Psnc Advanced Services

[Brinda]

Theaim of this study was to investigate the provision of community pharmacy services to children and young people with a focus on advanced services such as medicines use review. Perceptions and experiences of community pharmacists, pharmacy staff, young people and their parents or carers on the provision of such services were also explored.

While general engagement with children and young people appears high from the pharmacist's perspective, advice specific to children and young people with long-term conditions and the provision of advanced services in this group remains a challenge.

The scope of practice for pharmacists across the United Kingdom (UK) is widening, with pharmacists in the community now offer healthcare services that far exceed the traditional process of dispensing medicines. Community pharmacies operate under a contract with the National Health Service (NHS). In 2005, a change to the NHS Community Pharmacy Contractual Framework (CPCF) in England and Wales introduced three tiers of pharmaceutical services (essential, advanced, and enhanced).1The aim was to reward high-quality services and utilise the skills of pharmacists and pharmacy staff. All NHS pharmacies must deliver essential services (e.g., dispensing of medicines and promotion of healthy lifestyles) but can choose whether they provide advanced or enhanced services. Enhanced services are locally commissioned according to local need (e.g., palliative care support, care home support) whereas, advanced services may be offered nationally. There are currently six advanced services, two of which, the New Medicines Service (NMS) and Medicines Use Review (MUR), have a shared aim to improve and promote adherence as part of a patient-centred consultation with a pharmacist. Community pharmacies are remunerated GBP 28 per MUR conducted and have, until recently, been capped at a maximum of 400 per annual claim.1The choice of patient to approach for recruitment to MUR is at the discretion of the community pharmacist. However, to achieve payment, 70% must fall into one or more of the national target patient groups: high risk medicines; recently discharged from hospital with changes to their medicines; respiratory disease; and cardiovascular disease.2Providing advanced services, such as MUR, to young people is an ideal opportunity for pharmacists to improve health outcomes, reduce costs to the NHS, such as medicines waste at an early stage.1,2

Older adults are the established focus for pharmacy services. However, children and young people (CYP) make up more than 17% of the UK population which is similar in proportion to those aged over 65 years.3In the 11-15 year-old age group alone, approximately one in four report that they have a long-term condition (LTC).4Common conditions, several of which fall within the MUR national target groups, include asthma, diabetes, epilepsy, arthritis and mental health. Rates of medicine nonadherence in people with LTCs are commonly reported to average at about 50% whereas for children the average increases to around 60%, and for adolescents can be as high as 70%.567-8MURs may be offered free of charge to any patient, be they adult (>18 years), child (

The aim of this study was to investigate the provision of community pharmacy services to CYP with a focus on advanced services such as MUR. Perceptions and experiences of community pharmacists, pharmacy staff, CYP and their parents or carers on the provision of advanced services to CYP were also explored.

Four cross-sectional self- administered questionnaires were distributed to UK based pharmacists, pharmacy staff members, CYP and parents of CYP between September and December 2017 (Online appendix). Study approval was obtained from the School of Pharmacy, University of Birmingham Research Ethics Sub-Committee. Willingness to participate was confirmed; the right to withdraw at any stage and maintenance of confidentiality and anonymity was explained to all participants prior to completion of each questionnaire. Participants signed an informed consent to take part in the study.

Two different questionnaires were developed for pharmacists, one for community pharmacy staff and one for CYP and the parents of CYP. The questionnaires were developed by the research team and informed by published literature addressing pharmaceutical care to CYP and pharmacist roles in supporting CYP. Questionnaires contained a series of open, closed, multiple-choice questions and Likert scale responses. Questionnaires were subject to academic review, piloted on a subset of the target audience and revised accordingly prior to distribution.

Questionnaire 1 focused on obtaining a snapshot of current service provision of pharmacists to CYP, and consisted of 21 questions to collect demographic data and information about pharmaceutical care and pharmacy services offered to CYP, the participant's role and current involvement. Pharmacists were recruited by online survey link dissemination via a UK-wide independent prescriber newsletter and hard-copy distribution by researchers visiting local community pharmacies. While no restriction was placed on the participant's area of practice, the main channels of distribution targeted primary care and community-based pharmacists.

Pharmacy staff were included in the study if they had potential involvement in the recruitment process for pharmacy services such as MURs. This questionnaire (questionnaire 3) included 9 questions to collect pharmacy locations and annual figures (period covered 1stApril 2016 to 31stMarch 2017) for the number of MURs conducted with children in community pharmacies and, explore the community pharmacy staff role, experiences and challenges of recruitment of children for MURs. Pharmacy staff were recruited at the same time as pharmacists for the second questionnaire (described above) during the same researcher visit. A maximum of one member of non-pharmacist staff per pharmacy was recruited and hard copies of the questionnaire were used to collect responses.

Questionnaire 4 included a series of 20 questions and comprising two parts; one part for completion by CYP with long-term conditions and the second for completion by parents. Questions revolved around the long-term condition(s), number and frequency of medicines, and experiences of community pharmacy involvement healthcare provision.

CYP and parents were targeted for recruitment through primary and secondary schools, a university, social media and two community pharmacies. Eight primary and four secondary schools within the East and West Midlands were approached to facilitate recruitment to the study. Participating schools distributed an online link to students and parents via a weekly newsletter. Undergraduate students from the researcher's university were sent a link to the online questionnaire and asked to share. In addition, with the agreement of the community pharmacy proprietors, researchers based themselves in two community pharmacies for one day to recruit participants.

The main study outcomes included: current pharmacy services, pharmacy services uptake by CYP, pharmacy staff recruitment into services, experience of CYP with LTCs and their parents with pharmacy services.

Inclusion criteria in this study: pharmacists working in primary care both at community pharmacies and general practice; pharmacy staff working at community pharmacies and involved in the recruitment process for pharmacy services; CYP people with LTCs and parents of CYP with LTCs.

A total 92 pharmacists completed questionnaire 1 investigating current pharmacist roles with CYP. A response rate could not be generated due to the nature of recruitment. Pharmacists responded from all areas of the UK, the main proportion being from the West Midlands. It is notable that most respondents were independent prescribers with the main area of practice primary care. Demographic details are shown inTable 1.

Of the 46 pharmacies approached for recruitment to questionnaire 2, 38 pharmacists and 40 non-pharmacist members of pharmacy staff responded. Most respondents were from medium chain pharmacies in high street or town center locations. Demographic details are shown inTable 2.

One primary school of the 12 schools approached, distributed questionnaire 4 as hard-copies and online links to the parents or carers of 400 students. Due to the online nature of distribution via this and other routes, the number of participants from different recruitment sources and response rates could not be determined. There were a total of 78 responses to the online questionnaire of which 27 were excluded for nonsensical answers or for not meeting inclusion criteria. The age (mean 20.2 years, median 21 years, range 7 to 24 years) of the CYP respondents in this study suggests that most were recruited from the university student population. A total of 18 parents or carers of CYP with long-term conditions participated in this study. The age of the CYP they provided information about was broader (mean 10.2 years, median 9 years, range 2 to 22 years).Table 3shows the characteristics of CYP participants combined with the CYP information provided by parents and carers.

Despite the low numbers conducted the majority of pharmacists (35/38; 92.1%) were of the opinion that MURs could be of benefit to children. A common theme identified in additional free-text responses was the importance of improving knowledge and understanding for older children. When asked about the challenges of conducting MURs with children, three main themes emerged and had a particular focus on younger children; assessing competency and understanding; obtaining consent and absence of the child.

Although few participants reported themselves as having diabetes, other LTCs were generally as expected for CYP with respiratory (asthma) and mental health issues the most common. As anticipated for this population the majority reported only one LTC. Where more than one LTC was reported, the combinations were mainly associated conditions (e.g., asthma and eczema; depression and anxiety). All CYP reporting to have respiratory disease, named their condition as asthma. All CYP reporting a skin condition in this sample named their condition as eczema. Given the prevalence of asthma (20/69; 29.0%) and eczema (19/69; 27.5%), it is unsurprising that more than half (41/69; 59.4%) were prescribed two or more medicines and the frequency of administration for most was at least once a day (Table 3).

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