In total 44 pharmacists were invited to participate in the study. Sixteen responded, giving a response rate of 36.4%. The characteristics of participants are shown in Table 5. Data saturation was assessed after 15 interviews, and recruitment was continued to 16 interviews to ensure the number of interviews with pharmacists from the high- and low-giving quintiles was equal.
Interviews identified three main themes: pharmacy factors; public awareness; and external factors. These with the sub-themes and codes emerging under each are detailed in Table 6. The main themes, and most significant sub-themes, are discussed in a linear fashion; however, many are intrinsically linked. The perceptions of pharmacists giving comparatively high and low numbers of vaccinations are discussed together using illustrative quotes with participants identified by the codes H and L, respectively.
Pharmacy factors
How does pharmacy workload affect participation? Half of the pharmacists (n = 8) reported that workload was an important determinant of the number of vaccinations. In particular, having more than one pharmacist present helped by preventing disruption to the other activities:
‘... we’ve got two pharmacists here so it means that dispensing continues without disrupting the normal day-to-day activities.’
(H5)
Some (n = 8) reported prioritising vaccination over other services:
‘I did do less MURs [Medicine Use Reviews], part of that because I was doing vaccinations and had the other services to deal with.’
(L5)
One pharmacist gave an insight into pharmacies’ capacity to provide the service:
‘... there’s just not enough pharmacist hours in branch to do everything that pharmacists need to do … because we are busy you kind of don’t drive it as much as you could.’
(L5)
How do a pharmacy’s opening hours affect provision? A few pharmacists who provided a comparatively high number of vaccinations considered the availability of vaccination at weekends, at lunchtime, and in the evening specifically to be important determinants of vaccination numbers:
‘They also liked our opening times as well. They liked that you could come in in the evening and have it done.’
(H6)
‘I’ve got a friend who’s an electrician he’s working till half five at night goes out to work at half eight in the morning. He came to see me on a Saturday afternoon and had his flu vaccination.’
(H1)
This was corroborated by comments from pharmacists who gave low numbers of vaccines:
‘We don’t open on a Sunday … we close at lunchtime.’
(L6)
Pharmacists reported taking different approaches to delivery of the service and their role to support increasing vaccine uptake. These approaches can be split into two broad categories. The first, predominant among pharmacists giving comparatively high numbers of vaccinations, was to adopt a structured approach. This included ensuring that the pharmacy had facilities and processes that supported service delivery, improving efficiency, and maximising capacity to offer the service:
‘I think it was because I had everything to hand, everything laid out, I had all the paperwork. I planned the paperwork so I got each person that’s going to present I’ve already prepped 10 or 20 forms ready for them to turn up on a rolling basis.’
(H5)
‘We booked appointments to make sure we did have staff in that could deliver the vaccinations.’
(H8)
There are potentially many reasons why a pharmacy would adopt this approach. One pharmacist explained:
‘Every service we do we are quite keen that it’s gotta be profitable, there’s no point, we don’t see the point of doing something that doesn’t benefit profitability in any way.’
(H2)
Most pharmacists (n = 5) adopting a structured approach also implied that they were more responsive to people’s demands than were GP surgeries:
‘... you have to book an appointment at the surgery, there are only certain surgery times … so the patients liked it in terms of they could just walk in and have it straight away.’
(H6)
The second approach could be described as altruistic and was prevalent among pharmacists providing comparatively low numbers of vaccinations, who emphasised that providing vaccinations was, for the pharmacy profession in the UK, a recent development. These pharmacists took what they saw as a more public service (and ultimately conservative) approach.
Some of these pharmacists (n = 3) described offering a ‘mop up’ service, referring to only vaccinating people who had difficulty getting to their GP. These pharmacists deferred to GPs as the predominant provider:
‘We were always going to be a support service to them [GPs], for those people that couldn’t get to them for whatever reason.’
(L4)
They also avoided criticising practices’ vaccination arrangements and reported taking steps to minimise and avoid conflict with local GPs:
‘We could have more proactively promoted it but didn’t particularly want to step on the GPs’ toes.’
(L3)
Taking a more assertive approach was considered a risky strategy that would damage relationships with GPs, with a more substantial adverse impact on business in the longer term:
‘If you try and push too much it does get their back up a bit and when you’ve got good relationships, I know some of the big companies are really hammering it and what you gain there you lose in a lot of other things.’
(L8)
Only two pharmacists, however, reported that providing the service had had a detrimental impact on relationships with GPs:
‘... [the practice manager] was very much concerned with the fact that we were solely there to try and mop up.’
(L1)
‘Once they saw a lot of patients choosing to come here [to the pharmacy] straight away they got really, really defensive and made all kinds of sort of threats to try and stop me from doing it.’
(H4)
Positively, the second of these pharmacists reported that the local health board (LHB) provided mediation and that he had been able to work more closely with GPs afterwards:
‘The LHB sort of intervened and told the GP you can’t do that and suggested maybe they would provide us with a list of eligible patients that didn’t get it last year, which they did and that worked quite well. We were able to target those patients.’
(H4)
Some pharmacists (n = 4) reported that GPs had responded positively to the pharmacy providing the service, even encouraging people to use it:
‘The biggest surgery locally were directing people if they missed the GPs’ appointment, GPs’ days for doing vaccinations, were saying oh [pharmacist’s name] is doing it over in the chemist. If you go over there she might be able to do them for you.’
(H5)
A high number of pharmacists (n = 7) reported being unaware of strong views, either positive or negative, from GPs.
Over half of pharmacists (n = 9) thought that public awareness of pharmacy influenza vaccination was poor:
‘People didn’t know about the service.’
(L5)
‘… not terrific awareness for the NHS jabs, I think that missed out almost entirely. I’m struggling to think of people who came in and said I’ve heard you do NHS flu jabs, can I have one?’
(H7)
‘When we talk to people about it they are not always aware that we can do it. Stemming from that maybe an increased awareness would mean more people getting vaccinated.’
(H8)
External factors
Most pharmacists (n = 10) commented on the impact of various procedural delays. In particular, they reported that there had been a delay in receiving the Patient Group Direction (PGD), which provided the necessary authority to give vaccinations:
‘... we didn’t actually get the PGD until the week the service started.’
(L6)
‘... it was a very slow burner to start off but it was because the paperwork and all the sign-off for the PGD didn’t come through until after all of our local surgeries had already run their flu clinics.’
(L5)
Some pharmacists (n = 4), particularly those providing comparatively low numbers, thought preparation for the service had been poor, specifically identifying LHB disorganisation as a problem:
‘They [the LHB] don’t strike me as particularly organised. Stuff needs to get to us on time, well in advance really not just scraping through.’
(L7)
‘Everything came through from the Health Board fairly late on to be honest.’
(H7)
Of the pharmacists interviewed who had given a comparatively low number, half (n = 4) reported difficulties with securing adequate supplies of vaccine:
‘I kept on reordering and reordering. Eventually they just stopped coming in and then there was a shortage.’
(L5)
‘I’d say oh I’ve run out but I should have some in tomorrow you can try ringing about, and they never used to come back then … we’d have done more if we’d had the reliability of the supply chain.’
(L5)
Others (n = 2) reported that, although they were able to obtain vaccines, the costs of doing so resulted in a financial loss for the pharmacy. The result of this was that they faced a choice between meeting either their professional or commercial obligations. This was a scenario in which there was no satisfactory resolution:
‘I had to buy them [vaccines] in tens which meant that three of them were wasted. So I don’t know that I made any money at all last year but I’m not completely interested in that I’m also happy to provide a service … what do they [the LHB] want me to think when I open the new box, think I’m never gonna get rid of these 10 [vaccines], turn them [members of the public] all away … They’re risking us, risking us turning three or four people away.’
(L2)
