Research in Social and Administrative Pharmacy
Original ResearchHow to best manage time interaction with patients? Community pharmacist workload and service provision analysis
Introduction
The aging population and the prevalence of chronic diseases are challenging health systems to implement reforms toward higher sustainability.1 These reforms have often focused on primary healthcare (PHC) coverage, supported by multidisciplinary teams.2 Community pharmacists are adding significant contributions to PHC by fulfilling an increasing range of roles and responsibilities.3 This largely results from the professional practice promoted by Hepler and Strand, 4 who established the concept of “pharmaceutical care” almost three decades ago. In most health care systems, pharmacists are usually the first health care professional that patients access when seeking health advice, particularly for minor ailments or when making use of their medications. Pharmacists' position is ideal to leverage health care interventions, in particular those related to pharmacotherapy and pharmacovigilance activities.5
Pharmacists' interventions have potential benefits for health systems and patients.6, 7, 8 This potential derives from patients visiting community pharmacies more often than any other health care service due to their proximity and accessibility.9, 10, 11 Main drivers for these visits are patients' needs for medication supply and associated information.12, 13 To respond to this demand, a typology of three main services has emerged among community pharmacies14: provision of specialized product-related services (e.g. medicine dispensing, medicine compounding); information services (e.g. drug information programs, mailed refill reminders); and pharmacists' care services (e.g. immunizations and health screenings, diabetes management programs, medication therapy management). This movement is thought to be essential to the professions' future, with some authors advocating that the implementation of patient follow-up services and its sustainability has to be dramatically up-taken to make community pharmacists relevant to the health systems.15, 16, 17
Community pharmacists in Portugal work exclusively in independent pharmacies, since large chains are not allowed. The opening of community pharmacies is regulated, with main criteria being a minimum distance between pharmacies (350 m in a straight line) and the number of serviced inhabitants (minimum 3500 inhabitants). There are some exceptions to these rules, depending on the presence of a health care service in the vicinity or in areas with low population density. Pharmacies have to be opened at least 50 h a week. The presence of a responsible pharmacist – the technical director – is mandatory and a substitute has to be registered at the national medicines regulatory agency (INFARMED) to assure a pharmacist is present at all times. Non-pharmacist ownership is allowed, with the maximum number of pharmacies per owner capped at 4. Pharmacies have a National Health Service (NHS) contract for dispensing prescription medicines, with legislation establishing medicines' profit margins and patients' co-payments.18 Practicing pharmacists have to be mandatorily registered and licensed by the Portuguese Pharmaceutical Society. By the end of 2014, there were 8682 registered community pharmacists.19, 20 These are mostly young professionals (67% are less than 45 years old). There is a high number of females (80% of the practitioners), confirming a worldwide trend.21 The ratio of pharmacists per pharmacy has increased between 2000 and 2014, leading to an average of more than 3 pharmacists per pharmacy since 2014.17, 20 Simultaneously, the number of pharmacy technicians and auxiliaries per pharmacy has dropped, with pharmacists assuming the supply tasks and undifferentiated tasks as part of their work routine. This in turn may have contributed to patients' poor acknowledgment of different workers and competencies at the community pharmacy counter.22
Over the last twenty years Portuguese community pharmacies have developed consultation services to manage chronic patients and their therapies.23 These services have targeted the provision of tailored education on health, drug information, screening and monitoring of basic clinical parameters (e.g. blood glucose, acid uric, cholesterol, etc.), blood pressure and body mass index. There was also an effort to develop and implement nationwide pharmaceutical care programs for diabetes and hypertension. These programs were developed by the National Association of Pharmacies (ANF), an owners' association. The program for diabetes care was financially supported by the NHS from 2006 to 2009. When the financial support ended, 400 pharmacies were doing patient follow-up, with an average of three patients per pharmacy.24 Soon after, most pharmacies terminated the provision of the service. A recent survey found that in a sample of 403 pharmacies (14%), only 333 pharmaceutical care consultations were provided during a 5 days period.25 Apart from dispensing prescription medicines, none of the present services, e.g. smoking cessation programs, minor ailment counseling, and adherence support services, is supported by NHS remuneration; these services are entirely supported by medicines' profit margins and patients' direct payments.
With the onset of new services and practices, there is growing concern that pharmacists' workload is too demanding.26, 27 Workload can be defined as the amount of work an individual has to accomplish during a certain period of time.28, 29 Evidence suggests that higher workloads may have an impact on the quality of service provision, dispensing accuracy and act as a barrier to the practice change envisioned for the profession.30, 31, 32 A recent review of pharmacists' workload in the United Kingdom found that pharmacists spend most of their day dispensing medicines.29 Other studies report that about half of a workday is spent in professional activities, while approximately 30% is spent in administrative tasks and 20% resting and in house work.33, 34 A study in West Virginia found that pharmacists' increasing workloads hindered pharmacists' availability to spend time with patients.35 Also of importance is professionals' perception of high workload and work pressure from inadequate breaks or lack of staff.29, 34 Alongside the lack of incentives, “lack of time” is many times reported as a barrier to the development of pharmacists' new role in disease management,30, 36 which highlights the global concern with workload and its evaluation. Therefore, understanding what pharmacists do and how they spend their time is essential to the sustained development of new pharmacy services. Once evaluated, pharmacists' workload should be integrated into the design of new systems or services.
Although the issue of community pharmacists' workload has been addressed in recent studies,29, 37 additional evidence is needed on Portuguese community pharmacists' workload and the associated pattern of pharmacy services provision. New clues to better understand the situation will help policy-makers in the design of better strategies to increment the provision of pharmaceutical care services. Beyond knowing pharmacists' workload and the level of service provision, it is also necessary to look at the other end of the service chain i.e., to estimate the potential demand for new services. This is crucial information to support health care services planning and development.38 The relationship between services provision, consumption, demand and unsatisfied demand helps to address both service improvement and innovation. Establishing both ends of this continuum will allow predicting factors for success in advanced service provision.39
This study aimed to characterize the workload and activities performed by pharmacists in a set of community pharmacies, including the bundle of services provided and the time spent with patients. The overall objective was to describe Portuguese community pharmacists' workload and work patterns allowing for the comparison with community pharmacists' workload from other countries. An additional objective was to estimate current chronic medicines needs, to explore the potential demand for new pharmaceutical services.
Section snippets
Methods
To address the main objectives, a multi-method approach was chosen. Firstly, to study pharmacy services provision and characterize pharmacists' workload, an observational time-and-motion study using a thin-slicing approach was designed. Thin-slicing is an approach used in psychology research to describe the ability to find patterns in events based only on narrow windows of experience.40 Time-and-motion was used to understand how participants spent their time within each window.41 Thin-slicing
Service provision analysis
An overall view of the participating pharmacies is presented in Table 2, comprising baseline information on pharmacies workforce, number of weekly hours of operation, estimated number of prescriptions for an average month and the average prescription volume per professional/hour (maximum weekly working hours is 40 per professional).
The total observation time and number of activities registered are presented in Table 3. In aggregate, a total of 108 h of working time were recorded. During this
Pharmacists' workload
Study results have characterized community pharmacist's workload, work patterns and estimated demand for chronic medicines, providing a picture of a workday in these pharmacies.
Pharmacist's work pattern in this study was characterized by an 8-h working day, with a 2 h lunch break plus a 30 min break for a small meal, many times outside the pharmacy. During the day, a continuous succession of activities is interspaced with small breaks (less than a minute) especially when pharmacists were at the
Conclusion
In this study, it was clear that the dispensing of medicines still is the most time-consuming activity in a Portuguese community pharmacy. The assessment of a single day workload showed that pharmacists spend half of their day interacting with customers and patients, confirming the importance and potential of more specialized communication in the context of primary healthcare and chronic patient follow-up. The similarity with findings from other settings, in spite of different legal and
Acknowledgment
The authors would like to acknowledge the participant pharmacies for having allowed the observational study to take place.
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Funding: The research reported in this manuscript has been funded by the Portuguese National Science and Technology Foundation (FCT) through the ePharmacare project (Grant number: PTDC/CCI-CIN/122690/2010). Also of importance was the support of the Global Health and Tropical Medicine research center, GHTM – Grant number: UID/Multi/04413/2013.
Conflict of interests: None to declare.