Details of the 14 practices that took part in the process evaluation are shown in Table 1. A total of 17 IPCDs were audio-recorded across seven of these practices, discussing 30 patients. Multiple patients were usually reviewed and discussed as part of one IPCD; the length of IPCD audio-recordings ranged from 3 to 43 minutes depending on the number of patients recorded at a time (range 1–6 patients). In all, six GPs and 13 pharmacists (n = 5 practice, n = 5 PCN, and n = 3 study pharmacists) were interviewed across all 14 practices. Interviews took place in person (n = 1), by telephone (n = 5), or by video-call (n = 13), ranging in duration from 20 to 88 minutes.
Benefits of interprofessional collaborative discussions (IPCD)
GPs and pharmacists highly valued the IPCDs and described not only benefits but also some challenges.
Consolidates relationship between GP and pharmacist
GPs and pharmacists described the potential to feel isolated when working in primary care. When reflecting on usual care before the trial, GPs felt that pharmacists often worked separately, and pharmacists reported uncertainty about which GP to approach with medication queries in the busy primary care environment. Before the trial, communication was often ad hoc through electronic task messaging focused on single medication queries, often eliciting a ‘yes’ or ‘no’ response, and pharmacists described experiencing delays in receiving responses:
‘I think the risk in general practice is sometimes a role can be quite separate and it’s [IMPPP] really helped us in bringing us in together.’
(GP20)
Both pharmacists and GPs felt the IPCD brought them together and strengthened their relationship by getting to know each other and their roles, learning from each other, sharing values around deprescribing, and improved networking and communication. One pharmacist felt the trial enabled the GP to understand what they do. GPs described not necessarily working closely with pharmacy in usual care, whereas the trial enabled them to get to know their colleagues. The IPCD improved communication between practitioners and several GPs reflected that they now worked better as a team:
‘It improved the communication, the camaraderie as well with the doctors.’
(Pharmacist [PH] 16)
‘It’s definitely helped me understand her [pharmacist’s] role but also, I think it’s been really nice working as a team.’
(GP20)
‘… It’s probably strengthened my working relationship with [GP] and I guess it’s good for her to see what we do as well.’
(PH12)
Protected time allows discussion of the whole patient
GPs and pharmacists reported that the protected time afforded by the trial for the IPCD allowed two-way discussion as well as the opportunity to consider the whole patient, not just a simple medication query. Having a ‘dedicated’ GP was described as valuable because the pharmacist could check in with one person rather than having to identify someone to talk to within the practice. Protected time also allowed space for GPs and pharmacists to reflect on their own practice. One pharmacist described undertaking a more thorough review of patient notes and greater focus on deprescribing in preparation for the IPCD:
‘… I think because when you do it in that electronic way, you tend to just deal with that issue and move on. It doesn’t open up necessarily a dialogue […] when you’re doing it in a more dedicated way with focusing on each individual patient and looking at their whole pharmacology, not just maybe that a single medication that’s been flagged up as an issue — you get a much better idea of what’s going on with the whole patient.’
(GP5)
‘… It made you look at it a bit more in terms of because you’re preparing for the interprofessional discussion you are looking for things probably more thoroughly to discuss …’
(PH22)
Pharmacists reported coming to the IPCD meeting with notes or suggestions curated after assessment of the patient notes, and jointly discussing and reaching consensus with the GP on a plan to take to the subsequent review with the patient. Pharmacists and GPs described how GPs often had more in-depth knowledge of patients and the medication that might have been tried before. Some pharmacists took a leading role in the IPCD and felt GPs tended to have different insights into alternative strategies to try to reduce medication, including addressing lifestyle factors such as weight management (see IPCD audio transcript in Box 2):
‘… generally we just come to a consensus view, so there’s never certainly been any disagreements.’
(GP5)
‘… she’s [GP] more experienced than I am, she’s been doing it for much longer, so some patients she knows, so if I’m saying you know, so I can make this change and she’ll say “Oh we’ve tried that already, this was the outcome so maybe let’s try a different way.”’
(PH16)
‘She [GP] tends to just go with what I’ve suggested because it’s things that she’s like, “I wouldn’t know they needed a DOAC [direct oral anticoagulant] dose review.”’
(PH12)
The audio-recordings of the IPCDs (Box 2) supported the interview data showing how GPs and pharmacists had open discussions and reached consensus.
Helps manage complex patients and uncertainty
GPs and pharmacists described the IPCD as a highly valuable, helpful, and beneficial aspect of the IMPPP intervention. A more collaborative multidisciplinary team (MDT) approach was felt to be particularly important for patients with ongoing investigations or more problematic polypharmacy. This approach provided an opportunity to draw on knowledge, reflect and learn with colleagues, and to develop a plan before consultations with patients:
‘For problematic patients try to keep the MDT approach to it. So, like there’s targeted ones that we have that are difficult, so problematic polypharmacy […] to try and have a proactive chat about that beforehand because they’re difficult conversations to have and it is genuinely quite helpful to have a pre-plan.’
(PH14)
One GP felt that primary care is moving towards more multidisciplinary working and the IPCD was valuable for older patients with multimorbidity. Liaison with a colleague was particularly important when dealing with the clinical uncertainty that more complex patients bring. One pharmacist reported seeing benefits of the IPCD even after reviewing only a few patients. Some pharmacists wanted the IPCD to continue following the trial:
‘So it’s that judgement and the grey bit between the black and white of medicine. There’s a lot of grey and I think it’s helpful to discuss the grey bits with other colleagues because it helps you navigate more …’
(GP11)
‘I definitely value the GP discussion. I guess that’s the main difference compared to what I’m doing in my day-to-day role and I have seen a benefit from it, even in the very small numbers that we’ve done.’
(PH4)
A different perspective enables joint learning
GPs and pharmacists suggested that the IPCD enabled joint learning. GPs reflected that they respected pharmacists for their knowledge about drugs, including drug interactions, adherence, side effects, and current guidelines. Pharmacists felt GPs had a whole-person approach, and often raised things they had not considered. Some pharmacists felt they themselves had a more focused perspective compared with GPs, who looked at things more broadly and were more willing to suggest medication changes. The IPCD brought issues to the fore to ensure things were not missed:
‘I think the most valuable thing is actually is that clinical discussion with someone who’s got a different perspective to me, who’s a pharmacist, who has a lot more time and knowledge about drugs …’
(GP11)
‘I get my tunnel vision on and [GP] is able to say step back a little bit.’
(PH21)
‘… that interprofessional conversation allows me to talk it through with someone else because otherwise you’re left to your own devices […] that’s where you make a mistake.’
(PH16)
One pharmacist described the IPCD as a ‘very good learning event’ (PH4) and had altered decisions as a result of the discussions. One GP felt it allowed them to stay up to date with rapidly changing guidelines:
‘I’ve found it [IPCD] really helpful […] having someone to discuss things with is actually […] ‘cause guidelines and things are changing so rapidly it’s actually quite hard to […] say stay up to date.’
(GP11)
‘I was going to consider stopping amlodipine with the patient but actually when I spoke with GP, we decided to consider stopping his beta blocker […] I would say I changed my tack in terms of what I would’ve done had it just been me on my own without the GP.’
(PH4)
Joint learning was evident in discussions between GPs and pharmacists in the audio-recordings of the IPCDs (Box 3). There was shared knowledge of medication risks, patients’ previously known preferences, and seeking each other’s opinions while discussing patients.
Improved knowledge and confidence of pharmacists
Pharmacists described how the IPCD gave them confidence in their decision making and interactions with patients. It provided an opportunity to check and discuss potential medication changes with the GP, giving pharmacists experience of different deprescribing scenarios, improving clinical knowledge and therefore confidence in dealing with the same issues with future patients. Pharmacists felt that GPs were often more brave or assertive in making changes. Pharmacists often brought suggestions to the meeting that were confirmed by the GP, giving them reassurance in their decision making:
‘She [GP] was often a little bit more brave or assertive around changes, things that I wouldn’t probably have done which maybe in future will have given me a bit more confidence.’
(PH19)
‘… the conversation that [GP name] and I had was empowering for myself as well because he was happy with my comments and input. That brings a lot of confidence to me and what I’m doing.’
(PH24)
One pharmacist described being more confident in making decisions without checking with a GP:
‘… six months ago were impossible, changes that I wouldn’t have considered making without […] asking a doctor or asking someone to make a decision on, whereas I’m confident because I’ve seen it done multiple times and I can understand the reasoning behind it.’
(PH16)
Another pharmacist (PH22) also described how the IPCD as part of the trial had made them more confident to approach a busy GP for a chat in the future.
Additional reassurance provided to patients
Pharmacists also described this confidence extending to their interaction with patients as they had already formed a ‘pre-plan’ with the GP. Pharmacists and GPs both reflected that GPs were more likely to know the patient’s previous care and preferences. Pharmacists therefore felt more certainty following the IPCD to recommend potential changes to the patient. Pharmacists often emphasised the multiprofessional element of the review to patients, because they felt this helped to increase patient confidence and trust in any suggested changes to medication. Study pharmacists, compared with practice/PCN pharmacists, were more likely to emphasise this in order to build rapport with patients. It was felt that, though patients were getting used to seeing allied health professionals, some patients still wanted to know that the GP had been involved. One pharmacist recounted a patient who felt strongly that the GP needed to be involved in any decision making. Others reported how patients appreciated the additional time pharmacists had to discuss their medicines. Some practices had pharmacists who had been undertaking medication reviews for many years and patients seemed used to talking to the pharmacist. Study pharmacists (as opposed to practice/PCN pharmacists) were more reliant on GPs’ knowledge of patients:
‘You’re much more confident when you speak to the patients because I know what [GP name] thinks and then I can just follow that.’
(PH14)
‘I was just able to say “I’ve already spoken with your GP and we think it’s a good idea for you to start.”’
(PH14)
‘… particularly kind of elderly patients I think, they wanted to know that their own GP had been involved in this decision …’
(GP20)
‘… the patients have enjoyed the opportunities to really have a real sort of “deep dive” with me as a pharmacist with their medication.’
(PH4)
There was evidence in the IPCD recordings (Box 4) that GPs knew several patients well from previous interactions, including the patients’ adherence to medication and previous efforts at exploring alternative medications and deprescribing, which helped inform decision making.
Challenges of interprofessional collaborative discussions
Lack of time and wider practice engagement
Pharmacists reported finding time to fit in the IPCD discussion to be challenging, particularly those working across multiple sites. Though the trial did not require the IPCD to be in person, most practices felt it was important to have an in-person meeting and this could be difficult to arrange. Some pharmacists and GPs felt that the IPCD was not as valuable for less complex patients and pharmacists felt confident that they could deal with these patients on their own in routine care (though this did not adversely impact trial fidelity):
‘That’s the biggest restraint in general practice, isn’t it, is trying to fit it in and try and find time to do it […] coordinating across two sites was tricky because we decided to do it in person.’
(GP15)
‘Some of them [patients] were quite straightforward, which I’ll be able to manage myself.’
(PH22)
One pharmacist felt the IPCDs were often rushed and the GP had not prepared for their discussion:
‘… she’s [GP] good but it was often quite, I would say, a little bit rushed sometimes and there would be no preparation time on her behalf so it would be a bit like me presenting a case and study sort of thing and having feedback on it which was, you know, okay, but maybe it would have been different to see how she did it without my input.’
(PH19)
In most cases, only one GP and pharmacist in each practice were routinely involved in intervention delivery. Several pharmacists reflected that it would have been useful to involve more colleagues and/or everyone in the practice. This may have helped wider team relationships and improved understanding and engagement with polypharmacy:
‘… the main thing is having everyone engaged in the process, so sometimes I guess with the training it was two people from each practice so it’s probably really helpful like a prescribing masterclass session with everybody and, again, it helps just to engage people onto “this is what we’re trying to do” but it’s really hard with polypharmacy just because there’s like, I don’t know, 100 different indicators.’
(PH14)
