Community Pharmacy and General Practice collaborative and integrated working: a realist review
- Principal Investigator: Sophie Park
- 1 February 2022 to 30 April 2023
- Project No: 567
- Funding round: FR2
Context and Rationale:
The NHS Long-Term Plan represents a major change in policy direction and expectations: shifting away from competition, towards ‘integration and collaboration’ in primary care (1,7,8). This includes promoting integrated and collaborative working between General Practice (GP) and Community Pharmacy (CP) (30,31,32). This re-positions CP from supporting GP (for example ‘Medicine Use Reviews’), towards joint-working (2,3).This has been welcomed by most and initial attempts have included expectations of integrated working in NICE quality standards (4), ‘flu vaccine principles (5) and plans for GP referrals to CP (6, 35). There is a strong focus in many policies on technology systems to support integrated working. There is currently, however, minimal understanding about how effective CP-GP integrated and collaborative working might be achieved in practice, and how to maximise its success. In this review, we plan to explore the often overlooked wider human, policy, regulatory and professional elements that we believe influence working relationships, arrangements and policy implementation, enabling integration and
collaboration. For example, communication between organisations; negotiation of working practices, professional identities, roles and responsibilities; accountability; decision-making processes, priorities and boundaries; and how financial incentives and competition shape strategies, behaviours and policy implementation.
PPI and Practitioner Co-Applicant Experience Examples:
● A Community Pharmacy needs to contact one of its patients’ GP practice to clarify a prescription (e.g. a query about non-warranted prescription of antimicrobials, a prescription wrongly addressed to family members with the same surname, or inaccurate dosages etc.). The only means of communication is the GP’s public telephone number used by patients to book appointments and anyone else who needs to contact the practice. This is one example of how two important community care providers - GP and CP - have each developed and implemented different and non-interoperable systems which de facto have often resulted in introducing workflow hindrances and barriers to smooth working relationships.
● A rural practice has a medication dispensing service. They are anxious about service and income competition from other local CPs, threatening the practice with closure. After the senior GP partner retires, the practice is taken over by a local organisation running several practices, with its own dispensing arrangements. This limits other local CPs income due to introduction of geographical rule limits to who can dispense medication for patients, dependent on their address. This limits patients’ choice and range of available services. Local CPs feel further threatened by a widespread letter campaign to local patients offering an on-line CP service.
While attractive to some, many local patients are concerned that an on-line CP will not offer the same, personalised service and might result in greater prescription errors and delays. This is an example of the impact of local and national
competition both between CP services and between CPs and GPs; agendas and tensions which might shape how CP-GP providers interact and cooperate (or not); and their potential impact on patient care, access and choice.
Over 15 months we will conduct a Realist Review. We will bring together evidence such as policy documents, NICE guidance, research documents, and debate articles to help us to understand what helps and what hinders collaborative and integrated work between CP and GP. We will select articles because they are directly relevant to CP-GP working
relationships, or collaborative working between healthcare professionals more generally. We have conducted an initial scoping review and identified a significant field of potentially relevant information. Our review findings will be focused on the UK, but we have also identified international literature to help support the analysis. We will examine whether,
why, how and to what extent CP-GP collaborative and integrated working practices support effective and equitable care delivery for patients. Where challenges are identified, we will explore how these have been negotiated or overcome.
The project team includes people with a wide range of relevant expertise including public contributor co-applicants (PPI); front-line healthcare clinicians; workforce and training experts; and researchers. The project team (including PPI co-applicants) will meet every two months, working collaboratively with stakeholders. There will be three stakeholder
meetings. If we are funded, several individuals and organisations have agreed to act as stakeholders and support us in ensuring our research informs future practice and policy in this important area.
Impact: The outcome of this project will provide insights and solutions to maximise CP-GP collaboration and integration. This project will inform future CP-GP working relationships and processes. These working relationships and arrangements impact on patient experience, patient safety and medication errors, access, care and formal referral;
alongside professional capacity, training and workload. The review findings are likely to have broader relevance to other primary care interfaces and the future productive shaping of integrated and collaborative working.
Amount awarded: £157,056