TY - JOUR
AU - Sirois, Caroline
AB - Abstract Objectives Clinical services have allowed pharmacists to shift from product-oriented to patient-oriented services. However, the policy and social implications of clinical services in community pharmacies are not well described. The purpose of this scoping review was to identify these implications. Key findings We searched Pubmed and Embase, from inception to March 2019, as well as grey literature for publications that discussed policy (e.g. pharmacy model and pharmacist status) or social (e.g. role of pharmacists and interprofessional collaboration) implications of clinical services. Publications had to address clinical services provided by pharmacists in community settings that target the global long-term care of patients. We extracted data related to the implications and classified them into themes thereafter. The search process identified 73 relevant publications, of which 13 were included in regard to policy implications and 60 relative to social implications. Two themes emerged from policy implications: implementation and characteristics of policies, and professional status. Pharmacists’ independence from distribution, financial coverage of clinical services and innovative models of practice were addressed. Social implications involved three themes: roles and interprofessional collaboration, changes in practice and barriers and model of practices and services. Perceptions of pharmacists’ skills, organisational barriers, time constraints, lack of self-confidence and cultural shifts required to implement clinical services were included in these themes. Summary Our review demonstrates the changing role of community pharmacists in provision of clinical services within the healthcare system. The range of clinical services varies widely from one setting to another. The context of community pharmacy is not well suited to these changes in practice. pharmacy, clinical services, pharmacists, social implications, public policy Introduction Traditionally, the main role of community pharmacists has been to distribute medications.[1] In 1998, Cipolle et al. introduced cognitive services, referring to the use of pharmacists’ knowledge to improve the efficacy and safety of pharmacotherapy.[2] Cognitive services, defined as ‘[…] services that are judgmental or educational in nature rather than technical or informational’,[3] align with a shift from product-oriented to patient-oriented services. Clinical services are part of cognitive services and specifically aim to optimise patients’ outcome regarding their medication.[3] For example, clinical services comprise anticoagulation management programmes which have been shown safe and effective in improving goal achievement when compared with physician interventions, although not being cost effective yet.[4] Asthma care programmes have also been shown to improve quality of life while being cost effective among certain patients.[5] More recently, pharmacists have expanded their services to offer vaccination[6] and prescribe medications.[7] Although the range of clinical services differs from one country to another, community pharmacists invariably play a role in both individual and public health, as they are one of the most accessible healthcare providers.[8] As shown in these examples, clinical services have significant clinical and economic implications. Their potential in community pharmacies has been widely discussed in a number of reviews.[9–12] However, little is known on the influence clinical services have on policies and in turn how they are influenced by policies. For example, clinical services may have policy implications impacting pharmacy models and pharmacist status. Similarly, there is scant information on the social implications of clinical services. Social implications may be defined as the ‘effect of an activity on the social fabric of the community and well-being of […] individuals […]’.[13] For example, social implications could refer to how the provision of clinical services can influence cohesion between health care providers, relationships between pharmacists themselves, and the image of pharmacists in the society. Social implications of clinical services may thus include perceptions of the role of pharmacists, aspects of interprofessional collaboration and other role changes. The political and social implications of clinical services can have important influences on the implementation, development and maintenance of these services. To enable pharmacists to exercise them, it is paramount to understand what barriers and facilitators may be encountered and what consequences clinical services may have on the social and political fabric. In fact, knowing these elements and the reflections related to the provision of services could be useful for individuals and organisations (institutional or governmental), who wish to set up or enrich the offer of clinical services. Thus, there is a need to ascertain the policy and social implications of clinical services in community pharmacies to ensure they reach their full potential to improve individual and public health. The aim of this scoping review is to identify the policy and social implications of clinical services in community pharmacies across the globe. In order to limit its scope, the clinical services of interest in this review refer to medication therapy assessment, monitoring and deprescribing in order to improve therapy appropriateness. Methods Search strategy The systematic search strategy was developed by two of the authors (A.C.C. and C.S.) and was revised by a librarian specialised in health sciences (F. Bergeron). The key research question was formulated based on the elements of the PICO (population, intervention, comparison and outcome) framework: The population was pharmacists in community practices who offered clinical services (intervention), as opposed to traditional distribution services (comparison). The main outcomes were the public policy and social implications of those interventions. Key search terms included notably pharmaceutical services, deprescription, inappropriate prescription and community pharmacy. The structure of the search strategy was adapted to each database consulted. The complete search strategies are described in detail in Supplementary Tables S1–S3. The search was performed in March 2019 using PubMed and Embase. We also searched the grey literature, using Google, for relevant publications. Reference lists of included manuscripts were reviewed to ensure all original citations meeting our criteria were retrieved. Selection of publications To be included, the publications had to respond to the following criteria: (1) Discuss clinical services provided by pharmacists (2) Refer to a community pharmacy setting (3) Refer to medications in general (4) Available as full text in English, French, Spanish, Italian, German or Portuguese. (Languages our team understands or for which translators were available.) Conversely, we excluded publications: (1) Targeting technical or educational outcomes only. Hence, publications discussing adherence or self-management support only were not considered because they are more related to medication distribution. However, clinical services such as medication reviews, that may include compliance interventions, were included because they intended to improve health outcomes from a broader perspective, the goal being not only increased adherence or better administration technique. (2) Considering hospital-based settings. (3) Dealing with specific medications. We excluded those publications because they shift focus onto the product. For example, publications discussing warfarin management were excluded. However, publications about anticoagulant therapy were not. (4) Concerning acute treatment, as long-term care of patient was of interest. (5) Considering implications of clinical interventions that were not of the policy or social level (e.g. clinical or economic). (6) Available only as abstracts or presentations or in a language not previously mentioned. In order to ensure a thorough portrait, we did not exclude documents based on the year or country of publication. Similarly, all written sources of evidence were considered without restriction, from scientific papers to subjective opinions. Zotero was used to manage the search and remove duplicates. All titles and abstracts were first screened against the aforementioned inclusion criteria. Full text of publications not excluded at this stage were retrieved and reviewed according to the inclusion criteria. The application of inclusion criteria was recorded for each publication to generate a flow chart in accordance with the PRISMA requirements. Data extraction and analysis An Excel spreadsheet adapted to our objectives was used for data extraction. It comprised title, authors, country, study design, objective(s), public policy or social elements discussed, comments or important quotes and main findings. Policy implications referred to elements related to the pharmacist’s models of practice or status. Social implications referred to the image of the pharmacist in society, the aspects of interprofessional collaboration and the changes in the pharmacist’s role. Two independent reviewers (A.C.C. and C.D.) conducted the full-paper evaluation and data extraction. In case of a disagreement that could not be resolved by discussion, a third reviewer (C.S.) was invited to make a final decision. Included publications were divided into four categories based on the implications of the publication: policy, social, economic and clinical. This scoping review addresses the policy and social implications only, which are less reviewed dimensions in the literature. Two reviewers (A.C.C. and C.S.) reviewed the extracted data to identify major themes within the policy and social implications under which most results could be presented. Publications addressing both types of implications were classified under the more salient one according to their objectives or their outcomes after consensus between the reviewers (A.C.C. and C.D.). Results Study selection process The search process resulted in 3493 publications, of which 13 regarding policy implications and 60 addressing social implications were retained (Figure 1). Figure 1 Open in new tabDownload slide PRISMA flowchart describing the inclusion process of publications. Figure 1 Open in new tabDownload slide PRISMA flowchart describing the inclusion process of publications. Public policy implications Characteristics of included publications The 13 publications discussing policy implications are grouped in Table 1. Seven originated in the USA while the other half were published in the UK, Australia or New Zealand. All documents were published after 2000, with nine published after 2010. Eleven of the thirteen publications were opinions, such as editorials or commentaries, while two were qualitative research.[14, 15] Two themes related to public policy were identified. The first relates to the implementation of clinical services, describing policies and their characteristics (seven publications). The second theme is the professional status of pharmacists, which is the focus of six publications. Table 1 Key characteristics of publications discussing public policy implications of pharmacists’ clinical services (n = 13) Author (year) [citation] . Country . Title . Aims . Findings . Theme: Implementation and characteristics of policy Barlas S. (2010)[16] USA New directions for health care law in the USA: Emphasis on preventive, holistic therapies offers possibilities for pharmacists To describe changes made to the MTM by the Patient Protection and Affordable Care Act. Grants will be given to licensed pharmacists who will be employed by interprofessional groups caring for patients living with chronic diseases. Service offerings are expanding. Insurance companies are concerned about rising medication costs, but are not accounting for the benefits of reduced hospitalisations. Barlas S. (2015)[17] USA Pharmacists at centre of drug adherence pilot: Medicare is finally offering more flexibility for MTM programmes To describe the new MTM programme offered by the CMS The CMS aims to improve MTM services in order to update pharmacists’ role. Major elements of this new policy are written without significant pharmacist involvement. Payment will not be made by the CMS and pharmacists hope that the PDP prescription medication plan will reimburse their services since the CMS offers them financial incentives according to performance. Franco-Trigo L. (2019)[14] Australia A stakeholder visioning exercise to enhance chronic care and the integration of community pharmacy services. To define a multidisciplinary chronic care service. Workplace environment and quality of care influence implementation and prioritisation of initiatives such as improving teamwork, use of evidence-based practice and optimising work chain in pharmacy. The separation of the traditional and modern roles of pharmacists is considered a long-term objective. Gebhart F. (2005)[18] USA MTM slowly coming into focus To discuss the introduction of MTM in Medicare Part D. MTM can be integrated into the pharmacy delivery chain, but planning is necessary. The plan must define the service and its provider, the population that will receive it and the payment options. Gilbert A. (2013)[19] Australia Editorials: HMRs: Is the damage out of control? To describe the causes and implications of the HMR moratorium requested by the PGA to the Minister of Health. The PGA appears to have no interest in the separation of clinical services and distribution services, claiming that there has been abuse by pharmacists offering HMT services with a lack of rigour leading to budget overruns. McDonough RP. (2011)[20] USA Medication therapy management and collaborative practice: How to make it work To characterise methods of establishing a pharmacist-physician collaboration. Some states have collaborative practice agreements regulating interprofessional practices as part of the MTM programme. Pharmacists need to exceed expectations in being evidence-based interventionists for global long-term patient care. McMahan R. (2006)[21] USA Demystifying medication therapy management To describe the MTM programme. The MTM programme is a quality initiative that can have multiple approaches depending on the patient’s insurance. The plan does not always include a pharmacist and is designed to improve therapeutic outcome independent of medication distribution. Theme: Professional status Bellingham C. (2008)[22] UK How does the NHS view pharmacists? To discuss why the NHS does not recognise the true value of pharmacists’ clinical services. The historical role of the pharmacists has hampered fair recognition of their evolving responsibilities. Pharmacists must proactively pursue discussion with the NHS. Pharmacists should also demonstrate their impact on patients with innovative services instead of defending their current role. Hawk G. (2010)[23] UK Moving towards a general practice framework for community pharmacy To describe the importance of creating benchmarks for the development of professional skills. A skill-based guide was developed to ensure the efficacy and safety of pharmacy practice. This framework should be used to ensure the development of the profession and of services. The Harmonisation of Accreditation Group will certify skills and offer accreditation to pharmacists. Milenkovich N. (2012)[24] USA CMS pushes for independence of consulting pharmacists To comment on the consideration of new regulations allowing greater independence of clinical pharmacists The independence of clinical pharmacists from distribution could reduce conflicts of interest, bias, and over- or inappropriate prescribing, although opponents argue that an adequate regulatory system is already in place. Milenkovich N. (2015)[25] USA Expanding the role of pharmacists on the healthcare team To discuss barriers to integration of pharmacists into healthcare teams. Restrictive laws and regulations, lack of appropriate remuneration and limited electronic systems are the main obstacles discussed. It is paramount to recognise pharmacists as health care providers and to adopt policies that allow and encourage interdisciplinary health teams. Scahill S. (2010)[15] New Zealand Health care policy and community pharmacy: Implications for the New Zealand primary health care sector To describe the implications of policy changes for community pharmacists and the actions needed to put them in place. Standards of practice are often considered idealistic and implementation is sometimes lacking. Change must come from pharmacists rather than governments, with full commitment to service evaluation and active participation in organisational research. Unknown (2004)[26] UK Scotland moves away from volume-based contract To describe a new contract allowing pharmacists to move away from distribution. The contract allows pharmacists to be paid according to the clinical services they offer instead of traditional dispensing-based remuneration, ensuring the future of pharmacy. Quality interventions will be rewarded, and conflicts of interest diminished. It will enable pharmacists to concretely participate in the achievement of NHS objectives. Author (year) [citation] . Country . Title . Aims . Findings . Theme: Implementation and characteristics of policy Barlas S. (2010)[16] USA New directions for health care law in the USA: Emphasis on preventive, holistic therapies offers possibilities for pharmacists To describe changes made to the MTM by the Patient Protection and Affordable Care Act. Grants will be given to licensed pharmacists who will be employed by interprofessional groups caring for patients living with chronic diseases. Service offerings are expanding. Insurance companies are concerned about rising medication costs, but are not accounting for the benefits of reduced hospitalisations. Barlas S. (2015)[17] USA Pharmacists at centre of drug adherence pilot: Medicare is finally offering more flexibility for MTM programmes To describe the new MTM programme offered by the CMS The CMS aims to improve MTM services in order to update pharmacists’ role. Major elements of this new policy are written without significant pharmacist involvement. Payment will not be made by the CMS and pharmacists hope that the PDP prescription medication plan will reimburse their services since the CMS offers them financial incentives according to performance. Franco-Trigo L. (2019)[14] Australia A stakeholder visioning exercise to enhance chronic care and the integration of community pharmacy services. To define a multidisciplinary chronic care service. Workplace environment and quality of care influence implementation and prioritisation of initiatives such as improving teamwork, use of evidence-based practice and optimising work chain in pharmacy. The separation of the traditional and modern roles of pharmacists is considered a long-term objective. Gebhart F. (2005)[18] USA MTM slowly coming into focus To discuss the introduction of MTM in Medicare Part D. MTM can be integrated into the pharmacy delivery chain, but planning is necessary. The plan must define the service and its provider, the population that will receive it and the payment options. Gilbert A. (2013)[19] Australia Editorials: HMRs: Is the damage out of control? To describe the causes and implications of the HMR moratorium requested by the PGA to the Minister of Health. The PGA appears to have no interest in the separation of clinical services and distribution services, claiming that there has been abuse by pharmacists offering HMT services with a lack of rigour leading to budget overruns. McDonough RP. (2011)[20] USA Medication therapy management and collaborative practice: How to make it work To characterise methods of establishing a pharmacist-physician collaboration. Some states have collaborative practice agreements regulating interprofessional practices as part of the MTM programme. Pharmacists need to exceed expectations in being evidence-based interventionists for global long-term patient care. McMahan R. (2006)[21] USA Demystifying medication therapy management To describe the MTM programme. The MTM programme is a quality initiative that can have multiple approaches depending on the patient’s insurance. The plan does not always include a pharmacist and is designed to improve therapeutic outcome independent of medication distribution. Theme: Professional status Bellingham C. (2008)[22] UK How does the NHS view pharmacists? To discuss why the NHS does not recognise the true value of pharmacists’ clinical services. The historical role of the pharmacists has hampered fair recognition of their evolving responsibilities. Pharmacists must proactively pursue discussion with the NHS. Pharmacists should also demonstrate their impact on patients with innovative services instead of defending their current role. Hawk G. (2010)[23] UK Moving towards a general practice framework for community pharmacy To describe the importance of creating benchmarks for the development of professional skills. A skill-based guide was developed to ensure the efficacy and safety of pharmacy practice. This framework should be used to ensure the development of the profession and of services. The Harmonisation of Accreditation Group will certify skills and offer accreditation to pharmacists. Milenkovich N. (2012)[24] USA CMS pushes for independence of consulting pharmacists To comment on the consideration of new regulations allowing greater independence of clinical pharmacists The independence of clinical pharmacists from distribution could reduce conflicts of interest, bias, and over- or inappropriate prescribing, although opponents argue that an adequate regulatory system is already in place. Milenkovich N. (2015)[25] USA Expanding the role of pharmacists on the healthcare team To discuss barriers to integration of pharmacists into healthcare teams. Restrictive laws and regulations, lack of appropriate remuneration and limited electronic systems are the main obstacles discussed. It is paramount to recognise pharmacists as health care providers and to adopt policies that allow and encourage interdisciplinary health teams. Scahill S. (2010)[15] New Zealand Health care policy and community pharmacy: Implications for the New Zealand primary health care sector To describe the implications of policy changes for community pharmacists and the actions needed to put them in place. Standards of practice are often considered idealistic and implementation is sometimes lacking. Change must come from pharmacists rather than governments, with full commitment to service evaluation and active participation in organisational research. Unknown (2004)[26] UK Scotland moves away from volume-based contract To describe a new contract allowing pharmacists to move away from distribution. The contract allows pharmacists to be paid according to the clinical services they offer instead of traditional dispensing-based remuneration, ensuring the future of pharmacy. Quality interventions will be rewarded, and conflicts of interest diminished. It will enable pharmacists to concretely participate in the achievement of NHS objectives. CMS, Centres for Medicare & Medicaid Services; HMR, home medication review; MTM, Medication Therapy Management; NHS, National Health Services; PDP, prescription drug plan; PGA, Pharmacy Guild of Australia. Open in new tab Table 1 Key characteristics of publications discussing public policy implications of pharmacists’ clinical services (n = 13) Author (year) [citation] . Country . Title . Aims . Findings . Theme: Implementation and characteristics of policy Barlas S. (2010)[16] USA New directions for health care law in the USA: Emphasis on preventive, holistic therapies offers possibilities for pharmacists To describe changes made to the MTM by the Patient Protection and Affordable Care Act. Grants will be given to licensed pharmacists who will be employed by interprofessional groups caring for patients living with chronic diseases. Service offerings are expanding. Insurance companies are concerned about rising medication costs, but are not accounting for the benefits of reduced hospitalisations. Barlas S. (2015)[17] USA Pharmacists at centre of drug adherence pilot: Medicare is finally offering more flexibility for MTM programmes To describe the new MTM programme offered by the CMS The CMS aims to improve MTM services in order to update pharmacists’ role. Major elements of this new policy are written without significant pharmacist involvement. Payment will not be made by the CMS and pharmacists hope that the PDP prescription medication plan will reimburse their services since the CMS offers them financial incentives according to performance. Franco-Trigo L. (2019)[14] Australia A stakeholder visioning exercise to enhance chronic care and the integration of community pharmacy services. To define a multidisciplinary chronic care service. Workplace environment and quality of care influence implementation and prioritisation of initiatives such as improving teamwork, use of evidence-based practice and optimising work chain in pharmacy. The separation of the traditional and modern roles of pharmacists is considered a long-term objective. Gebhart F. (2005)[18] USA MTM slowly coming into focus To discuss the introduction of MTM in Medicare Part D. MTM can be integrated into the pharmacy delivery chain, but planning is necessary. The plan must define the service and its provider, the population that will receive it and the payment options. Gilbert A. (2013)[19] Australia Editorials: HMRs: Is the damage out of control? To describe the causes and implications of the HMR moratorium requested by the PGA to the Minister of Health. The PGA appears to have no interest in the separation of clinical services and distribution services, claiming that there has been abuse by pharmacists offering HMT services with a lack of rigour leading to budget overruns. McDonough RP. (2011)[20] USA Medication therapy management and collaborative practice: How to make it work To characterise methods of establishing a pharmacist-physician collaboration. Some states have collaborative practice agreements regulating interprofessional practices as part of the MTM programme. Pharmacists need to exceed expectations in being evidence-based interventionists for global long-term patient care. McMahan R. (2006)[21] USA Demystifying medication therapy management To describe the MTM programme. The MTM programme is a quality initiative that can have multiple approaches depending on the patient’s insurance. The plan does not always include a pharmacist and is designed to improve therapeutic outcome independent of medication distribution. Theme: Professional status Bellingham C. (2008)[22] UK How does the NHS view pharmacists? To discuss why the NHS does not recognise the true value of pharmacists’ clinical services. The historical role of the pharmacists has hampered fair recognition of their evolving responsibilities. Pharmacists must proactively pursue discussion with the NHS. Pharmacists should also demonstrate their impact on patients with innovative services instead of defending their current role. Hawk G. (2010)[23] UK Moving towards a general practice framework for community pharmacy To describe the importance of creating benchmarks for the development of professional skills. A skill-based guide was developed to ensure the efficacy and safety of pharmacy practice. This framework should be used to ensure the development of the profession and of services. The Harmonisation of Accreditation Group will certify skills and offer accreditation to pharmacists. Milenkovich N. (2012)[24] USA CMS pushes for independence of consulting pharmacists To comment on the consideration of new regulations allowing greater independence of clinical pharmacists The independence of clinical pharmacists from distribution could reduce conflicts of interest, bias, and over- or inappropriate prescribing, although opponents argue that an adequate regulatory system is already in place. Milenkovich N. (2015)[25] USA Expanding the role of pharmacists on the healthcare team To discuss barriers to integration of pharmacists into healthcare teams. Restrictive laws and regulations, lack of appropriate remuneration and limited electronic systems are the main obstacles discussed. It is paramount to recognise pharmacists as health care providers and to adopt policies that allow and encourage interdisciplinary health teams. Scahill S. (2010)[15] New Zealand Health care policy and community pharmacy: Implications for the New Zealand primary health care sector To describe the implications of policy changes for community pharmacists and the actions needed to put them in place. Standards of practice are often considered idealistic and implementation is sometimes lacking. Change must come from pharmacists rather than governments, with full commitment to service evaluation and active participation in organisational research. Unknown (2004)[26] UK Scotland moves away from volume-based contract To describe a new contract allowing pharmacists to move away from distribution. The contract allows pharmacists to be paid according to the clinical services they offer instead of traditional dispensing-based remuneration, ensuring the future of pharmacy. Quality interventions will be rewarded, and conflicts of interest diminished. It will enable pharmacists to concretely participate in the achievement of NHS objectives. Author (year) [citation] . Country . Title . Aims . Findings . Theme: Implementation and characteristics of policy Barlas S. (2010)[16] USA New directions for health care law in the USA: Emphasis on preventive, holistic therapies offers possibilities for pharmacists To describe changes made to the MTM by the Patient Protection and Affordable Care Act. Grants will be given to licensed pharmacists who will be employed by interprofessional groups caring for patients living with chronic diseases. Service offerings are expanding. Insurance companies are concerned about rising medication costs, but are not accounting for the benefits of reduced hospitalisations. Barlas S. (2015)[17] USA Pharmacists at centre of drug adherence pilot: Medicare is finally offering more flexibility for MTM programmes To describe the new MTM programme offered by the CMS The CMS aims to improve MTM services in order to update pharmacists’ role. Major elements of this new policy are written without significant pharmacist involvement. Payment will not be made by the CMS and pharmacists hope that the PDP prescription medication plan will reimburse their services since the CMS offers them financial incentives according to performance. Franco-Trigo L. (2019)[14] Australia A stakeholder visioning exercise to enhance chronic care and the integration of community pharmacy services. To define a multidisciplinary chronic care service. Workplace environment and quality of care influence implementation and prioritisation of initiatives such as improving teamwork, use of evidence-based practice and optimising work chain in pharmacy. The separation of the traditional and modern roles of pharmacists is considered a long-term objective. Gebhart F. (2005)[18] USA MTM slowly coming into focus To discuss the introduction of MTM in Medicare Part D. MTM can be integrated into the pharmacy delivery chain, but planning is necessary. The plan must define the service and its provider, the population that will receive it and the payment options. Gilbert A. (2013)[19] Australia Editorials: HMRs: Is the damage out of control? To describe the causes and implications of the HMR moratorium requested by the PGA to the Minister of Health. The PGA appears to have no interest in the separation of clinical services and distribution services, claiming that there has been abuse by pharmacists offering HMT services with a lack of rigour leading to budget overruns. McDonough RP. (2011)[20] USA Medication therapy management and collaborative practice: How to make it work To characterise methods of establishing a pharmacist-physician collaboration. Some states have collaborative practice agreements regulating interprofessional practices as part of the MTM programme. Pharmacists need to exceed expectations in being evidence-based interventionists for global long-term patient care. McMahan R. (2006)[21] USA Demystifying medication therapy management To describe the MTM programme. The MTM programme is a quality initiative that can have multiple approaches depending on the patient’s insurance. The plan does not always include a pharmacist and is designed to improve therapeutic outcome independent of medication distribution. Theme: Professional status Bellingham C. (2008)[22] UK How does the NHS view pharmacists? To discuss why the NHS does not recognise the true value of pharmacists’ clinical services. The historical role of the pharmacists has hampered fair recognition of their evolving responsibilities. Pharmacists must proactively pursue discussion with the NHS. Pharmacists should also demonstrate their impact on patients with innovative services instead of defending their current role. Hawk G. (2010)[23] UK Moving towards a general practice framework for community pharmacy To describe the importance of creating benchmarks for the development of professional skills. A skill-based guide was developed to ensure the efficacy and safety of pharmacy practice. This framework should be used to ensure the development of the profession and of services. The Harmonisation of Accreditation Group will certify skills and offer accreditation to pharmacists. Milenkovich N. (2012)[24] USA CMS pushes for independence of consulting pharmacists To comment on the consideration of new regulations allowing greater independence of clinical pharmacists The independence of clinical pharmacists from distribution could reduce conflicts of interest, bias, and over- or inappropriate prescribing, although opponents argue that an adequate regulatory system is already in place. Milenkovich N. (2015)[25] USA Expanding the role of pharmacists on the healthcare team To discuss barriers to integration of pharmacists into healthcare teams. Restrictive laws and regulations, lack of appropriate remuneration and limited electronic systems are the main obstacles discussed. It is paramount to recognise pharmacists as health care providers and to adopt policies that allow and encourage interdisciplinary health teams. Scahill S. (2010)[15] New Zealand Health care policy and community pharmacy: Implications for the New Zealand primary health care sector To describe the implications of policy changes for community pharmacists and the actions needed to put them in place. Standards of practice are often considered idealistic and implementation is sometimes lacking. Change must come from pharmacists rather than governments, with full commitment to service evaluation and active participation in organisational research. Unknown (2004)[26] UK Scotland moves away from volume-based contract To describe a new contract allowing pharmacists to move away from distribution. The contract allows pharmacists to be paid according to the clinical services they offer instead of traditional dispensing-based remuneration, ensuring the future of pharmacy. Quality interventions will be rewarded, and conflicts of interest diminished. It will enable pharmacists to concretely participate in the achievement of NHS objectives. CMS, Centres for Medicare & Medicaid Services; HMR, home medication review; MTM, Medication Therapy Management; NHS, National Health Services; PDP, prescription drug plan; PGA, Pharmacy Guild of Australia. Open in new tab Theme one: implementation and characteristics of policies The publications we retrieved explained how the development of clinical services in community pharmacies has impacted health policies and their characteristics. For one, the delivery of clinical services entails a need for pharmacist independence, which necessitates policies and corresponding legislation that recognise this need.[14, 16, 17, 24, 26] However, some stakeholders, such as Australian owner associations, may be uninterested in pharmacists moving away from traditional practice.[19] While there are few details on stakeholders’ motives for avoiding division of services, economic interest in maintaining the current business model of the community pharmacy is an important factor. Furthermore, there is also fear that pharmacists may lack rigour in offering clinical services, as volume-based remuneration of services may drive the prioritisation of quantity over quality in Australia.[19] Some American authors mention that interdisciplinary collaboration is an important part of clinical service delivery in community pharmacies.[20] As such, a policy should incorporate agreements with other health professionals to facilitate the implementation of clinical services.[20] Examples of governmental strategies to strengthen the pharmacist’s role in primary care include the creation of programmes such as Medication Therapy Management in the USA or Home Medication Review in Australia. These programmes explicitly include clinical services performed in interprofessional collaboration.[17, 19] Coverage of clinical services remains an issue. Some authors assert that modifying contracts and agreements with stakeholders and payers in the USA would facilitate the integration of services, help increase access for patients and strengthen the recognition of the role of pharmacists.[17, 18, 20] Policies may help to support innovative models. Some authors argue that policymakers are willing to begin expanding the role of pharmacists, but the pharmacists themselves must be proactive in implementing services in their practice.[20, 22] A qualitative study exposed that because organisational and governmental standards are often idealistic, pharmacists also need to be involved in the creation of appropriate standards for community settings.[15] Hence, change must come from pharmacists, who must improve their practice and go beyond their traditional tasks in order to centre patients in their practice. Policies will then have to be adapted to this cultural change.[15–17, 25] Theme two: professional status The second theme identified is evidently related to the first, as professional status of pharmacists and other health professionals is inscribed in existing policies. Bellingham suggests that the historical role of pharmacists in the UK may contribute to current issues regarding their recognition.[22] The historical lack of clinical service delivery and the exclusion of community pharmacists from healthcare teams are important examples of this. Patients and physicians associate pharmacists with their traditional role and do not ask them to perform clinical services.[22] Professional status might be regulated by policies leading to the inclusion of pharmacists in healthcare teams, but there is presently no standardisation.[16, 17, 20, 21] Some authors consider that the independence of pharmacists from distribution favours the implementation of clinical services in community settings.[19, 24, 26] They argue it reduces conflicts of interest such as sales incentives.[24] In the USA, strict regulations may preclude pharmacists’ independence from distribution. For example, there is only limited access to the ‘provider status’, which allows for billing for clinical services.[24, 25] In Australia, the Home Medication Review offers pharmacists the opportunity to perform clinical services without delivering medication.[3] Social implications Characteristics of included publications The 60 publications discussing social implications are grouped in Supplementary Table S4. Most documents were published in Europe, North America, Australia and New Zealand (52). Eighteen publications were published after 2015. A total of 27 publications were qualitative research,[27–53] 28 were commentaries, 4 were literature reviews[54–57] and 1 was a randomised controlled trial.[58] Three closely related themes, with overlapping elements, were identified: the role of pharmacists and their collaboration with physicians and patients (n = 12), barriers to implementation of clinical services (n = 5) and pharmacy models and services (n = 43). Table 2 summarises the information retrieved from the publications. Table 2 Summary of publications (n = 60) discussing social implications of pharmacists’ clinical services Theme . Observation . Goal . Challenge . Role and collaboration Clinical services are related to the pharmacists' role.[27, 31, 59] To increase awareness of pharmacists’ skills among other professionals.[43, 52, 53, 60, 61] Mistrust of pharmacist’s skills and misunderstanding of pharmacy purpose.[29, 32, 37, 38, 40, 43, 62–64] Change and barriers Current pharmacy model promotes an unsuitable environment and tension with provision of clinical services.[30–32, 34, 35, 36, 48, 65–66] To enhance pharmacist confidence and motivation towards integration of clinical services.[30, 36, 40, 43, 57, 58, 67–71] Lack of proper consultation space, time and incentives.[19, 30, 32, 34, 43, 48, 55, 68] Models and services Models of clinical service implementation are mostly influenced by the organisation of work and the cultural change at the heart of it.[35, 43, 45, 48, 57, 72, 73, 74, 75, 76] To regroup around strong leaders that initiate model implementation.[31, 33, 46–48, 53, 54, 77, 78] All stakeholders must support pharmacists' initiatives.[39, 40, 45, 56, 69, 79, 80, 81] Theme . Observation . Goal . Challenge . Role and collaboration Clinical services are related to the pharmacists' role.[27, 31, 59] To increase awareness of pharmacists’ skills among other professionals.[43, 52, 53, 60, 61] Mistrust of pharmacist’s skills and misunderstanding of pharmacy purpose.[29, 32, 37, 38, 40, 43, 62–64] Change and barriers Current pharmacy model promotes an unsuitable environment and tension with provision of clinical services.[30–32, 34, 35, 36, 48, 65–66] To enhance pharmacist confidence and motivation towards integration of clinical services.[30, 36, 40, 43, 57, 58, 67–71] Lack of proper consultation space, time and incentives.[19, 30, 32, 34, 43, 48, 55, 68] Models and services Models of clinical service implementation are mostly influenced by the organisation of work and the cultural change at the heart of it.[35, 43, 45, 48, 57, 72, 73, 74, 75, 76] To regroup around strong leaders that initiate model implementation.[31, 33, 46–48, 53, 54, 77, 78] All stakeholders must support pharmacists' initiatives.[39, 40, 45, 56, 69, 79, 80, 81] Open in new tab Table 2 Summary of publications (n = 60) discussing social implications of pharmacists’ clinical services Theme . Observation . Goal . Challenge . Role and collaboration Clinical services are related to the pharmacists' role.[27, 31, 59] To increase awareness of pharmacists’ skills among other professionals.[43, 52, 53, 60, 61] Mistrust of pharmacist’s skills and misunderstanding of pharmacy purpose.[29, 32, 37, 38, 40, 43, 62–64] Change and barriers Current pharmacy model promotes an unsuitable environment and tension with provision of clinical services.[30–32, 34, 35, 36, 48, 65–66] To enhance pharmacist confidence and motivation towards integration of clinical services.[30, 36, 40, 43, 57, 58, 67–71] Lack of proper consultation space, time and incentives.[19, 30, 32, 34, 43, 48, 55, 68] Models and services Models of clinical service implementation are mostly influenced by the organisation of work and the cultural change at the heart of it.[35, 43, 45, 48, 57, 72, 73, 74, 75, 76] To regroup around strong leaders that initiate model implementation.[31, 33, 46–48, 53, 54, 77, 78] All stakeholders must support pharmacists' initiatives.[39, 40, 45, 56, 69, 79, 80, 81] Theme . Observation . Goal . Challenge . Role and collaboration Clinical services are related to the pharmacists' role.[27, 31, 59] To increase awareness of pharmacists’ skills among other professionals.[43, 52, 53, 60, 61] Mistrust of pharmacist’s skills and misunderstanding of pharmacy purpose.[29, 32, 37, 38, 40, 43, 62–64] Change and barriers Current pharmacy model promotes an unsuitable environment and tension with provision of clinical services.[30–32, 34, 35, 36, 48, 65–66] To enhance pharmacist confidence and motivation towards integration of clinical services.[30, 36, 40, 43, 57, 58, 67–71] Lack of proper consultation space, time and incentives.[19, 30, 32, 34, 43, 48, 55, 68] Models and services Models of clinical service implementation are mostly influenced by the organisation of work and the cultural change at the heart of it.[35, 43, 45, 48, 57, 72, 73, 74, 75, 76] To regroup around strong leaders that initiate model implementation.[31, 33, 46–48, 53, 54, 77, 78] All stakeholders must support pharmacists' initiatives.[39, 40, 45, 56, 69, 79, 80, 81] Open in new tab Theme one: role and collaboration Clinical services are intimately related to the role pharmacists play.[59] This role is exercised in a complex environment, in close relationship with several other health professionals. Increasing knowledge of pharmacists’ skills among other professionals would facilitate interprofessional collaboration, and thereby the growth of clinical services.[43, 60] Indeed, some authors indicate that certain physicians do not trust the skills of pharmacists and appear to be largely unaware of the wide range of skills they possess in medication management.[40, 63] According to an American report, those misconceptions make collaboration difficult, suggesting that a redefined role could help integrate pharmacists in healthcare teams.[27] Physicians who collaborated with pharmacists offering clinical services in the USA considered them an asset for achieving healthcare goals.[52] Some authors state that physicians and patients have differing perspectives on clinical services provided by pharmacists, but both have incomplete information about the pharmacists’ role.[32, 38, 43, 62, 64] Although patients trust their pharmacists and approve of their extended role, they still see this role as peripheral to traditional distribution.[29, 37, 62] Even where clinical services models are being implemented, in the Netherlands for example, pharmacists continue to accord great respect and consideration to their traditional role.[53] Regardless, pharmacists must pursue the trend of offering broader, quality services given their proven added value to global patient care.[31] Theme two: change and barriers A variety of barriers that limit the integration of clinical services in community pharmacies have been identified. Organisational barriers have been widely discussed.[30–32, 34, 48] A Canadian publication exposes that the current model, built around distribution, promotes an unsuitable environment in tension with provision of clinical services.[31] Community pharmacies are generally structured for medication distribution rather than clinical services, and hence may not have the appropriate facilities (e.g. consultation rooms) for providing clinical services.[31, 34, 35, 47, 48, 65] Pharmacists also lack time to perform clinical services properly when distribution remains the main objective.[30, 32] Considering current financing structures and incentives, providing clinical services goes against the current business model in which profit comes solely from distribution. Some owner associations such as the Pharmacy Guild of Australia show no interest in the separation of clinical and distribution services[19] in line with a common idea among many owners’ that offering clinical services is not sustainable.[34, 48] Pharmacists also evoke personal concerns, which curtail the implementation of clinical services. Lack of self-confidence limits pharmacists’ proactivity in offering clinical services.[30, 69] Lack of motivation to overcome institutional inertia prevents proper implementation, as pharmacists believe organisational change must come first.[30, 36, 57, 67, 68] The time needed to implement clinical services is a challenge, regardless of the complexity of services.[30, 32, 43, 55, 70] To overcome those problems, it has been suggested that training and supervision by mentors should be favoured, which should also help solve self-confidence issues.[30, 36, 40, 43, 58, 70, 71] Theme three: models and services The most influential factors in models of clinical service implementation were related to the organisation of work, but also to the cultural change at the heart of it.[35, 45] Models must be built around strong leaders who delegate technical tasks and reorganise the physical environment of community pharmacies.[46–48, 53] For example, pharmacists in Australia can offer clinical services independently from distribution in home medication reviews.[19, 82] The expertise that pharmacists acquire from high-level training such as the Pharm. D. degree provides them with tools to make recommendations to physicians and build interprofessional collaboration. However, personal development is not enough[28, 68, 79, 83, 84]; the government must support change in pharmaceutical clinical service models.[39, 40, 45, 56, 69, 79] Pharmacy owners must also be supportive, to achieve the goal of a complete, accessible, integrated and patient-centred pharmacy.[31, 33, 54] Owners are concerned about the financial sustainability of providing such services.[34] However, increased demand from patients for clinical services such as remunerated medication reviews could allay their fears.[38, 58] A cultural shift is required, in which pharmacy owners help lead implementation of clinical services and encourage employed pharmacists to become leaders themselves..[35, 43, 48, 57] Discussion Our scoping review sheds light on community pharmacists’ provision of clinical services in relation to public policies and social implication. The social and environmental context of community pharmacy hinders the implementation of such clinical services. Pharmacists’ role in interprofessional teams is inconsistent, clinical models face limiting distribution-linked incentives and personal concerns restrain pharmacists in committing to clinical services. Furthermore, policies recognising the new professional status of community pharmacists cannot by themselves address all identified barriers. Our scoping review offers a global perspective of clinical services delivered by pharmacists. Our rigorous and comprehensive search method, constructed with the help of a specialised librarian, has favoured complete listing of available publications. Nonetheless, it is possible that some important publications were missed. Likewise, unpublished clinical projects were not included in the analysis. Similarly, some contracts between pharmacists and governmental bodies could not be traced by our search strategy. With a clear shift towards clinical services in community pharmacies, many pharmacists must have implemented such services without any trace in research papers. We may therefore have missed relevant elements in our analyses that may have influenced some of our conclusions. Documents published from 2015 onwards deal more frequently with social themes than policy ones. Although all publications expose similar conclusions over time, the more recent ones analyse more in depth the services implemented and the pharmacist’s perception with regard to the integration of the healthcare team. Older publications more often discuss the theories and identified elements leading to innovation. It is difficult to establish a clear chronology for implementation of clinical services: do extended roles for pharmacists lead to the provision of clinical services, are clinical services seen as an opportunity for willing pharmacists to extend their practice, or is it a circular continuum? The absence of a standardised implementation method may be partly responsible for the apparent confusion about pharmacists’ roles reported in the literature. In some contexts, the role of the pharmacist can be expanded through policies even before they offer clinical services, whereas in other contexts it is because the pharmacists offer the services that their role is confirmed. As a result, patients and healthcare professionals may have difficulty understanding the role pharmacists may play in healthcare. The range of clinical services is broad, from simple to complex. Implementation may thus progress along this continuum. Indeed, in some countries, such as India, pharmacists offer clinical services in terms of over-the-counter recommendations,[3, 85] while in many other countries, clinical services comprise medication reviews to optimise global patient care.[9, 58, 86] More recently, community pharmacists in Canada, the UK and Australia, among others, can prescribe medications for some minor ailments.[87, 88] On the other hand, pharmacist independent prescribers registered in the UK following completion of certification are allowed to prescribe any medication for previously diagnosed or undiagnosed conditions within their competence.[88] The social role of the pharmacist, and the social implications of clinical services, can therefore be different from one setting to another. Furthermore, in some countries, like India, pharmacies do not need to have a pharmacist as owner, which influences role recognition.[85] Policies in developing countries such as India seem to be absent from the literature we surveyed, a possible result of the lack of role recognition. Nevertheless, though clinical service provision differs around the globe, barriers to implementation are similar. Indeed, the lack of time, proper consultation space, remuneration and self-confidence is common to all settings. The creation of new community pharmacy models addressing those barriers could facilitate clinical service implementation.[49, 89] In some countries such as the UK and Canada remuneration is already reorienting from distribution to clinical services.[26, 87] The success of policies promoting clinical services may be limited if the barriers are not appropriately identified and assessed. Our scoping review could help eventual stakeholders make decisions related to clinical services implementation. For instance, insurers could understand that pharmacists need to be paid accordingly to clinical services instead of distribution and therefore could reimburse deprescription-aimed consultations. Governments could involve pharmacists in less traditional positions, helping their integration in healthcare teams in order to facilitate role understanding and inter-collaboration. Pharmacy owners could rearrange their pharmacy’s setting in order to accommodate private consultations. Pharmacists could also be considered as independent healthcare provider in regard of policies and work in community setting without being associated with distribution of medication. Software providers could ensure information can be easily shared between health professionals, leading to an improved collaboration between healthcare teams. Many authors mention that policies broadening pharmacists’ scope of practice are often idealistic, with inadequate consideration of barriers in community pharmacy. It appears essential to address those barriers to ensure that policies fulfil their intended goals. Finally, many authors argue that community pharmacists are insufficiently involved in healthcare systems, owing particularly to inadequate recognition of their status. Interestingly, physicians and patients often see pharmacists’ role as peripheral to clinical services, although physicians and patients do not always share the same perspective. This may result from the fact that physicians and patients encounter pharmacists through the same pathway, namely prescriptions, and thus recognise them mainly as distributors. Recognition of the pharmacist’s importance in health care will require that both patients and providers have a better understanding of the services pharmacists can provide. Future studies could help identify ways to expose pharmacists’ role while determining the most appropriate actors to do so. Nevertheless, providing clinical services in community settings could lead to undesirable consequences if the roles of all actors are not well defined. Tensions could arise if physicians feel that pharmacists overstep their field of practice. Policies must also ensure there is no inequity in the financial coverage of clinical services so that there is no differential access depending on the provider. For example, if insurers pay physicians for specific services that could also be delivered by pharmacists, then pharmacists should also be remunerated accordingly to deliver such services. The scoping review revealed that some social and policy dimensions of clinical services are less explored in the literature. For example, few publications discuss how concrete legislation influences the implementation of clinical services in pharmacy. In particular, comparing and contrasting legislations between countries in relation to variation of pharmacists’ role would be of interest. Our results reveal many similarities with the process that led to nurse practitioners’ recognition. In a scoping review, Maier describes policies involving ‘task-shifting from physicians to nurses’ across the globe.[90] She reveals a lack of standardisation in role recognition and the importance of policies as facilitators.[90] The internal and organisational barriers limiting nurse practitioners’ independent practice are similar to those enumerated in our review. Nurses are also encumbered by lack of educational standards, misconception about their role, lack of leadership and restrictive policies.[91] The experience of advanced nursing practice implementation might encourage pharmacy stakeholders to also demonstrate evidence of specialised training, experience and knowledge.[92] Pharmacists, much like nurses, must present the clinical importance of their extended scope of practice to stakeholders in order for them to understand and promote it.[93] As mentioned earlier in our review, interprofessional collaboration is essential to ensure that the pharmacist’s role and scope of practice are well accounted for. While multiple authors report on the collaboration between pharmacists and physicians, the emerging prescribing role of nurse practitioners brings up an important new avenue for future research. Conclusion This scoping review sheds light on social and public policy implications of clinical services performed by community pharmacists. Despite the diversity of contexts presented in the publications, the results are consistent in several respects. Role recognition, interprofessional collaboration, creation of new models centred on clinical services and policy attesting change are some of those implications. Our review exposes the limits and facilitators linked to implementation of clinical services programmes across the globe: deficient environment, internal conflicts and lack of recognition. Pharmacists themselves have an active role to play for proper service implementation. Exposing those implications could help them implement clinical services in interested jurisdictions by offering a foundation for further discussion on the issue. Acknowledgement We thank Frederic Bergeron for his help with the bibliographic search and Myles Gaulin for the linguistic revision. Funding A.C.C. received a scholarship from the ‘Centre de recherche sur les soins et les services de première ligne de l’Université Laval (CERSSPL-UL)’. 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TI - Clinical services in community pharmacies: a scoping review of policy and social implications
JF - International Journal of Pharmacy Practice
DO - 10.1093/ijpp/riaa007
DA - 2021-03-17
UR - https://www.deepdyve.com/lp/oxford-university-press/clinical-services-in-community-pharmacies-a-scoping-review-of-policy-2RM4D0izjQ
SP - 116
EP - 125
VL - 29
IS - 2
DP - DeepDyve
ER -