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General practitioners’ experiences with, views of, and attitudes towards, general practice-based pharmacists: a cross-sectional survey

General practitioners’ experiences with, views of, and attitudes towards, general practice-based... Background: There is limited United Kingdom (UK) literature on general practice-based pharmacists’ (PBPs’) role evolution and few studies have explored general practitioners’ (GPs’) experiences on pharmacist integration into general practice. Therefore, this study aimed to investigate GPs’ experiences with, views of, and attitudes towards PBPs in Northern Ireland (NI). Methods: A paper-based self-administered questionnaire comprising four sections was mailed in 2019 to 329 gen- eral practices across NI and was completed by one GP in every practice who had most contact with the PBP. Descrip- tive analyses were used and responses to open-ended questions were analysed thematically. Results: The response rate was 61.7% (203/329). There was at least one PBP per general practice. All GPs had face-to- face meetings with PBPs, with three-quarters (78.7%, n = 159) meeting with the PBP more than once a week. Approxi- mately two-thirds of GPs (62.4%, n = 126) reported that PBPs were qualified as independent prescribers, and 76.2% of these (n = 96/126) indicated that prescribers were currently prescribing for patients. The majority of GPs reported that PBPs always/very often had the required clinical skills (83.6%, n = 162) and knowledge (87.0%, n = 167) to provide safe and effective care for patients. However, 31.1% (n = 61) stated that PBPs only sometimes had the confidence to make clinical decisions. The majority of GPs (> 85%) displayed largely positive attitudes towards collaboration with PBPs. Most GPs agreed/strongly agreed that PBPs will have a positive impact on patient outcomes (95.0%, n = 192) and can provide a better link between general practices and community pharmacists (96.1%, n = 194). However, 24.8% of GPs (n = 50) were unclear if the PBP role moved community pharmacists to the periphery of the primary care team. An evaluation of the free-text comments indicated that GPs were in favour of more PBP sessions and full-time posts. Conclusion: Most GPs had positive views of, and attitudes towards, PBPs. The findings may have implications for future developments in order to extend integration of PBPs within general practice, including the enhancement of training in clinical skills and decision-making. Exploring PBPs’, community pharmacists’ and patients’ views of this role in general practice is required to corroborate study findings. Keywords: General practice, General practitioners, Primary health care, Pharmacists, Cross-sectional Background Primary care has been defined as a “first-contact, acces - *Correspondence: c.hughes@qub.ac.uk Primary Care Research Group, School of Pharmacy, Medical Biology sible, continued, comprehensive and coordinated care” Centre, Queen’s University Belfast, 97 Lisburn Road, Belfast, Northern [1]. This care is provided by multidisciplinary teams Ireland BT9 7BL, UK © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Hasan Ibrahim et al. BMC Primary Care (2022) 23:6 Page 2 of 12 including general practitioners (GPs), pharmacists, prac- with PBPs as this may affect the degree to which they col - tice nurses, and other healthcare professionals (HCPs) laborate with one another [19], and may contribute to such as dieticians and physiotherapists [1, 2]. Primary the ongoing development of the role. As integration of care in the United Kingdom (UK) faces unprecedented PBPs into general practices is a new initiative, there will challenges due to the growing complexity of an age- be barriers to successful interprofessional collaboration ing population and their care needs [3]. Ageing is often that will need to be overcome. An Australian study iden- linked with an increased prevalence of multimorbidity tified the views of GPs and pharmacists (i.e. community (the presence of two or more chronic conditions) and pharmacists and PBPs) on the integration of pharmacists polypharmacy (the concomitant use of four or more into general practice and found several benefits such as medicines), which increases the demand for primary care improved collaboration and communication amongst the services and GPs [3]. Furthermore, primary care faces a primary healthcare team [20]. This Australian study also workforce crisis arising from issues around recruitment identified barriers such as negative practitioner percep - and retention of GPs and practice nurses [3]. Therefore, tions, and insufficient funding and infrastructure [20]. one approach to alleviate some of the pressures within A Canadian study described the barriers and facilitators primary care has been the integration of pharmacists into that the primary care teams (PBPs, GPs and nurse practi- general practices, known as general practice-based phar- tioners) experienced during pharmacist integration [21]. macists (PBPs) [4]. Barriers and facilitators existed around relationships, In 2015, five-year PBP pilot schemes were launched trust and respect, definition of pharmacist role, support, in both England and Northern Ireland (NI) to integrate pharmacist personality and professional experience, pres- PBPs into general practice [4, 5]. A shortage of approxi- ence and visibility of pharmacists, and resources [21]. mately 8000 GPs in England with a projected excess Literature is now emerging which describes the views of 11,000–19,000 newly qualified pharmacists by 2040 and experiences of HCPs with the integration of phar- encouraged National Health Service (NHS) England to macists into general practice [20–23]. Several studies launch a £15 m initiative in 2015. This initiative aimed to stressed the need to collect more detailed information employ more than 490 PBPs across 658 general practices regarding the context of the PBP role as little is known to provide more support in the management of long- about how PBPs affect the healthcare system, including term conditions and enhance the standard of care for patients and HCPs [24–26]. Moreover, there is limited patients [4, 6–8]. Further investment was announced in UK literature on PBPs’ role evolution and few studies 2016 as NHS England planned to invest a further £100 m have explored GPs’ experiences on pharmacist inte- to recruit and train an additional 1500 pharmacists by gration into primary care practice to date; none have 2020/2021 [7, 9]. In NI, the Department of Health allo- explored the views of GPs in NI, where there has been cated £17 m of funding to support PBPs in general prac- regional deployment of PBPs across practices. Further- tices across NI [10]. It is anticipated that there will be more, the findings of studies conducted in other parts of 300 whole time equivalent PBPs in post by the end of the the UK may not be generalisable to NI where established pilot scheme in NI (2020/2021) [5]. services and funding mechanisms are different. As the PBPs, as qualified experts in medications with a variety main reason for PBP integration into general practices of knowledge and skills, have been able to improve access was to reduce pressure on general practice, no research to healthcare and reduce waiting times for appointments has explored the views of NI GPs regarding the role of in general practice [11]. Furthermore, PBPs have deliv- PBPs and how this may have affected their workload ered a range of activities that have been found to enhance and delivery of primary care. Therefore, this quantitative patient outcomes (e.g. resolution of medication-related cross-sectional study aimed to address this gap in the lit- problems and improved prescription appropriateness) erature by investigating: 1) GPs’ experiences with PBPs, [12, 13]. These activities include medication review and 2) their views about the PBP role and its impact upon medication reconciliation [11, 12, 14]. Moreover, if the patients, and 3) their attitudes towards collaboration with PBP is qualified as an independent prescriber, they are PBPs. able to prescribe in areas in which they are competent, and conduct chronic disease review clinics [11, 14]. They Methods may also undertake administrative tasks such as clinical Study design, population, and setting audit and prepare prescribing protocols [15]. The study used a cross-sectional design. One GP, in each Establishment of interprofessional collaborative work- general practice in NI, who had the most contact with ing [16] between primary HCPs is essential to improve the PBP, was invited to participate in this study. General service delivery and patient outcomes [17, 18]. It is practices are independent, small businesses, often oper- important to explore GPs’ attitudes towards collaboration ating from their own premises [2]. The job role of a GP Hasan I brahim et al. BMC Primary Care (2022) 23:6 Page 3 of 12 can be designated as partner (GP responsible for running (e.g. GPs, PBPs, and community pharmacists) on the role the business side of the practice and employing staff), of PBPs [20–23, 38]. The nature and style of questions salaried (GP receiving a salary for a contracted number and presentation of questionnaire were considered to of hours worked), or locum (GP providing temporary help optimise the response rate [39]. The questionnaire staffing cover at any time). The Business Services Organi - (see Additional file  1) comprised four sections: (A) demo- sation (BSO) website (see Table  1) maintains an up-to- graphic information about the GP respondent and their date database of general practice postal addresses in NI working environment; (B) extent of GPs’ collaboration [29]. There were 329 GP practices, 1342 registered GPs with PBPs; (C) GPs’ attitudes towards collaboration with (excluding locums), and more than 2 million registered PBPs determined through administration of the Attitudes patients in NI on 4th September 2019 [30]. General prac- Towards Collaboration Instrument for GPs (ATCI-GP); tices are provided funding from the Health and Social and (D) GPs’ views on the role of PBPs and their impact Care Board (HSCB) (see Table  1) based on the number in primary care. and types of patients registered with them [2]. ATCI-GP (Section C) is a validated five-point Likert In NI, there are 17 GP Federations (a group of general scale developed to measure GP attitudes towards GP- practices, forming an organisational entity and working pharmacist collaboration [19]. Permission was granted together within their geographical area) which offer the from the authors of the ATCI-GP to use the scale and to PBP terms and conditions of employment and provide substitute the word ‘pharmacist’ for ‘practice-based phar- occupational maternity pay as well as a sick pay scheme macist/PBP’ throughout the scale’s statements. [31, 32]. Working patterns will be determined by the GP The entire questionnaire was piloted with three aca - Federation and must meet the business needs of the Fed- demic GPs from the School of Medicine, Queen’s Univer- eration [32]. The salary of PBPs in NI depends on their sity Belfast who were similar to the population of interest. experience and qualifications [32]. There were 2715 They completed the questionnaire by self-administration. pharmacists registered in NI in 2020 of whom 12% were They were asked for their comments and general feed - working as PBPs [33, 34]. Many PBP positions in NI gen- back regarding the content and flow of the questionnaire eral practices have been filled by experienced community and their responses were used to refine its content and pharmacists [33, 35]. layout (i.e. face validity) and to estimate the time taken for its completion. The pilot responses were not included Questionnaire in the final sample or analysis. A postal questionnaire was selected as the most efficient Questionnaires were mailed, on two occasions during method of administration which facilitates data collec- September (first mailing) and October (second mailing tion from a large sample of participants in a relatively to improve response rate) 2019 to the 329 general prac- short period of time compared to other survey methods tices in NI, accompanied by a covering letter and a return [36, 37]. This method also requires less social interaction pre-paid addressed envelope. The cover letter which with respondents (i.e. self-completion), thus social desir- accompanied the questionnaire was directed to the Lead/ ability bias and interviewer bias are reduced [36, 37]. Senior GP in each general practice (responsible for qual- The questionnaire was developed by the research team ity improvement and primary care management in the members (AHI, CH, HB), following a comprehensive lit- general practice) and requested that the GP who had erature search regarding perceptions of various HCPs the most contact with the PBP in their practice should Table 1 Summary of the key features of a number of health care organisations in Northern Ireland [27, 28] Health care organisations in NI Description Health and Social Care Trusts [27] - Five Trusts (the Belfast, Northern, Southern, South Eastern and Western Trusts) together with the NI Ambu- lance Trust. - Administrative health organisations which are responsible for the management and administration of health and social care services on a geographical basis. Health and Social Care Board [27] - Organisation responsible for commissioning health services, performance management of the Health and Social Care Trusts and service improvement. Business Services Organisation (BSO) [27] - Organisation responsible for the delivery of a variety of commercial support and specialist professional services to the Health and Social Care sector. - The BSO website provides comprehensive resources for primary care, such as the COMPASS report which is a prescribing information summary that is issued quarterly for each GP practice to provide GPs with feedback on their prescribing [28]. Hasan Ibrahim et al. BMC Primary Care (2022) 23:6 Page 4 of 12 complete the questionnaire. If the practice did not have a in NI in which the majority of GPs’ patients predomi- PBP, the cover letter requested that the questionnaire was nantly reside, indicating broad geographical distribution still completed by a GP in order to obtain views on the at practice level. Three-quarters (76.8%, n  = 156) of GPs implementation of PBPs in general practice. indicated that they worked in medium-sized practices In the cover letter, participants were assured of the con- based on list sizes (i.e. 3000–10,000 patients). There was fidentiality and anonymity of the collected data. Consent at least one PBP per general practice. The respondents was deemed to be implicit if GPs returned completed answered all the sections in the questionnaire as all GPs questionnaires. This consent process was approved by the had a PBP working in their general practices at the time School of Pharmacy Ethics Committee – see later) [40]. of the study. Statistical analysis Characteristics of practice‑based pharmacists All returned questionnaires were coded then descriptive and general practitioners – practice‑based pharmacists’ analyses were conducted such as age and gender distribu- communication tion within the sample. Responses to the ATCI-GP state- Approximately two-thirds of GPs (64.5%, n  = 129) ments (Section C), and GPs’ views statements (Section D) reported that PBPs had been working within general on the role of PBPs and their impact upon patients were practice for 2 years or less at the time of questionnaire also analysed descriptively, by calculating the percentage completion. Just over 45% of GPs (45.4%, n  = 84) indi- of agreement or disagreement to each statement. Data cated that PBPs provided four to six sessions in GPs’ entry was doubled checked manually by the researcher practices per week. Almost two-thirds of GPs (62.4%, (AHI) to ensure the absence of any errors within the data. n = 126) reported that PBPs were qualified as independ - Where there were missing responses in a questionnaire, ent prescribers, with 76.2% (n  = 96/126) indicating that these were coded as missing and were omitted from the PBPs were currently prescribing for patients. final analysis. SPSS version 26.0 [41] was used for all sta - All GPs had face-to-face meetings with PBPs, with tistical analysis. three-quarters (78.7%, n  = 159) meeting with the PBP A broad approach was taken to analyse responses to more than once a week (see Additional file  2 – Figure A). open-ended questions [42]. The responses were read The main issues usually discussed during these meetings several times to achieve a general understanding, and were: medication issues, medication review, prescrib- grouped under broad categories as a means to summarise ing issues, patient issues, transitions between care sec- the main findings. tors (e.g. hospital discharge and outpatient letters), work issues, audit and COMPASS reports, practice/system/ Results Federation level issues, and training for PBPs. GPs used A total of 203 completed questionnaires were received more than one method to communicate with PBPs, but following both mailings, providing a response rate of the majority (95.5%, n  = 192) indicated that face-to- 61.7% (203/329). face was the most common and preferred approach (see Additional file  2 – Figures B and C). Moreover, the GPs Demographic data listed the most common reasons for the GPs to commu- Table  2 presents non-identifiable demographic data nicate with the PBPs and for PBPs to communicate with about GPs and their working environment. Some demo- the GPs, e.g. patient issues and prescribing queries (see graphic characteristics of the GPs (i.e. gender and age) Additional file 3). were compared with those of the entire population of Frequency of face-to-face contact between PBPs and GPs in NI from data published on the BSO website (see patients varied (see Additional file  4 – Figure A), e.g. Table  2) [29]. Almost 60% (57.4%, n  = 116) of GPs were 20.7% of GPs (n = 41) reported that PBPs had daily con- male, which was a slightly larger proportion compared tact with patients, and 14.1% of GPs (n  = 28) reported to the GP population in NI (42.4%; n  = 573). GPs had a that PBPs did not meet face-to-face with patients. Addi- mean age of 50.4 (SD ±8.6) years and there were slight tionally, they revealed that the main issues usually dis- differences in the age groups between the GP respond - cussed during these meetings were chronic disease ents and all GPs in NI (see Table  2). On average, GPs management clinic issues, medication problems, patient had obtained a Certificate of Completion of Training or education, and other topics such as flu vaccinations. Fur - equivalent (qualified as a GP) 23.6 (SD ± 9.4) years ago. thermore, the majority of GPs (93.0%, n = 187) reported The mean number of sessions spent by GPs in general that the most common and preferred method of com- practice per week was 7.1 (SD ± 1.5). There was approxi - munication between PBPs and patients was by telephone mately equal distribution of the responses across the (see Additional file 4 – Figures B and C). location of general practices and the five Trust areas Hasan I brahim et al. BMC Primary Care (2022) 23:6 Page 5 of 12 Table 2 Demographic profile of GP respondents (n = 203) in Northern Ireland Number of GP Number of NI GPs respondents (%) (%) Gender Female 85 (42.1) 778 (57.6) Male 116 (57.4) 573 (42.4) Prefer not to say 1 (0.5) * Age (years) 25–39 28 (14.2) 456 (33.8) 40–44 24 (12.2) 239 (17.7) 45–49 26 (13.2) 179 (13.2) 50–54 44 (22.3) 188 (13.9) 55–59 51 (25.9) 184 (13.6) ≥ 60 years 24 (12.2) 102 (7.5) Average years since the GP respondent had obtained Certificate of Completion of Training 23.6 (± 9.4) * (CCT) or equivalent (qualified as a GP) (± SD) Average number of GPs’ sessions per week (± SD) 7.1 (±1.5) * Location of general practices Rural 61 (31.0) * Suburban 66 (33.5) * Urban 70 (35.5) * Trust area of Northern Ireland in which majority of GPs’ patients predominantly reside Belfast 40 (20.0) * Northern 48 (24.0) * South Eastern 41 (20.5) * Southern 39 (19.5) * Western 32 (16.0) * Size of general practices Small (< 3000 patients) 17 (8.4) * Medium (3000–10,000 patients) 156 (76.8) * Large (> 10,000 patients) 30 (14.8) * Other health and social care professionals working within general practices General practitioner (GP) – Partner 197 (98.5) * General practitioner (GP) – Salaried 81 (44.5) * Practice-based pharmacist (PBP) 203 (100) * Practice nurse 194 (98.0) * Others 117 (91.4) * Data published quarterly (equating to July–September 2019, published on October 1st 2019) on the BSO website [29] * Information unavailable The majority of GPs (70.6%, n  = 142) indicated that the (55.2%, n  = 111), and the PBP’s previous experience consulting room was always/very often available for PBPs, (54.2%, n  = 109). Furthermore, 9.0% of GPs (n  = 18) while 19.9% of GPs (n = 40) indicated that this room was specified that PBPs’ activities were determined by: prac - sometimes available to PBPs (see Additional file 5 ). tice need, Federation demands, the HSCB’s plans [10], PBPs provided a wide range of activities (see Fig.  1), the lead PBP, or the PBP’s interests. most commonly medication reconciliation and medica- This survey investigated the frequency of issues tion reviews. Most GPs (92%, n  = 185) noted that PBPs’ encountered by GPs when dealing with PBPs (see activities were allocated in general practice through Table  3). The majority of GPs reported that PBPs mutual agreement between the GP and PBP. In addi- always/very often had the required clinical skills (83.6%, tion, these activities were determined by the PBP’s cur- n  = 162) and knowledge (87.0%, n  = 167) to provide rent skills (63.7%, n = 128), the PBP’s level of confidence safe and effective care for patients and had the required Hasan Ibrahim et al. BMC Primary Care (2022) 23:6 Page 6 of 12 Fig. 1 Activities of practice-based pharmacists in general practice as reported by responding general practitioners Table 3 Frequency of issues encountered by the general practitioners when dealing with practice-based pharmacists Statement Always Very often Sometimes N (%) Rarely Never N (%) N (%) N (%) N (%) I do not have time to contact the PBP 1 (0.5) 13 (6.7) 48 (24.7) 74 (38.1) 58 (29.9) The PBP struggles to adapt to the needs of the practice 1 (0.5) 5 (2.5) 28 (14.1) 69 (34.7) 96 (48.2) The PBP has the clinical skills to provide safe and effective care for patients 81 (41.8) 81 (41.8) 25 (12.9) 6 (3.1) 1 (0.5) The PBP has the required experience to meet the needs of the practice 75 (38.1) 80 (40.6) 36 (18.3) 6 (3.0) 0 (0) The PBP is unavailable in the practice when I need them 4 (2.0) 29 (14.6) 77 (38.7) 62 (31.2) 27 (13.6) The PBP has the confidence to make clinical decisions 35 (17.9) 82 (41.8) 61 (31.1) 15 (7.7) 3 (1.5) The PBP has the knowledge to provide safe and effective care for patients 71 (37.0) 96 (50.0) 23 (12.0) 2 (1.0) 0 (0) Patients are reluctant to accept and book an appointment with the PBP 1 (0.6) 1 (0.6) 53 (32.3) 81 (49.4) 28 (17.1) experience to meet the needs of the practice (78.7%, Attitudes towards collaboration with practice‑based n = 155). However, 31.1% (n = 61) stated that PBPs only pharmacists sometimes had the confidence to make clinical decisions. Responses to the statements taken from the ATCI-GP Almost 40% of GPs (38.7%, n  = 77) identified that (Section C) are summarised in Table 4. The majority of sometimes, PBPs were unavailable in the practices when GPs (> 85%) agreed/strongly agreed with each of these they were needed, and 32.3% (n  = 53) stated that some- statements, thereby displaying largely positive attitudes times patients were reluctant to accept and book an towards collaboration with PBPs. appointment with the PBPs. Hasan I brahim et al. BMC Primary Care (2022) 23:6 Page 7 of 12 Table 4 Attitudes of general practitioners towards collaboration with practice-based pharmacists Statement Strongly disagree/ Neither agree nor Agree/ disagree disagree strongly N (%) N (%) agree N (%) 1. The professional communication between myself and the PBP is open and honest 2 (1) 5 (2.5) 194 (96.5) 2. The PBP is open to working together with me on patients’ medication management 1 (0.5) 5 (2.5) 195 (97.0) 3. The PBP delivers high quality healthcare to patients 2 (1.0) 7 (3.5) 191 (95.5) 4. The PBP has time to discuss matters with me relating to patients’ medication regimens 7 (3.5) 16 (8.0) 178 (88.5) 5. The PBP meets the professional expectations I have of him/her 4 (2.0) 16 (8.0) 181 (90.1) 6. I can trust the PBP’s professional decisions 1 (0.5) 5 (2.5) 195 (97.0) 7. The PBP actively addresses patients’ medical concerns 5 (2.5) 18 (9.1) 175 (88.3) 8. The PBP and I have mutual respect for one another on a professional level 1 (0.5) 2 (1.0) 196 (98.5) 9. The PBP and I share common goals and objectives when caring for the patient 4 (2.0) 6 (3.0) 191 (95.1) 10. My role and the PBP’s role in patient care are clear 6 (3.0) 26 (12.9) 169 (84.1) 11. I have confidence in the PBP’s expertise in medicines and therapeutics 2 (1.0) 5 (2.5) 196 (96.6) 12. The PBP has a role in assuring medication safety (for example, to identify drug interactions, 1 (0.5) 1 (0.5) 201 (99.0) adverse reactions, contraindications etc.) 13. The PBP has a role in assuring medication effectiveness (for example, to ensure the patient 1 (0.5) 11 (5.4) 191 (94.1) receives the optimal drug at the optimal dose etc.) Table 5 Views of general practitioners on practice-based pharmacists and their impact on primary care Statement Strongly Neither agree Agree/ disagree/ nor disagree strongly disagree N (%) agree N (%) N (%) 1. I welcome the PBP as part of the team 1 (0.5) 4 (2.0) 197 (97.5) 2. The role of the PBP is clear to me 5 (2.5) 26 (12.9) 171 (84.7) 3. I understand the difference between the roles of community pharmacists and PBPs 2 (1.0) 9 (4.5) 191 (94.6) 4. The introduction of the PBP role may take roles away from other members of the practice team 53 (26.2) 28 (13.9) 121 (59.9) 5. The introduction of the PBP role moves community pharmacists to the periphery of the primary care 130 (64.4) 50 (24.8) 22 (10.9) team 6. PBPs can provide a better link between general practices and community pharmacists 3 (1.5) 5 (2.5) 194 (96.1) 7. The introduction of the PBP role will have a positive impact on patient outcomes 3 (1.5) 7 (3.5) 192 (95.0) 8. PBPs will help in improving GPs’ knowledge and confidence about medications 7 (3.5) 14 (6.9) 181 (89.6) 9. PBPs will help to alleviate pressure within primary care 3 (1.5) 21 (10.4) 178 (88.1) 10. Having a PBP employed in general practices will save the NHS money by potentially freeing up GP 15 (7.4) 36 (17.8) 151 (74.8) time 11. Having a PBP employed in general practices will save the NHS money by reducing medicine waste 4 (2.0) 31 (15.3) 167 (82.7) General practitioners’ views about the practice‑based community pharmacists to the periphery of the pri- pharmacist role and its impact in primary care mary care team (statement 5). In relation to the PBP role and its impact on primary care, the majority of GPs agreed/strongly agreed with Free text comments many statements listed in Table  5 (notably statements More than half of GPs (59.1%, n  = 120) provided free 1, 3, 6, 7, 8 and 9). However, GPs had mixed views if the text comments at the end of the questionnaire. Most introduction of the PBP could remove roles from other (n  = 78) reported that they had positive experiences members of practice teams (statement 4) and 24.8% with PBPs and/or indicated the benefits of the PBP role of GPs (n  = 50) were unclear if the PBP role moved to general practice and patient care. Hasan Ibrahim et al. BMC Primary Care (2022) 23:6 Page 8 of 12 “The PBP is an extremely important and helpful GPs indicated that PBPs were providing a wide range addition to both patients, GPs, and nurses. It has of activities. Medication reconciliation and medication helped to improve our medicines knowledge and reviews were a major part of PBPs’ role. Most of these undoubtedly improves safety” (GP191) activities have been reported previously, demonstrating that the activities of PBPs in NI were generally similar An evaluation of the free text comments from those to those noted in the literature [12, 13, 52, 53]. Further- 120 GPs indicated several comments (see Additional more, over 90% of GPs reported that PBPs’ activities were file  6) such as GPs being in favour of more PBP input determined through mutual agreement between the GP via more sessions, and more full-time posts. Further- and PBP. This may reflect the presence of an established more, there were comments related to preference for relationship and good communication between the GP working arrangements to be overseen by practices and PBP. rather than Federations and further training for phar- Most GPs reported that PBPs always or very often macists in clinical skills. had the clinical skills and the knowledge to provide safe and effective care for patients. This was reassur - Discussion ing as pressure on general practices is driven by an age- Summary ing population [3], the vast majority of whom are more This study has revealed that the majority of GPs in our likely to struggle with complex medication regimens sample had positive views about the role of PBPs and that are associated with adverse events [54]. However, positive attitudes towards collaboration with PBPs. approximately a third of GPs stated that PBPs only sometimes had the confidence to make clinical deci - sions which may increase GPs’ workload; less confident Comparison with existing literature PBPs may require reassurance and input from GPs on All GPs had at least one PBP in their general practices, regular basis. This may reflect the novelty of this role thereby highlighting the timeliness of the topic of this and variation in previous experience that could limit study. Three-quarters of GPs indicated that the PBP was PBPs’ confidence and ability to assume particular currently prescribing for patients. This was a positive responsibilities [25]. finding as the benefits of pharmacists being able to pre - Approximately 40% of GPs identified that some - scribe medicines has been highlighted previously [43, times the PBPs were unavailable in the practices when 44], such as better utilisation of pharmacists’ skills and they were needed. Previous studies identified the lim - knowledge, and enhancing patient care [44]. In contrast, ited time that pharmacists spent in the practice due less than 30% of GPs indicated that there were some to working part-time hours as a potential barrier to PBPs currently not prescribing for patients which could integrating pharmacists into general practices [20, 51, limit their role in a general practice. In this context, 55]. This finding highlights the importance of having a PBPs could not implement changes and had to rely on full-time PBP in the practice. Moreover, a third of GPs a GP or another prescriber to address any recommen- stated that sometimes patients were reluctant to accept dations [45]. Non-medical prescribers not actively pre- and book an appointment with PBPs. This could be scribing has previously been reported in the literature due to patients’ unfamiliarity with and lack of aware- [46, 47]. This has been attributed to a lack of financial ness of the PBP role [20, 51, 56]. Karampatakis et  al. support, lack of awareness of pharmacist prescribing [57] explored patients’ experiences of PBPs and found by other HCPs, lack of access to patient clinical infor- that patients were unaware of pharmacists’ presence in mation [44, 47], and pharmacists lacking confidence in general practice and/or unclear when to contact phar- their ability as prescribers [48]. Furthermore, a lack of macists. However, the study indicated that PBPs had support from GPs and a lack of GP confidence in phar - the ability to improve the timely access to, and qual- macist prescriber abilities might be challenges encoun- ity of, services in primary care. Furthermore, the study tered by pharmacists as they develop as prescribers [48]. highlighted that there was a need to properly educate All GPs had face-to-face meetings with PBPs. This patients and the public about PBPs, including roles and is positive, as lack of direct communication has been responsibilities [57]. identified as one of the challenges associated with the GPs’ attitudes towards collaboration were largely posi- collaboration of two professions, particularly commu- tive, suggesting the development of strong interpro- nity pharmacists and GPs [49, 50]. As PBPs are sharing fessional collaboration and showing respect and trust a workplace with GPs, this can enhance interprofes- between the two professions is essential [21, 38]. To sional communication and improve these relationships develop this relationship, time, good communication, [24, 38, 51]. and effort on both parts are required [21, 58]. When PBPs Hasan I brahim et al. BMC Primary Care (2022) 23:6 Page 9 of 12 work alongside GPs as part of a team, improvements in be relevant to other parts of the UK. It is important to patient outcomes and greater patient satisfaction can be note that there were some differences between the key achieved [13, 59]. demographics of the responding GPs and the overall Almost all GPs welcomed the PBP as part of the pri- GP population in NI. Moreover, the study result may mary care team. Previous studies have also noted positive not be generalisable to GPs in NI who did not take GP views towards the integration of PBPs into general part in this study as it is not possible to conclude that practice [20, 38, 52]. In this present study, the majority non-responding GPs would have held similar views. of GPs agreed/strongly agreed that the role of PBPs was However, as noted, there was a high response rate and clear to them. Understanding the role of the pharmacist several findings were consistent with other interna - by practice team members is essential in order to ensure tional quantitative and qualitative studies on this topic their successful integration and utilisation of pharma- [25, 51, 52, 67]. The questionnaire was not formally cists’ skills and contributions [21, 51, 60]. Previous stud- validated, however, the pilot phase was intended to ies reported a lack of clarity on PBPs’ role and suggested address certain issues concerning face validity. Using the need for a clear definition [21, 51]. A recent qualita- an anonymous self-administered questionnaire which tive study indicated that community pharmacists were included both positive and negatively phrased items aware of pharmacists’ presence in general practice but may have minimised the potential for social desirability were uncertain about details such as employment mod- bias [68]. els, roles and responsibilities. This highlights that there is a need to inform community pharmacists about PBPs’ Implications for research and practice scope of practice and to introduce formal regular meet- The findings from the present study may have implica - ings between community pharmacy and general practice tions for future developments in order to extend inte- staff [61]. gration of PBPs within general practice, including the Most GPs agreed/strongly agreed that PBPs could pro- enhancement of training in clinical skills and clinical vide a better link between general practices and commu- decision-making. Moreover, an evaluation of the free- nity pharmacists. In contrast, approximately 25% of GPs text comments indicated support for additional PBP were unclear if the PBP role moved community pharma- input via more sessions and more full-time posts, dif- cists to the periphery of the primary care team. Other ferent working arrangements, and development of studies have reported mixed views from GPs and phar- further skills which may impact upon the successful macists on this topic, highlighting positive effects such integration of PBPs within general practice. As most GP as improving communication between GPs and commu- respondents had positive views and attitudes regarding nity pharmacists [53, 61]. Potential negative effects may the role of PBPs and their impact in the primary care, be role duplication or undermining the position of com- this may encourage other countries to integrate phar- munity pharmacists [20, 55]. Investigating the impact of macists into general practice where there are health PBP on the role of the community pharmacist would be workforce shortages [69]. Aspects of the findings might important to ensure both branches of the profession can also be useful to Australia, Canada and New Zealand, practise in a complementary manner for the benefit of all of which have formal programmes for integrating patients and the profession. and evaluating pharmacists’ services in general practice [70–72]. Importantly, future research should explore patients’ views and awareness of the role of the PBPs as Strengths and limitations well as their ability to differentiate between community A major strength of this study was its response rate of pharmacists’ roles and PBPs’ roles. Additionally, further over 60% (61.7%; n  = 203 GPs). This response rate was work is required to explore PBPs’ and community phar- considered acceptable, based on recommendations in macists’ views of this role in general practice to corrob- the literature [62]. Moreover, it was either higher than or orate study findings. comparable to the response rate obtained in postal sur- veys distributed in other studies in NI to GPs [63, 64], or to individual practices [65], or other cross-sectional stud- Conclusions ies published in primary care journals [66]. This response Most GPs in this cross-sectional survey highlighted rate also indicated the topicality of this innovation in pri- that PBPs always/very often had the required clinical mary care, and the interest of the general practice profes- skills and the knowledge to provide safe and effective sion. The method of administration and completion may care for patients. However, a lack of confidence to make also have reduced response bias. clinical decisions was noted and should be addressed Study limitations must be acknowledged. The study to enhance integration of PBPs into general practices. sample was limited to NI, and some findings may not Hasan Ibrahim et al. BMC Primary Care (2022) 23:6 Page 10 of 12 Funding The majority of GPs displayed largely positive attitudes Ameerah Hasan Ibrahim is supported by a PhD research scholarship from the towards collaboration with PBPs. Furthermore, most Al-Zaytoonah University of Jordan in Jordan. The funder played no role in the GPs had positive views about the PBP role, its impact in design, analysis, or conduct of the study. primary care and almost all GPs welcomed PBPs as part Availability of data and materials of practice teams. The findings may have implications The data underlying this article will be shared on reasonable request to the for future developments in order to extend integration corresponding author. of PBPs within general practice and to add to the evi- dence base regarding PBPs’ impact in primary care. Declarations Ethics approval and consent to participate The study received ethical approval from the Queen’s University Belfast School Abbreviations of Pharmacy Research Ethics Committee (Reference Number: 010PMY2019). ATCI-GP: Attitudes Towards Collaboration Instrument for GPs; BSO: Business All methods were performed in accordance with the relevant guidelines and Services Organisation; GPs: General practitioners; HSCB: Health and Social regulations. Consent was deemed to be implicit if GPs returned completed Care Board; NHS: National Health Service; NI: Northern Ireland; PBP: General questionnaires (as approved by the Ethics Committee). Participants were practice-based pharmacists; UK: United Kingdom. informed in the cover letter that completion and return of the anonymous questionnaire represented implied consent. Supplementary Information Consent for publication The online version contains supplementary material available at https:// doi. Not applicable. org/ 10. 1186/ s12875- 021- 01607-5. Competing interests Additional file 1. General practitioner questionnaire. Description of data: The authors declare that they have no competing interests. Questionnaire that was distributed to general practitioners during this study. Received: 26 May 2021 Accepted: 1 December 2021 Additional file 2. GP-PBP communication as reported by responding GPs. Description of data: Three figures (A, B, and C) depicting GP-PBP commu- nication reported by GPs: Figure A shows frequency of face-to-face meet- ings between GPs and PBPs; Figure B shows the most common method(s) References of communication between GPs and PBPs; and Figure C shows the most 1. World Health Organisation Europe. Main terminology of primary health- preferred method(s) of communication between GPs and PBPs. care. 2004. Available from: http:// www. euro. who. int/ en/ health- topics/ Additional file 3. Most common reasons for GP-PBP communication Health- syste ms/ prima ry- health- care/ main- termi nology. (Accessed 22 Jan as reported by responding GPs. Description of data: Table summarising 2021). the most common reasons for GP-PBP communication (with selected 2. Health and Social Care Board. General medical services - general practi- examples) reported by GPs. tioners (GPs). 2021. Available from: http:// www. hscbo ard. hscni. net/ our- work/ integ rated- care/ gps/ (Accessed 30 Aug 2021). Additional file 4. PBP-Patient communication as reported by responding 3. Baird B, Charles A, Honeyman M, Maguire D, Das P. Understanding GPs. Description of data: Three figures (A, B, and C) depicting PBP-Patient pressures in general practice. 2016. Available from: https:// www. communication reported by GPs: Figure A shows frequency of face- kings fund. org. uk/ sites/ defau lt/ files/ field/ field_ publi cation_ file/ Under to-face meetings between PBPs and patients; Figure B shows the most stand ing- GP- press ures- Kings- Fund- May- 2016. pdf (Accessed 3 Jan common method(s) of communication between PBPs and patients; and 2021). Figure C shows the most preferred method(s) of communication between 4. NHS England. Clinical pharmacists in general practice. 2015. Available PBPs and patients. from: https:// www. engla nd. nhs. uk/ gp/ gpfv/ workf orce/ build ing- the- Additional file 5. Frequency of availability of a consulting room for use by gener al- pract ice- workf orce/ cp- gp/ (Accessed 30 Aug 2021). the PBP. Description of data: Figure showing the frequency of availability 5. Strategic Leadership Group for Pharmacy. Practice-based pharmacists’ of a consulting room for use by the PBP as reported by GPs. statement. 2016. Available from: https:// www. health- ni. gov. uk/ sites/ defau lt/ files/ publi catio ns/ health/ pract ice- based- pharm acists. pdf Additional file 6. Recommendations and issues for the PBP role with sup - (Accessed 16 Jan 2021). porting comments reported by GPs. Description of data: Table summaris- 6. The Pharmaceutical Journal. Pharmacists in GP surgeries is a pragmatic ing the recommendations and issues that have been reported by GPs in solution. 2015. 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General practitioners’ experiences with, views of, and attitudes towards, general practice-based pharmacists: a cross-sectional survey

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Copyright © The Author(s) 2022
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2731-4553
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10.1186/s12875-021-01607-5
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Abstract

Background: There is limited United Kingdom (UK) literature on general practice-based pharmacists’ (PBPs’) role evolution and few studies have explored general practitioners’ (GPs’) experiences on pharmacist integration into general practice. Therefore, this study aimed to investigate GPs’ experiences with, views of, and attitudes towards PBPs in Northern Ireland (NI). Methods: A paper-based self-administered questionnaire comprising four sections was mailed in 2019 to 329 gen- eral practices across NI and was completed by one GP in every practice who had most contact with the PBP. Descrip- tive analyses were used and responses to open-ended questions were analysed thematically. Results: The response rate was 61.7% (203/329). There was at least one PBP per general practice. All GPs had face-to- face meetings with PBPs, with three-quarters (78.7%, n = 159) meeting with the PBP more than once a week. Approxi- mately two-thirds of GPs (62.4%, n = 126) reported that PBPs were qualified as independent prescribers, and 76.2% of these (n = 96/126) indicated that prescribers were currently prescribing for patients. The majority of GPs reported that PBPs always/very often had the required clinical skills (83.6%, n = 162) and knowledge (87.0%, n = 167) to provide safe and effective care for patients. However, 31.1% (n = 61) stated that PBPs only sometimes had the confidence to make clinical decisions. The majority of GPs (> 85%) displayed largely positive attitudes towards collaboration with PBPs. Most GPs agreed/strongly agreed that PBPs will have a positive impact on patient outcomes (95.0%, n = 192) and can provide a better link between general practices and community pharmacists (96.1%, n = 194). However, 24.8% of GPs (n = 50) were unclear if the PBP role moved community pharmacists to the periphery of the primary care team. An evaluation of the free-text comments indicated that GPs were in favour of more PBP sessions and full-time posts. Conclusion: Most GPs had positive views of, and attitudes towards, PBPs. The findings may have implications for future developments in order to extend integration of PBPs within general practice, including the enhancement of training in clinical skills and decision-making. Exploring PBPs’, community pharmacists’ and patients’ views of this role in general practice is required to corroborate study findings. Keywords: General practice, General practitioners, Primary health care, Pharmacists, Cross-sectional Background Primary care has been defined as a “first-contact, acces - *Correspondence: c.hughes@qub.ac.uk Primary Care Research Group, School of Pharmacy, Medical Biology sible, continued, comprehensive and coordinated care” Centre, Queen’s University Belfast, 97 Lisburn Road, Belfast, Northern [1]. This care is provided by multidisciplinary teams Ireland BT9 7BL, UK © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Hasan Ibrahim et al. BMC Primary Care (2022) 23:6 Page 2 of 12 including general practitioners (GPs), pharmacists, prac- with PBPs as this may affect the degree to which they col - tice nurses, and other healthcare professionals (HCPs) laborate with one another [19], and may contribute to such as dieticians and physiotherapists [1, 2]. Primary the ongoing development of the role. As integration of care in the United Kingdom (UK) faces unprecedented PBPs into general practices is a new initiative, there will challenges due to the growing complexity of an age- be barriers to successful interprofessional collaboration ing population and their care needs [3]. Ageing is often that will need to be overcome. An Australian study iden- linked with an increased prevalence of multimorbidity tified the views of GPs and pharmacists (i.e. community (the presence of two or more chronic conditions) and pharmacists and PBPs) on the integration of pharmacists polypharmacy (the concomitant use of four or more into general practice and found several benefits such as medicines), which increases the demand for primary care improved collaboration and communication amongst the services and GPs [3]. Furthermore, primary care faces a primary healthcare team [20]. This Australian study also workforce crisis arising from issues around recruitment identified barriers such as negative practitioner percep - and retention of GPs and practice nurses [3]. Therefore, tions, and insufficient funding and infrastructure [20]. one approach to alleviate some of the pressures within A Canadian study described the barriers and facilitators primary care has been the integration of pharmacists into that the primary care teams (PBPs, GPs and nurse practi- general practices, known as general practice-based phar- tioners) experienced during pharmacist integration [21]. macists (PBPs) [4]. Barriers and facilitators existed around relationships, In 2015, five-year PBP pilot schemes were launched trust and respect, definition of pharmacist role, support, in both England and Northern Ireland (NI) to integrate pharmacist personality and professional experience, pres- PBPs into general practice [4, 5]. A shortage of approxi- ence and visibility of pharmacists, and resources [21]. mately 8000 GPs in England with a projected excess Literature is now emerging which describes the views of 11,000–19,000 newly qualified pharmacists by 2040 and experiences of HCPs with the integration of phar- encouraged National Health Service (NHS) England to macists into general practice [20–23]. Several studies launch a £15 m initiative in 2015. This initiative aimed to stressed the need to collect more detailed information employ more than 490 PBPs across 658 general practices regarding the context of the PBP role as little is known to provide more support in the management of long- about how PBPs affect the healthcare system, including term conditions and enhance the standard of care for patients and HCPs [24–26]. Moreover, there is limited patients [4, 6–8]. Further investment was announced in UK literature on PBPs’ role evolution and few studies 2016 as NHS England planned to invest a further £100 m have explored GPs’ experiences on pharmacist inte- to recruit and train an additional 1500 pharmacists by gration into primary care practice to date; none have 2020/2021 [7, 9]. In NI, the Department of Health allo- explored the views of GPs in NI, where there has been cated £17 m of funding to support PBPs in general prac- regional deployment of PBPs across practices. Further- tices across NI [10]. It is anticipated that there will be more, the findings of studies conducted in other parts of 300 whole time equivalent PBPs in post by the end of the the UK may not be generalisable to NI where established pilot scheme in NI (2020/2021) [5]. services and funding mechanisms are different. As the PBPs, as qualified experts in medications with a variety main reason for PBP integration into general practices of knowledge and skills, have been able to improve access was to reduce pressure on general practice, no research to healthcare and reduce waiting times for appointments has explored the views of NI GPs regarding the role of in general practice [11]. Furthermore, PBPs have deliv- PBPs and how this may have affected their workload ered a range of activities that have been found to enhance and delivery of primary care. Therefore, this quantitative patient outcomes (e.g. resolution of medication-related cross-sectional study aimed to address this gap in the lit- problems and improved prescription appropriateness) erature by investigating: 1) GPs’ experiences with PBPs, [12, 13]. These activities include medication review and 2) their views about the PBP role and its impact upon medication reconciliation [11, 12, 14]. Moreover, if the patients, and 3) their attitudes towards collaboration with PBP is qualified as an independent prescriber, they are PBPs. able to prescribe in areas in which they are competent, and conduct chronic disease review clinics [11, 14]. They Methods may also undertake administrative tasks such as clinical Study design, population, and setting audit and prepare prescribing protocols [15]. The study used a cross-sectional design. One GP, in each Establishment of interprofessional collaborative work- general practice in NI, who had the most contact with ing [16] between primary HCPs is essential to improve the PBP, was invited to participate in this study. General service delivery and patient outcomes [17, 18]. It is practices are independent, small businesses, often oper- important to explore GPs’ attitudes towards collaboration ating from their own premises [2]. The job role of a GP Hasan I brahim et al. BMC Primary Care (2022) 23:6 Page 3 of 12 can be designated as partner (GP responsible for running (e.g. GPs, PBPs, and community pharmacists) on the role the business side of the practice and employing staff), of PBPs [20–23, 38]. The nature and style of questions salaried (GP receiving a salary for a contracted number and presentation of questionnaire were considered to of hours worked), or locum (GP providing temporary help optimise the response rate [39]. The questionnaire staffing cover at any time). The Business Services Organi - (see Additional file  1) comprised four sections: (A) demo- sation (BSO) website (see Table  1) maintains an up-to- graphic information about the GP respondent and their date database of general practice postal addresses in NI working environment; (B) extent of GPs’ collaboration [29]. There were 329 GP practices, 1342 registered GPs with PBPs; (C) GPs’ attitudes towards collaboration with (excluding locums), and more than 2 million registered PBPs determined through administration of the Attitudes patients in NI on 4th September 2019 [30]. General prac- Towards Collaboration Instrument for GPs (ATCI-GP); tices are provided funding from the Health and Social and (D) GPs’ views on the role of PBPs and their impact Care Board (HSCB) (see Table  1) based on the number in primary care. and types of patients registered with them [2]. ATCI-GP (Section C) is a validated five-point Likert In NI, there are 17 GP Federations (a group of general scale developed to measure GP attitudes towards GP- practices, forming an organisational entity and working pharmacist collaboration [19]. Permission was granted together within their geographical area) which offer the from the authors of the ATCI-GP to use the scale and to PBP terms and conditions of employment and provide substitute the word ‘pharmacist’ for ‘practice-based phar- occupational maternity pay as well as a sick pay scheme macist/PBP’ throughout the scale’s statements. [31, 32]. Working patterns will be determined by the GP The entire questionnaire was piloted with three aca - Federation and must meet the business needs of the Fed- demic GPs from the School of Medicine, Queen’s Univer- eration [32]. The salary of PBPs in NI depends on their sity Belfast who were similar to the population of interest. experience and qualifications [32]. There were 2715 They completed the questionnaire by self-administration. pharmacists registered in NI in 2020 of whom 12% were They were asked for their comments and general feed - working as PBPs [33, 34]. Many PBP positions in NI gen- back regarding the content and flow of the questionnaire eral practices have been filled by experienced community and their responses were used to refine its content and pharmacists [33, 35]. layout (i.e. face validity) and to estimate the time taken for its completion. The pilot responses were not included Questionnaire in the final sample or analysis. A postal questionnaire was selected as the most efficient Questionnaires were mailed, on two occasions during method of administration which facilitates data collec- September (first mailing) and October (second mailing tion from a large sample of participants in a relatively to improve response rate) 2019 to the 329 general prac- short period of time compared to other survey methods tices in NI, accompanied by a covering letter and a return [36, 37]. This method also requires less social interaction pre-paid addressed envelope. The cover letter which with respondents (i.e. self-completion), thus social desir- accompanied the questionnaire was directed to the Lead/ ability bias and interviewer bias are reduced [36, 37]. Senior GP in each general practice (responsible for qual- The questionnaire was developed by the research team ity improvement and primary care management in the members (AHI, CH, HB), following a comprehensive lit- general practice) and requested that the GP who had erature search regarding perceptions of various HCPs the most contact with the PBP in their practice should Table 1 Summary of the key features of a number of health care organisations in Northern Ireland [27, 28] Health care organisations in NI Description Health and Social Care Trusts [27] - Five Trusts (the Belfast, Northern, Southern, South Eastern and Western Trusts) together with the NI Ambu- lance Trust. - Administrative health organisations which are responsible for the management and administration of health and social care services on a geographical basis. Health and Social Care Board [27] - Organisation responsible for commissioning health services, performance management of the Health and Social Care Trusts and service improvement. Business Services Organisation (BSO) [27] - Organisation responsible for the delivery of a variety of commercial support and specialist professional services to the Health and Social Care sector. - The BSO website provides comprehensive resources for primary care, such as the COMPASS report which is a prescribing information summary that is issued quarterly for each GP practice to provide GPs with feedback on their prescribing [28]. Hasan Ibrahim et al. BMC Primary Care (2022) 23:6 Page 4 of 12 complete the questionnaire. If the practice did not have a in NI in which the majority of GPs’ patients predomi- PBP, the cover letter requested that the questionnaire was nantly reside, indicating broad geographical distribution still completed by a GP in order to obtain views on the at practice level. Three-quarters (76.8%, n  = 156) of GPs implementation of PBPs in general practice. indicated that they worked in medium-sized practices In the cover letter, participants were assured of the con- based on list sizes (i.e. 3000–10,000 patients). There was fidentiality and anonymity of the collected data. Consent at least one PBP per general practice. The respondents was deemed to be implicit if GPs returned completed answered all the sections in the questionnaire as all GPs questionnaires. This consent process was approved by the had a PBP working in their general practices at the time School of Pharmacy Ethics Committee – see later) [40]. of the study. Statistical analysis Characteristics of practice‑based pharmacists All returned questionnaires were coded then descriptive and general practitioners – practice‑based pharmacists’ analyses were conducted such as age and gender distribu- communication tion within the sample. Responses to the ATCI-GP state- Approximately two-thirds of GPs (64.5%, n  = 129) ments (Section C), and GPs’ views statements (Section D) reported that PBPs had been working within general on the role of PBPs and their impact upon patients were practice for 2 years or less at the time of questionnaire also analysed descriptively, by calculating the percentage completion. Just over 45% of GPs (45.4%, n  = 84) indi- of agreement or disagreement to each statement. Data cated that PBPs provided four to six sessions in GPs’ entry was doubled checked manually by the researcher practices per week. Almost two-thirds of GPs (62.4%, (AHI) to ensure the absence of any errors within the data. n = 126) reported that PBPs were qualified as independ - Where there were missing responses in a questionnaire, ent prescribers, with 76.2% (n  = 96/126) indicating that these were coded as missing and were omitted from the PBPs were currently prescribing for patients. final analysis. SPSS version 26.0 [41] was used for all sta - All GPs had face-to-face meetings with PBPs, with tistical analysis. three-quarters (78.7%, n  = 159) meeting with the PBP A broad approach was taken to analyse responses to more than once a week (see Additional file  2 – Figure A). open-ended questions [42]. The responses were read The main issues usually discussed during these meetings several times to achieve a general understanding, and were: medication issues, medication review, prescrib- grouped under broad categories as a means to summarise ing issues, patient issues, transitions between care sec- the main findings. tors (e.g. hospital discharge and outpatient letters), work issues, audit and COMPASS reports, practice/system/ Results Federation level issues, and training for PBPs. GPs used A total of 203 completed questionnaires were received more than one method to communicate with PBPs, but following both mailings, providing a response rate of the majority (95.5%, n  = 192) indicated that face-to- 61.7% (203/329). face was the most common and preferred approach (see Additional file  2 – Figures B and C). Moreover, the GPs Demographic data listed the most common reasons for the GPs to commu- Table  2 presents non-identifiable demographic data nicate with the PBPs and for PBPs to communicate with about GPs and their working environment. Some demo- the GPs, e.g. patient issues and prescribing queries (see graphic characteristics of the GPs (i.e. gender and age) Additional file 3). were compared with those of the entire population of Frequency of face-to-face contact between PBPs and GPs in NI from data published on the BSO website (see patients varied (see Additional file  4 – Figure A), e.g. Table  2) [29]. Almost 60% (57.4%, n  = 116) of GPs were 20.7% of GPs (n = 41) reported that PBPs had daily con- male, which was a slightly larger proportion compared tact with patients, and 14.1% of GPs (n  = 28) reported to the GP population in NI (42.4%; n  = 573). GPs had a that PBPs did not meet face-to-face with patients. Addi- mean age of 50.4 (SD ±8.6) years and there were slight tionally, they revealed that the main issues usually dis- differences in the age groups between the GP respond - cussed during these meetings were chronic disease ents and all GPs in NI (see Table  2). On average, GPs management clinic issues, medication problems, patient had obtained a Certificate of Completion of Training or education, and other topics such as flu vaccinations. Fur - equivalent (qualified as a GP) 23.6 (SD ± 9.4) years ago. thermore, the majority of GPs (93.0%, n = 187) reported The mean number of sessions spent by GPs in general that the most common and preferred method of com- practice per week was 7.1 (SD ± 1.5). There was approxi - munication between PBPs and patients was by telephone mately equal distribution of the responses across the (see Additional file 4 – Figures B and C). location of general practices and the five Trust areas Hasan I brahim et al. BMC Primary Care (2022) 23:6 Page 5 of 12 Table 2 Demographic profile of GP respondents (n = 203) in Northern Ireland Number of GP Number of NI GPs respondents (%) (%) Gender Female 85 (42.1) 778 (57.6) Male 116 (57.4) 573 (42.4) Prefer not to say 1 (0.5) * Age (years) 25–39 28 (14.2) 456 (33.8) 40–44 24 (12.2) 239 (17.7) 45–49 26 (13.2) 179 (13.2) 50–54 44 (22.3) 188 (13.9) 55–59 51 (25.9) 184 (13.6) ≥ 60 years 24 (12.2) 102 (7.5) Average years since the GP respondent had obtained Certificate of Completion of Training 23.6 (± 9.4) * (CCT) or equivalent (qualified as a GP) (± SD) Average number of GPs’ sessions per week (± SD) 7.1 (±1.5) * Location of general practices Rural 61 (31.0) * Suburban 66 (33.5) * Urban 70 (35.5) * Trust area of Northern Ireland in which majority of GPs’ patients predominantly reside Belfast 40 (20.0) * Northern 48 (24.0) * South Eastern 41 (20.5) * Southern 39 (19.5) * Western 32 (16.0) * Size of general practices Small (< 3000 patients) 17 (8.4) * Medium (3000–10,000 patients) 156 (76.8) * Large (> 10,000 patients) 30 (14.8) * Other health and social care professionals working within general practices General practitioner (GP) – Partner 197 (98.5) * General practitioner (GP) – Salaried 81 (44.5) * Practice-based pharmacist (PBP) 203 (100) * Practice nurse 194 (98.0) * Others 117 (91.4) * Data published quarterly (equating to July–September 2019, published on October 1st 2019) on the BSO website [29] * Information unavailable The majority of GPs (70.6%, n  = 142) indicated that the (55.2%, n  = 111), and the PBP’s previous experience consulting room was always/very often available for PBPs, (54.2%, n  = 109). Furthermore, 9.0% of GPs (n  = 18) while 19.9% of GPs (n = 40) indicated that this room was specified that PBPs’ activities were determined by: prac - sometimes available to PBPs (see Additional file 5 ). tice need, Federation demands, the HSCB’s plans [10], PBPs provided a wide range of activities (see Fig.  1), the lead PBP, or the PBP’s interests. most commonly medication reconciliation and medica- This survey investigated the frequency of issues tion reviews. Most GPs (92%, n  = 185) noted that PBPs’ encountered by GPs when dealing with PBPs (see activities were allocated in general practice through Table  3). The majority of GPs reported that PBPs mutual agreement between the GP and PBP. In addi- always/very often had the required clinical skills (83.6%, tion, these activities were determined by the PBP’s cur- n  = 162) and knowledge (87.0%, n  = 167) to provide rent skills (63.7%, n = 128), the PBP’s level of confidence safe and effective care for patients and had the required Hasan Ibrahim et al. BMC Primary Care (2022) 23:6 Page 6 of 12 Fig. 1 Activities of practice-based pharmacists in general practice as reported by responding general practitioners Table 3 Frequency of issues encountered by the general practitioners when dealing with practice-based pharmacists Statement Always Very often Sometimes N (%) Rarely Never N (%) N (%) N (%) N (%) I do not have time to contact the PBP 1 (0.5) 13 (6.7) 48 (24.7) 74 (38.1) 58 (29.9) The PBP struggles to adapt to the needs of the practice 1 (0.5) 5 (2.5) 28 (14.1) 69 (34.7) 96 (48.2) The PBP has the clinical skills to provide safe and effective care for patients 81 (41.8) 81 (41.8) 25 (12.9) 6 (3.1) 1 (0.5) The PBP has the required experience to meet the needs of the practice 75 (38.1) 80 (40.6) 36 (18.3) 6 (3.0) 0 (0) The PBP is unavailable in the practice when I need them 4 (2.0) 29 (14.6) 77 (38.7) 62 (31.2) 27 (13.6) The PBP has the confidence to make clinical decisions 35 (17.9) 82 (41.8) 61 (31.1) 15 (7.7) 3 (1.5) The PBP has the knowledge to provide safe and effective care for patients 71 (37.0) 96 (50.0) 23 (12.0) 2 (1.0) 0 (0) Patients are reluctant to accept and book an appointment with the PBP 1 (0.6) 1 (0.6) 53 (32.3) 81 (49.4) 28 (17.1) experience to meet the needs of the practice (78.7%, Attitudes towards collaboration with practice‑based n = 155). However, 31.1% (n = 61) stated that PBPs only pharmacists sometimes had the confidence to make clinical decisions. Responses to the statements taken from the ATCI-GP Almost 40% of GPs (38.7%, n  = 77) identified that (Section C) are summarised in Table 4. The majority of sometimes, PBPs were unavailable in the practices when GPs (> 85%) agreed/strongly agreed with each of these they were needed, and 32.3% (n  = 53) stated that some- statements, thereby displaying largely positive attitudes times patients were reluctant to accept and book an towards collaboration with PBPs. appointment with the PBPs. Hasan I brahim et al. BMC Primary Care (2022) 23:6 Page 7 of 12 Table 4 Attitudes of general practitioners towards collaboration with practice-based pharmacists Statement Strongly disagree/ Neither agree nor Agree/ disagree disagree strongly N (%) N (%) agree N (%) 1. The professional communication between myself and the PBP is open and honest 2 (1) 5 (2.5) 194 (96.5) 2. The PBP is open to working together with me on patients’ medication management 1 (0.5) 5 (2.5) 195 (97.0) 3. The PBP delivers high quality healthcare to patients 2 (1.0) 7 (3.5) 191 (95.5) 4. The PBP has time to discuss matters with me relating to patients’ medication regimens 7 (3.5) 16 (8.0) 178 (88.5) 5. The PBP meets the professional expectations I have of him/her 4 (2.0) 16 (8.0) 181 (90.1) 6. I can trust the PBP’s professional decisions 1 (0.5) 5 (2.5) 195 (97.0) 7. The PBP actively addresses patients’ medical concerns 5 (2.5) 18 (9.1) 175 (88.3) 8. The PBP and I have mutual respect for one another on a professional level 1 (0.5) 2 (1.0) 196 (98.5) 9. The PBP and I share common goals and objectives when caring for the patient 4 (2.0) 6 (3.0) 191 (95.1) 10. My role and the PBP’s role in patient care are clear 6 (3.0) 26 (12.9) 169 (84.1) 11. I have confidence in the PBP’s expertise in medicines and therapeutics 2 (1.0) 5 (2.5) 196 (96.6) 12. The PBP has a role in assuring medication safety (for example, to identify drug interactions, 1 (0.5) 1 (0.5) 201 (99.0) adverse reactions, contraindications etc.) 13. The PBP has a role in assuring medication effectiveness (for example, to ensure the patient 1 (0.5) 11 (5.4) 191 (94.1) receives the optimal drug at the optimal dose etc.) Table 5 Views of general practitioners on practice-based pharmacists and their impact on primary care Statement Strongly Neither agree Agree/ disagree/ nor disagree strongly disagree N (%) agree N (%) N (%) 1. I welcome the PBP as part of the team 1 (0.5) 4 (2.0) 197 (97.5) 2. The role of the PBP is clear to me 5 (2.5) 26 (12.9) 171 (84.7) 3. I understand the difference between the roles of community pharmacists and PBPs 2 (1.0) 9 (4.5) 191 (94.6) 4. The introduction of the PBP role may take roles away from other members of the practice team 53 (26.2) 28 (13.9) 121 (59.9) 5. The introduction of the PBP role moves community pharmacists to the periphery of the primary care 130 (64.4) 50 (24.8) 22 (10.9) team 6. PBPs can provide a better link between general practices and community pharmacists 3 (1.5) 5 (2.5) 194 (96.1) 7. The introduction of the PBP role will have a positive impact on patient outcomes 3 (1.5) 7 (3.5) 192 (95.0) 8. PBPs will help in improving GPs’ knowledge and confidence about medications 7 (3.5) 14 (6.9) 181 (89.6) 9. PBPs will help to alleviate pressure within primary care 3 (1.5) 21 (10.4) 178 (88.1) 10. Having a PBP employed in general practices will save the NHS money by potentially freeing up GP 15 (7.4) 36 (17.8) 151 (74.8) time 11. Having a PBP employed in general practices will save the NHS money by reducing medicine waste 4 (2.0) 31 (15.3) 167 (82.7) General practitioners’ views about the practice‑based community pharmacists to the periphery of the pri- pharmacist role and its impact in primary care mary care team (statement 5). In relation to the PBP role and its impact on primary care, the majority of GPs agreed/strongly agreed with Free text comments many statements listed in Table  5 (notably statements More than half of GPs (59.1%, n  = 120) provided free 1, 3, 6, 7, 8 and 9). However, GPs had mixed views if the text comments at the end of the questionnaire. Most introduction of the PBP could remove roles from other (n  = 78) reported that they had positive experiences members of practice teams (statement 4) and 24.8% with PBPs and/or indicated the benefits of the PBP role of GPs (n  = 50) were unclear if the PBP role moved to general practice and patient care. Hasan Ibrahim et al. BMC Primary Care (2022) 23:6 Page 8 of 12 “The PBP is an extremely important and helpful GPs indicated that PBPs were providing a wide range addition to both patients, GPs, and nurses. It has of activities. Medication reconciliation and medication helped to improve our medicines knowledge and reviews were a major part of PBPs’ role. Most of these undoubtedly improves safety” (GP191) activities have been reported previously, demonstrating that the activities of PBPs in NI were generally similar An evaluation of the free text comments from those to those noted in the literature [12, 13, 52, 53]. Further- 120 GPs indicated several comments (see Additional more, over 90% of GPs reported that PBPs’ activities were file  6) such as GPs being in favour of more PBP input determined through mutual agreement between the GP via more sessions, and more full-time posts. Further- and PBP. This may reflect the presence of an established more, there were comments related to preference for relationship and good communication between the GP working arrangements to be overseen by practices and PBP. rather than Federations and further training for phar- Most GPs reported that PBPs always or very often macists in clinical skills. had the clinical skills and the knowledge to provide safe and effective care for patients. This was reassur - Discussion ing as pressure on general practices is driven by an age- Summary ing population [3], the vast majority of whom are more This study has revealed that the majority of GPs in our likely to struggle with complex medication regimens sample had positive views about the role of PBPs and that are associated with adverse events [54]. However, positive attitudes towards collaboration with PBPs. approximately a third of GPs stated that PBPs only sometimes had the confidence to make clinical deci - sions which may increase GPs’ workload; less confident Comparison with existing literature PBPs may require reassurance and input from GPs on All GPs had at least one PBP in their general practices, regular basis. This may reflect the novelty of this role thereby highlighting the timeliness of the topic of this and variation in previous experience that could limit study. Three-quarters of GPs indicated that the PBP was PBPs’ confidence and ability to assume particular currently prescribing for patients. This was a positive responsibilities [25]. finding as the benefits of pharmacists being able to pre - Approximately 40% of GPs identified that some - scribe medicines has been highlighted previously [43, times the PBPs were unavailable in the practices when 44], such as better utilisation of pharmacists’ skills and they were needed. Previous studies identified the lim - knowledge, and enhancing patient care [44]. In contrast, ited time that pharmacists spent in the practice due less than 30% of GPs indicated that there were some to working part-time hours as a potential barrier to PBPs currently not prescribing for patients which could integrating pharmacists into general practices [20, 51, limit their role in a general practice. In this context, 55]. This finding highlights the importance of having a PBPs could not implement changes and had to rely on full-time PBP in the practice. Moreover, a third of GPs a GP or another prescriber to address any recommen- stated that sometimes patients were reluctant to accept dations [45]. Non-medical prescribers not actively pre- and book an appointment with PBPs. This could be scribing has previously been reported in the literature due to patients’ unfamiliarity with and lack of aware- [46, 47]. This has been attributed to a lack of financial ness of the PBP role [20, 51, 56]. Karampatakis et  al. support, lack of awareness of pharmacist prescribing [57] explored patients’ experiences of PBPs and found by other HCPs, lack of access to patient clinical infor- that patients were unaware of pharmacists’ presence in mation [44, 47], and pharmacists lacking confidence in general practice and/or unclear when to contact phar- their ability as prescribers [48]. Furthermore, a lack of macists. However, the study indicated that PBPs had support from GPs and a lack of GP confidence in phar - the ability to improve the timely access to, and qual- macist prescriber abilities might be challenges encoun- ity of, services in primary care. Furthermore, the study tered by pharmacists as they develop as prescribers [48]. highlighted that there was a need to properly educate All GPs had face-to-face meetings with PBPs. This patients and the public about PBPs, including roles and is positive, as lack of direct communication has been responsibilities [57]. identified as one of the challenges associated with the GPs’ attitudes towards collaboration were largely posi- collaboration of two professions, particularly commu- tive, suggesting the development of strong interpro- nity pharmacists and GPs [49, 50]. As PBPs are sharing fessional collaboration and showing respect and trust a workplace with GPs, this can enhance interprofes- between the two professions is essential [21, 38]. To sional communication and improve these relationships develop this relationship, time, good communication, [24, 38, 51]. and effort on both parts are required [21, 58]. When PBPs Hasan I brahim et al. BMC Primary Care (2022) 23:6 Page 9 of 12 work alongside GPs as part of a team, improvements in be relevant to other parts of the UK. It is important to patient outcomes and greater patient satisfaction can be note that there were some differences between the key achieved [13, 59]. demographics of the responding GPs and the overall Almost all GPs welcomed the PBP as part of the pri- GP population in NI. Moreover, the study result may mary care team. Previous studies have also noted positive not be generalisable to GPs in NI who did not take GP views towards the integration of PBPs into general part in this study as it is not possible to conclude that practice [20, 38, 52]. In this present study, the majority non-responding GPs would have held similar views. of GPs agreed/strongly agreed that the role of PBPs was However, as noted, there was a high response rate and clear to them. Understanding the role of the pharmacist several findings were consistent with other interna - by practice team members is essential in order to ensure tional quantitative and qualitative studies on this topic their successful integration and utilisation of pharma- [25, 51, 52, 67]. The questionnaire was not formally cists’ skills and contributions [21, 51, 60]. Previous stud- validated, however, the pilot phase was intended to ies reported a lack of clarity on PBPs’ role and suggested address certain issues concerning face validity. Using the need for a clear definition [21, 51]. A recent qualita- an anonymous self-administered questionnaire which tive study indicated that community pharmacists were included both positive and negatively phrased items aware of pharmacists’ presence in general practice but may have minimised the potential for social desirability were uncertain about details such as employment mod- bias [68]. els, roles and responsibilities. This highlights that there is a need to inform community pharmacists about PBPs’ Implications for research and practice scope of practice and to introduce formal regular meet- The findings from the present study may have implica - ings between community pharmacy and general practice tions for future developments in order to extend inte- staff [61]. gration of PBPs within general practice, including the Most GPs agreed/strongly agreed that PBPs could pro- enhancement of training in clinical skills and clinical vide a better link between general practices and commu- decision-making. Moreover, an evaluation of the free- nity pharmacists. In contrast, approximately 25% of GPs text comments indicated support for additional PBP were unclear if the PBP role moved community pharma- input via more sessions and more full-time posts, dif- cists to the periphery of the primary care team. Other ferent working arrangements, and development of studies have reported mixed views from GPs and phar- further skills which may impact upon the successful macists on this topic, highlighting positive effects such integration of PBPs within general practice. As most GP as improving communication between GPs and commu- respondents had positive views and attitudes regarding nity pharmacists [53, 61]. Potential negative effects may the role of PBPs and their impact in the primary care, be role duplication or undermining the position of com- this may encourage other countries to integrate phar- munity pharmacists [20, 55]. Investigating the impact of macists into general practice where there are health PBP on the role of the community pharmacist would be workforce shortages [69]. Aspects of the findings might important to ensure both branches of the profession can also be useful to Australia, Canada and New Zealand, practise in a complementary manner for the benefit of all of which have formal programmes for integrating patients and the profession. and evaluating pharmacists’ services in general practice [70–72]. Importantly, future research should explore patients’ views and awareness of the role of the PBPs as Strengths and limitations well as their ability to differentiate between community A major strength of this study was its response rate of pharmacists’ roles and PBPs’ roles. Additionally, further over 60% (61.7%; n  = 203 GPs). This response rate was work is required to explore PBPs’ and community phar- considered acceptable, based on recommendations in macists’ views of this role in general practice to corrob- the literature [62]. Moreover, it was either higher than or orate study findings. comparable to the response rate obtained in postal sur- veys distributed in other studies in NI to GPs [63, 64], or to individual practices [65], or other cross-sectional stud- Conclusions ies published in primary care journals [66]. This response Most GPs in this cross-sectional survey highlighted rate also indicated the topicality of this innovation in pri- that PBPs always/very often had the required clinical mary care, and the interest of the general practice profes- skills and the knowledge to provide safe and effective sion. The method of administration and completion may care for patients. However, a lack of confidence to make also have reduced response bias. clinical decisions was noted and should be addressed Study limitations must be acknowledged. The study to enhance integration of PBPs into general practices. sample was limited to NI, and some findings may not Hasan Ibrahim et al. BMC Primary Care (2022) 23:6 Page 10 of 12 Funding The majority of GPs displayed largely positive attitudes Ameerah Hasan Ibrahim is supported by a PhD research scholarship from the towards collaboration with PBPs. Furthermore, most Al-Zaytoonah University of Jordan in Jordan. The funder played no role in the GPs had positive views about the PBP role, its impact in design, analysis, or conduct of the study. primary care and almost all GPs welcomed PBPs as part Availability of data and materials of practice teams. The findings may have implications The data underlying this article will be shared on reasonable request to the for future developments in order to extend integration corresponding author. of PBPs within general practice and to add to the evi- dence base regarding PBPs’ impact in primary care. Declarations Ethics approval and consent to participate The study received ethical approval from the Queen’s University Belfast School Abbreviations of Pharmacy Research Ethics Committee (Reference Number: 010PMY2019). ATCI-GP: Attitudes Towards Collaboration Instrument for GPs; BSO: Business All methods were performed in accordance with the relevant guidelines and Services Organisation; GPs: General practitioners; HSCB: Health and Social regulations. Consent was deemed to be implicit if GPs returned completed Care Board; NHS: National Health Service; NI: Northern Ireland; PBP: General questionnaires (as approved by the Ethics Committee). Participants were practice-based pharmacists; UK: United Kingdom. informed in the cover letter that completion and return of the anonymous questionnaire represented implied consent. Supplementary Information Consent for publication The online version contains supplementary material available at https:// doi. Not applicable. org/ 10. 1186/ s12875- 021- 01607-5. Competing interests Additional file 1. General practitioner questionnaire. Description of data: The authors declare that they have no competing interests. Questionnaire that was distributed to general practitioners during this study. Received: 26 May 2021 Accepted: 1 December 2021 Additional file 2. GP-PBP communication as reported by responding GPs. Description of data: Three figures (A, B, and C) depicting GP-PBP commu- nication reported by GPs: Figure A shows frequency of face-to-face meet- ings between GPs and PBPs; Figure B shows the most common method(s) References of communication between GPs and PBPs; and Figure C shows the most 1. World Health Organisation Europe. Main terminology of primary health- preferred method(s) of communication between GPs and PBPs. care. 2004. Available from: http:// www. euro. who. int/ en/ health- topics/ Additional file 3. Most common reasons for GP-PBP communication Health- syste ms/ prima ry- health- care/ main- termi nology. (Accessed 22 Jan as reported by responding GPs. Description of data: Table summarising 2021). the most common reasons for GP-PBP communication (with selected 2. Health and Social Care Board. General medical services - general practi- examples) reported by GPs. tioners (GPs). 2021. 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Journal

BMC Primary CareSpringer Journals

Published: Jan 14, 2022

Keywords: General practice; General practitioners; Primary health care; Pharmacists; Cross-sectional

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