Qualitative findings
All findings are presented within the domains of the FISpH. Implementation factors participants had experienced were either classified as actual barriers or actual facilitators. Factors which participants perceived would happen, suggested or planned to employ in the future were classified as potential barriers or potential facilitators.
External system
The external system concerns the wider political and healthcare system including regulating authorities and professional bodies. A great concern was a lack of stable and reliable contracts for community pharmacies.
“The last measures that have been in place, were announced, then withdrawn again. This means, something is commissioned but then in the end only half or a third is remunerated.” [P13]
Participants demanded a precise definition of the MR-service from the relevant authorities together with adequate remuneration.
“[MR] is a romantic idea, but if the legal framework is vague and does not ensure the financial viability of the service, the entire thing does not stand a chance.” [P16]
The proposed future service-fund as well as the commissioning of MR-services as a result of changes to German legislation were deemed to be potential facilitators provided this would secure an adequate remuneration.
“I think [the service-fund] will come and we will get a foot in the door and then we can build on that.” [P6]
However, the lack of transparency of the national pharmacy organisation (ABDA) regarding the nature of the negotiated pharmaceutical services with the insurers was perceived as an actual barrier.
“The national pharmacy organisation is lying very low, … and once [the contract] is finalised, we’ll all be taken by surprise because it will announce that MR delivery for all patients starts the day after tomorrow.” [P4]
Participants agreed that the professional bodies were responsible to offer implementation support and to raise awareness of MRs’ aims, scope and benefit.
“Maybe that's another suggestion to get the professional bodies to better pave the way and ... take everyone along step by step.” [P24]
“I believe that … it is important to use the media to demonstrate these benefits [of pharmacists’ MRs].” [P16]
The current undergraduate curriculum for pharmacy students emerged as an actual barrier as many graduating pharmacists lacked the pharmacotherapy knowledge to perform MRs.
“We [in German university education] are very focused on chemistry and the preparation of medicines and technology. … it’s not that they’re worthless, [that knowledge is] just not very useful for medication reviews.” [P19]
Effective interprofessional collaboration with doctors was considered a potential facilitator as both the pharmaceutical and the medical perspective were necessary to optimise a patients’ medication.
“Both doctor and pharmacist [are responsible. … if you really look into [the medication] together, I think, the opportunities are tremendous.” [P12]
Local setting
The local setting includes patients, health care professionals and inhabitants of the community where the pharmacy is located. Many factors within the local setting were seen to be facilitators. All participants reported long standing and trustful relationships with their patients and the local community. Participants appreciated that patients regularly turned to them for advice as a first port of call.
“[Patients] don’t dare to ask the doctor, because they feel inferior …, this inhibition threshold is far lower with us pharmacists.” [P12]
Since the MR-service was largely unknown to the public, pharmacists regretted that patients did not feel a need for an MR and did not demand it.
“It never happened that a patient directly asked for [an MR]. I think the main problem is to notice the need to have their [patient’s] medication reviewed. … in addition [the patient] needs to know that an MR exists.” [P20]
However, once patients had been through a medication review, they were reportedly very satisfied with the outcomes.
“[Patients] thought it was great, thanked me a lot, gave a five-star rating on Google.” [P14]
The extent of the interprofessional collaboration between doctors and pharmacists varied. Still, many participants were optimistic that the collaboration would grow over time, and this would become a facilitator for MRs.
“The first couple years […] were awkward. A doctor even said, ‘you’re throwing a spanner in my work’. However, after a personal dialogue, we came to a mutual understanding” [P17]
Organisation: Community pharmacy
This domain captures all influences from within the pharmacy such as layout and workflow, staffing, teamwork, resources, organisational culture, and environmental stressors. Several participants described the current situation in the community pharmacy as not very conducive to the implementation of MRs since a heavy workload together with staff shortages rendered workdays very busy.
“It is impossible to allow a pharmacist to remove themselves to the office when we’ve got a shortage of pharmacists.” [P17]
Participants had to cope with a high level of bureaucracy. Excessive documentation, complicated delivery contracts and frequent updating of the pharmacy’s licenses were recognized to be external stressors and consequently actual barriers.
“It’s definitely all the bureaucracy ... which I as the owner have to do outside of pharmacy hours.” [P18]
Nevertheless, many participants felt a strong tension for change towards services that made more appropriate use of their pharmaceutical knowledge.
“We can probably only survive if we do exactly that [MR]. As otherwise, Amazon will drop your Asthma inhaler onto your balcony and then we’re done!” [P7]
The medication review service aligned well with several participants’ culture and vision for community pharmacy as they were hoping to enhance their standing as healthcare professionals.
"I hope, we're moving more towards a healthcare role. … not only doing logistics … I believe we can do more." [P20]
Many participants desired better software tools for MR delivery. The lack of supporting software made MRs time consuming and time was reported to be the scarcest resource overall.
“Well, you’d certainly need to rely on a certain amount of [software] support to make an MR feasible, implementable and to make it quicker.” [P6]
Further support for the implementation of MRs could be generated by including other members of the pharmacy team. A participant suggested delegating some tasks to pharmacy technicians.
“Considering the staffing crisis, this can quickly turn the sophisticated pharmaceutical services we’re trying to establish into havoc within five years. That’s a real danger and can only be compensated for if we include the technicians somehow.” [P24]
Individuals: Pharmacists
This domain encompasses personal attributes of the pharmacists, their knowledge, values and motivation as well as reported self-efficacy and skills. Many participants thought an important barrier was the lack of sufficient pharmacotherapy knowledge.
“Clinical aspects, evidence base, and guidelines are not part of the education. … if simple blood pressure targets aren’t known, and colleagues suggest calculating them as ‘100 plus age’ … what can you say?” [P6]
Other participants argued that the necessary knowledge could be acquired and stressed the need for a continuous professional development.
“You have to keep at it. You really need to attend every [MR] seminar. Otherwise, you’ll forget.” [P22]
Many participants believed in their own self-efficacy but doubted their colleagues’ skills. A participant argued that pharmacists in general were sufficiently motivated and self-efficient to perform medication reviews well.
“I think that pharmacists have the skills to do it, that we have the heart to do it. It is not enough to have the data. You really have to want it.” [P15]
Potential positive outcomes for the patient safety by performing more medication reviews were strong motivators for many participants.
“If we consider the thousands of needless hospitalisations caused by adverse drug events, I can see a huge potential for cost savings for the health insurances.” [P17]
In addition, MRs would contribute to high job satisfaction according to several participants.
“I chose this profession because I wanted to understand how [medicines] work and MRs represent the essence of the profession.” [P24]
Characteristics of MR
Potential benefits of MRs for patients, community pharmacy and the healthcare system are covered in this domain. Other characteristics of MR-implementation and delivery that are covered here include complexity, adaptability, and costs.
Implementation of medication reviews was viewed as complex because the service consists of several steps that needed consideration and planning.
“You need to make an appointment … prepare everything, that’s half an hour, then you need to sit down with the patient for at least another half an hour and talk it through.” [P11]
The complexity of an MR entailed several associated costs that were not necessarily covered by the remuneration. Participants described this as a potential barrier.
“If an MR takes an hour, the pharmacist costs 50€ (50 USD), if you add a little for further operating costs, you will have to charge 70€ before you would start to break even.” [P19]
To facilitate implementation, several participants suggested to start with simpler types of MR. This would make the MR more feasible for pharmacists with little prior experience.
“The most important aspect is … that you can say if the MR should be small, medium or large. … to allow you to come into contact with it more often … it lowers the inhibition threshold.” [P24]
Offering medication reviews would benefit community pharmacy as an organisation according to several participants. One participant was hopeful that the reputation of their pharmacy would improve.
“What are the benefits? To be honest, we certainly do hope for an image enhancement” [P6]
Other participants thought MRs had increased the appeal of community pharmacy as a workplace.
“I think that [MRs] were an additional motivation to start working here. … especially for young staff who don’t have a clear picture of the profession.” [P21]
Medication reviews were believed to benefit patients as they increased medication safety for example by stopping unnecessary medicines.
“Sometimes medicines are being continued that should have been stopped. Why does [the patient] take this? It’s on the list.” [P12]
Patients also benefitted from an increase in confidence, receiving information about their medication.
“Patients are inundated with information, and no one seeks the dialogue with them. … patients often get intimidated. In community pharmacy, we can solve problems, we can dispel fear.” [P15]