Pharmacy users’ perceptions, awareness and future expectations of community pharmacy in England: a focus group study

Abstract

Objective

To explore pharmacy users’ perceptions of current and future provision of community pharmacy services in England.

Methods

Qualitative, reconvened focus groups were conducted with community pharmacy users. An initial focus group explored preliminary views. Participants were then given an evidence brief describing community pharmacy before a reconvened focus group two weeks later. Transcripts were analysed using inductive thematic analysis.

Key findings

Eleven individuals participated across two reconvened focus groups. Participants valued community pharmacies and staff, but lacked awareness of their services and roles: ‘… I don’t think the general public is aware of all of this … it gives you a very different perspective’. Urgent care and long-term conditions management were identified as suitable for future development, facilitated by training, closer collaboration with general practices, shared access to health records, and premises with more space and confidentiality: ‘I still think of it as a retail space more than as a health service’. Concerns were expressed about working conditions in community pharmacy and unplanned closures: ‘doesn’t sound like a great place to work’. Participants anticipated greater use of technology but did not want this to replace face-to-face contact with pharmacy staff: ‘I am not saying it’s inaccurate, it is so remote and impersonal’.

Conclusions

Pharmacy users would value a greater role for community pharmacy in addressing the challenges currently faced by the health service in England, provided that their concerns on a range of issues are addressed.

community pharmacy, primary care, delivery of care, lay perspectives, health promotion, pharmaceutical public health, workforce, professional practice, professional training, education

Introduction

The National Health Service (NHS) in England is currently facing unprecedented work pressures in both primary and secondary care, due to increasing patient demand, decreasing numbers of key staff such as general practitioners (GPs), poor morale, and lower per capita funding in real terms [1, 2]. This has been described as a ‘crisis’ [1].

Community pharmacy is a fundamental sector of primary care in England and provides dispensed medicines and other core services for health and well-being [3]. There are over 11,000 community pharmacies in England located close to most of the population, that receive around 1.2 million visits daily largely without appointments [4, 5]. Community pharmacy services for the management of long-term conditions (LTCs) [6], minor ailments [7], and public health [8] have been shown to be effective. Better utilization of community pharmacies could contribute in part to the resolution of the current challenges facing the NHS [9]. Community pharmacies, however, are also experiencing challenges with sustained underfunding and closures [10].

It is widely recognized that healthcare services are likely to be improved through understanding the experiences of service users [11]. Earlier studies from the UK show limited public awareness of community pharmacy services as a whole [12–14] and while the public acknowledged community pharmacists’ professionalism [15], some individuals still preferred services provided by GPs [13]. However, studies of public perceptions in England have focussed only on specific services such as medicines management [16], LTCs [17], or public health [18]. Studies conducted in other parts of the UK may not apply to England, as the available community pharmacy services are different. This current study therefore aimed to explore pharmacy users’ perceptions of their overview of all community pharmacy services in England and their suggestions for future developments.

Methods

A reconvened focus group design was used to accommodate the poor public awareness of community pharmacy found in numerous studies [19]. The first focus group enabled participants to discuss their preliminary views of community pharmacy services based upon their existing knowledge. At the end of this meeting they were given a five-page evidence brief (Supplementary Material) which included facts and figures about community pharmacy services, service descriptions, and key findings from two recent, related studies [20, 21]. Participants were asked to read this evidence brief before a second (follow-up or reconvened) focus group was held 2 weeks later.

This study was approved by the Research Ethics Approval Committee for Health from the University of Bath (reference number: EP 17/18 256) in March 2019. Reporting is in accordance with the Consolidated Criteria for Reporting Qualitative Research (Supplementary Table 1, Supplementary Material).

Participant identification and eligibility

Participants were eligible for inclusion if they self-reported use of a community pharmacy at least once a month for themselves or someone else, and spoke English to a level suitable for participation and consent. Individuals who were registered health professionals or who did not wish to be audio-recorded were excluded.

Participant recruitment

Recruitment leaflets were personally delivered to all 23 community pharmacies and 2 local health charities in Bath, a city in south west England with a population of ~100,000. These organizations were asked to display the leaflets on their premises during the 4 weeks before the initial focus group meetings. People interested in participating were asked to contact the researchers, who then sent them an invitation letter/email including a participant information sheet and consent form. All participants were offered a £10 voucher and expenses for each meeting. The desired sample size was two focus groups, each of 5–12 participants, with the same individuals participating in the reconvened focus group [22, 23]. Purposive sampling was undertaken using a sampling matrix based on characteristics agreed by the research team (age, gender, frequency of community pharmacy use) to achieve a diverse sample.

Data collection

All focus groups were conducted by a moderator (E.P.) and a facilitator, using different topic guides for the initial and reconvened meetings. The initial topic guide (Supplementary Material) was informed by a review of community pharmacy policy in England from 2008 to 2017 [21] and professional stakeholders’ expectations for the future of community pharmacy practice in England [20], both based on the Walt and Gilson policy framework [24]. It explored participants’ current use of community pharmacies, their awareness of community pharmacy services, and their perceptions of community pharmacy premises and staff. The reconvened topic guide (Supplementary Material) was informed by participants’ responses during their first focus group and explored participants’ reflections on the evidence brief, their expectations for community pharmacy services in the future, their perceptions of an ‘ideal’ community pharmacy, and their views on collaboration between community pharmacies and GPs. The focus groups were scheduled for a maximum of 60 min and were held at city centre University of Bath premises.

Written informed consent was obtained before the initial focus groups. Each group was audio-recorded and anonymously transcribed verbatim by experienced transcribers from the University of Bath. All transcripts were checked for accuracy and confidentiality by one researcher (E.P.). A pilot focus group was conducted with five postgraduate students to test and refine the content of the topic guides and increase the moderator and facilitator’s familiarity with them. The topic guides and evidence brief were revised based on pilot feedback.

Data analysis

Inductive reflexive thematic analysis was used [25]. Analysis was conducted iteratively, based on the six-phase process described by Braun and Clarke. Manual coding was interpreted to generate initial themes and subthemes using NVivo v.12 software (QSR International). Initially, themes were generated inductively by separately considering transcripts from the initial and reconvened focus group meetings. The results were then merged and examined together. Themes were iteratively refined for cohesiveness using a thematic map, before the final themes were named and defined. These processes were led by one researcher (E.P.), with regular discussion and agreement with the research team, who reviewed a proportion of the coding and all of the final themes and subthemes.

Results

Of 12 individuals who indicated willingness to participate, 11 attended the focus groups (Table 1) in June and July 2019. Two pairs of focus group meetings (initial and reconvened) were conducted, involving six and five participants, respectively. One participant was unable to attend the initial focus group and was interviewed (using the initial focus group topic guide) before participating in the reconvened group. The transcription of this interview was analysed alongside the two initial focus group transcriptions.

Table 1.

Characteristics of study participants.

Focus group	Participant number	Frequency of community pharmacy use	Services used	Gender	Age category (years)
1	1	Weekly to monthly	Regular prescriptions Occasional OTCa advice	Male	60–69
	2	Weekly to two monthly	Regular prescriptions Occasional signpostingb Retail purchases	Female	60–69
	3	Monthly	Regular prescriptions Occasional OTCa advice	Female	40–49
	4	Weekly	Regular prescriptions Acute prescriptions	Female	60–69
	5	Monthly	Regular prescriptions Occasional OTCa purchases	Male	50–59
	6	Monthly	Regular prescriptions Occasional OTCa advice	Female	70–79
2	7	Monthly	Regular prescriptions Occasional OTCa and retail purchases Advanced services	Male	80–89
	8	Monthly	Regular prescriptions Occasional OTCa purchases	Female	70–79
	9	Weekly	Regular prescriptions Occasional phone consultations	Female	60–69
	10	Monthly	Regular prescriptions Occasional OTCa advice Advanced services	Female	40–49
	11	Monthly to two monthly	Regular prescriptions Occasional OTCa advice Occasional retail purchases Advanced services	Male	70–79

^a‘OTC’ refers to over-the-counter medications that can be purchased without a prescription.

^b‘Signposting’ refers to a pharmacy user asking advice from pharmacy staff about the most appropriate health services to access to meet a particular health need.

Three themes with eight subthemes were generated from the analysis (Table 2). ‘Current community pharmacy service provision’ describes participants’ views and awareness of community pharmacy services and staff. ‘Expanding community pharmacy services in the future’ describes perceptions of the future of community pharmacy services. ‘Future development of technology in community pharmacy’ describes perceptions of the involvement of technology in future community pharmacy services, including its impact on medication supply, communication with patients, and information sharing. There were significant links between the second and third themes, as several technologies were seen as facilitators for the development of future pharmacy services.

Table 2.

Themes and subthemes developed from reflexive thematic analysis.

Themes	Subthemes
Current community pharmacy service provision	Perceptions about community pharmacy services and workforce
	Community pharmacy role awareness
Expanding community pharmacy services in the future	Development of community pharmacy services
	Facilitators of community pharmacy services
	Concerns about community pharmacy services
Future development of technology in community pharmacy	Technology for dispensing medicines
	Technology for sharing patient information
	Making technology work for patients

Current community pharmacy service provision

Participants valued community pharmacy services and staff, especially convenience, proximity of premises to their homes, relationships with staff, and service provision for specific groups (e.g. children, mothers, and elderly). Consultations without an appointment and accessibility were also highly valued. Regularly seeing the same pharmacy staff, and thus developing a rapport and receiving a personalized service was also important for some participants.

[y]ou made a key point about appointments … the notion that you can walk into a pharmacy and ask … that ease of access which is the key thing that pharmacy has to offer. (ID1, initial meeting)

I do like the fact that there are people you can relate to really, they’re quite approachable that’s what I choose. I think in healthcare you have to think that somebody is actually interested in you really, that they don’t just want to fob you off. (ID10, initial meeting)

Despite their positive perceptions, participants lacked awareness about the general role of community pharmacies and their services. However, participants were aware from their own experience of enhanced services related to public health such as smoking cessation and vaccination, mostly from posters in pharmacies or advertising.

I was aware that we could have a flu jab and so one year I went and had my flu jab … which was actually quite handy, but last year I had it done in the surgery. (ID6, initial meeting)

Participants were mostly unaware of organizations or individuals related to community pharmacy until they had read the evidence brief before the reconvened meetings. The need to raise public awareness of community pharmacy was therefore highlighted.

I wouldn’t really have known this; I don’t think the general public is aware of all of this and it gives you a very different perspective….just how dependent on pharmaceutical services we are and how much we actually use them… (ID1, reconvened meeting)

Expanding community pharmacy services in the future

LTCs were identified as suitable for community pharmacy involvement and were described as ideal by some participants, particularly to alleviate GP workload. Opinions diverged regarding medication reviews; some participants preferred GP rather than community pharmacist involvement.

There is no reason the doctors do get involved … just going on from month to month that could be done straight through the pharmacist. (ID5, reconvened meeting)

Feelings about mental health service provision were mixed. Some participants identified a role in providing advice about medicines and appropriate signposting, while others were unclear about the community pharmacy sector’s potential contribution and how it could be quantified and remunerated. Some were negative due to workload and the time required for such interventions.

[I] think this [mental health] is a huge, huge area … pharmacists are obviously part of the picture but what part they will be, I wouldn’t want to say. (ID11, reconvened meeting)

Whilst urgent care was identified as a potential role for community pharmacy, some participants considered general practice to be more appropriate for these healthcare needs.

[i]t is just too unique a moment to take to the chemist, I can’t even imagine how it would be, how it would be applied actually. (ID3, reconvened meeting)

There was substantial support, however, for pharmacy-based delivery of minor ailment services. Participants also discussed the possibility of additional healthcare professionals, e.g. paramedics, working from pharmacy premises.

To support this expansion of roles, participants suggested the need for training for all community pharmacy staff. This was important for urgent care, mental health consultations, and tasks such as phlebotomy. There was also support for further integration of community pharmacies with other parts of primary care, particularly working more closely with GPs (referring to doctors, participants did not discuss other healthcare professionals working in general practice during the focus groups). They suggested that this would be rewarding for community pharmacists, GPs, and patients, and could relieve general practice work pressures. Suggestions for facilitating collaboration included improving digital systems and communication between the two professions (e.g. teleconferencing), which are discussed in more detail below in the ‘Future development of technology in community pharmacy’ theme. Co-location of GPs and community pharmacies was suggested to promote collaborative working and improve patient care. Some participants suggested moving some services from general practice to community pharmacies, e.g. contraception-related services and minor surgical interventions.

It is quite clear that the two health professionals should work together as a team with the GPs and if that was improved upon that would be a big plus. (ID8, reconvened meeting)

Participants suggested that community pharmacy premises should be redesigned to enhance privacy. Whilst they were aware of and had sometimes used consultation rooms, lack of privacy made them hesitant to use these facilities. Many participants highlighted the need for larger premises to incorporate additional services, acknowledging the cost and practical constraints. Some suggested that this could be achieved with the partial or complete removal of retail items and that this could promote perceptions of community pharmacies as healthcare services rather than profit-based businesses.

[I] deliberately use that term chemist shop because I still think of it as a retail space more than as a health service… (ID3, reconvened meeting)

Some thought that financial investment and additional remuneration for community pharmacists would enhance employment and promotion of their role. Similarly, pharmacists being more receptive to changes would improve care provision in the future while another explained the benefits of the ability to prescribe and access full medical records for pharmacists.

[w]hat I would like to see is … that more money is invested … so that the sector becomes a really attractive employment sector for well-paid pharmacists who can remain in post if they want to for years and develop relationships with their customers… (ID3, reconvened meeting)

Participants were concerned about the impact of social change, such as an ageing, multimorbid population, on pharmacy services. Additional concerns related to politics and economics. One participant was particularly concerned about the effects of reduced funding on public health services and the resultant societal effects.

[t]he destruction of public health services generally … local authorities have had their budgets cut … public health initiatives have been run down everywhere … austerity is impacting on homelessness, drug abuse, smoking, obesity, etc. There are symptoms of poverty in many places … that is storing up uncontrollable pressures on the future of any health service … and it worries me enormously. (ID11, initial meeting)

Participants’ concerns also included government policy changes and a potentially tense relationship between pharmacy bodies. The departure of the UK from the European Union (Brexit) created uncertainty, particularly in terms of medication supply.

Health inequalities were another concern anticipated to increase pressure on community pharmacy. Equitable healthcare provision for all population groups was deemed important, particularly for vulnerable individuals (e.g. disabled, lower socioeconomic groups, and rural areas). One participant suggested community pharmacist visits to community centres to reach isolated populations.

[w]hat we would like to see is the facilities that the pharmacies offer … offered to the whole population … rather than just pockets of privilege. (ID5, reconvened meeting)

Participants were aware of closures of many community pharmacies, as well as lack of government consultation about this, even before reading the evidence brief.

[t]he government … trying to close down a lot of pharmacies because they think we have too many of them, but no one is actually being consulted about this… (ID1, initial meeting)

Participants were also concerned about the possibility of an inadequate supply of pharmacy graduates. They described a decline in the numbers of people entering medical schools and expressed their uncertainty whether a similar pattern would be seen in pharmacy. Brexit was predicted to have effects on the pharmacy workforce and the need to improve pharmacy working conditions was discussed.

[d]oesn’t sound like a great place to work and I think that really needs to be improved … because pharmacists will inevitably go into the private sector and into working for pharmaceutical companies if working in the chemist shop isn’t a satisfactory place… (ID3, reconvened meeting)

Furthermore, participants were also concerned about community pharmacy workload and many referred to pressures caused by working conditions (based on their own experience, rather than the evidence brief), describing a busy environment that hinders the provision of non-dispensing services. The impact of this intense workload on staff quality of working life caused concerns. The increased workload of staff also had an impact on participants’ decisions, as many avoided visiting pharmacies for non-dispensing services.

[a] community pharmacist, they are so busy trying to get everything ready … they get things ready really quickly actually and they are very good, I always sort of think I don’t want to bother them too much with my minor ailments and so on. (ID6, initial meeting)

Future development of technology in community pharmacy

Participants described a future with automated medicine supply, which was perceived positively for some repeat prescriptions. Online pharmacies and medication deliveries were expected to expand, causing concerns about the safe use of medications and potential lack of personalized services.

They advertise on television, Pharmacy2U and they want people who have four or more medicines and they will just pop it through to you and it’s so remote … I am not saying it’s inaccurate, it is so remote and impersonal. (ID4, reconvened meeting)

Participants described technology affecting their interactions with pharmacy staff, referring to mobile health applications and online consultations. Some found these services impersonal and prone to misinterpretation, while others were positive. Human interaction was important for participants who explained that there are benefits of technology for medication dispensing, but that they would like to maintain face-to-face interaction with staff to understand the use of medicines. There were also concerns about the impact of expanding technology to populations that might not be able to use it (e.g. the elderly) as it might exclude them from pharmacy services.

[m]ost people want interaction, they want to go into a chemist and have a chat with a pharmacist who we know and they know us and they can see if we are not feeling very well … but policy and economic drives and … corporate drives are away from that so that is where the conflict is… (ID1, reconvened meeting)

Whilst most participants had positive attitudes towards pharmacist access to their health records and thought it facilitated integration with primary care, some had concerns regarding confidentiality.

If it had a filtration system [sic] … whereby the pharmacists could see my medication history, blood test result history, but I wouldn’t want them seeing some of the other things… (ID6, reconvened meeting)

Discussion

This study provides an insight into pharmacy users’ views of current and future community pharmacy services. The current positive perception but low awareness of community pharmacy services echoes UK studies over the past 20 years [19]. Attributes such as convenience, accessibility, relationships, and communication with the pharmacists [12, 13, 16], are still valued, and participants in this study wanted to see tangible actions to support the sector financially, improve working conditions, and raise public awareness of community pharmacy services [17]. Interestingly, convenience, accessibility, and satisfaction with services have also been identified internationally [26, 27], although satisfaction may be lower in the Middle East [26].

There was evidence that GPs were perceived to have greater knowledge, training, and authority compared with community pharmacists [19], which could affect public willingness to seek care from the community pharmacy sector. Most participants however were supportive of closer collaboration between community pharmacies and general practice. Lack of training has been identified by others in the UK and internationally as a barrier to service development [13, 27]_, but participants highlighted the need for training to promote public confidence in pharmacy-based urgent care services.

The current study identified concerns regarding community pharmacy environment, workload, and inadequate time for non-dispensing services (leading to their avoidance) and these have been previously identified in the UK and internationally [12, 13, 17, 26–28]. The development of existing and new services requires appropriate planning and remuneration to address these concerns and facilitate service delivery and uptake.

Whilst community pharmacies are often located in socially deprived areas [5], their geographical proximity does not always translate into more equitable access. Marginalized groups have been excluded from services through lack of translators, wheelchair access, domiciliary visits, guidelines, and training [29, 30]. Community pharmacy’s role in addressing health inequalities requires careful planning using an evidence-based approach [31], especially as new technology is introduced.

Strengths and limitations

The key strength of this study is its exploration of pharmacy users’ views about current and future general community pharmacy service provision in England, without being limited to views on specific services or diseases, as this has not been previously described. The reconvened focus group technique enabled participants to develop informed views and participant continuity was maintained despite the recognized complexity of this approach [23]. However, the small overall sample size and recruitment from one city limits the representation of pharmacy users’ views. In addition, a limited number of pharmacy users expressed interest in participation, so the final sample was selected by convenience rather than purposively as initially planned. The addition of less regular community pharmacy users, users with a more diverse background, and users from different areas would have provided useful knowledge. The analysis could also have been influenced by the research team’s professional background, as three members are pharmacists. This was addressed by including a non-pharmacist researcher (PO) at all stages, on-going reference to the original data, and the adoption of a reflexive approach to ensure awareness of this potential influence.

Recommendations

These findings suggest that government and pharmacy-representative organizations should promote community pharmacy collaboration with other sectors of primary care, particularly GPs. Automated dispensing should be encouraged, while ensuring that technology is used in ways that enhance interaction with patients, make it easy to see staff in-person, and do not cause digital inequalities. Community pharmacy access to medical records in a way that addresses concerns about confidentiality is also important. These organizations should also ensure that staff are suitably trained for new roles and work to increase public awareness of community pharmacy. The government should ensure that the sector is adequately funded to provide safe and high-quality services, while maintaining the accessibility of the community pharmacy network by avoiding unplanned closures. Finally, community pharmacy contractors should ensure that pharmacies have sufficient space and privacy.

Conclusions

Despite low awareness of many community pharmacy services, there is a positive perception of known services among pharmacy users. Once users have greater awareness of the sector, there is considerable support for greater community pharmacy involvement in extended and new services, particularly through collaboration with the wider primary care team. Investment in premises and personnel is needed to achieve and promote community pharmacy’s potential.

Acknowledgements

The authors would like to sincerely thank all the members of the public who participated in the study. They would also like to thank Dr Bharat Shah CBE, Sigma Pharmaceuticals and the Harold and Marjorie Moss Charitable Trust Fund. Dr E. Paloumpi’s PhD was funded by The Bharat Shah PhD Scholarship. Dr Paloumpi was also supported by the Harold and Marjorie Moss Charitable Trust Fund. The authors would also like to thank Dr Mary Carter and Dr Teerapong Monmaturapoj for facilitating the focus groups.

Author contributions

E.P.: Conceptualization; Methodology; Project administration; Data curation; Formal analysis; Writing—original draft, review & editing. M.D.J.: Conceptualization; Methodology; Supervision; Funding acquisition; Writing—review & editing. P.O.: Conceptualization; Methodology; Supervision; Writing—review & editing. M.W.: Conceptualization; Methodology; Supervision; Funding acquisition; Writing—review & editing.

Conflict of interest statement:

None declared.

Funding

Dr E. Paloumpi’s PhD was funded by Dr Bharat Shah CBE and Sigma Pharmaceuticals. Dr Paloumpi was also supported by the Harold and Marjorie Moss Charitable Trust Fund. The sponsors had no role in the study design, data collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article for publication.

Data availability

The data supporting the findings are not available, as focus group participants did not consent to share this information. The two topics guides and the evidence brief used during this research are available in Supplementary Material.

Data accessibility

P.O. and M.D.J. had and continue to have full access to the study data, which is stored on University of Bath servers. E.P. and M.C.W. had the same access until they left the University of Bath in 2022 and 2019, respectively. They now have access via P.O. and M.D.J.

Author notes

Evgenia Paloumpi. The views expressed in this paper are purely those of the author. They do not necessarily reflect the views or official positions of the European Commission and the ERC Executive Agency.