Volume 8, Issue 1 , Pages 36-46, January 2012
Integration and differentiation: A conceptual model of general practitioner and community pharmacist collaboration
Article Outline
Abstract
Background
The drive for integrative systems and collaboration across organizations and professions involved in the provision of health and social care has led to the development of a number of scales and models that conceptualize collaborative behavior. Few models have captured the dynamics of the collaboration between community pharmacy and general medicine, 2 professional groups that are increasingly being encouraged to adopt more collaborative practices to improve patient care.
Objectives
This article presents a new model of collaboration derived from interviews with general practitioners (GPs) and community pharmacists in England involved in service provision that required some form of collaboration.
Methods
Qualitative interviews were conducted with purposive samples of 13 GPs and 18 community pharmacists involved in the provision of local pharmaceutical services pilots and 14 GPs and 13 community pharmacists involved in the provision of repeat dispensing.
Results
The model highlights key components of collaboration, including the importance of trust, communication, professional respect, and “knowing” each other. It is argued here that previous models fail to recognize the asymmetry and differentiation between GPs and community pharmacists, including differences in perception toward and importance assigned to trust and communication. GPs were found to adopt demarcation strategies toward community pharmacies and pharmacists, with independent pharmacies being favored over multiple chains and regular pharmacists favored over locum/sessional pharmacists. This differentiation was repeatedly highlighted by GPs and found to affect their ability or willingness to collaborate.
Conclusion
The model provides a foundation for the future development of strategy and research focused on the improvement or study of collaborative relationships between community pharmacy and general practice.
Keywords: Community pharmacy, General practice, England, Interprofessional, Collaboration, Relationships, Pharmacy services
Introduction
Recent health policy and guidance, in the UK and elsewhere, have increasingly encouraged community pharmacists and general practitioners (GPs) to adopt a more multidisciplinary and collaborative approach to health care delivery. Despite a common interest in optimizing the benefits and minimizing the risks of medication to patients, community pharmacists and GPs have tended to work in isolation from one another with only minimal contact on routine matters.1 Furthermore, the GP-community pharmacist relationship is often described as historically conflictual and competitive2 with tension centered on the commercial aspect of community pharmacy.3, 4
The Department of Health5 in England first outlined its vision for community pharmacy to be recognized as “an integral part of the National Health Service (NHS) family” and for pharmacy services to be “more clearly integrated with the work of other primary care professionals—particularly GPs” in 2003. Following this, in 2005, contractual changes for community pharmacists were introduced, which attempted to expand the role of community pharmacy through the provision of more cognitive services, several of which necessitated GP cooperation.6 In 2008, the Department of Health7 in England concluded that relationships between GPs and community pharmacists had not developed as expected, that professional relationships were strained, and that there was a need for closer cooperation for integrated care.
Several conceptual models have been developed to describe and aid understanding of the stages and characteristics of collaboration and integration between health and/or social care professionals and services8, 9, 10; however, little attention has been given so far to understanding how these concepts and their characteristics relate to the community pharmacy and general practice relationship.
Collaboration and integration
In health and social care literature, terms such as integration, collaboration, and cooperation are often used interchangeably and suffer from conceptual confusion. “Integration,” a term favored by health care policy makers in England, is a concept with roots in organizational theory. Lawrence and Lorsch11 placed great emphasis on the concepts of “integration“ and “differentiation” in relation to the understanding of organizational systems. Their contingency theory suggests that for organizations to deal with their external environment, there is a need for them to become segmented into units, with each unit addressing a certain portion of the external environment; this leads to differentiation. For the organization to accomplish their overall goal, these units need to be linked together, leading to integration.
For the purposes of this article, integration is viewed as an end point and these other concepts are viewed as different types of integration or even methods through which integration could be achieved. The conceptual framework of integration in public health by Axelsson and Axelsson8 summarizes this idea well by characterizing integration into 4 forms: “coordination,” “cooperation,” “contracting,” and “collaboration”. “Contracting” involves integration that is achieved through formal contractual arrangements; “coordination” involves integration being achieved through a common management hierarchy; “cooperation” is integration also achieved through hierarchical management but complimented with voluntary and mutual agreements; and “collaboration” is when integration is achieved through voluntary and mutual arrangements.8 These 4 forms are also characterized by their varying levels of vertical and horizontal integration. Horizontal integration is defined as “integration which takes place between organisations or units that are on the same hierarchical level or have the same status.” Vertical integration “takes place between organisations and units on different levels of a hierarchical structure.”8
The preferred terminology across much of the work in the area of integration of services is “collaboration” rather than these other related terms. However, consensus does not always exist in terms of definition or how “collaboration” is related to these other types of integration. Axelsson and Axelsson8 argue that most integration within the public health arena involves either “cooperation” or “collaboration.” They suggest that as there is no common hierarchy across most organizations involved in public health, there is little vertical integration, which, according to their model, indicates that the most common integration type is “collaboration.” Loxley12 agrees that collaboration is an appropriate description in the context of health and welfare working together but takes a different stance on the 2 related terms. She argues that collaboration is the most appropriate term as it acknowledges the interwoven conflict between professionals, whereas “cooperation” implies more of a consensus. Sullivan13 agrees that the concepts of cooperation and collaboration are related but do not mean the same thing. Conversely, however, she concludes that “cooperation is only the first step to collaboration.”
For the purposes of this article, the term “collaboration” will be used. Aspects of the GP-pharmacist relationship in England resonate with both Axelsson and Axelsson’s and Loxley’s take on “collaboration.” In England, and the UK, arrangements for GPs and pharmacists working together are not formalized or financed in the same manner as they are in other European countries, such as Germany and Switzerland.14, 15 The US also has more formalized arrangements in the shape of “collaborative practice agreements” between physicians and pharmacists.16 In the UK, such relationships often rely on voluntary informal arrangements and therefore reflect to some extent Axelsson and Axelsson’s description of “collaboration.” The 2 professions also have a history of tension and competition,2, 3, 4 which also resonates with Loxley’s description of collaboration.
Models of interprofessional collaboration
Several models focus more on the collaboration of professional groups and individuals than services or organizations. Armitage9 devised a 5-stage taxonomy of collaboration in primary care (Fig. 1). Bond et al17 used this taxonomy to assess the collaboration of GPs and district nurses and GPs and health visitors and discovered that the most common form of collaboration was level 3 “communication.”
Fig. 1
Armitage’s taxonomy of collaboration.9
Hudson et al10 provide a similar 4-point continuum of collaboration developed for the primary and social care interface, including isolation/encounter, communication, collaboration, and integration. This model also incorporates the dimension of “trust,” with “collaboration” and “integration” being characterized by higher levels of trust. Further work by Hudson (cited in Leathard18) presents a similar model, incorporating recent health and social care reforms such as the “co-location” of professionals and the role of “commissioning” in collaborative relationships.
In relation to GP-pharmacist specific models, the most developed is McDonough and Doucette’s16 collaborative relationship model for pharmacists and physicians in the US (Fig. 2). This theoretical model was synthesized from previous models of interpersonal relationships, including theories of social exchange, business relationships such as the buyer-seller relationship and organizational behavior, and collaborative care models primarily relating to nurses and physicians. This model attempts to demonstrate factors influencing the level of collaboration, including participant characteristics (level of education, training experience, and age), context characteristics (practice environment, type, and size), and exchange characteristics (trustworthiness, relationship initiation, and role specification). From this theoretical model, the authors developed the Physician/Pharmacist Collaboration Index questionnaire to measure drivers for physician-pharmacist collaborative relationships.19, 20 The exchange characteristics of trustworthiness and role specification were reported to be the most significant factors influencing collaborative relationships for both professional groups.
Fig. 2
The collaborative relationship model of McDonough and Doucette.16
Although the collaborative relationship model of McDonough and Doucette empirically tested drivers of collaboration, the stages of collaboration presented are theoretical and synthesized from existing models, rather than drawn from GP and pharmacist’s own accounts of collaborative relationships. This article explores themes of collaboration drawn from 2 discrete studies involving GPs and community pharmacists, examines the applicability of existing models to this particular context, and then presents a new model for conceptualizing the GP-pharmacist relationship.
Method
Details of the 2 studies informing this article are shown in Table 1. Study 1 involved case study evaluation of a new form of pharmacy contract in England, entitled “local pharmaceutical services” (LPS). Contracts were agreed locally between pharmacists and their primary care trust (a local body responsible for the commissioning of health care) and involved the provision of an array of extended services (eg, medication reviews, treatment of minor ailments, and out-of-hours services), many of which required direct collaboration between pharmacist and GP. The second study was the evaluation of repeat dispensing by community pharmacists. All community pharmacists have been required to offer a repeat dispensing service as part of their NHS contractual obligations since April 2005. Repeat dispensing involves GP and pharmacist cooperation for patient referral into the service and subsequent monitoring of drug use. This evaluation captured data on the function of the service in its early stages before national rollout.21 Both studies were mixed-method evaluations, including qualitative interviews with community pharmacists and GPs. This article reports on the secondary analysis of interview data from these 2 studies. All interviews were recorded and transcribed verbatim, and data were organized and analyzed with the aid of Nvivo 7 software (QSR International: Melbourne, Australia). After coding the transcripts, biographical case summaries of each GP and community pharmacist were produced, giving an overview of their views and attitudes about collaboration and indicating their current level of collaborative activity. Each case summary was examined in relation to each other, with the content and emerging categories compared between and within cases, following principles of the constant comparative method as described by Glaser and Strauss.22 From the data, a number of themes characterizing varying degrees of collaboration emerged. Each interviewee was then categorized into a level of collaboration, using a terminology similar to that of Hudson et al10 and Armitage9 (Fig. 3). To aid the interpretation of our findings, we also examined a number of existing models based on other health and/or social care professions and contexts (as presented in the Introduction section) to see where similarities and differences may be present. The different levels of collaboration identified then formed the basis of our conceptual model, with each of the themes forming a component of the relationship.
Table 1. Outline of the studies
| Study | Method | Sample |
|---|---|---|
| Study 1: “The evaluation of LPS pilots” | In-depth semistructured interviews | 6 case study primary care trust sites, involving interviews with 13 GPs and 18 community pharmacists |
| Study 2: “National evaluation of repeat dispensing by community pharmacists” | In-depth semistructured interviews | Purposive sample of repeat dispensing providers including 14 GPs and 13 community pharmacists |
Fig. 3
Conceptual model of GP-pharmacist collaboration.
Results
Three main stages of collaboration between GPs and community pharmacists were identified from the data: level 1 “isolation,” level 2 “communication,” and level 3 “collaboration” (Fig. 3). The highest level of collaboration was seen between a small number of pharmacists and GPs involved in the LPS pilots, with the lowest levels often associated with those involved in the repeat dispensing service. Fig. 3 presents the conceptual model that outlines the 3 levels and demonstrates how they are characterized by a number of factors. Each theme is outlined in more detail below, and quotes from the interviewees have been selected to illustrate these. Community pharmacist is referred to as CP and repeat dispensing as RD in the illustrative quotes provided.
Proximity and location
Co-location was included in some of the previous models outlined,16, 18 and the current study’s findings support the idea that this can facilitate stronger working relationships.23 Previous models, however, do not take account of the type of location and the proximity of other GP practices and pharmacies. A small number of pharmacists and GPs in this study were based in rural locations and were the sole practice and pharmacy in these settings. These respondents stated that these circumstances aided the development of collaborative relationships:
I think it’s down to local circumstances. It’s so easy to run [repeat dispensing] here … it’s one surgery, one pharmacy, whereas in [name of town], its multiple surgeries, multiple pharmacies, somewhat more difficult to manage the situation.
(CP 3, RD—level 3)
In contrast, feelings of nonfamiliarity and distance were identified in city locations:
Interviewer: So the pharmacies that you work with, how many different pharmacies can your patients use?
GP: Well we’re in the middle of a large city. The answer is certainly dozens.
Interviewer: Do you have much contact with the pharmacists?
GP: No.
(GP 6, RD—level 1)
“Knowing” each other
For GPs involved in collaboration, an overriding factor appeared to be historical relationships with pharmacists. Many of the GPs spoke about “knowing” the pharmacist:
We’re lucky here, we know the pharmacists and they know us.
(GP 9, RD—level 3)
GPs mentioned the difficulty they had “knowing” locum/sessional pharmacists or pharmacists working in large chains and consequently felt reluctant to work with these types of pharmacists or pharmacies. Issues with continuity also arose for pharmacists in terms of confusion over service arrangements in surgeries with large numbers of GPs. This was, however, not articulated in terms of not “knowing” the GPs but described as a more pragmatic issue in terms of GPs not having awareness of the service:
“… because there are only two GPs trained in the repeat dispensing scheme out of a surgery of, say, six or eight, not all the doctors are aware, so if a different doctor sees that patient they don’t know to let us know.”
(CP 1, RD—level 2)
“Knowing” each other could be either viewed as a nuance of trust or distinguished from trust in terms of familiarity. Luhmann24 indicates that familiarity is an unavoidable fact of life, whereas trust is a solution for specific problems of risk (which in this case would be risk to the patient), although trust can only be achieved in a familiar world.
Trust
The importance of the GP trusting the pharmacist and for this trust to build up over time was commonly mentioned by the respondents. Distrust was associated with the commercial aspect of pharmacy. In relation to the repeat dispensing service, some GPs appeared distrustful of the motivations of pharmacists:
They want to obviously dispense more items because they get paid for every item, don’t they?
(GP 3, RD—level 1)
One of their concerns [with repeat dispensing] is that the pharmacist will claim for everything on the prescription whether they’ve dispensed it or not.
(CP 5, RD—level 1)
Distrust was also directed toward the type of pharmacy and type of pharmacist. Some GPs reported that their relationships were strongest with single independent pharmacies rather than multiple chain pharmacies. GPs reported finding it difficult to work with multiple chain pharmacies, which had many staff members and little continuity; they also expressed a certain level of suspicion about the motivation of these chains and indicated that the pharmacists may be “just average” in terms of skills. Locum/sessional pharmacists were also viewed with suspicion by some of the GPs and criticized for not knowing the patient and the various systems in place:
I wouldn’t be happy for it unless I had a close relationship with the pharmacists and I trusted them to tell me if things are going wrong … I’m not sure how well it would work with a chain chemist, as the continuity may not be there … if they had more locums I wouldn’t trust the system so well as they wouldn’t necessarily know the patients.
(GP 11, RD—level 2)
The main criticism directed toward GPs by pharmacists was their lack of awareness about pharmacy’s potential contribution to patient care or about the specific services that the pharmacists were trying to operate. The solution to this issue was conceptualized in terms of simple “quick fixes,” such as a joint training session or a visit to the practice by the pharmacist. The inherent assumption was that this was sufficient to educate the GP and for the GP to meet the pharmacist and feel comfortable about working collaboratively. GPs, on the other hand, talked about the need for trust to build up over time, thus demonstrating the varying level of importance assigned to trust by the 2 professions.
For those pharmacists and GPs with high levels of collaboration, “knowing” and “trusting” each other appeared to have developed into mutual dependency. Community pharmacists are arguably dependent on the GP for the generation of prescriptions to be dispensed, whereas the GP is not necessarily dependent on the pharmacist, which exhibits hierarchy in the medical division of labor. Mutual dependency was exhibited by 1 GP through an expression of concern about the possibility of the existing pharmacist leaving:
I still have a bit of a worry … we have such a good relationship with [the current pharmacist] and because of his style and his abilities and so on, if he suddenly took off to Australia or somewhere … [the practice] could get dumped with somebody who wasn’t interested.
(GP 1, LPS—level 3)
Communication
Varying degrees of communication were seen across the respondents. Some GPs and pharmacists had minimal communication despite being involved in a collaborative service:
We don’t talk to the pharmacists about it; maybe we should [do so].
(GP 3, RD—level 1)
It’s unfortunate that that relationship doesn’t seem to be there … I haven’t seen much evidence of, “Doctor X has phoned me up about this, and I’ve resolved this.” It’s usually, “I’ve sent a fax off, the medication is being done.”
(CP 5, LPS—level 1)
One GP also stated that he had less contact with the pharmacist after the introduction of repeat dispensing because the scheme had resulted in less problems and medication queries.
We have slightly less contact now because we are not speaking to them about certain prescriptions once a month. It’s sort of once a year now.
(GP 10, RD—level 2)
The direction of communication was also an important factor. For those with lower levels of collaboration, communication appeared to be unidirectional from pharmacist to GP.
They do give us a ring now and again if they have a problem or if they have a query.
(GP 4, RD—level 2)
Reciprocal communication was exhibited by those with higher levels of collaboration, which also links to the idea of mutual dependency. In the first quote below, the GP is explaining the level of communication and history he had with the local pharmacist before the start of the LPS service:
There was a lot of phone communication, but travelling both ways, him querying scripts and us asking for advice … I would often pop into the shop … and have a chat with him … I suppose I would see him, talk to him, two or three times a week.
(GP 1, LPS—level 3)
… it’s a two-way process. They’re always actually ringing me and I’m ringing them.
(CP 11, RD—level 3)
The sustainability of communication was also an important factor. Pharmacists reported that initial communication had been good but had later “tailed off,” with GP practices failing to inform them of changes to patient medication or to forward necessary referrals or paperwork. This was indicative of the earlier finding regarding the “quick fix” approach of some pharmacists at the start of the service and a failure to adopt a more long-term approach or strategy.
Roles and responsibilities
GPs with high levels of collaboration adopted a nonterritorial approach to roles and responsibilities:
We have a source on tap of drug information, and I can see his role in checking medication being extended to a whole host of things … he could run clinics in the building and he could run surgeries in theory.
(GP 1, LPS—level 3)
There was also recognition of the expertise of pharmacy as an enhancement to the skill set of GPs rather than a substitution:
If the right patient gets to the right person, they do a better job perhaps than the doctors … more thorough for certain things … certainly advice regarding drug interactions, it could be argued that the pharmacist does that better … we’re all fairly modern in our approach, we can live with it.
(GP 6, LPS—level 3)
Some GPs exhibited a territorial approach and a preoccupation with defined boundaries and roles, particularly those involved in repeat dispensing. Other GPs expressed the view that the pharmacist could play a useful substitute role dealing with minor ailments, if appropriately trained, with the intention of easing GP workload. As these quotes demonstrate, these GPs were open to collaborating with pharmacists but in a manner that still maintains and reinforces their medical dominance:
We should use pharmacists’ skills more—it reduces GP workload.
(GP 3, LPS—level 2)
I would much prefer that I spent my time dealing with complex stuff than spend my day doing unnecessary things that somebody else can do.
(GP 9, LPS—level 2)
This view of set roles and boundaries was not limited to GPs. Some pharmacists involved in repeat dispensing expressed similar views. In relation to the selection of patients for the scheme, some pharmacists with close working relationships with GPs were recommending patients they felt were suitable. Others expressed the view that this was the role of the GP and not something for the pharmacist to be involved with. Issues of responsibility also arose, with some pharmacists feeling reluctant to take on this level of responsibility:
I’d rather not have the responsibility on my head … I’d like [the GPs] to be the ones who explain, initiate the whole service, and I can just be there as an addition … [GPs] can be firm when they need to, whereas I have customers to think about who could go to another pharmacy very easily if they hear something they don’t want to hear.
(CP 4, RD—level 2)
Professional respect
GPs who appeared disinterested in collaboration expressed concerns about pharmacists’ level of training, indicating limited confidence in their ability:
I guess we need to educate them, but I don’t feel that’s my responsibility … we’re going to have to chase it up and make sure they are doing it properly
(GP 3, RD—level 1)
The commercial aspect of community pharmacy was viewed negatively and with suspicion by some GPs. As the previous quote from the pharmacist above demonstrates, the issue of commercial consideration can arise for the pharmacist as well.
The demarcation of the profession of pharmacy was reinforced again by GPs in relation to professional respect. Overall, they demonstrated respect for the profession but again distinguished between types of pharmacy and pharmacists:
They seem better than your average pharmacist that you’d find in a supermarket … I hadn’t realised until now how highly trained some pharmacists are.
(GP 9, LPS—level 2)
I think [GPs] have confidence in the profession but they are aware that there are many part-time or locum pharmacists and perhaps are not confident that, owing to the nature of their part-time work or the fact that they may be working in one town one day and in a different pharmacy the next, they may be concerned about the continuity.
(CP 5, RD—level 2)
Discussion
Previous models of integration and collaboration outlined in this article provide elements that are useful for the conceptualization of GP-community pharmacist collaboration and integration. The conceptual framework of Axelsson and Axelsson8 offers a useful categorization of horizontal and vertical integration. Overall, the collaboration between GPs and community pharmacists in our studies was dependent on mutual and voluntary agreements. The LPS pilots provided the most salient example of this, with the community pharmacists entering into contract with their local primary care trust to provide a service but the GPs not being contractually obliged or incentivized to cooperate with the service. In the model of Axelsson and Axelsson,8 collaboration involves little vertical integration and a high level of horizontal integration, which takes place between “organisations or units that are on the same hierarchical level or have the same status.” Arguably, GPs and community pharmacists are not positioned on the same hierarchical level, with GPs having the power to diagnose and prescribe for a population of patients.25, 26 Freidson27 argues that the medical profession is afforded autonomy and dominance that provide the “opportunity to develop a protected insularity without peer among occupations lacking the same privileges.” An attempt to reinforce medical dominance through a preoccupation with traditional roles and the identification and derision of the commercial aspect of pharmacy was demonstrated by some GPs. This is reminiscent of Weber’s theory of social closure, whereby one group monopolizes advantages by closing off opportunities to another group; convenient and visible characteristics are used to declare competitors as outsiders28, 29; however, some community pharmacists in our study also contributed to the reinforcement of traditional roles and boundaries as well. It thus might be concluded that vertical integration may not be achievable, and there is a need to recognize that mutual and voluntary arrangements may not be the most appropriate approach for the 2 professions.
Unsurprisingly, the model of McDonough and Doucette16 is most comparable with our findings, as it is tailored toward physicians and pharmacists. However, our findings reveal several factors that have not been considered in existing models. Absent from the existing models is the identification of the differentiation and asymmetry of the GP-pharmacist relationship. This includes recognition of asymmetry in power and status and recognition of differing perceptions regarding the components of a collaborative relationship and the importance assigned to these, such as effective communication. Traditionally, communications have tended to be limited to routine matters such as querying prescriptions or alerting GPs to potential problems. This relates to the role of pharmacists historically functioning as the final check before the patient is given the medication. Subsequently, everyday communication with GPs and their practice may involve reporting any mistakes or errors that have occurred. This raises the interesting notion that pharmacists could be viewed as “bearers of bad news,” only initiating communication with GPs when there is a problem. Previous research and literature indicate that communication is an inherent and necessary part of good team working and interprofessional collaboration.30 However, our findings suggest that GPs could frame this differently, with communication perceived as not as necessary when things are going well.
The findings from this study on trust concur with the work of McDonough and Doucette,16 which demonstrated that trustworthiness was an important factor in collaborative relationships and the earlier model of Hudson et al10 indicating the dynamics between trust and integration. However, both models do not consider the varying need to trust by profession. This study’s findings suggest that there is an imbalance in terms of the importance assigned to trust. GP perceptions of collaborative relationships involve the need to trust the pharmacist, with the pharmacist earning the GPs’ trust through being well established in the area or demonstrating effective or efficient service provision, whereas pharmacist perceptions of collaborative relationships involve the GP being aware of the pharmacist and/or the service provided. The pharmacist’s need for GP awareness may be related to the traditional isolation of community pharmacy from general practice—making the general practice aware of the pharmacy and the services offered may feel like a step in the right direction.
The demarcation of community pharmacy by GPs was also another important finding. Later work that used the model of McDonough and Doucette found that context characteristics, such as type of pharmacy or practice, were not strongly associated with the level of collaboration19, 20; however, this work measured the individuals’ pharmacy or practice type against their own level of collaboration. As our findings suggest, the type of pharmacy or type of staff working in the pharmacy may influence the level to which the GP is willing to collaborate. Differences between regular and locum community pharmacists and chain and independent pharmacies were repeatedly raised by GPs in relation to trust, “knowing” the pharmacist and professional respect.
The new model identifies the key components of the collaborative relationships exhibited by GPs and community pharmacists in our sample and highlights the asymmetry and differentiation between the 2 professional groups. One limitation of the model is that it may capture more strongly the views and opinions of GPs rather than community pharmacists. This, however, is another example of the differentiation in the relationship. The GPs interviewed vocalized their opinions of community pharmacy, expressing judgment concerning role, abilities, and responsibilities and the need to “know” and trust. In comparison, the community pharmacists interviewed expressed less dominant views of GPs and spoke of the need for GP awareness and cooperation.
The GP and pharmacist sample consisted of practitioners already involved in some degree of collaboration, through either repeat dispensing or an LPS service. Therefore, the sample includes individuals who may be more attracted to or open to collaboration, and this should be taken into account when interpreting the findings. However, the sample also included GPs with little interest in collaboration and captures the minimum level of collaboration required from the 2 professions through repeat dispensing, a service that all community pharmacists in England are contractually obliged to provide, if required. The findings also capture some of the higher levels of collaboration through the LPS sample.
Further empirical work will be required to test the applicability of the conceptual model in relation to the evolution of the community pharmacist’s role and expansion of service provision in the future. The model proffered here does not concentrate on the operationalization of collaboration in terms of solutions to improving collaboration or achieving integration, and further research is required to examine how professionals could potentially progress from one level to another, focusing on how relationships are established, maintained, and developed. In terms of implications for practice, it is important for policy makers to understand the nature and complexity of this relationship to inform their decisions. Thus far, collaboration problems between GPs and community pharmacists have frustrated policy. This model provides a foundation for the future development of strategy and research focused on the improvement or study of collaborative relationships between community pharmacy and general practice.
Acknowledgments
The authors acknowledge Rebecca Elvey and Charles Morecroft for their help in conducting the interviews and thank all the GPs and community pharmacists involved. The 2 studies presented in this article were funded by the Department of Health in England. The interpretations presented in this article are those of the authors and not necessarily those of the Department of Health in England.
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PII: S1551-7411(10)00172-5
doi:10.1016/j.sapharm.2010.12.005
© 2012 Elsevier Inc. All rights reserved.
Volume 8, Issue 1 , Pages 36-46, January 2012
