The public's perception of the role of community pharmacists in Wales

Objective To investigate the general public's perceptions of the community pharmacist's (CP) role in Wales by exploring understanding, awareness of services provided and potential interventions for promoting the role of CPs. Methods Qualitative methodology using focus group (FG) discussions exploring opinions, facilitated by a moderator (pharmacist) and an assistant. Topics discussed included the following: what a CP does; reasons for visiting; from whom they seek advice on medicines or lifestyle issues; use of traditional and newer services and promotion of services. The groups, totalling 32 participants, represented non‐users and users of pharmacy services, that is pupils from a local secondary school (x1 group), people from the local community (x3) and patients plus carers from a Parkinson's disease group (x1). FG discussions were recorded and transcribed verbatim, and analysis was undertaken to identify themes. Key findings Traditional dispensing and supply of medicines roles were clearly recognised, but poor awareness of the newer services emerged, particularly in public health roles. CP's professionalism was acknowledged, but there was confusion over where they ‘fit’ within the National Health Service or with General Practitioners, with concerns or misconceptions raised over the impact of commercialism on professionalism. Conclusions Based on these findings, the public is accepting of the extended role of CPs and would engage with CPs for a wider range of services. However, there is a lack of awareness of what public health services are available. Considerable work is needed to increase public awareness, during the strategic development of these services in Wales

Medicines prescribed by non-medical independent prescribers in primary care in Wales: a 10-year longitudinal study April 2011–March 2021

OBJECTIVES: The therapeutic classes of medicines prescribed by non-medical independent prescribers (NMIPs) working in primary care in Wales has not been studied in detail. The aim of this study was to conduct a 10-year longitudinal analysis of NMIP prescribing in Wales from April 2011 to March 2021. The study examined the British National Formulary (BNF) chapters from which medicines were prescribed by NMIPs, whether this changed over time, and whether there was variation in prescribing across the geographic regions of Wales. DESIGN: Retrospective secondary data analysis of primary care prescribing data. Monthly prescribing data for the 10 National Health Service financial years (April to March) from April 2011 to March 2021 were obtained from the Comparative Analysis System for Prescribing Audit software. Data were analysed according to BNF chapter, to identify in which therapeutic areas NMIPs were prescribing, and whether this changed over the study period. RESULTS: The number of items prescribed by NMIPs increased during the study period. From April 2011 to March 2021 prescribing in seven BNF chapters equated to approximately 80% of total items, with cardiovascular system medicines most prescribed. In the financial year 2011–2012 the BNF chapters with the greatest proportion of items prescribed were infection (18%) and respiratory system (13%), while in 2020–2021, these had changed to cardiovascular (23%) and nervous system (19%). The number of items prescribed in each health board in Wales varied, however, the BNF chapters contributing the largest percentages of items to the health board totals were broadly comparable. CONCLUSIONS: The BNF chapter with the most prescribed items changed from infection to cardiovascular during the study period, suggesting an increase in chronic disease management by NMIPs. The impact of this on the delivery of primary care services and patient outcomes is a focus for future work

Classic e-Delphi survey to provide national consensus and establish priorities with regards to the factors that promote the implementation and continued development of non-medical prescribing within health services in Wales

Objective To provide national consensus and establish priorities with regards to the factors that promote the implementation and continued development of non-medical prescribing within health services. Design Classic e-Delphi survey. Setting National study in Wales. Participants Pharmacists, nurses and allied health professionals with the independent/supplementary prescribing qualification. Results A total of 55 non-medical prescribers agreed to become members of the expert panel of whom 42 (76%) completed the round 1 questionnaire, 40/42 (95%) completed round 2 and 34/40 (85%) responded to round 3. Twenty-one statements were developed, and consensus was achieved on nine factors representing those necessary for the successful implementation of non-medical prescribing and five representing actions required for its continued development. Strategic fit between non-medical prescribing and existing service provision, organisation preparedness, visible benefits, good managerial and team support, and a clear differentiation of roles were each important influences. Conclusion Given the high degree of consensus, this list of factors and actions should provide guidance to managers and commissioners of services wishing to initiate or extend non-medical prescribing. This information should be considered internationally by other countries outside of the UK wishing to implement prescribing by non-medical healthcare professionals

Antibiotics for acute respiratory tract infections: a mixed methods study of patient experiences of non-medical prescriber management

ABSTRACT Objective: To 1) explore patients’ expectations and experiences of nurse and pharmacist non- medical prescriber led management of respiratory tract infections, 2) to examine whether patient expectations for antibiotics affect the likelihood of receiving them, and 3) to understand factors influencing patient satisfaction with respiratory tract infection consultations. Design: Mixed methods Setting: Primary care Participants: Questionnaires from 120 patients and follow-up interviews with 22 patients and 16 nurse and pharmacist non-medical prescribers. Results: Patients had multiple expectations of their consultation with 43% expecting to be prescribed an antibiotic. There was alignment between self-reported patient expectations and those perceived by non-medical prescribers. Patient expectations for non-antibiotic strategies, such as education to promote self-management, were associated with receipt of those strategies, whereas patient expectations for an antibiotic were not associated with receipt of these medications. ‘Patient-centred’ management strategies (including reassurance and providing information) were received by 86.7% of patients. Regardless of patients’ expectation or the management strategy employed, high levels of satisfaction were reported for all aspects of the consultation. Taking concerns seriously, conducting a physical examination, communicating the treatment plan, explaining treatment decisions, and lack of time restrictions, were each reported to contribute to patient satisfaction. Conclusion: Non-medical prescribers demonstrate an understanding of patient expectations of respiratory tract infection consultations and use a range of non-antibiotic management strategies, particularly those resembling a patient-centred approach. Overall, patients’ expectations were met and prescribers were not unduly influenced by patient expectations for an antibiotic. Patients were satisfied with the consultation, indicating that strategies used by non-medical prescribers were acceptable. However, the lower levels of satisfaction among patients who expected but did not receive an antibiotic, indicates that although NMPs appear to have strategies for managing RTI consultations, there is still scope for improvement and these prescribers are therefore an important group to involve in antimicrobial stewardship

Community pharmacists in Englands' opinions on skill-mix and delegation

Objectives Following the 2005 contractual framework amendment, the expanding role of community pharmacy team members required a shift in entrenched views on roles and duties. This study aimed to report on community pharmacists’ opinions on skill mix and explore how they can be addressed so that skill mix may be optimised. Methods An invitation to complete an online questionnaire was distributed via email, marked for the attention of the lead pharmacist. Following a low response, a paper‐based questionnaire was sent to all community pharmacies in England (n = 11,816). Questions elicited data about the respondent, the pharmacy (including staffing profile) and opinions on skill mix. Key findings A total of 1154 returns were received, representing a 10% response rate. Of these, most were pharmacy chains (76%; n = 877), with 5–9 staff (54%; n = 600); commonly open 40–49 hours (42%; n = 487), dispensing <6000 prescriptions per week (41%, n = 533). From 26 statements on skill mix, three factors were identified by principal‐components factor analysis: ‘working well’, ‘feeling the pressure’ and ‘open to development’. Characteristics associated with ‘working well’: pharmacy owners, single businesses, with pharmacy technician(s), dispensing fewer prescriptions and open shorter hours. Characteristics associated with ‘feeling the pressure’: pharmacy chains, open longer hours, large numbers of prescriptions and relief pharmacists. Characteristics associated with ‘open to development’: recently qualified, second pharmacists, working longer hours, chains and dispensing lower numbers of prescriptions. Conclusions Although limited by a low response, results suggest being in a position to influence (more experienced, business owners) may be associated with more positive opinions. Further training (including about legalities and leadership) could contribute to optimising skill mix in community pharmacies

Polyester-derived microfibre impacts on the soil-dwelling earthworm Lumbricus terrestris

Microplastic (MP) pollution is everywhere. In terrestrial environments, microfibres (MFs) generated from textile laundering are believed to form a significant component of MPs entering soils, mainly through sewage sludge and compost applications. The aim of this study was to assess the effect of MFs on a keystone soil organism. We exposed the earthworm Lumbricus terrestris to soil with polyester MFs incorporated at rates of 0, 0.1 and 1.0 %w/w MF for a period of 35 days (in the dark at 15 oC; n = 4 for each treatment). Dried plant litter was applied at the soil surface as a food source for the earthworms. We assessed earthworm vitality through mortality, weight change, depurate production and MF avoidance testing. In addition, we measured stress biomarker responses via the expression of metallothionein-2 (mt-2), heat shock protein (hsp70) and superoxide dismutase (sod-1). Our results showed that exposure and ingestion of MFs (as evidenced by subsequent retrieval of MFs within earthworm depurates) were not lethal to earthworms, nor did earthworms actively avoid MFs. However, earthworms in the MF1.0% treatment showed a 1.5-fold lower cast production, a 24.3-fold increase in expression of mt-2 (p < 0.001) and a 9.9-fold decline in hsp70 expression (p < 0.001). Further analysis of soil and MF samples indicated that metal content was not a contributor to the biomarker results. Given that burrowing and feeding behaviour, as well as molecular genetic biomarkers, were modulated in earthworms exposed to MFs, our study highlights potential implications for soil ecosystem processes due to MF contamination

Exploring the implementation of Discharge Medicines Review referrals by hospital pharmacy professionals: A qualitative study using the consolidated framework for implementation research

Background The Discharge Medicines Review (DMR) is a community pharmacy service in Wales that aims to reduce medicines-related harm after care transitions, including hospital discharge. To undertake a DMR, the Community Pharmacist must receive a patient's discharge medicines information, either electronically, by fax or presented by the patient. Although the DMR has evidenced benefits for improving patient safety, its evaluation showed inconsistent uptake, which Community Pharmacists partially attributed to hospitals not providing the necessary information. Objective Aiming to develop recommendations to improve hospital engagement to DMR referrals, this study explores hospital pharmacy professionals' views of the service. Methods Qualitative focus groups, using hermeneutic phenomenology, were conducted in 16 hospitals across Wales, using a quota sampling method to include 61 Pharmacists and 31 Pharmacy Technicians. To understand the suboptimal engagement to DMR referrals, framework analysis was undertaken using the Consolidated Framework for Implementation Research (CFIR). Results The data were mapped onto all five CFIR domains, each containing barriers and facilitators to engagement with DMR referrals and suggestions for improvement. Only one hospital had successfully implemented DMR referrals, with many participants lacking any knowledge of the service or how to refer to it. Specific barriers included a clear absence of processes to implement referrals and engage hospital pharmacy professionals. A considerable barrier was many participants' perceptions that Community Pharmacist roles were less clinically orientated and patient-centred than their own, viewing them almost as a different profession. Participants believed that local champions for DMR referrals could promote engagement and integrate them into the workflow of hospital pharmacy professionals. Further recommendations to improve engagement was staff training for DMRs and regular feedback of its value. Conclusion Policymakers may use the findings and recommendations from this study to promote hospital pharmacy staff engagement to similar community pharmacy services like the Discharge Medicines Service in England

Prescribing trends over time by non-medical independent prescribers (NMIPs) in primary care settings across Wales (2011-2018): a secondary database analysis

Introduction: As of 2015, as part of the implementation of the Welsh Government primary care plan and primary care clusters, the Welsh Government has encouraged non-medical healthcare professionals working in primary care to train as independent prescribers (IPs). Objectives: This research aimed to identify the number of NMIPs in primary care in Wales and describe their prescribing trend of items between 2011 and 2018, in order to compare their prescribing pattern before and after the implementation of primary care clusters for Wales. Design: Retrospective secondary data analysis and interrupted time series analysis in order to compare prescribing by non-medical independent prescribers (NMIPs) preimplementation and postimplementation of primary care clusters across Wales. Results: Over the study period, 600 NMIPs (nurses n=474 and pharmacists n=104) had prescribed at least one item. The number of nurse IPs increased by 108% and pharmacists by 325% (pharmacists had the largest increase between July 2015 and March 2018). The number of items prescribed by NMIPs increased over time by an average of 1380 per month (95% CI 904 to 1855, p<0.001) after the implementation of primary care clusters compared with 496 (95% CI 445 to 548, p<0.001) prior its implementation. Approximately one-third of the items prescribed by NMIPs was within Betsi Cadwaladr University Health Board (HB) with only 4% in Powys Teaching HB. Conclusion: The number of NMIPs and their volume of prescribing in primary care in Wales has increased following the implementation of primary care clusters in 2015. This suggests that the Government’s recommendations of using NMIPs in primary care have been implemented. Future studies should focus on efficiency and quality of prescribing by NMIPs in primary care