Community Pharmacy and General Practice Collaboration and Integration: what works, when and why?

 Authors: Professor Sophie Park, Dr Emily Owen-Boukra, Professor Cate Whittlesea

Key messages from our realist review:

Community Pharmacy and General Practice have worked alongside each other for many years. Recent UK National Health Service policies have sought to encourage community pharmacies to increase services for patients. Many assume this will reduce GP workload, but this is not inevitable. We recently conducted a National Institute for Health and Care Research, School of Primary Care Research (SPCR) funded review of the evidence about community pharmacy and general practice collaborative and integrated working (1, 2). Key messages from the evidence include:

• Community pharmacies can complement general practice services but are not a straightforward replacement.
• Financial remuneration models need to support collaborative working, rather than promoting competition.
• Patients need trusted professionals to support how and when they engage with and across community pharmacy and general practice services. When patients can see that community pharmacists (CPs) and general practitioners (GPs) are working together, this helps build patient trust, so that they can engage with one/other service as they need.
• If supported to work together, community pharmacies and general practices can increase patient safety and quality of care through complementing each other's work.
• However, if not well-planned or resourced, new policies have the potential to increase workload for CPs and GPs. For patients this can cause frustration, additional labour, and potentially impact safety and quality of care.

For CP-GP collaboration and integration to work well, they need resources (time, space, money) to get to know each other and develop ways of becoming more familiar with each other’s work. Common ground and critical differences can then be better understood by them and patients, so that both CPs and GPs can support patients to attend where their care needs can best be met. We cannot expect CPs to mop up the current GP workforce crisis. Paradoxically, policies which position CPs as competing for GP work are likely to worsen, rather than improve GP workforce challenges. Potentially, CP workforce challenges will also worsen if services are not well planned, organised, and resourced.

Patients often need continuity and a trusted professional to help them navigate their healthcare engagement. Where support is provided to enable CPs and GPs to work well together, this can happen. Often, where systems enable, GPs and CPs will work well together to pick up on different important elements of patient needs: helping to support patient care in synergistic and complementary ways. However, if not well planned, CPs seeing patients can mean that patients must attend both CP and GP, and/or GP workload can expand, for example through increasing informational workload (e.g. CPs sending GPs written documentation of patient encounters to read, file and action). Gaps can also arise, meaning patient problems are missed or not fully addressed if patients are unsure where to attend; or who to tell particular information; or assume one/other professional already knows certain information. Confusion and/or conflicting advice can result in worse patient safety and quality of care. Effective communication requires human connection and IT systems which complement rather than replace this. GPs and CPs often focus on different elements of care and patients often adapt how they present their problems to reflect this. We cannot assume that a patient ‘problem’ and ‘solution’ will be the same regardless of who they interact with. Similarly, GP and CP spaces can differ in supporting a variety of patient needs and behaviours (e.g. some like the open access of CPs; others like the privacy of a GP/CP space; some find one/other more accessible while others associate stigma with a space e.g. CP side rooms for emergency contraception or illicit drug users).

Collaboration and integration require support. We cannot expect GPs, CPs and patients to pick up the pieces for policies which try to provide a quick fix for fundamentally underfunded and over-stretched services. CPs provide high-quality patient care, but they cannot ‘replace’ GPs. While there is great potential for CPs and GPs to work in partnership with each other and with patients to deliver care, this requires system-level support. For further information about our project and research, please see our short report (2).

‘Pharmacy First’ Case Study:

'Pharmacy First' is an initiative in its infancy attracting significant recent media attention. Policymakers assume that ‘Pharmacy First’ will reduce GP workload by increasing CP-patient encounters. Demand and capacity are, however, elastic +/- expandable and are not always fixed or transferable. Access to  ‘Pharmacy First’, for example, might generate additional or new patient encounters, rather than simply replace a GP encounter elsewhere.

Difficulties have arisen navigating the payment model and with exchange of clinical information where needed between professionals. The fee for service payment a CP receives varies depending upon whether a patient attends directly ('walk in'), or through formal GP referral. The latter is paid more money. However, this payment model is difficult to evidence (e.g. a GP receptionist suggesting to a patient over the phone: you could try the pharmacy first). Both CP and GP ultimately want what is best for their patients. This might include working together to support a patient with a clinical problem.  However, this ambition is challenging amidst unintended consequences of a potentially competitive system and remuneration  model. This might, for example, dis-incentivise conversations with patients about attending a GP or CP directly in future, even where potentially appropriate. Patient individual preferences (e.g. ease of access at one or other site, or preferred relationship with one or other CP/GP) become potentially lost as professionals try to help patients and staff navigate of an imperfect system and related payment models.

Communication between clinical staff is crucial to support patient safety. Currently, an IT system to support the 'Pharmacy First' process is not widely implemented. A CP will therefore not routinely know who is the GP of an attending patient. This makes feedback about treatment initiation or clinical concerns/uncertainties challenging to share, putting patients at potential risk. If introduced, an IT system needs to be carefully considered. While a routine, un-distilled 'information transfer' is attractively simple, this is likely to expand rather than reduce work for those generating, reviewing and acting upon documents. Clinical risk can often be easier to manage directly with a patient: gauging and sharing decisions with patients about risk indirectly can be challenging and time-consuming. For example, having a conversation can be very efficient to clarify particular red flags; check historical patterns of pre-existing behaviours (e.g. depression episodes); or disease flares (e.g. atypical but recurrent presentations of a disease). An agile and flexible IT system could support interactions between GPs and CPs, sharing distilled and relevant information to inform future care, but needs careful planning involving CP, GP and patients.

The short report is available to read here: 

 https://ora.ox.ac.uk/objects/uuid:2a2c0cde-1ec9-4a05-9cdf-3c60fbbdb0b8/files/s7h149r801 

References

1. Owen EC, Abrams R, Cai Z, Duddy C, Fudge N, Hamer-Hunt J, et al. Community pharmacy and general practice collaborative and integrated working: a realist review protocol. BMJ Open. 2022;12(12):e067034.
2. Park S, Owen E, Cai Z, Duddy C, Fudge N, Hamer-Hunt J, et al. Collaborative and Integrated Working between General Practice and Community Pharmacy: Findings from a Realist Review. University of Oxford 2024 7th May 2024. https://ora.ox.ac.uk/objects/uuid:2a2c0cde-1ec9-4a05-9cdf-3c60fbbdb0b8/files/s7h149r801 

Funding: 

This output has been developed by Sophie Park following funding for project 567 from the National Institute for Health Research (NIHR) School for Primary Care Research.