An investigation of the structures and processes of pharmacist prescribing in Great Britain: a mixed methods approach.
Dapar, Maxwell Patrick
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The aim of this research was to investigate the structures and processes of pharmacist prescribing in Great Britain, focusing on primary care settings. A ‘sequential-mixed methods’ was employed in the conduct of the research. The first phase was a cross-sectional postal questionnaire of all pharmacist prescribers (n= 1654 in January 2009), to quantify the extent and nature of prescribing and key factors associated with prescribing practice. Response rate was 42.3% (n=695). The pharmacy practice setting was significantly associated with prescribing (those in hospital or general medical practice were more likely to have prescribed (p< 0.05), than respondents in community practice). Factor analysis of attitudinal statements on prescribing implementation revealed factors, grouped as: ‘administrative structures and processes’, ‘perceptions of pharmacists’ prescribing role’ and ‘facilities for prescribing’. Scores for ‘facilities for prescribing’ varied depending on practice setting. Respondents in community practice recorded lower median scores compared with those in general medical practices. However, there were no statistically significant differences in median scores between respondents based in GP and hospital settings. In-depth qualitative work undertaken in the second phase further explored facilitators of, and challenges to prescribing practice (e.g. the lack of defined prescribing roles) identified in phase one. Semi-structured interviews were conducted with a purposive sample of 34 prescribers. Prescribers were selected from diverse settings, including secondary care from England and Scotland, to highlight key factors contributing to prescribing success which could potentially inform extrapolations of successful practice from one setting to the other. The ‘framework’ approach to qualitative data analysis was rigorously applied, revealing that the professional isolation and issues around access to clinical data and administrative support in the community setting may have negatively impacted on prescribing implementation. Notably, a perceived lack of clarity and definition of the pharmacist prescribing role was a key theme in hindering prescribing practice of pharmacists irrespective of setting. Participants described ‘ideal’ roles which they perceived as potentially providing clarity, definition and direction to facilitate implementation. The original data generated through this research highlights that prescribing implementation is less than desired, especially in community pharmacies. Pharmacist prescribing appears to have progressed little since supplementary prescribing developments in 2004, even with the much heralded arrival of independent prescribing in 2006. Interestingly, phase 2 participants suggested a ‘hybrid supplementary/independent’ prescribing model, as more likely to succeed. In this model, pharmacist prescribers favour a cooperative practice arrangement in which doctors diagnose and pharmacists prescribe. The implication of these findings and specific recommendations for policy makers, other key stakeholders and practitioners are discussed in detail within the thesis.