"Is there a distinct role for pharmacists to contribute to children's healthcare in schools?" To explore the potential healthcare role of the pharmacist in Nottingham schools.
De Montfort University and The University of Nottingham
Background: The role of the pharmacist has evolved over the years from one limited to compounding and dispensing to one which has a greater advisory component.1
Pharmacists could further develop their role by proactively accessing the public as opposed to patients visiting the pharmacy. This could be done via delivery of talks / workshops to institutions such as schools. Healthcare education forms part of the National Curriculum and is primarily delivered by teachers. However, research has shown that teachers need support in order to deliver education on health-related topics.2
Method: Ethical approval was received from the De Montfort University Faculty of Health and Life Sciences Ethical Committee (HLSFREC Ref 698) in consideration of anonymity, confidentiality, voluntary participation and informed consent of participants. Quantitative and Qualitative research methods were used. Postal questionnaires, consisting of fourteen questions involving ticking boxes, ranking using numbers and making comments were sent to all 127 headteachers at state and independent primary, secondary and special schools in Nottingham City. Semi-structured interviews were used to allow further elaboration to establish the current and explore the potential role for pharmacists to contribute to children’s healthcare education.
Results: Thirty-eight (30%) questionnaires were returned. Two headteachers and one headteacher’s representative took part in the semi structured interviews.
Headteachers were positive and welcoming of pharmacists’ contribution to healthcare education in Nottingham schools with 32 (84%) of respondents Agreeing or Strongly Agreeing with pharmacists delivering advice on the safe use of medicines. Twenty-nine (76%) Agreeing or Strongly Agreeing on input to education relating to Abuse and Misuse of Medicines and 31 (82%) Agreeing or Strongly Agreeing on involvement from pharmacists on the effective use of medicines such as checking inhaler techniques of asthmatic children. Interviews revealed healthcare education was taught during Personal Social Health Education (PHSE), Science lessons and Topic work.
Headteachers generally viewed pharmacists as having a distinct role to contribute to healthcare education in schools.
Healthcare education in Nottingham schools, generally follows the National Curriculum and is delivered mainly in the classroom by teachers. There is limited input from school nurses who are generally available in a supportive role for teachers and school children to approach for healthcare related information and advice. Differences between the healthcare education requirements between primary and secondary schools was mainly concerned with subject matter and level of understanding of the different age groups.
Limitations of the study include restricted geographical area and hence sample size and the introduction of bias through the nature of interviewing.
Implications: The research opens the door for further work to investigate the barriers that pharmacists may encounter and how these may be overcome. Pharmacist contribution in this area could be invaluable as it could lead to improvements in general public health by informing and educating members of the public from a young age in a school setting. It would expand the “role of the pharmacist” by utilising their knowledge and skills outside of the pharmacy environment.
Anderson, S. (2007). ‘Community pharmacy and public health in Great Britain, 1936-2006: how a phoenix rose from the ashes.’ Journal of Epidemiology and Community Health. Vol. 61, No. 10, pp. 844-848
Bell, H. Et al. (2000). ‘Primary School teachers Knowledge of Asthma: The Impact of Pharmacist Intervention.’ Journal of Asthma. Vol. 37, No. 7, pp. 545-555
Preliminary Exploration of the Role of paramedics in Care Homes
Mark Kingston(1), Leigh Keen(2), Stephanie Green(3), Lesley Griffiths Griffiths(4)
(1)Swansea University Medical School, (2)Welsh Ambulance Services NHS Trust, (3)Enabling Research In Care Homes (ENRICH), (4)Patient and Public Representative
Background: Half a million people live in UK care homes. General practices struggle to deliver primary care for residents due to high demand and staff shortages. Meanwhile, ambulance services are seeing an increase in 999 calls from care homes. In response, some areas are involving paramedics in proactive and reactive support to care homes. This is part of a policy and service led shift towards paramedics undertaking non-emergency care. It is hoped that through early intervention in care homes, the role may improve care and reduce 999 calls – freeing up resources for use elsewhere. Yet such workforce changes require urgent evaluation to understand implications for residents, staff and health services. We aimed to explore the role of non-emergency paramedics in care homes to support the design of robust studies in this area.
Methods: We convened a Research Development Group of care home, ambulance service, health board, primary care, public and academic representatives. We:
Conducted fact-finding visits to sites
Analysed 999 call data from care homes
Surveyed ENRICH (Enabling Research in Care Homes) care home managers in England and Wales
Held a stakeholder workshop to explore the issues
Results: We identified sites in England and Wales where paramedics provide non-emergency care in care homes. Operating models varied with paramedics employed by ambulance services, health boards and practices. Monthly 999 data from 300 homes confirmed high call and hospital conveyance rates above 60%. We received questionnaires from 50 care homes. Respondents thought paramedics were well suited to assessing residents, identifying issues, improving care and avoiding admissions. They foresaw benefits to inter-professional working, clinical support and person-centred care, but raised concerns over professional boundaries and role clarity. These messages were reinforced in our workshop, where the value of timely assessment was highlighted, alongside challenges of funding and governance.
Implications: The role of paramedics is shifting into primary and community work, including care homes. It is imperative that research is aligned and informs evidence based practice. We are developing PERCH2, a feasibility study evaluating the impact of paramedics working with care homes.
Motivating factors behind skill mix change: Results from a survey of practice managers in England
Jon Gibson, Sharon Spooner, Matt Sutton, Imelda McDermott, Mhorag Goff, Kath Checkland, Anne McBride, Mark Hann, Damian Hodgson
University of Manchester
Background: In the context of a shortfall in GPs, General Practice Forward View (GPFV) has set out changes in training and employment to utilise the skills of a varied range of practitioners i.e. ‘skill mix’ to provide services to patients. The scale and distribution of employment of each type of practitioner is published by NHS Digital and can be monitored at practice level. However this does not provide information about the motivation that drives current employment of specific practitioner types or indicate future plans.
Methods: To identify key motivating factors behind GP practice decisions and plans about their current and future workforce composition. Practice managers in England were invited to complete an online questionnaire. More than 1,000 participating practice managers answered questions about their current workforce, motivating factors behind employment decisions, plans for future workforce composition, specific financial support linked with employing staff (e.g. from HEE or CCG funding) and their ‘ideal’ workforce.
Results: Initial analysis suggests that Physician Associates have generally been employed to increase appointment availability (78% of practices) and release GP time (68%). Those who have employed Pharmacists (66% of practices) have typically received financial assistance and 21% of practices reported that this was ongoing. When asked to construct an ideal workforce, ‘new’ roles (e.g. physician associates, clinical pharmacists, paramedics) accounted for 20% of that workforce on average, which is a significantly larger proportion than are currently in post.
Implications: Although data collection and analysis are not yet complete, the results of this survey provide novel insights into the underlying motivating factors behind employment decisions, specifically for new roles.
Implementing new roles in primary care: Ambiguity
Abigail Tazzyman, Pauline Nelson, Fay Bradley, Jane Ferguson, Lisa Brunton, Damian Hodgson
University of Manchester
Background: The primary care workforce within the UK is in crisis. Well-documented pressures due to ageing populations, subsequent increases in the number and complexity of patient consultations, new technology and the rising cost of treatment are known to contribute to the crisis. This has been exasperated by funding reductions, a lack of investment in workforce and difficulties with recruitment and retention leading to a significant shortage of doctors within primary care. In response to the shortage of general practitioners policy makers across the sector have begun to look at new ways of working. A key aspect of this is the introduction of new roles – specifically the introduction of both clinical and non-clinical staff from different occupations introduced to take on some of the general practitioner workload. It is hoped such new roles will enhance patient access and satisfaction, and prove cost effective in the absence of sufficient numbers of general practitioners to meet demand. In this paper we explore how new roles have been implemented in primary care and consider in particular the challenges posed by ambiguity and variation in new role definition.
Method: This paper is based on semi-structured interviews (and one focus group) with national and regional GP and primary care policy leads, CCG/provider leads across an English region and operational level interviews with training/service leads, role holders or host GP practice staff. The five individual new roles studied were: care navigator, paramedic, pharmacy technician, physiotherapist and social prescribing link worker. A total of 87 participants took part in 61 interviews and one focus group between August 2018 and July 2019.
Results: Interviewees understood the purpose of new roles to be to alleviate pressures on the workload of existing professionals, notably GPs. Though benefits for patients in terms of greater and more appropriate access to health care were raised, these were seen by most as secondary to workforce pressure and the need to improve the working lives of GPs in particular, and these priorities impacted how roles were implemented.
A lack of clarity across the board on what each new role entailed was observed by interviewees. The high level of ambiguity meant little consistency existed as to the remit of each role, such that individuals in new roles sometimes felt the work they were tasked with did not match their expectations of the role, their level of education/training or the post described in job advertisements. This inconsistency posed issues for moving jobs even within the sector.
However, this ambiguity also enabled individual organisations (usually GP practices) to mould new roles, particularly more junior roles. While this was beneficial for individual GP practices, this often meant that the job satisfaction, career paths and workforce development were not considered in the design of such roles. Delegation of undesirable or inappropriate work as well as deskilling were also raised as issues.
Implications: The level of ambiguity and resultant inconsistency in role design and job quality for new roles being implemented within primary care has implications for their sustainability and retention of the individuals that occupy them. Primary care varies significantly across the sector and restriction from over standardisation of job roles can be an issue. Given existing recruitment and retention issues however, investment into new ways of working would benefit from a greater balance towards more role clarity and consideration of job quality and longer term career paths to ensure the roles created provide jobs that both attract and retain workforce within the sector in the long-term.
Evaluating an alcohol health champion community intervention: how do newly trained champions perceive and understand their training and role?
Suzy Hargreaves(1), Cathy Ure(1), Elizabeth Burns(1), Margaret Coffey(1), Suzanne Audrey(2), Penny Cook(1)
(1)University of Salford, (2)University of Bristol
Background: Community engagement in public health interventions is a known way of enabling people to have a level of control and empowerment over their own health. However, this approach can create challenges in planning interventions from a commissioning point of view (1). When assets that already exist in a community, such as people’s values, capacity, skills, knowledge, connections and potential are used in an intervention, this is known as an ‘assets-based approach’(2). The Communities in Charge of Alcohol (CICA) programme is an assets-based approach, training community members across the local authority boroughs in Greater Manchester to become Royal Society of Public Health (RSPH) Level 2 trained alcohol health champions (AHCs) to give brief advice to reduce alcohol harm and to get involved in the alcohol licensing process (3). The current study focuses on interviews with newly trained AHCs and aimed to explore what motivates community members to get involved and how they experience the training programme. Looking at the first three months following training, this part of the evaluation aimed to discover any facilitators or barriers in putting the training, knowledge and skills into practice and how AHCs made sense of the role.
Method: Within three months of attending the training, a sample of AHCs were invited to take part in an in-depth, semi-structured interview. The recruitment was facilitated by local CICA coordinators, who put forward AHCs with a variety of motivations for taking part. Five interviews were conducted with AHCs coming from three different CICA intervention areas and framework analysis was used to identify and code the themes and sub-themes.
Results: A number of overarching themes were identified: carrying out the role of an AHC; enablers to the establishment of CICA; experiences and perceptions of training to become an AHC; how AHCs made sense of the licensing process; wider societal influence and context. Within these wider themes, many sub-themes were recognised, including: what people bring to the role of the AHC in terms of beneficial personal assets and knowledge; expectations and feelings about the role; barriers to carrying out the role; relationships between AHC and the community; feelings of a sense of involvement and belonging; making sense of the training; feelings about the accredited RSPH qualification; understanding of the licensing process; understanding the wider determinants and effects of drinking and the role of alcohol in society; and, effects of budget cuts to local facilities and services. The themes and sub-themes gave a wider contextual understanding of the circumstances that can affect the roll-out and embedding of a community intervention.
Implications: The results of this part of the evaluation of CICA will contribute to the understanding of the ways in which asset-based, community-centred research can be used in public health interventions. Asset-based approaches are encouraged (4) but evidence as to its use in public health interventions is scarce. This evaluation examines the context in which a community-based intervention is implemented, and the mechanisms of action required to be successful.
Brunton G, Thomas J, O'Mara-Eves A, Jamal F, Oliver S, Kavanagh J. Narratives of community engagement: a systematic review-derived conceptual framework for public health interventions. BMC Public Health. 2017;17(1):944.
Foot J, Hopkins T. A glass half-full: how an asset approach can improve community health and well-being. Improvement and Development Agency; 2010.
Cook PA, Hargreaves SC, Burns EJ, de Vocht F, Parrott S, Coffey M, et al. Communities in charge of alcohol (CICA): a protocol for a stepped-wedge randomised control trial of an alcohol health champions programme. BMC Public Health. 2018;18(1).
National Institute for Health and Care Excellence. Behaviour change: general approaches. National Institute for Health and Care Excellence; 2007.
Hybrid professionals in senior leadership roles: responding to role expectations through job crafting
Faculty of Medical Leadership and Management
Background: Research on the medical profession and management has typically described how members of the profession adapt and respond to changing organisational, societal and political pressures. To date, studies examining doctors in leadership roles have sought to understand the influence and adaptation of identity as doctors’ transition into and enact leadership roles and how they integrate, claim and use management and leadership logics. There is little research examining how medical professionals who hold the most senior positions in organisations may craft their jobs in response to their own and colleagues’ expectations. This study sought to understand how medical directors (MD) interpret, experience and craft their jobs, specifically in response to their own and senior leader expectations.
Method: This study came about as a result of a review of the medical director role commissioned from a UK government. The focus of the review was to understand the current expectations and experiences of medical directors, their chairs and chief executives (CE) in large NHS organisations across the country, the changes in the role since it was established and how it may need to change for the future. Semi-structured telephone interviews were undertaken between September 2018 and August 2019 and included 11 MDs, seven CEs and four chairs. Observation was not possible as part of the commissioned review.
Initial data analysis was guided by role theory, specifically the sent expectations of senior colleagues, MDs interpretation of expectations on them as well as their own expectations for performance in the role. The second stage of the analysis focused on job crafting theory (Wrzesniewski and Dutton, 2001).
Findings suggest that MDs do engage in job crafting. This study found three different categories of medical director job crafting- active, pragmatic and limited. These categories describe medical directors’ approach to and engagement in the role, particularly in relation to job crafting.
Cognitive crafting was evident in the differences in how MDs perceived the scope and possibilities of their role. ‘Active’ job crafters were clear in the broad potential of the role to impact the organisation and system while ‘pragmatic’ job crafters recognised the potential but tended to focus on professional leadership.
Task crafting was present in both active and pragmatic groups, mostly through developing their human resource support and delegation so that they could focus on strategic elements of the role, with the active group tending to be more successful in obtaining the resources needed. Task crafting efforts appeared to be linked to members of the role set (chairs and CEs) and their perception of the need for resource support.
Relational crafting was less emphasised amongst MDs, here it was evident, the focus tended to be on building better relationships with colleagues within the organisation.
Insights from interviews with CEs and chairs suggest that their perceptions and expectations of the role, whether shared explicitly or implicitly, may affect MDs’ enactment of the role. The potential influence of chairs and CEs was particularly evident with regards to assumed sufficient resource for ‘pragmatic’ MDs to carry out their role, and the contrasting account of the incumbent.
Implications: This research contributes to our understanding of how job crafting works amongst professionals in hybrid roles. Practically, these early findings have implications for how MDs may develop their roles and for colleagues in how they enable (or limit) the proactivity and contribution of MDs. Traditional views of what MDs do ie managing professional colleagues, providing medical advice to the board, may be limiting the potential contribution of these hybrid leaders to addressing the organisational and system needs.
Advanced Clinical Practice Roles in the NHS: panacea or challenge for workforce problems?
Vari Drennan MBE(1), Mary Halter(2), Francesca Taylor(2)
(1)Joint Faculty Kingston University & St.George's University of London, (2)Kingston University & St. George's University of London
Background: Developing and retaining a health care workforce to meet increasing patient demand within financial constraints is a major issue in all health systems. The English National Health Service (NHS) has significant medical and nursing shortages. National policy is promoting Advanced Clinical Practice (ACP) roles in nursing, midwifery, allied health professionals and health scientists to improve patient experience, productivity and NHS staff work and career experience [NHS England, Long Term Plan 2019]. ACP roles are “delivered by experienced, registered health and care practitioners. It is a level of practice characterised by a high degree of autonomy and complex decision making.” [Health Education England, NHS Improvement, NHS England. Advanced Clinical Practice Multi-professional Framework for England. 2018]. The Interim NHS People Plan  allocated funds to scale up the education of ACPs However, our scoping literature review identified scant evidence for most ACP roles or the extent of adoption across the NHS. This qualitative study investigated:
What are the perceptions at senior management and senior clinical level of development and adoption of ACP roles in NHS services?
What are factors that support or inhibit development and adoption of ACP roles?
Method: A qualitative study in the interpretative tradition among senior managers, clinicians and those with lead roles for workforce/ACP development in acute, community and emergency service NHS trusts in Greater London. Semi-structured interviews were conducted with 20 participants in 2019. Thematic analysis undertaken of the data. Emerging findings were presented to a pan-London expert group to confirm credibility of findings.
Findings: There was great variety in the number of ACP roles within trusts but in the main they were a very small percentage of staff, often in single services. Most were very new although in some services, e.g. emergency departments, there was a ten plus year history of development. Five main ‘influencers’ were identified in their development: a strategic response to medical shortages, commissioner-funded ACP roles in new integrated care services and primary care, education commissioner-funded ACP training, roles developed by individuals and the desire to retain experienced staff. Two key factors were reported as enablers sustaining ACP posts – finance for substantive posts and evidence of value of ACP posts. Visible organisational support for such roles was also viewed as important. Inhibiting factors to adopting, developing and sustaining ACP roles were: lack of identified finance and resources for ACP training and positions; confusion and lack of knowledge of ACPs amongst clinicians and managers; and a nervousness (sometimes resistance) to introducing a new role with little evidence and many unanswered questions about effectiveness and consequences. None of the participants were able to offer any internal or publicly available evaluations of ACP roles, including of public responses to the new roles.
Implications: While the policy agenda is to promote ACP roles there is limited understanding, confusion and nervousness at the operational level. Development scenarios that introduce new monies for such roles such as commissioning will reduce some of the inhibiting factors. However, where the introduction of ACP roles requires funding to move from one part of a service to another, and potentially from one staff group to another, the growth of these roles is likely to be contested. The paucity of publically available evidence on the effectiveness of ACP roles requires urgent attention.
Pharmacy on the front lines: The unique role of an urgent care pharmacist
Natasha Burns, Prof. Damian Hodgson, Dr Sally Jacobs
University of Manchester
Background: Current health care policy initiatives (NHS England, 2019) promote pharmacists undertaking new roles and integrating across health care sectors. The NHS is experiencing unprecedented demand for services and pharmacists are seen as an important part of the solution to this strain on services (Avery et al, 2012). In 2018 it was announced that the Integrated Urgent Care programme, supported by the Pharmacy Integration Fund, would be expanding to enable pharmacists to lead on person-centred medicines optimisation in virtual acute settings (reference needed here). To date, there is very little literature examining the role of pharmacists working within integrated urgent care. This paper will discuss the findings of an exploratory qualitative study conducted with integrated urgent care pharmacists situated within a clinical hub operated by a regional ambulance service The main aim of the study was to examine whether the urgent care pharmacists engaged in identity work and how their presence impacted upon professional boundaries and multidisciplinary working.
Method: This study undertook a qualitative approach through the method of semi-structured interviews in order to enable deep rooting in the perspective of the participants and produce in-depth rich data. Interviews took place with pharmacists working at a clinical hub based within a regional ambulance service and other health care professionals. Ethical approval was granted through The University of Manchester ethics committee and the Health Research Authority. Thirteen interviews took place over a period of three weeks in the summer of 2019 as part of my Master’s thesis. Interview topics included questions relating to identity, professionalism, the clinical hub setting and the challenges this new role presented. The interviews were audio-recorded, transcribed verbatim and analysed using template analysis (King, 2004).Coding was conducted using NVIVO and four ‘a priori’ themes were identified – Professionalism, identity, multidisciplinary team working and the integrated urgent care setting.
Results: The main findings demonstrated four professional identities common to urgent care pharmacists’ – patient-centred carers, medicines experts and advisors, scientists and communicators. The strongest identity put forward by participants were that of patient-centred carers. Health care policy has been refocused on patient-centred care for quite some time (NHS England, 2015) and might explain why it has been adopted into pharmacists’ professional identity. The role of pharmacists as communicators is a distinctive element of professional identity derived from this study. Evidence is presented indicating identity work taking place in order to meet the unique challenges of the urgent care environment, which is supported by professional socialisation within the clinical hub.
Implications: As new roles develop throughout pharmacy practice, it is important to consider the impact this will have on the profession and the professional identities of pharmacists operating within new care models. Opportunities must be seized to provide early exploration of the degree to which identity work is undertaken by pharmacists in new contexts. Attention must also be drawn to the need for pharmacists, managers and service leads to articulate and reflect on the implicit professional identity expectations which affect conduct in new contexts. . This study shows early indications of identity work taking place and has the potential for wider research, particularly in relation to professional boundary negotiation within clinical hubs and multidisciplinary teams.
Avery AJ, Rodgers S, Cantrill JA, et al. (2012) A pharmacist-led information technology intervention for medication errors (PINCER): a multicentre, cluster randomised, controlled trial and cost-effectiveness analysis. Lancet 379(9823):1310–1319
King, N. (2004). Using templates in the thematic analysis of texts. In: C. Cassell and G. Symon, eds., Essential Guide to Qualitative Methods in Organizational Research. London: Sage Publications
NHS England (2019) The Long Term Plan. https://www.longtermplan.nhs.uk/ (Accessed 23rd May 2019)