Structured questionnaires comprises of a list of questions along with a list of answers to choose from (Reis, 2009). Unstructured questionnaires are the type where a list of questions have been designed by the researcher and no answers are given to choose from, thus giving the respondent blank space to fill in with their desired answers (Reis, 2009). These are the types where the respondents are given complete prudence to write their personal opinions about the topic (Reis, 2009). Another commonly used type of questionnaire is the semi-structured questionnaires (Foddy, 1993). These comprise of both structured and unstructured questions (Foddy, 1993). In order to keep the focus on the research topic, the researcher leaves some options as close and the rest open for the respondents to answer as they wish (Foddy, 1993).The biggest advantage of using semi-structured questionnaires is that it has the qualities of both close and open ended questionnaires (Foddy, 1993).
3.2. Qualitative Approach- Interviews
It has been argued that one cannot say which specific type of questionnaire is best to use (Davies, 2007). Each particular type has its own advantages and disadvantages (Davies, 2007). For this particular research, the tool that was chosen to know the views of community pharmacists regarding the HLP programme was close ended structured questionnaires which was to be followed by qualitative research to explore and analyse the findings. Qualitative research was used in order to gain insight knowledge about people's beliefs, behaviour and understanding of the HLP and also the reasoning behind such attitude. This gave the researcher an opportunity to ask questions to the respondent that may had aroused by looking at their answers to the questionnaires. Hence, this outweighed the disadvantage of close ended questionnaires.
Interview is a process in which information is exchanged between the interviewer and the interviewee (Bourquin et al., 2011). Interviews are considered to be one of the most powerful tool among the rest of the methods because it has the power of gaining in-depth experience and information (Bourquin et al., 2011). Majority of the past researchers have always chosen interviews as a means to understand the deep hidden meanings behind the answers of the respondents (Bourquin et al., 2011). There are many types of interviews that have been used successfully by researchers (Foddy, 1993). There are structured interviews, unstructured interviews, semi-structured interviews, telephonic interviews, focus group interviews and web based interviews (Frey and Oishi, 1995).
Interviews and focus groups are the two main types of qualitative research. Focus group involves interviews of the desired research participants in small groups. The questions are asked to all the group members and it gives an opportunity for everyone to discuss their views, opinions and perceptions regarding a particular topic (Kitzinger, 1995). It is a quick and simple way to gather information from a group of people as it involves group interaction through which people can share their experiences and opinions (Kitzinger, 1995). This method not only helps in understanding the participants' views but also has been reported to be an excellent technique of finding out staff needs and attitudes (Kitzinger, 1995). The disadvantage of this method is that it would take a long time to collect data from groups as the meeting has to be organised in accordance to all the participants' availability. Since, the allocated data collection time was six weeks; this method was thought to not be an ideal one to use in the research. In regards to telephonic and web based interviews, the researcher would not have been able to have long conversations with the interviewee as there might be connectivity problems and distraction from the things happening around. However, the advantage of such interviews is that it would be less time consuming and more convenient for the interviewer (Frey and Oishi, 1995).
Interviews are a process in which verbal communication takes place face to face with the belief that honest and true exchange of information would occurs (Brinkmann & Kvale, 2009). It is also hoped that information relevant to the topic will be exchanged without any biased factors being involved in the process (Oatey, 1999). Semi-structured interviews involves a set of pre-planned questions and the communication increases by asking questions depending on the interviewee's response as the interview goes along (Gleadle, 2011). The advantage of conducting semi-structured interview is that it has the capability of covering the points that have been missed by the researcher and can also give a better understanding of the respondents' opinions and attitude. These interviews also allow in depth discussion about the topic. However, the discussion at times can go off track and lead to waste of time and resources (John, 2008). There are a number of factors that need to be taken into account while conducting face-to-face interviews. The interviewer need to make sure that an interpersonal distance is maintained between himself and the interviewee and there is always an eye contact during communication. The pitch of sound of the researcher conducting the interview should neither be too low nor too high and should speak at a pace that can be understood by the interviewee (Cahn et al., 2011). Another important factor is that the researcher should also take care of the gestures and body language in order to avoid any wrong meanings that could be derived by the respondent (John, 2008).
Thus, questionnaires allow easy collection and interpretation of data for the researcher (John, 2008). Since, the questionnaire consisted of structured questions the researcher had adopted semi-structured interviews as well in order to get an in-depth knowledge about the respondent's experiences and opinions. It also gave an opportunity for the researcher to clarify the participants' answers to the questionnaires while conducting the interview. This approach had also resulted in a high response rate, as the questionnaires were handed over to the participants just before the interview started. The questionnaires were also structured in a way which could be completed in five minutes and thus, left more time for the interview.
4. Method
This study focussed on evaluating the perceptions of Community Pharmacists regarding the Healthy Living Pharmacy (HLP) programme in Hertfordshire, which was launched in May, 2012. This programme focuses on improving public health and reducing health inequalities.
4.1 Sample Framework
In order to carry out the research, Hertfordshire PCT was chosen as the sample framework. A list of Pharmacies in Hertfordshire that have signed the Expression of interest was supplied by the local PCT for our assistance. According to the list, seventeen pharmacies had signed the Expression of interest to become a part of the HLP programme. These seventeen pharmacies were divided among the four researchers for validation of the sample to check their level of HLP accreditation. This was taken as a group task due to time constraints, as it was not possible for one researcher to speak to all seventeen pharmacists in two day's time.
The researchers phoned up those seventeen pharmacies in order to pilot the study. The purpose of the calls was to confirm which all pharmacies have attended the first introductory session of HLP and signed the Expression of interest. The researcher was also to find out whether the Pharmacists have attended any training sessions till date and heard back from the local PCT in regards to their accreditation. Other purpose of these phone calls was to identify the sample size of pharmacists that had to be interviewed by each researcher individually. These phone interviews had also given a chance to the researchers to gain experience of interviewing pharmacists which proved to be useful in the future research. However, the outcome of these pilot calls led to change in samples for the four researchers as it was found that none of the seventeen pharmacies had attained the HLP accreditation. Hence, from four samples the researchers ended up with two samples which were divided amongst the four researchers. Two researchers together were to find the perceptions of the seventeen pharmacists that have signed the Expression of interest according to the list provided by the local PCT. Whereas, the other two researchers were to randomly select ten local pharmacies who were not mentioned in the provided list and gain an understanding of their views and opinions regarding public health and HLP programme. This was done to gain knowledge about the reasoning behind the difference in their opinions and approach to HLP programme. Hence, this particular research is focussed on the views of the Pharmacists who had not signed the Expression of interest to become a HLP, according to the list provided by the PCT.
4.2 Preparation of Invitation Letters and questionnaires
The researcher started preparing the invitation letter that had to be sent to fifty randomly selected pharmacies in Hertfordshire. A random sample was chosen in order to get in-depth knowledge of Pharmacists of different age groups and level of experience.
In the invitation letter, the researcher had mentioned the purpose of the study and also stated that this research project has got ethical approval from University of Hertfordshire and is supported by the local PCT and LPC. This was mentioned to ensure the Pharmacists that this project had the required approvals. It also contained the details on their participation which included twenty minutes face-to-face interview and assurance that all the collected data will be maintained in a confidential matter and used anonymously. The researcher had also mentioned the importance of their participation as an encouraging tool. The contact details of the researcher and his supervisor were also cited, in case if the participants wanted to clarify any queries. The researcher also stated that they will be contacted in a week's time in order to know their decision (Appendix 4). These invitation letters were sent by post to the selected sample (50 pharmacies).
It was decided among the four researchers that demographic questionnaires should be prepared in order to get them filled in by the participants before the interview. This was to save time from asking few closed questions and thus, leaving more time for the researcher to conduct a semi-structured interview.
In designing the questionnaire and choosing the options for the answers various factors were taken into account. For the question regarding age, brackets of ten years gap were chosen, starting from 21 years as that would have taken newly qualified pharmacists into consideration. And the bracket was given up to 65 years as that used to be the official age for retirement. The options given for qualification question consisted of BSc. (Bachelor of Science) and MPharm (Master of Pharmacy) as these are the two most common degrees offered in United Kingdom for Pharmacists. Doctorate of Pharmacy (DPharm), a course which is offered only by few Universities in the UK and is mainly offered in United States was not put in the options. However, a blank was provided with this question, so that the participants can put in their qualification which was not given as an option. There was also a question without any options regarding any post graduate qualification. This was put in, in order to know how the participants' opinions differ in accordance to their qualifications.
The next two questions were regarding the time when they got qualified and how many years of experience have they got working as a Community Pharmacist. The researcher was not able to find any evidence to guide the answers choices for these two questions. Hence, five years brackets were used. The other questions were regarding the participant's official position, type of pharmacy and other staff available at the premises for their support. These questions were included in order to link their answers with staff involvement in offering the pharmacy services and whether the decisions were taken by themselves regarding the services provided by them or they had to abide by the companies policies. The options for the number of items dispensed were decided on the basis of the drug tariff's payment brackets. A question was also included asking whether there is a General Practitioner (GP) practice within a mile vicinity from the pharmacy, in order to know the Pharmacists relationship with the local GP and whether they recommend any of their patients to use any of the Pharmacy's enhanced services. Lastly, a table was provided which included a list of services that a pharmacy can provide in additional to dispensing medications. This was for the participants to decide which services according to them are public health services and which of them are provided by their pharmacies and why.
All these questions were discussed and decided amongst the four researchers and the supervisor and it was decided that all of them should have the same questions as the collected data had to be compared (Appendix 5).
After the demographics were decided, the next task was to start preparing the questions for semi-structured interviews. It was decided to have a set of certain questions ready to be asked, while few questions had to be made up during the course of the interview. The questions were regarding the barriers and encouraging factors in becoming a HLP, their staff members' involvement in providing HLP services and their opinions on including HLP in NHS (National Health Service) contract. Questions regarding the Pharmacists relationships with other Healthcare professionals' were also included in order to determine the benefits of collaborative working (Appendix 6). A consent form was also prepared for the participants to sign at the start of the interview. In the consent form it was mentioned that the interview will be audio-taped and the data will be used only for research purposes (Appendix7). Hence, the material required for the interviews was finalised and ready.
4.3 Pilot Interviews
In order to gain experience and confidence in conducting interviews in a Professional manner and environment, the researcher conducted two pilot interviews with the staff members of the pharmacy course. The staff members that were chosen were Practice Pharmacists, so that they could help in developing the questionnaires. The pilot interviews were held in meeting rooms for about fifteen minutes each in the same manner as the researcher would have had conducted the actual interviews. The participants were asked to sign the consent form, fill in the demographic questionnaire and were audio-taped. The participants gave the researcher feedback on his performance and through these pilot interviews, the researcher gained a feeling of face-to-face interview and also received advice on how to frame questions during the course of the interview.
4.4 Phone calls to Pharmacists
All these tasks were completed within a week's time after sending the invitation letters to the Pharmacists. The next step was to phone the Pharmacies and speak to the Pharmacists to book an interview with them at a time suitable for both the researcher and the participant. The researcher introduced himself on the phone and inquired whether they have received the invitation letter and if not, their email addresses were taken and the letter was emailed to them. Meetings were booked with the Pharmacists who had agreed to take part in the research These Pharmacists were then interviewed at their pharmacies, audio-taped and the collected data was analysed.
5. Analysis
The aim was to interview at least 10 Pharmacists and analyse the data quantitatively as well as qualitatively. However, out of the 50 Pharmacists to whom the invitation letters were sent, only 11 Pharmacists (22%) had agreed to take part in the research. The reasons for not participating in the research are summarised below in the table.
Table 1. Reasons for non-participation of Pharmacists.
Majority (~54%) of the Pharmacists refused to take part in the project due to time constraints. At some pharmacies (18%), the regular pharmacists were on holiday and the locums didn't have time for interview. Other reasons for not taking part in the research were staff issues, premises, personal issues and interests.
Some data was collected through questionnaires, which were filled in by the Pharmacists before the interview .The following main questions were asked in the demographic questionnaires.
Table 2. Summary of Demographic Questionnaire
According to Table 2, most of the participants were male (8 out of 11). In regards to the age, they were all spread through different age groups. However, majority of the participants (~36%) were within the age group of 41-50 years and 27% of the participants were within the 21-30 years age range. There were two pharmacists (18%) in the age range of 51-65 years and one in the 31-40 years age range. The researcher also came across a Pharmacist who was not comfortable in answering the age question. Hence, the mode for the age range question was 41-50 years.
Figure 1. Time since Qualification and years of experience
In regards to the qualification questions, only one Pharmacist had a post graduate degree in MSc. However, it was noted that ~64% of the Pharmacist had achieved MPharm degrees and only ~36% of the Pharmacists had BSc. Degrees.
The next two questions were regarding the time as to how long it has been since they have qualified and how long have they been working as a community Pharmacist. Around 91% of the Pharmacists had been working as community pharmacists since they have qualified. Only one pharmacist (No. 7 in the table 2) had been working in a community pharmacy for 6-10 years though it had been more than 25 years since he got qualified as a pharmacist. The mode for these two questions was above 25 years as most of the pharmacists fall into that category.
Figure 2. Employment status of the Pharmacists
Among the participants on average, ~55% of them were Pharmacy managers, 36% were pharmacy owners and 9% were Superintendent Pharmacists. It was noticed that in sole independent pharmacies the responsible Pharmacists were the owners themselves. The mode for this question was Pharmacy managers. Among the 55% of the pharmacy managers, 27% of them were employed in independent multiple (<5 stores) pharmacies and 9% were working in corporate multiple and 18% were employed in supermarket pharmacies.
Figure 3. Support on the premises for Pharmacists
Majority (~82%) of the Pharmacists had dispensers on the premises for their help and 45% of them had second pharmacists as well. There were only 5 Pharmacies that had qualified counter assistants to serve the customers. And only two pharmacists had employed qualified technicians. None of the pharmacies had Accuracy checking technicians on their premises. All the Pharmacies dispensed more than 2,360 items in a month and 91% of the pharmacies were in close vicinity from GP practise.
Table 3. Summary of Public Health Services
According to table 3, all 11 pharmacists collected repeat prescriptions from the surgeries and offered smoking cessation and tMUR services. 91% of the pharmacists believed that smoking cessation is a public health service and plays a vital role in promoting public health. However, only 2/11 Pharmacists offered needle and syringe exchange and this was mainly because there is not much demand for this service. In regards to EHC, 45% of the pharmacists offered this service over the counter as they felt that they will have to do a lot of paper work in order to offer it through PGD (Patient group directives), which in turn was time consuming for them. Hence, only 18% of the participants offered this service through PGD.
According to only 36% Pharmacists, delivering dispensed medications to patient's homes was a public health service even though 81% pharmacists had offered this service. In regards to cholesterol monitoring, only 27% pharmacists offered this service as according to others, it was expensive to buy the equipment required for carrying out the test. However, 72% of the pharmacists agreed that it is a public health service. Seasonal influenza vaccinations were provided only by 36% of the pharmacies as this service is already being offered by their local GPs who were situated within one mile distance from the pharmacies. The same reason was given by the participants who did not offer blood pressure monitoring service.
Table 4. Observational Checklist
On observing the presentation of the pharmacies, it was found that all of them had health leaflets and private consultation rooms. Most of the pharmacies (apart from two) were thought to be appealing to customers because of their posters, clean shelves and non-medical products. However, one pharmacy's shop floor was very disorganised and had many obstacles in the walking paths.
Semi-structured interviews were conducted with a total of 11 Pharmacists to gain a deeper understanding of their perceptions regarding HLP programme. The results from these interviews are thematically arranged below:
5.1 Understanding of Public Health
The participants were asked about their opinions on public health and the researcher came up with the following themes based on their response:
Providing Services
Participants were of the view that public health was about providing services to the public. However, they had different opinions regarding the purpose of these services.
According to two pharmacists, public health was about providing services to cater the needs and requirements of the people around you.
"Basically what the public requires or needs in regards to their health"
(Line 2, HLP 2)
According to 36% of the Pharmacists, public health was to look after and improve the health of the public which would make a difference to the community.
"Public health is as the name suggests looking after the health of the
general public." (Lines 2 & 3, HLP 9)
Promotion of services
According to a participant, public health was to promote the services provided for the well-being of the public.
"It's just promoting health services. So, convenient access to any health service and advice." (Lines 2&3, HLP 7)
Only one participant had raised a point regarding information that needs to be provided to the public in order to lead a healthy life.
"I think it is where we are providing information to the general community on health issues." (Lines 2&3, HLP 11)
5.2 Understanding of HLP Programme
There was not much awareness about this programme amongst the Pharmacists as the researcher had to give them a brief overview of the programme before the interview as it is apparent from the following quote:
"I haven't read up too much on it to be honest. "(Line 16, HLP 1)
Healthy Lifestyle
Few Pharmacists (36%) had the opinion that this programme was regarding healthy living as most of the common health conditions such as hypertension, diabetes and asthma are somehow related to lifestyle (Lines 6-9, HLP 4). Diet, exercise, alcohol consumption and smoking were considered to be the most important contributing factors for healthy living. (Line 5, HLP 8)
According to 3/11 pharmacists, HLP programme was about promoting healthy lifestyle through services and advice, which in turn would make a large difference to the society.
"I believe it consists of a number of services provided by the pharmacy such as Chlamydia and health Promotion campaigns such as smoking cessation which is monitored by the PCT. Hence, working to promote healthy living among the public." (Lines 6-9, HLP 10)
Extended role of the Pharmacists
Two Pharmacists spoke about the other pharmaceutical services being offered by community pharmacists other than just dispensing medications for the welfare of the public (Lines 4-6, HLP 2).
"There is a step-up from advanced, enhanced services to targeted MUR, weight management, etc." (Lines 5 & 6, HLP 5)
However, two pharmacists had low level of knowledge about the program as they had spoken about the requirements that need to be fulfilled in order to become a HLP rather than what it entails.
"Healthy Living pharmacy programme, they need to have accreditation to do certain services like the emergency contraception, smoking cessation and Chlamydia, are the three that I am aware of. And the supervised consumption as well."
(Lines 6-9, HLP 11)
5.3 Application for Healthy Living Pharmacy and support needed
The researcher wanted to determine whether the pharmacists had applied to become a part of HLP programme and the reasons behind for not signing up.
Awareness
Around 36% of the Pharmacists didn't have appropriate information about the program and showed interest to gain some knowledge about the programme in order to decide whether to sign up for this programme or not. (Line 11, HLP 8)
One pharmacist said that there was not any difference between this programme and what they do on daily basis. He didn't understand the objectives of this program. (Lines 13&14, HLP 10)
Satisfaction
In contrast, another pharmacist had complained that he wasn't satisfied with the whole framework. It has to be more appropriate in terms of training, timing and targets (Line 11, HLP 7).
One Pharmacist's response was totally different to what others had said. He wanted the interpretations to be documented as the public would demand written recommendations and interpretations.
"Time consuming perhaps and people find it a bit mundane in the sense that we talk about health but it is not documented." (Lines 11 & 12, HLP 3)
Training and funding support
Five pharmacists said that they require training and materials for providing the services. But they didn't prefer to go for training sessions quite often due to time constraints. (Lines 14&15, HLP 7)
However, majority (~67%) of the pharmacists had shown interest in attending training sessions regarding alcohol consumption, EHC, weight-management, self-care and cholesterol monitoring
"..Probably the Blood pressure and cholesterol ones as a lot of people want to know that kind of thing. Maybe EHC as well." (Lines 44 & 45, HLP 7)
According to six pharmacists, funding from the PCT was required in order to hire more staff to offer the services and better payment structure for offering these extra services and achieving the targets.
"..Remuneration. There should be salary remuneration for providing the
extra services." (Lines 25 & 26, HLP 9)
5.4 Participation in HLP
Only two pharmacists had attended the first introductory session. The researcher had also found that five pharmacists had signed the expression of interest, but majority of the Pharmacists had not signed. The reasons were found to be associated with information, time and staff.
Lack of information and time
Around 45% of the Pharmacists had not attended the session as they were not informed about it. (Line 33, HLP 10).
Two pharmacists could not attend the session due to timing problems as they were not able to leave the pharmacy premises due to staffing issues. (Line 27, HLP 7). However, other two pharmacists were on holiday.
"Because I think it was not a requirement to attend and because it was not necessary to attend." (Lines 35&36, HLP 1)
Staff issues
One pharmacist raised a point about the skills and knowledge of the staff as they will be involved in providing these services. Extra training would also be required.
"Again training and as a team we are not quite there to be able to provide these services as my staff do not have the skills or experience that they need to do this.
So, they also need that training and extra sort of support"
(Lines 31-34, HLP 7)
Staff involvement in providing HLP services
All pharmacists had agreed that staff would be involved in offering HLP services. However, different ways of involvement were mentioned, as discussed below:
Majority (6/11) of the pharmacists said that staff will have to identify the people who are in need of the services, educate them about the services provided at their pharmacy and sign-post to the pharmacist for further intervention and advice.
"In cases where people come in to buy smoking cessation products, the staff member can target those customers and refer to pharmacists regarding advice and counselling." (Lines 52-54, HLP 4).
It was also said that staff members would assist the pharmacists in carrying out the services such as blood pressure monitoring and keep the pharmacists intervention to a minimum (Lines 88-89, HLP 3).
Staff training
Majority (8/11) of the staff was not trained for offering HLP services. The pharmacists had plans to get them trained in the future depending on the services and capability of the staff. (Lines 57 & 58, HLP 9)
"It all depends on the suitability of the staff. It all depends on the service and its requirements. Some of the services can only be provided by Pharmacists such as injections. So, it should be considered on a one to one basis." (Lines 38-41, HLP 5)
5.5 Use of Pharmaceutical services by customers on a weekly basis
This was to gain knowledge about the services provided by the pharmacy and majority of which services are used by the customers.
Majority (82%) of the pharmacists offered their extra pharmaceutical services to 10-15 people in a week, however 2/11 pharmacists said around 50-60. The main services that were mentioned were:
Smoking Cessation
This service was considered to be one of the most common services that people came in for (Line 78, HLP 1). In contrast to this, two pharmacists thought that this service had slow uptake.
"That is very slow. Very slow uptake. Since, the start of the year we just had 2 quits. In total we had 6 people on the programme but we lost most of them."
(Lines 64-66, HLP 7)
Other services
According to three pharmacists, MUR uptake was quite high (~10 people) and NMS was carried out on phone for the convenience of the public. (Lines 59 & 60, HLP 7)
Only 2/11 pharmacists had mentioned about needle exchange and Chlamydia testing.
Pharmacists (2/11) thought that counselling people over the counter about general health and minor ailments was one of the most important services they provide.
"..most importantly counselling for depressed patients." (Line 104, HLP 3).
Few other services that were mentioned were weight management (1-2 users), delivery of medications and flu vaccinations which was dependent on weather. EHC was sold over the counter mainly.
It was also found that, 9/11 pharmacists had customers that had inquired about the services they did not offer. The customers were sign-posted to the nearest pharmacy or surgery from where they could avail the desired services.
"Just sign-post to the nearest pharmacy" (Line 55, HLP 2)
5.6 Opinions of the Pharmacists on including HLP programme in NHS pharmacy contract
All pharmacists wanted this programme to be included in the NHS contract. However, there was difference in opinion regarding the title it would fit under. These titles have been mentioned below:
Advanced Service
Around 36% of the pharmacists agreed that this programme should be categorised under advanced services as there is good foundation for essential services, hence there is a need to enhance the services. The other reasons were that this programme already consists of advanced and essential services being put together under one umbrella and also that everyone does not want to be a part of this programme, so it should not be categorised as essential (Line 66, HLP 2 & Lines 117-119, HLP 9).
Essential Service
In contrast to this, 27% pharmacists said that it should be essential because it will then become mandatory to provide the same advice and services to everyone.
"Things have changed now. Before it was just about prescriptions, but now since other advanced services like MUR and NMS have been proved to be very helpful in managing medication problems, it would be good to have healthy living programme as people will have a healthy lifestyle then" (Lines 90-94, HLP 4)
Enhanced Service
One pharmacist thought that it should be categorised as enhanced, as part of the services are already essential and advanced (Line 83 & 84, HLP 5).
However, three pharmacists didn't have any opinions on it as they were unsure about how well this programme would fit in within the NHS pharmacy contract due to communication gap amongst the healthcare professionals (Lines 76-82, HLP 7).
5.7 Barriers for providing HLP services
These were considered to be the same as the support needed for the Pharmacists to become a part of HLP programme (Lines 104-107, HLP 4).
Only one pharmacist thought that there was no need of providing the services as the GPs already did (Line 122, HLP 9).
5.8 Facilitators for providing HLP services
According to three pharmacists, training and proper timing would encourage them to become a HLP.
"In regards to timing, if it was possible to go during the day then it would be much better as we can get a locum to cover." (Lines 91-93, HLP 7)
PCT
Four pharmacists considered that proper guidance and framework from the PCT would act as facilitators. They also considered collaborative working with other healthcare professionals to be an important factor.
"I believe the standards and procedure should be well conversed with the pharmacies and should offer incentives for encouraging the pharmacies to offer all the services. There should be clear guidance as to when to refer to other healthcare professionals." (Lines 97-100, HLP 10)
Two pharmacists thought that the accreditation process was time consuming as it has to be renewed every year.
"We need to get the CPP accreditation, and we haven't had time to get those. Not only that we need to have it every year, which I believe is unnecessary"
(Lines 17-19, HLP 11)
However, they all had support from the PCT and LPC in terms of materials required for providing the services, particularly for smoking cessation.
5.9 Relationship with other healthcare professionals
All pharmacists said that they had good relationship with the local GPs and they also recommended their patients to make use of pharmacy services such as smoking cessation, Chlamydia, morning after pill and flu vaccines.
GP Practice meetings
Only two Pharmacists attended GPs practice meetings and were satisfied that they also have a bit of input in those meetings.
"They are quite interesting. It is a mourning exercise more than anything else. We have quite a bit of input in it. They listen to us." (Lines 87 & 88, HLP 6)
The rest of the Pharmacists (82%) had never attended any of their meetings mainly because they had never been invited and also due to time constraints (Lines 131-134, HLP 11).
Nurses and Care takers
With regards to other healthcare professionals such as nurses and care takers, the pharmacists supplied bandages and dressings for nursing homes. Their interaction was mainly regarding nursing homes patients' medications. In contrast, one pharmacist's opinion was as follows:
"We have a good relationship with carers. But nurses are getting very difficult. Because nurses like certain pharmacists and they stick to them. So, we hardly get to see them." (Lines 94 & 95, HLP 6)
6. Discussion
According to this study, 39/50 pharmacists had refused to take part in the research mainly because seven pharmacists were locums and did not want to take part in the research. The other common reason that was encountered was lack of time due to busy pharmacy and shortage of staff. According to a research carried out by Bryant, Coster, Gamble & McCormick (2009), it was concluded that pharmacists are one of the busiest professionals and their job requires a lot of active participation. However, there is also evidence that the employment status of the pharmacists have an effect on their participation in research projects (Harding, Rosenbloom & Taylor, 2000).
The researcher had also noticed that 8/11 pharmacists were employed in independent pharmacies and were the pharmacy owners themselves. However, there were only 2/11 supermarket pharmacists and 1/11 corporate pharmacist that had agreed to take part in the research. This indicated that the independent pharmacists were more willing to be a part of the research and this is in line with Harding, Rosenbloom & Taylor (2000) who had suggested that pharmacists working for large ownerships usually do not take part in research studies.
6.1 Understanding of public health and HLP
In regards with the understanding of public health amongst the Pharmacists, there was no knowledge regarding health protection, quality and effectiveness of the health services. The pharmacists spoke about providing healthcare services for the welfare of the public and only 2/11 pharmacists spoke about promotion of the health services such as smoking cessation and providing the customers with information/advice on health issues in order to enable them to lead a healthy life. None of the Pharmacists spoke about nutrition, pregnancy, children's health and improving the provision of healthcare services as compared to the public health definition given by the department of health. The definition of public health has changed with time and pharmacists had just answered this question in one line sentence rather than elaborating on the main categories of public health (protection, promotion and prevention). This can be supported by a study that was carried out by Bissell & Jesson (2006), in which the respondents had completely different opinions about public health. According to a respondent, public health was defined as: "The application of pharmaceutical knowledge, skills and resources-to the science and art of preventing disease, prolonging life, promoting, protecting and improving health for all through organised efforts of society." (Walker, 1999). This definition took into consideration the emerging role of the pharmacists in pharmaceutical public health.
Majority of the pharmacists were not aware of the HLP programme as it was launched in Hertfordshire in May, 2012. The pharmacists had not received any information on the programme through their local PCTs. While a pharmacist that was working in a supermarket pharmacy said that they just follow the head office's instructions and if the local PCT wants them to be a part of HLP, then they would have contacted their head office. However, the Pharmacists had different opinions about the services that contribute to improving public health. Majority (10/11) of the pharmacists had considered smoking cessation to be a public health service and 11/11 pharmacies had been providing this service to the public. The other two services that were commonly offered were NMS and MUR. It has also been reported that the Pharmacists have the potential to make a cost-effective and significant involvement in offering smoking cessation service if they are provided with the appropriate training and materials support (Bond, Lennox, Silcock, Sinclair & Winfield, 1999).
Even without much knowledge about the HLP programme, the pharmacists spoke generally about healthy living and their opinions were based around promoting healthy lifestyle through advice and support and the services that were specifically mentioned were smoking cessation, management of chronic conditions and alcohol consumption. These services also form a part of HLP programme. 2/11 pharmacists had also spoken about the extended role of the pharmacists rather than just dispensing medications. This was also the aim of the HLP programme and this research has shown that the community Pharmacists are taking a step up in order to deliver services for the welfare of the public. However, offering these additional services along with the essential ones such as dispensing is increasing the workload of the pharmacists and thus, leaving them with little time to attend other meetings and seminars (Aslani, Benrimoi, Chen, Roberts & Williams, 2008).
6.2 Barriers and Facilitators in the provision of HLP services
Issues were raised regarding the remuneration and training for offering the advanced/enhanced services. These factors were considered as barriers in becoming an HLP and the pharmacists demanded support from the PCT to address these matters, including funds to hire more qualified staff members. This is in line with a study carried out by Cervetto & Keene (1995), where lack of time, training space and finance were considered to be the main barriers in the pharmacists' involvement in promoting healthcare services. In turn, this might be due to lack of financial resources for the health authorities as reported by Anderson (2006).
The participants of this study had shown interest in attending training sessions and improve the provision of their services. This willingness among the pharmacists to attend health promotion campaigns has also been reported by Anderson (2000). It was also noticed that the pharmacists wanted to promote healthy living through giving advice to the public, but were not able to do so due to time constraints as they spent most of their time in the dispensary and could not get many opportunities to communicate with the customers (Anderson, 1998). Hence, this suggested the need of trained staff in the dispensary to allow the Pharmacist to carry out other interventions. The pharmacies remuneration framework is also a cause to make the pharmacists tied up in the dispensary (Bissell et al., 2006).
In terms of the staff involvement for providing services, the pharmacists were of the view that they should be the one who will be targeting people and also assisting the pharmacist to carry out the services. However, there was still lack of training amongst the staff members and some of them had a mind-set regarding the essential services and were not willing to move up and perform other advanced/enhanced services. Pharmacy staff training has been a barrier since many years as reported by Smith & Watson (2004). It was also report that the staff members did not receive the required amount of training, which in turn reduced the confidence that pharmacists had in their staff members (Smith et al., 2004). According to another study, it was found that the pharmacists wanted to delegate some of their management duties to the staff members; however this was not achievable due to the lack of appropriate training (Hunt, Jones & Rutter, 2008). The reasons for not sending the staff for training were found to be associated with poor funding for the pharmacies which in turn also affected the recruitment of qualified/experienced staff (Hassell, Samuels & Schafheutle, 2008). It was also suggested that the staff should be multi-skilled so that they can take care of the counter as well as dispensary duties, leaving more time for the pharmacist for interacting with the customers (Hunt et al.,2008). During the course of this project it was noticed that 8/11 pharmacists had dispensers to assist them in the dispensary and 5/11 of them also had second pharmacists. However, only 5/11 pharmacists had counter assistants. Majority of the pharmacists had support from only two staff members (dispenser and a second pharmacist or counter assistant and a dispenser), who would handle both the counter and dispensary duties. Hence, all pharmacists had issues with the number of staff members available to help them and the amount of training they had received. The number of items dispensed monthly in each pharmacy was above 2,360, which also indicated that they had a lot of customers and the pharmacy was often busy with customers. This in turn does not allow a single pharmacist to take care of the counselling as well as dispensing at the same time. Majority (6/11) of the pharmacists had been in practice since more than 10 years, which also indicates that they have been experiencing these problems for a long time. In contrast to this, it has also been reported by Savage (1999), that extensive involvement of pharmacists in dispensing and checking process and the unavailability of trained staff hampers their involvement in other essential services. In contrast to this it was found that pharmacist-customer interaction has increased by three times since 1973 (Savage, 1999).
Two pharmacists thought that people were not aware of the services provided by pharmacies apart from dispensing medications. They thought that there was lack of awareness about the pharmacists' role in promoting healthy living through advice and advanced/enhanced services. The pharmacists wanted leaflets, advertisements in order to promote their role and inform people that they can avail the healthy living services at the pharmacy. This in turn shows the need of support from the LPC and PCT to promote awareness among the general public. This issue has also been reported by Krska & Morecraft (2010), it was found that there was lack of awareness among the local public regarding the contribution of the community pharmacies in improving public health. According to a report issued by All Party Parliamentary Group (2009) on public health, it was recognised that the community pharmacies can play a major role in improving public health, however there was also an acknowledgement of the lack of awareness of this role among the public (Krska et al., 2010).This issue can be addressed by the use of displays, posters and leaflets which could help in educating the people about the pharmacy services (Anderson & Rajyaguru, 2002).
In this research, the pharmacists had concerns about collaborative working with the GPs and other healthcare professionals. They wanted support from the GPs in regards to the MUR, NMS and other services as they have not received appropriate acknowledgement for these services from the GPs. However, the pharmacists said that they maintained a good relationship with the GPs in terms of queries regarding patients' medications. Only 2/11 pharmacists could attend their practice meetings and were content that they also had a bit of input into those meetings and their suggestions were taken into consideration. The rest of the pharmacists (8/11) had not attended any of the GP practice meetings mainly because they were not invited and secondly due to time constraints. One pharmacist did not even have the knowledge that they could also attend the GPs meetings. This shows lack of communication and collaborative working among the healthcare professionals. There is need of better communication and collaboration between the healthcare professionals and evaluation of the initiatives for promoting the role of the pharmacists (Edwards & Spencer, 1992).
Hence the barriers and facilitators in proving healthy living pharmacy services were perceived to be the same amongst the participants.
There were two pharmacists, who had very different opinion about the HLP services. They did not understand the aim of the HLP programme and were not satisfied with the framework of this programme. This may be due to the fact that Pharmacists think that they are being isolated from other professionals which lead to little scope of discussion and reflection on their upcoming roles (Bissell et al., 2006). They also thought that the GPs already offer those services, so what is the need for the pharmacists to duplicate them. However, it can be argued that patients can gain access to these services whenever they wish according to their convenience. But in case of GP surgeries they need to book an appointment well before in time. So, HLP programme could be time saving for both the public and GPs. Hence the GPs play an important role in promoting the pharmacy services by sign-posting their customers to pharmacists and for that to happen there should also be emphasis on enhancing the pharmacists-GPs relationship (Aslani et al., 2008).
Since, the independent pharmacies are located in the heart of the communities, it would be crucial to provide them with the required funding to offer the public health services. This would increase the access of these services amongst the local public including the most deprived groups of the community as they might not be able to afford long distance travelling in order to gain access to supermarket pharmacies (Ghost, 2003). Customers have also felt that long opening hours and the location of the local community pharmacies adds to their advantage of accessing the services according to their convenience (Alcorn, Bathia, Luger & Power, 2000).
In regards to making HLP a part of NHS pharmacy contract, the pharmacists had different opinions about it. Some thought that it should be an advanced/enhanced service as it will then be dependent on the people whether to offer those services or not. Their decision would be based on the demand of the services in their local community. However, 3/11 pharmacists wanted it to be an essential service as they will then have to provide the same service to everyone and of the same standard. There have been problems regarding the level and quality of the healthcare services in the primary care, which results in many patients not being able to receive the interventions (Bowler & Gooding, 1995).
Hence, Pharmacists contribution will lead to more positive outcomes in terms of public health and would also resolve the issue of inequality in the provision of healthcare services.
6.3 Observational Analysis discussion
This project was to explore the pharmacists' perceptions about public health and HLP. However, an attempt was made by the researcher to determine how a customer would feel when he enters into the pharmacy. Hence, part of the project was to explore the perceptions of the general public (Table 4).
Health leaflets were available in every pharmacy, but the numbers of them were variable. Similar leaflets with the same message were not available at the pharmacies and some of the pharmacies had only two leaflets. This can be related to the pharmacists' issues regarding awareness, as the PCT should be providing the same leaflets to every pharmacy in Hertfordshire so that the same message goes out to the public. However, there could be ignorance from the pharmacists' side as well, as they might not have paid much attention to the leaflets due to their busy schedule. Two pharmacies did not have clean and tidy shelves, which made the pharmacies look unorganised. One pharmacy had a very small area in the shop floor for the customers to wander around and was very congested. These factors influence the priority of the customers to visit the pharmacy. 82% of the pharmacies had non-medical products in their shop floor as well. This could attract more public as they can get their medications and essential amenities from the same place. Also, people would like to visit clean places as it would relate to their medications in some way.
There have been issues regarding the privacy while taking methadone and getting advice on sexual health and other matters in the pharmacy. People did not want to take methadone in front of other customers as they felt embarrassed (Alcorn et al., 2000).However, during the research, the researcher had noticed that all the pharmacists had private consultation rooms to address this matter. The consultation rooms were big enough to accommodate two-three people, allowing them to communicate at their own ease. This would also make the patient feel more secure and confident about the fact that the pharmacists also maintain confidentiality. This would in turn make people realise that apart from GPs who usually don't work over the weekends, pharmacists are also available when advice/support is needed in terms of health.
6.4 Limitations of the Study
The researcher was not able to interview large sample of Pharmacists due to time constraints and the unwillingness of the Pharmacists to take part in the research. The majority (8/11) of the pharmacists were the owners of independent pharmacies, so that might be the reason for similar answers on funding and staff issues. However, the corporate pharmacies might have different understanding of public health and Healthy Living Pharmacy programme. Hence, the collected data cannot be generalised, as the pharmacists in different positions would have had different perspectives.
With regards to data collection, the interviews were recorded which acted as secondary data. Hence, while transcribing the interview recordings, the researcher might have interpreted the answers with a different understanding to that of the participant. One pharmacist had even refused to record the interview and was in a rush as he had to cope up with the work. Thus, the researcher was not able to gain deeper understanding of that particular pharmacist's opinions.
The researcher did not have any published evidence to support choices given for the years of experience and qualification questions. Thus, there was no published work to allow comparison of the collected data for those questions as to how does pharmacists perspectives change with experience. The collected data was coded into themes by the researcher. However, due to time constraints it was not possible to get it checked by a colleague to determine whether the coding has been done at an appropriate level or not.
