GPs’ and pharmacists’ views of integrating pharmacists into general practices: a qualitative study

Background Practice-based pharmacists (PBPs) have been introduced into general practice across the UK to relieve some of the pressures within primary care. However, there is little existing UK literature that has explored healthcare professionals’ (HCPs’) views about PBP integration and how this role has evolved. Aim To explore the views and experiences of GPs, PBPs, and community pharmacists (CPs) about PBPs’ integration into general practice and their impact on primary healthcare delivery. Design and setting A qualitative interview study in primary care in Northern Ireland. Method Purposive and snowball sampling were used to recruit triads (a GP, a PBP, and a CP) from across five administrative healthcare areas in Northern Ireland. Sampling of practices to recruit GPs and PBPs commenced in August 2020. These HCPs identified the CPs who had most contact with the general practices in which the recruited GPs and PBPs were working. Semi-structured interviews were recorded, transcribed verbatim, and analysed using thematic analysis. Results Eleven triads were recruited from across the five administrative areas. Four main themes in relation to PBPs’ integration into general practices were revealed: evolution of the role; PBP attributes; collaboration and communication; and impact on care. Areas for development were identified such as patient awareness of the PBP role. Many saw PBPs as a ‘central hub–middleman’ between general practice and community pharmacies. Conclusion Participants reported that PBPs had integrated well and perceived a positive impact on primary healthcare delivery. Further work is needed to increase patient awareness of the PBP role.

community pharmacies will also agree. 17,18 Therefore, sampling was initiated by contacting three GPs (known to two of the authors), to ask them to identify potential GPs and PBPs whom they knew and who might be interested in the study. These GPs asked permission from these potential participants to share their contact details with the researcher (the first author). In turn, during the interviews, a recruited GP and PBP were asked to nominate and suggest the name of a potential CP participant with whom the practice had most contact. The researcher contacted that pharmacist using publicly available contact details. Therefore, triads were recruited, each consisting of a GP, PBP, and CP, from across the five Health and Social Care Trust areas in NI (that is, administrative healthcare areas in NI) with a view to recruiting up to three triads per area and one triad per practice.
The researcher invited potential HCP participants by telephone/email. If interested, the researcher provided a formal invitation letter and information sheet. Interviews were conducted with the GP and PBP within the potential triad when both the GP and PBP agreed to participate. If a CP within a triad did not agree to participate, the GP and PBP interviews were retained for analysis and it was noted that a CP could not be recruited.

Data management and analysis
All interviews were recorded, transcribed verbatim, and checked for accuracy. To ensure anonymity and confidentiality, each participant was assigned a two-digit identification number reflecting the triad with which the participant was associated (for example Triad 1: GP01, PBP01, CP01). Transcripts were imported and managed in NVivo 12 Pro.
Data analysis, using thematic analysis, 30 was performed in parallel with data collection by two independent researchers. Data from interviews with each type of HCP were analysed separately to monitor data saturation within each HCP category. Themes were reviewed and refined by the research team. The quality and rigour of research reporting was closely monitored (Supplementary Table S1).

RESULTS
Eleven triads were recruited from across the five administrative areas (Table 1), at which point data saturation was deemed to have occurred. A CP in one triad from the Western Trust was unable to participate because of COVID-19 vaccination workload; however, the GP and PBP interviews were retained for analysis. Of the 32 interviews conducted, most were undertaken by telephone (n = 22), with the remainder using Microsoft Teams.

Demographic data
In total, 11 GPs, 11 PBPs, and 10 CPs participated ( Table 1). The participants' demographics demonstrated variety in terms of key characteristics relevant to the research as they were recruited from a range of geographical areas (that is, five administrative areas; see Supplementary Information S4 for more details about demographic data). At the time of the study,

How this fits in
Little is known about primary healthcare professionals' views on the impact of practice-based pharmacists (PBPs) in general practice. Participants interviewed in this study reported that PBPs had integrated well and perceived a positive impact on primary healthcare delivery. The findings indicated that continued integration would need PBPs, all members of the practice team, and community pharmacists (CPs) to understand each other's roles well and to communicate clearly to ensure the delivery of efficient PBP-led patient care. A number of areas for development were identified, such as patient awareness of the role and communication pathways between PBPs and CPs. most GPs (n = 8, 73%) had two PBPs working part time in their practices. More than half of participating PBPs (n = 6, 55%) had been working as a PBP for >2 years. CPs had been in community practice for an average of 18.1 (standard deviation 11.1) years.

Main themes from thematic analysis
Thematic analysis revealed four main themes in relation to PBPs' integration into general practices. This study found that the evolution of the role; PBP attributes; collaboration and communication; and impact on care contributed to integration of PBPs into general practice. Furthermore, integration and impact on care were interrelated (as indicated by the doubleheaded arrow in Figure 1) in that integration led to an impact on care, and impact on care contributed to better integration. PBPs and GPs reported that conducting chronic disease review clinics (see Supplementary Information S5 for definition) in general practice would continue to be an expanding and evolving role for PBPs, with better integration as they undertook more clinical roles. However, there were workload pressures and time constraints that sometimes prevented this happening, leading to prioritisation of medication reconciliation and medication reviews: 'I feel practice pharmacists have a very good knowledge base and very good capability and skills to be able to contribute to the long-term management review clinics but sometimes that is not possible because their time is needed elsewhere in the medication reconciliation process and medication reviews in general.' (PBP05) PBPs reported that time was wasted doing some administrative tasks that could be passed to pharmacy technicians to allow the PBP to do more clinical work and ultimately achieve better integration:  '… get away from the hospital letters, start the technician role, get more clinics, see more patients that would be for me a better integration.' (PBP10) In addition, GPs revealed that having more full-time PBPs in general practice would allow more activities to be undertaken: 'Our practice-based pharmacists are busy … I suppose if we could have more full-time pharmacists that would be fantastic … there's a huge amount of work that could be done.' (GP06) Practices used different approaches to decide which activities the PBP would undertake. As PBPs were employed by a federation, this could influence what PBPs did. Participants described that there were 'two bosses', 'a blended approach', or 'dual function' to decide the activities of PBPs within general practices (that is, through the key performance indicators set by the federation and the needs of the practice): 'Sometimes it can be quite difficult because you nearly have two bosses; you have your federation boss and then you have your practice manager and your lead GP in your doctor surgery.' (PBP01) However, some GPs and PBPs believed that practices should have had more input into how they wanted the PBP to work within the practice: 'Full integration for me would really be where the role of the pharmacist is very much driven by the individual practice … so driving on the structure of the practice.' (GP05) Many participants highlighted a lack of awareness of the PBP role by others, including patients as summarised below.
GPs' awareness of the PBP role. GPs and PBPs emphasised that the PBP role had not been clearly defined at the beginning of the initiative. However, they reported this had evolved and was now much clearer: 'I think it has become much clearer over time … initially when the practice-based pharmacist was first introduced into the practice, we probably thought [of] some of the things that they could do and then after being with us, we were able to see more and more the value of them.' (GP08) Participants reported several benefits of collaboration between GPs, PBPs, and CPs: streamlining healthcare delivery, reduction in duplication of effort, rapid response to each HCP, and improved patient outcomes and safety: 'Ultimately collaboration will seek to reduce duplication of effort and ultimately, if we're working together synergistically for the patient, that will improve patient outcomes … it streamlines everything … and things are done so much quicker …' (PBP10) Most GPs and PBPs identified that having more formal meetings, involving the PBP in practice meetings and social activities, having full-time PBP positions in the general practice, and having designated times to communicate and to meet regularly would enhance communication, working relationships, and consequently achieve better integration: '… each time that a practice pharmacist has come to our practice, we have spent time developing these relationships and then, unfortunately, sometimes they've had to move on … and sometimes there's a reluctance to invest time unless you're sure that the pharmacist that you're getting is going to be there for long term.' (GP07)

'… being permanently employed within a practice is key … it [PBP role] needs to be a permanent role … so that GPs get what they want from practice-based pharmacists … and practice-based pharmacists can develop relationships with GPs and patients within the practice as well …' (PBP02)
Completion of PBPs' tasks. A number of PBPs highlighted the difficulties of covering too many practices and the effect on some tasks, for example, following up hospital letters: '… you would find it kind of hard to sort of go to one surgery one day and then go to another surgery the next day, we need to be able to build up relationship with other workers in the primary care team, but also be able to build it up with patients, and also some following up things, it just kind of sort of the hospital letters when you are and then that's you move on to the next surgery …' (PBP03) The response to CPs' queries. Some CPs described occasional delays in response if a PBP was not in the practice on a full-time basis: '… I have noticed that you know a surgery with a practice-based pharmacist, you get [a] response much quicker, whereas compared to a surgery that wouldn't have one or the practice-based pharmacist doesn't work that day, there will be delay sometimes.' (CP04) PBPs were considered to be in a perfect position to link between different professionals and to act as the first point of contact in general practice for CPs. Many saw PBPs as a 'central hub-middleman' between general practice and community pharmacies and between primary and secondary care. CPs felt that it was easier to communicate with the PBP as opposed to GPs who had historically dealt with queries from CPs: 'I'm sort of the middleman … I pass all that information into our community pharmacy to make sure that they can order the right items for the patient …' (PBP01) '

Theme 4: impact on care
GPs and PBPs reported that PBPs reduced GPs' workload and saved time by conducting activities previously performed by GPs. As a result, this provided the GP with more time to see patients, resulting in better patient care: 'They [PBPs] have given us more time … we're not trying to terminate the consultation in order to do the huge pile of paperwork so we can do more work directly with the patient … and that the patient will get the benefit of that.' (GP06) Furthermore, GPs indicated that PBPs were an invaluable source of information, ensuring that GPs were aware of the most current guidelines.
'They [PBPs] are a great source of information … they are able to sit down and look at the drugs and really take the time to go through them properly … they are very up to date as well on the guidelines, as well quite a lot of time they are keeping us up to date with the guidelines …' (GP10) GPs and PBPs also reported that PBPs' activities enhanced patient safety as they had more time to focus on hospital discharge letters, chronic disease review clinics, and queries from community pharmacies and secondary care. These activities reduced interruptions experienced by GPs during their work and ultimately reducing the risk of errors. GPs also reported that the PBP was detail oriented: 'It has made our life better and safer and more pleasant … it has done that for me when you're coming into a busy day and they're at the end of it, you have maybe got sixty letters to process, you know, mistakes are going to be made with tiredness and with just too much volume of stuff … so there's attention to detail and having a bit more time …' (GP03) Participants indicated that the PBP had a critical role in medicines optimisation, particularly for the older population who were at higher risk of adverse drug events and those with polypharmacy: 'I feel like medicines optimisation is kind of our main role … our medication review specifically wants to focus on those patients with polypharmacy … those that are frail and elderly …' (PBP06)

DISCUSSION Summary
This qualitative study highlighted that the PBP role had evolved since its introduction across general practice in NI and the PBP role has had a positive impact on GPs, CPs, and patients. Insights were provided into participants' views on what had contributed to integration (for example, a good GP-PBP collaboration) as well as aspects that required further attention (for example, patients' awareness of the role) to ensure better and continuing integration of PBPs into general practice.

Strengths and limitations
The qualitative design and the triad approach provided a more comprehensive overview of the working relationships between the three HCP groups and allowed for an in-depth and thorough understanding of participants' views. Data were analysed independently by two researchers and decisions were made on the themes through a consensus approach, enhancing the trustworthiness of the findings and in accordance with the COREQ checklist. 16 A number of limitations should be noted. First, recruitment was limited to one UK geographical region. Most participants were recruited through snowball sampling that may have introduced potential bias. No PBPs were interviewed who had previously worked in hospital pharmacy (that is, all had a community pharmacy experience), which could affect the transferability of the findings. However, despite this, three key HCPs from different NI trust areas were included and their perspectives are broadly similar to those reported in the literature, thereby reinforcing the transferability of these findings.

Comparison with existing literature
In this study, it was apparent that the PBP role varied between practices and there were several activities undertaken by PBPs that have previously been identified. 12,24,26,[31][32][33][34][35][36][37][38][39][40] However, insufficient time and current workload were perceived as barriers to undertaking some activities and have been noted in other research. 23,34,38,39 Integrating pharmacy technicians into general practice was suggested as a way to save PBP time to conduct more clinical work and thus make better use of PBP skills. Previous studies have shown that there is the potential to expand the role of pharmacy technicians in the UK to become more involved in the future delivery of medication reviews. [39][40][41] Lack of patient awareness of the role was highlighted by nearly all participants. As the PBP role was relatively new and varied between GP practices, participants believed that patients did not understand the difference between CPs and PBPs, which is consistent with other studies. 21,25,[42][43][44] Nearly all participants in the current study emphasised the need to properly inform patients and primary care team members about PBPs, including roles and responsibilities, to raise patients' awareness and therefore encourage the uptake of PBPs' services, ultimately leading to better integration of the PBP. 20,34,38,39,42,44 Further work to explore patients' understanding and views of the PBP role in general practice is necessary to corroborate the participants' concerns in the current study.
Awareness of the PBP role was one of the key aspects that requires further attention to achieve better integration. This current study indicates that, although most GPs were aware of the role, participants reported that a minority were not. Furthermore, the PBP role was not entirely clear to CPs, which has been previously reported. 21,45 Clearly defined roles improve collaboration and decrease misunderstandings about responsibilities and authority. [46][47][48] Consistent with the findings in this study, previous studies highlighted that scheduling meetings with individual team members was a common approach to informing the team about the role. 49,50 Having full-time PBPs was described as a way to enhance communication. Many highlighted the advantage of having a full-time PBP to build and develop strong relationships and ultimately better integration into a team. This has been reported elsewhere. 23,24,33,34 Working across many practices could possibly lead to a lack of continuity, thus hindering integration, 11,40 while also having an impact on tasks such as managing repeat medication re-authorisation. 39 A previous study found that patients reported difficulties in arranging appointments with PBPs who covered multiple practices. 23,42 The findings of this current study have indicated that PBPs are ideally placed to use their skills and knowledge to help the GP practices and liaise with CPs. Evidence has shown that PBPs provide valuable services to ease the burden on the GP and reduce patient waiting times. [51][52][53] In the current study, it was perceived that PBPs had an impact not only on GP workload but also on patient safety and care, and medicines optimisation. These are reassuring findings as, for example, 20% of hospital admissions among older people are the result of adverse effects of prescribed medications. 54

Implications for practice
There are a number of recommendations for practices based on the results of this study. As the role of the PBP is expected to expand to include more clinical patient-facing roles, pharmacists must be prepared for this. New standards for the initial education and training of pharmacists across the UK have been recently introduced, for example, qualified to undertake independent prescribing from the point of registration. 55 Furthermore, this study revealed that PBPs would need clinical skills to allow them to undertake their role and would need the confidence to be able to use these skills. A recently published Delphi study has produced a core set of clinical skills required for pharmacist prescribers working in general practice that could inform training. 56 However, expansion of the role and increasing patient awareness of the role may exacerbate workload issues. Therefore, having more PBPs and pharmacy technicians in general practice may help to address these demands.
A number of policies have been launched in the UK to expand the current integration of PBPs in general practice. [57][58][59] Therefore, the findings from this study provide valuable insights for policymakers, practice managers, and service commissioners into what is required to ensure better, efficient, and smooth integration of PBPs. The findings from this study may be useful in countries where consideration is being given to the development of pharmacist services in general practice.