinions of community pharmacy
Pilot focus group
Steering group
Focus group 1
Wider reference group
Recorded and transcribed. Analysed to identify themes.
Focus group 2 Focus group 3
Themes explored further in next group.
Focus group 4 Focus group 5 Focus group 6
Final themes identified Five community groups
Further discussion and confirmation with five community groups. Field notes taken. Final analysis conducted.
Figure 1 Table 2
Study methodology. Sample description
Sampling criteria
Sample description (n = 25)
Gender Medical need
10 men and 15 women 10 people had a high level of medical need (attendance at day hospital, MacMillan input) 6 people lived in rural communities, 14 lived in urban settings, residence of 5 was undefined 17 people described experiences of living with common long-term conditions (chronic obstructive pulmonary disease, Alzheimer’s disease, Parkinson’s disease, heart conditions) 14 people expressed feelings of little or no social support, although most acknowledged that they have some family involvement and/or family carers; 7 people described themselves as caring for another older person (one of these was under 65 years old)
Rurality Diagnosis
Social support
the most expensive product, or who do not try to sell anything at all (Table 3, quotes 5 and 6). Participants described pharmacists as having positive attitudes and viewed respect towards older people by community pharmacy staff as a valued part of the service provided (Table 3, quote 7). Participants gave examples of the types of personal service they particularly valued, including delivering other necessary items alongside medication for those with poor mobility and making home visits to those who are housebound (Table 3, quotes 8 and 9). © 2014 Royal Pharmaceutical Society
Many participants were not aware of the communication between community pharmacists and general practices. Those who were aware expressed satisfaction with the communication, recognising the importance of this in ensuring that contra-indicated or interacting medicines were not prescribed (Table 3, quotes 10 and 11). Small versus large stores Participants voiced a perception of different levels of service provided by independent pharmacies and larger national chains. Independents were perceived to provide more personalised service and advice (Table 3, quotes 12 and 13). In particular, big queues in large national pharmacy chains were off-putting (Table 3, quote 14). Some participants valued the opportunity to buy products within pharmacies, e.g. toiletries and cosmetics, while others felt this detracted from the role of the service (Table 3, quotes 15 and 16).
Service factors The structure of service provision and the range of services available appeared to be important to many participants. This included awareness of services, stock availability, and pick-up and delivery service. Awareness of services There was a general lack of awareness of the range of services available within community pharmacies, with some participants only recognising the dispensing role (Table 4, quote 1). International Journal of Pharmacy Practice 2015, 23, pp. 121–130
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Table 3
Personal and relational factors
Quote number 1
2
3 4
5 6 7
8 9
10
11
12
13
14
15 16
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Quote E1: ‘They go all the way through to the young girl who’s just started.’ E2: ‘They’re all very good.’ E1: ‘When I go to the chemist, I go to my chemist with confidence that I’m going to get looked after by confident people.’ F5: ‘When that rash started like spots, it was like bites . . . so I says “We’ll go and have a wee chat to the chemist,” right, and they . . . had a look and have a wee talk to you, right, then gave you whatever and “Come back” they’ll say, and if it doesna clear up then you can go to your GP. So it’s really reassuring, isn’t it?’ E1: ‘The other thing is you go in and they know your name – it’s not a pub, it’s the place where they know your name and that’s my chemist.’ B1: ‘It’s the personal touch as well.’ B3:‘ I think if you go to the same one all the time it helps.’ B1: ‘Definitely helps but there are three different pharmacists in the one I use. The service is the same . . . whether it’s the owner or [the] two employees the service is still the same. They still know who you are and they know to phone you, I’m very impressed with it anyway.’ B1: ‘In spite of the fact their shop is there to sell things they don’t try to sell you the expensive things . . . and in fact they can recommend something cheaper for you, for long-term ointments, say.’ E2: ‘You know they weren’t trying to sell you something.’ E1: ‘They’re very friendly about it, and on those occasions when I made mistakes I left the place feeling reasonably happy. I didn’t feel . . .’ E2: ‘Stupid.’ E1:‘Stupid or guilty.’ E2: (laughs) E1: ‘Not more than usual but . . . I wasn’t paraded in front of everybody and made a fool of . . . I realise I’m a mature man, an old man now, but they’re very good.’ A1: ‘Every Thursday she comes with a bolster pack, you know, for your pills, and if you need anything you can phone when she’s coming up, like toothpaste or anything, and she brings it up.’ E2: ‘At one point . . . [my sister] had . . . new medicines she had prescribed and she felt very ill after it and the chemist . . . went down to my sister’s and spoke to her about the medicine and stuff . . . and gave her a wee bit of confidence to try it for a couple of days.’ B1: ‘There was a mistake made with my prescription at the doctor’s end and I pointed it out at the surgery, nothing happened; it was wrong the next time, told the pharmacist . . . it was fixed. The wrong strength of tablets, which was very important. . . . Most of us are sort of independent. I never thought for one minute of saying to the pharmacist, you sort it out with . . . the doctors. . . . That’s quite useful now’ E2: ‘My sister, she has . . . very bad stomach problems and she is allowed to take Gaviscon . . . and there was one time they sent down, is it a . . . generic . . . and she felt quite ill after it. . . . But I don’t know if the chemist can say to the doctor, “Look, I’m sorry, this patient isn’t happy with this at all.” ’ E2: ‘I went into [national pharmacy chain] and asked and the girl said “Well, that’s all we’ve got over there,” sort of thing.’ Fac: ‘So it’s not the same level of service?’ E2: ‘Oh, no.’ Fac: ‘If the [national chain] that you mentioned was closer to home, do you think you would go in there or would you maybe look for a kind of local chemist?’ E2: ‘I think actually I would look for a chemist, a chemist chemist.’ E1 :‘I’d go for a local one.’ E1: ‘But . . . at one time or another . . . I went into [national chain] with a prescription, and I’ve never been back because I hated the size of the queues.’ E2: ‘Yes.’ E1: ‘And it wasn’t very sympathetic, so I prefer to go back to my local chemist.’ E1: ‘Well . . . going into other chemist shop you feel that, “Oh, this is a cosmetic shop, this is something different, it’s not geared up for me as a patient.” ’ F6: ‘I love all the chemist shops. I like . . . the hair products and body lotions . . . and things for the skin. I could spend ages in the chemist, ages and ages.’
For presentation of results, the focus groups have been randomly assigned the letters A to F. Within the focus group respondents have been randomly assigned a number. ‘F6’ represents the sixth person in focus group F, for example. Note on language: ‘Chemist’ is used throughout interchangeably with ‘pharmacist’ or ‘pharmacy.’ ‘Bolster’/‘blister’, a monitored dosage system. Scots ‘wee’, English ‘small’ or ‘quick’. Scots ‘doesna’, English ‘does not’. Fac, facilitator.
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Table 4
Older people’s opinions of community pharmacy
Service factors
Quote number 1 2
3
4
5
6 7
8 9 10
11 12
13
14 15 16
17
18 19
Quote A2: ‘No, no, the chemist is only the pills.’ E1: ‘The sort of thing just now is my voice is going and I’m getting . . . chesty, so I can go to the chemist and say “This is what’s happening,” and he would recommend something to me, which means I don’t have to go to the doctor’s for that, but if it were to go on for a longer time then I could go to the doctor’s . . . a person with different qualifications.’ F4: ‘Sometimes you feel that whatever it is, you can’t really bother the doctor with it.’ F5: ‘That’s right, it’s, you feel it’s just a wee thing.’ F6: ‘Go and ask the chemist.’ F4:‘If you should be bothering the doctor then he’ll [the chemist] tell you to.’ F4: ‘[Yeah], I’ve used that.’ F6: ‘No, never used that.’ F5: ‘How do you get that, like, what do you do?’ Fac: ‘Just usually a form you’ve got to fill out, usually ask at the desk and fill out a form.’ F5: ‘Where do you get that form then?’ Fac: ‘Usually just the chemist’s.’ F6: ‘That’ll be one of the bigger ones.’ Fac: ‘I think they all do that, I think.’ F5: ‘And they’ll tell you what they can do, what’s available, like what they can. . .’ Fac: ‘They’ve got a list of medicines that they’re allowed to give without having to go through a doctor.’ B1: ‘I think it’s fine . . . The dentist told me what to use and when I went into the chemist to buy this, he said “. . .You can get that in from [Minor] Ailments”, and . . . I’ve used it a couple of times since quite successfully . . . Essentially I mean some of these things that you’re buying across the counter 5 or 6 pounds at a time, when you’re entitled to free prescriptions you . . . don’t want to go to the doctor, you know what you need or the chemist can tell you what you need, and I found it useful . . . The service is good.’ F6: ‘You get the Zantac and in [national pharmacy chain] they said to me one day, they said, “Our own make . . . is the same thing and they’re so, and they’re a lot cheaper than what the actual Zantac are”, you know, and that’s good.’ C1: ‘One bad thing that happened to me last winter, I went for my usual prescription, which is . . . forget the name of it now (pause), just the usual thing for my chesty cough, and one of the pharmacists served me . . . She says “Oh, you can’t take that with your drugs”, so she told me what I had to take.’ B2: ‘If I’ve got the cold or flu there is some things that I can’t take because of the medication that I do take. I can’t get the information in [supermarket]. Therefore I go to, I’ve got to go to a chemist to get advice.’ B1: ‘I think it should be handled by the pharmacist. If that means the pharmacists have to open additional hours, so be it.’ E1: ‘If they had a bigger shop, yes, they could provide bigger services. I would not feel happy about (sighs) going to a chemist for a health check. I wouldn’t mind vaccinations or inoculations. Blood tests (long pause), not sure about that. I feel that if I go to a doctor’s surgery and the nurse takes my blood everything is spot on for cleanliness and procedures. Whereas I think if you go to a chemist shop or pharmacy and there is something else happening in there, it’s just another service, I don’t know whether I’d get the same standard.’ E1: ‘I don’t think the chemist has facilities for giving me a health check. . . . The shop is a bit too crowded, I think, for that sort of thing. Also I would be very conscious of people that are able to hear what you’re saying.’ Fac: ‘If you thought [health checks were] being offered . . . at your local chemist, would you take it up?’ F5: ‘Yeah I would, saves you going into the doctor and waiting to get an appointment and phoning at eight o’clock in the morning to see if you can get one and . . . I would, I would definitely, just walk in and get it done.’ B4: ‘I went in last Friday, and I actually felt the pharmacist was quite rude and abrupt. “Come back tomorrow for one”, and I said, “Well, can I take the others today?” and he turned and said to the girl beside him, “Can’t she come back this afternoon for it?”, which would have been a six-mile trip into town again in the afternoon and then again the next day for any others.’ B1: ‘I know they’ve done that in the past, borrow from [national pharmacy chain] across the road or something like that.’ B1:‘Sometimes they don’t have the total quantity. They give me part quantity and immediately offer to deliver the others and phone me if there’s any problem.’ B4:‘I don’t have to order it, but as it’s prescriptions he’s getting on a regular basis you would think that they would.’ B5: ‘They would hae them in stock and they didnae hae them in stock.’ B4: ‘But even just a phone call, you know, to say they’re not ready so . . . save you a journey.’ D4: ‘If you’re not in, he’ll, well, I’ve got a wider letterbox so he puts it through the door.’ D6: ‘Well you see they wouldnae . . . put that through the door, you know what I mean. So you were having to phone up and say you were gonna [going to] be in . . . and at that time I’d had both my eyes cataract and there was nurses . . . coming four times a day putting drops in eyes.’ D8: ‘Aye, I know what you mean.’ D6: ‘But . . . it seems that you’ve got . . . to collect it and you’ve got to be the one that. . .’ E1: ‘Well, they collect my prescriptions demands and they deliver the prescriptions at their shop so that they are virtually missing out my visits to the surgery.’ B1: ‘With the prescription (eh) they have offered to deliver them permanently so that I don’t need to go for them at all, but I don’t want that ’cause that keeps me willing to go out, so it’s matter of choice that I go. It’s actually a mile and a half from the chemist but (eh) I must say (eh) the service I get is impeccable, it really is.’
For presentation of results, the focus groups have been randomly assigned the letters A to F. Within the focus group respondents have been randomly assigned a number. ‘F6’ represents the sixth person in focus group F, for example. Note on language: ‘Chemist’ is used throughout interchangeably with ‘pharmacist’ or ‘pharmacy.’ ‘Bolster’/‘blister’, a monitored dosage system. Scots ‘wee’, English ‘small’ or ‘quick’. Scots ‘doesna’, English ‘does not’. Fac, facilitator.
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The services that were discussed and valued most frequently by the participants were the provision of advice about medicines and minor ailments, counter-prescribing and functioning as a point of first contact before the GP (Table 4, quotes 2 and 3). Only a small proportion of the participants had heard of the Minor Ailments Service (a service that allows specific groups of patients, including older people, access to a range of medicines for minor ailments free of charge from community pharmacies) (Table 4, quote 4). Those who had heard of it had become aware through the suggestion from pharmacy staff. The service was described as a service that allowed them to avoid GP appointments while minimising cost (Table 4, quote 5). Some participants highlighted that pharmacy staff could also assist in minimising cost by providing advice on cheaper generics when they were self-medicating (Table 4, quote 6). Examples were given of the types of advice given by community pharmacists, including advice on over-the-counter medicines and their potential interactions with prescribed medicines (Table 4, quote 7). Despite acknowledging the convenience of being able to purchase over-the-counter medication in other locations, e.g. supermarkets, some people expressed a preference for pharmacies to be allowed to sell all medicines so that advice is available (Table 4, quote 8). However, it was recognised that this might require review of opening times at weekends and evenings (Table 4, quote 9). People expressed some ambivalence in attitudes towards potential new (or in some cases existing) services such as health checks or vaccinations. Specific concerns included cleanliness and privacy (Table 4, quotes 10 and 11). However, the ability to walk in without making an appointment sounded appealing to others (Table 4, quote 12). Stock availability Participants highlighted issues around stock supplies, resulting in them having to make repeat journeys to complete their prescription. This was often compounded by the distance between home and the pharmacy (Table 4, quote 13). It was recognised that some pharmacies tried different solutions to limit inconvenience, e.g. borrowing from another pharmacy or arranging for the items out of stock to be delivered (Table 4, quotes 14 and 15). However, participants found it harder to understand stock supply issues relating to regular repeat prescriptions, regarding which they felt that pharmacies should be aware how much is required every month (Table 4, quote 16). Pick-up/delivery There was much discussion within the groups regarding variation in the ordering, collecting and delivery services © 2014 Royal Pharmaceutical Society
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provided by community pharmacies (Table 4, quote 17). Participants wanted different options for collection of prescriptions and delivery of medicines. Some people chose to keep walking to the community pharmacy to keep them active. Others valued being able to get medication delivered to their home (Table 4, quotes 18 and 19).
Discussion The study participants emphasised personal and relational factors, such as being treated with respect and continuity of service provision, as important aspects of using a pharmacy. These factors were felt to contribute to building trust in the services provided, and the lack of this kind of relationship adversely affected the experience of using large stores compared to the experience of using smaller pharmacies. These data do not suggest that there are marked differences in the experiences of people living in rural areas compared with those in urban areas, although large stores are more likely to be found in town centres. Participants also demonstrated a lack of awareness of existing services available from community pharmacies. Systems of prescription ordering, collection and delivery caused much discussion, and a lack of availability of common medicines led to negative experiences being described. Participants wished to maintain their independence as far as possible, and this extended to activities around medicines management. The purposive sampling resulted in a cross-section of the local population participating in the focus groups. Representation was gained of rural and urban population, as well as housebound and independent-living people with common long-term conditions. The use of day hospitals and day centres allowed access to hard-to-reach people who would not have been able to attend without ambulance transport. The sample size was relatively small, and the original aim was to include at least 30 people in the focus groups. We experienced poor recruitment to three focus groups. However, the small numbers did not appear to inhibit freeflowing conversation and interaction. A larger number of participants may have revealed new issues. However, it was felt that as no new themes were emerging by the final focus group, data saturation had been reached by this point. Field notes taken at further public consultation events allowed ratification of the themes with a wider group of people. Participants from minority ethnic groups did not attend the groups. This is a reflection of the local population of older people, and further work is required to ascertain the opinions of older people of minority groups. The people who attended the groups generally were already prescribed repeat medicines. The results therefore may not reflect the views of older people who do not take repeat medicines but who use community pharmacies for other services such as health promotion. The opinions of some carers and a International Journal of Pharmacy Practice 2015, 23, pp. 121–130
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wider range of people were included through involvement in the public consultation events. A larger proportion of respondents lived in urban settings than in rural, reflecting the local demography. However, analysis of the data does not suggest that the level of rurality affected the experience of community pharmacy other than the cost involved in accessing services (e.g. in time taken) when repeated journeys to the community pharmacy were required. The type of pharmacy (independent, large national chain, etc.) utilised by the participant was more a determinant of the experience. Continued participation in everyday activities, such as using local community facilities, and the maintenance of good physical health are known to be important for reducing isolation, increasing self-esteem and maintaining good mental health for older people.[18] Community pharmacies in Scotland provide a range of services, including health promotion and advice and treatment for minor ailments, and are integral to many local communities.[13] In the context of current European strategies to empower communities,[19] community pharmacies can also be seen as part of the infrastructure necessary to ‘allow others to discover their ability and competencies to manage their own lives’ by the provision of technical expertise.[20] Indirect age discrimination has been defined as any ‘apparently neutral practice that disadvantages older people’.[21] In these terms, a large store that is easily utilised by younger people but is not as easily utilised by older people could be seen as discriminatory. It is interesting to note that this finding relates to the customer service within a large pharmacy store rather than the geography of the store itself. People in the study described enjoying the shopping experience; however, when continuity of pharmaceutical care and personalised service were being discussed, the experiences of using large stores were more negative. ‘The Right Medicine’[13] described the need for effective strategies to empower and inform patients and carers about medicines. The strategy recognised the important role of pharmacists in promoting independence and working to improve the quality of life of vulnerable groups, such as older people. The Chronic Medication Service provides a contractual methodology through which community pharmacists can assess the pharmaceutical care needs of patients with long-term conditions and work to improve the outcomes achieved from their medicines. The lack of awareness of services by some people in each focus group demonstrates issues with access to services from which older people may benefit. Similar results were also found in a recent study in the UK.[22] Communicating information about services in a format that reaches older people is necessary if the potential benefit to older people is to be realised. The current system of advertising services on posters and leaflets within the pharmacy seemed ineffective © 2014 Royal Pharmaceutical Society
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in informing the people in this study. Participants in this study would be happy to be offered services that might benefit them; word of mouth seemed to be a frequent way of finding out about existing services. This finding has important consequences for pharmacists, who should make the patient their first concern.[23] In order to provide the best care to older people, pharmacists need to take on an active role in promoting nationally contracted services to this age group. Pharmacies offer services that collect prescriptions from general practices and deliver the dispensed medicines to the patient’s home. Different pharmacies devise different systems to achieve a similar service outcome. The complexity of the diverse systems for collection and delivery of prescriptions was worked around by the people in this study rather than understood. A similar result was found in a recent study,[22] which concluded that people adapt to the systems available. People expressed different preferences for collection and delivery services. In general, where good communication was common practice, people had more satisfactory experiences of these services. The lack of availability of common medicines for immediate dispensing led to much discussion in the groups, and generally negative opinions and experiences were expressed. Older people who took multiple medicines were more likely to experience this problem. The lack of availability of stock for the major consumers of medicines has implications for the perception of the whole community pharmacy service, especially where the view of community pharmacy is encompassed by ‘The chemist is only the pills’. Better solutions to the ongoing problems of medicines supply in community pharmacy are needed. The two themes of personal and relational factors and service factors interlink. Good services build trust, and good relationships mean that the service is perceived to be good. Pharmacies that meet the needs of older people have a community focus. They provide a personalised service; help with cost minimisation for patients, including not selling medicines if they are not needed; and provide good advice. This is their unique selling point. A recent white paper from the Department of Health in England highlights that a potential overemphasis on the business side of community pharmacy needs to be balanced by a contractual framework that rewards clinical activity.[24] The perceptions of people in this study were that some large pharmacy stores did not provide continuity of care or personalised services. Although these pharmacies might offer lower-cost medicines, the benefits of this cost minimisation were offset by the need to queue for services. This has implications for both rural and urban areas, as large pharmacies are widely distributed. Recent legislation in the UK emphasises that the need for new or relocated pharmacy services should be determined by the assessed need for pharmaceutical care within the local population.[25,26] In this International Journal of Pharmacy Practice 2015, 23, pp. 121–130
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context, the local demographics are an important factor for future decision-making, as smaller pharmacies in this study were perceived to provide better service. The WHO Health 2020 strategy for Europe states that ‘building the individual and community strengths that protect and promote health’ is a priority for reducing health inequalities.[19] There were some examples of community pharmacies already contributing to this in this study, as in the case of a housebound patient requesting toiletries as part of the prescription delivery service. This can be seen as a personalised service contributing to self-care. It would be interesting to see how much community pharmacy delivery services already contribute to self-care and support. The Reshaping Care for Older People in Scotland agenda emphasises that ‘growing community capacity that focuses on preventative and anticipatory support’ will improve outcomes for older people.[27] Participants expressed a wish to remain independent for as long as possible, and this extended to medicines management, with one particular participant declining offers of prescription delivery services in order to maintain his walks to the pharmacy as a regular activity. There is a growing recognition within the health and social care system that re-enablement is a necessity rather than a luxury for the future due to demographic changes.[27] The percentage of older people in the population is expected to rise, while the percentage of working-age people in the population (from which carers have traditionally been drawn) is expected to fall.[27] Maintaining independence in medicine-taking may well become even more important in the future as services have to evolve to work with people to enable them to do for themselves what is currently being done ‘to’ or ‘for’ them. Assets-based approaches to support medicines management by older people are a required practice development. Within NHS Scotland, the launch of the Healthcare Quality Strategy has committed all NHS Services to develop mutually beneficial partnerships with patients and their families that respect individual needs and values, demonstrating compassion, continuity, clear communication and shared decision-making.[28] It is clear from the results of this study that some community pharmacies are already achieving this in terms of personal and relational factors.
References 1. Department of Health (UK). Medicines and older people: implementing the medicines-related aspects of the NSF for older people. London: Department of Health, 2001. © 2014 Royal Pharmaceutical Society
Conclusion This study provides a reference point to inform what is ‘reasonable and adequate’ provision of community pharmacy services for older people. The study enabled some insights into what older people value about community pharmacy services, what creates problems and confusion for them, and how these services might contribute to delivering policy initiatives of the Scottish Government. In particular, pharmacies can work towards maintaining independence in medicinestaking for older people through building relationships and having a community focus. The prominent issues surrounding out-of-stock medicines and collection and delivery services were important factors perceived as decreasing the value achieved from community pharmacy. Participants described a preference for ‘smaller pharmacies’ where continuity of the relationship with the pharmacist was achieved. Pharmacies situated close to where people live were perceived to offer more desirable standards of service.
Declarations Conflict of interest The Author(s) declare(s) that they have no conflicts of interest to disclose.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Acknowledgements We would like to acknowledge the work of Lorna MacRae in the transcription of the data. We would also like to thank all the staff and charities who helped organise the groups and the participants for their time.
Authors’ contributions All authors designed the study. KW and FG conducted the focus groups and undertook initial analysis of the data. AR and BW then further checked interpretation and coding. KW drafted the paper.
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