All pharmacists approached to give feedback agreed; however, in a small number of cases, the pharmacist could not commit to attending the focus group. Overall, 32 pharmacists were involved in either a focus group or individual interview (Table
): seven following completion of at least one patient’s initial consultation (“Early”, quotations annotated “FG1”), 18 after completion of the service (“End”, quotations annotated “FG2” and “I2”), and seven six months after service completion (“Follow-up”, quotations annotated “FG3” and “I3”). Eight concepts relating to the service provision were identified from the transcript analysis: the training, challenges with the recruitment and consultation of patients, the service components, logistics of the service provision, relationships with the GPs, perceptions of the patients’ experiences, professional rewards, and the future of the service.
The clinical and practical skills training in asthma management was perceived to train pharmacists to a high standard:
"“My husband’s a GP, and he looked through the course and what we learnt, and he said we’re better qualified than most GPs now to handle asthma.” (FG3-1)"
Training in spirometry was described by one participant as “probably the pinnacle part that you want to take away from that day” (FG1-4), and there were requests for greater emphasis on this section to improve pharmacists’ confidence, exemplified by the pharmacist who was “dead scared a doctor would ask me, ‘what does this [spirometry result] mean?’” (FG3-2)
Comments suggested that training group sizes should be limited to 20 people, as per the size of the groups in this study, for optimal skills development and peer support.
Challenges with recruitment of and consultation with patients
Confidence with recruiting patients was critical to the patients’ engagement with the service; some pharmacists found promoting the service daunting and a new experience, and some requested more training in patient recruitment into this type of clinical service. Key recruitment strategies were revealed:
"“Work out what are the selling points … and why is it good for them to be involved in a university trial, and what outcomes we’re after … and how to hit their trigger points when you’re recruiting them.” (FG1-6)"
"“You need to talk to patients at length and allay their fears and talk about their desires and all that sort of stuff … the time to do this is in the afternoon when you’ve got the time.” (FG2-N3)"
"Some pharmacists had no problems reaching their goal of 10 recruited patients:"
"“I didn’t really have any trouble getting the 10. They all stuck through the three visits, but a lot of them dropped off for the [post-study] follow-up visit.” (FG3-3)"
"“The customers really wanted to be part of the university and they saw it as a privilege.” (FG1-6)"
Pharmacists reflected on their approach to patient recruitment, suggesting that recruitment is a developmental process, despite their training in how to identify and approach suitable patients:
"“I could've been a lot more careful about whom I recruited … [later] I found candidates who would’ve benefited more from the program … I thought, ‘oh gosh, I wish I'd made you one of my candidates.’” (FG3-2)"
"“I’d probably do it differently if I did it again … I did it by going back through script records to see who would be suitable, and … the ones that I ended up recruiting … probably weren’t the 10 people who would benefit most from that program … I still feel as though they have all benefited from it, but I think I’d put a little bit more thought into how I would pick them out again.” (I2-V4)"
A number of the pharmacists found themselves recruiting mainly older patients into the service, apparently due to their availability and commitment:
"“I had around 10 young people who didn’t actually turn up for their appointments … but certainly semi-retired men and women were perfect.” (FG1-7)"
"“It was very, very difficult to get working people to come … I had to [consult them] on Saturday afternoons … just a time that they could find to fit me in.” (FG3-2)"
Once recruited, lack of commitment by patients caused frustration for the pharmacists. Despite reminders, some failed to attend appointments. Patients’ reluctance to persist with the program may have resulted from the long initial consultation, which involved the most research documentation. One pharmacist reflected after the study that the most challenging group to recruit, young males, “probably needed the program the most” (FG3-2).
Critique of the service components
The pharmacists largely reflected positively on the practical application of the service. The provision of spirometry was well received by pharmacists, and reportedly, their patients, providing a unique element to the service. Some of the pharmacists would have liked to perform the spirometry earlier in the visit to engage the patient:
"“They loved looking at the graphs and trying to understand what this meant and what that figure meant … trying to get them to use the spirometer in such a way that they got an ‘A’ quality on their report …They were there to try and beat the machine.” (I2-N7)"
Criticisms of the service components pertained to the need for more educational aids for patients, a more efficient system to monitor patients’ attainment of their therapeutic goals, and frustration with the amount and flow of the research documentation, which was perceived to deter patient continuance:
"“[The research documentation] needs to be very careful that it’s not overly clunky, that it’s not too big and unwieldy. Too big and unwieldy will scare people away.” (I2-N6)"
"“Every time I see the package lying on my desk, I just look through the paperwork and shake my head, and think … whether it was shown to someone who actually spends their day at the coalface … The way the questionnaires are laid out … they just don’t flow very well … maybe you need a sort of panel … of community pharmacists that you can just call on … for a bit of input before things are being finalised.” (FG3-5)"
The pharmacists developed a flexible approach in their assessment of individuals’ needs within the bounds of the service:
"“Some people love it. They’d come in every month if you want them to … they’re those sort of people that … like other people to be looking after them, whereas you get the other ones … you could spend half an hour with them and that would be fine.” (I3)"
"“You had to adjust mentally, I suppose, prioritise the information you felt that each particular patient needed … You physically can’t give someone 20 pieces of information.” (FG3-5)"
Logistics of service provision
The dominant theme relating to logistics of the service was the need for the pharmacist to be available to provide the service. Engaging a locum and/or changing staff rosters may be necessary to deliver the service:
"“I’ve had to try and get a second pharmacist in and try and schedule the appointments in one after the other on like a certain morning a week. The hardest part is trying to free up myself to do it.” (I2-V3)"
"“It was purely time management for me. I had to manage my time personally better, and we had a diary book that we booked people in, because we would use the [private] room for other things.” (FG2-V1)"
The pharmacists were very conscious of the need to provide undisturbed consultations, which raised further issues around workflow, privacy and location of the consultation.
Relationships with GPs
A feature of the service was the role of the pharmacist as a both a clinical advisor and intermediary between patients and GPs. This required awareness of the service by GPs and communication pathways to propose interventions in individuals’ asthma management. The pharmacists reflected on the need for more formalised and proactive communication strategies with GPs. Pharmacists’ attempts to communicate directly with GPs to discuss the service or therapeutic recommendations for patients were variable, as this is a new type of service in primary care, and no pharmacist reported any GP-initiated communication:
"“They [GPs] didn’t seem to know anything about it, despite introductory letters obviously being sent out by ourselves and also from you [researchers], so there was a lot of time spent in educating them.” (FG1-3)"
"“I collected a whole list of local doctors and sent them letters and tried to get some sort of response, but unfortunately, none of the GPs really care about this.” (FG2-N1)"
"“You try and be diplomatic in how you pitch [the clinical recommendation] … from the point of view of saying it’s another idea, and you put all of the dot points down with question marks in front of them, because obviously there may be information that the GPs have that you’re not privy to.” (I2-N5)"
"“Most of my communications to [GPs] about plans are written, so there’s really no verbal communication.” (FG2-Q2)"
The pharmacists perceived that the underlying issues were misunderstanding about the service and the potential threat to GPs’ roles and income stream:
"“Not so much resentment, but a misunderstanding. ‘Well, why on earth are you doing this sort of thing? Why are you interfering with what seems okay to me?’” (FG3-2)"
"“He [the GP] was just concerned that because he hadn’t acted on anything, I was actually going to report him.” (FG2-Q1)"
Successful interventions mediated by contact with GPs included requests for asthma action plans and medication changes:
"“I actually suggested changes to medication in probably four or five people. The doctors weren’t at all perturbed about that. They gave them a go.” (FG3-2)"
"“I asked [my patients] to take the written notes to the doctor next time they visited, which most of them did.” (FG2-V1)"
"“I asked for quite a few asthma action plans, and it’s quite comical the funny little scraps of paper the patients were given … I would’ve hoped for something a little bit more user friendly.” (FG3-1)"
Perceptions of the patients’ experiences
Overall, feedback from pharmacists about patients’ experience of the asthma service was very positive, translating to enhanced professional pride and relationships with patients:
"“Just that little bit of interaction they have with you on those visits makes a world of difference. They find you much more approachable.” (FG1-4)"
For many patients, this comprised a new type of interaction with their pharmacist, and the pharmacists considered themselves ‘change agents’:
"“One of my guys was just amazed that somebody did want to talk about his asthma.” (FG1-3)"
"“I found that middle-aged men … were the least cooperative … least likely to make a good effort on the spirometry and all that kind of thing. But in the end they did, because … they did actually see improvement … they actually became more enthusiastic about the spirometry.” (FG3-2)"
A common theme, for those patients who engaged with the program, was improved asthma control and improved understanding of the condition. Pharmacists proudly reported positive feedback from their study patients as health improvements became apparent, and this patient feedback was key to the pharmacists’ motivation and professional satisfaction throughout the service delivery:
"“They hadn’t been to an asthma educator … and they find [the service] really, really useful in terms of understanding inhaler technique and … goal setting.” (FG2-N4)"
"“One of the ladies I found quite interesting … through discussion, we found out that she was probably an … ibuprofen-sensitive asthmatic. We’ve got her off it, we’ve got her onto another anti-inflammatory, and she’s been great ever since … so she’s kind of been singing our praises, which is kind of nice.” (I2-V5)"
The variable nature of asthma control and commitment by patients resulted in some challenges for the pharmacists, suggesting the need for longer-term involvement with at-risk patients:
"“One of my patients … gave up smoking, and everything improved. Then for the final visit, everything was downhill again.” (FG3-4)"
"“Often, you’d do the spirometry and they’d be okay, but … they would then deteriorate and possibly even get better by the time they came and saw you the next time.” (FG3-4)"
"“Some of my results I think were a bit skewed because of … dust storms or winter or whatever. Some people with asthma deteriorated, when I would have hoped it would improved as a result of PAMS … as the study progressed, I realised I was probably out of my depth with them.” (FG3-1)"
Satisfaction from enhanced clinical practice and empathy were evident in pharmacists’ reflections on their involvement, even early in the program:
"“I really enjoy these programs because it’s a side of your professional career that you don’t get to ‘do’ very often.” (FG3-5)"
"“I suppose it’s really brought asthma into focus in our pharmacy … we are a lot more focused on helping people with their inhaler technique and checking whether devices are appropriate for people.” (FG1-5)"
"“I think I’m far more attuned to them [people with asthma] and I think I can communicate well with them because I think I know where they’re coming from.” [FG3-7]"
There were also changes that reportedly occurred in the pharmacy business as a result of the service, such as patients committing to the pharmacy’s smoking cessation program and a perception of greater client loyalty.
Although there were no clear trends between the three phases of data collection, a number of pharmacists envisaged a future for this asthma management service throughout the trial. Suggestions included extending the service to children. Practical developments such as allocating a day each week for drop-in consultations, and the provision of a mobile out-of-hours asthma service, may address difficulties with issues of patient commitment. Further, reduction in the research-related documentation would shorten the initial consultation and enhance efficiency. The pharmacists’ support was exemplified by:
"“I would like to continue with it for a lot of reasons. It fulfils a professional need in me, and I like it in that respect. It can be seen by people as a professional service.” (FG2-N3)"
"“We’ve got to put into people’s minds that pharmacy can provide other types of services … part of that is all about public relations; part of that is to provide a service and kick it around for a while until we find out what works and what doesn’t work.” (FG2-N3)"
A concern for the unmet needs of asthma patients founded comments about sustaining the program:
"“There’s no-one better placed to pick up poorly-controlled asthmatics than pharmacy.” [FG3-6]"
A future for the program would depend on an established remuneration process for the pharmacists. Pharmacists favoured a patient co-payment system so that consumers would be required to contribute towards the costs of its provision (and therefore associate a monetary value to the service), and yet it would remain affordable to the majority if it were Government-subsidised. An alternative suggestion was to involve other types of practitioners, such as nurse practitioners, in this service.