Family Practice, 2020, 1–8

doi:10.1093/fampra/cmaa044

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Qualitative Research

Pharmacists in general practice: a qualitative

process evaluation of the General Practice
Pharmacist (GPP) study
Oscar James, Karen Cardwell, Frank Moriarty , Susan M Smith and
Barbara Clyne*, , on behalf of the General Practice Pharmacist (GPP)
Study Group
HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland (RCSI),
123 St. Stephens Green, Dublin 2, Republic of Ireland

*Correspondence to Barbara Clyne, HRB Centre for Primary Care Research, Department of General Practice, Royal College
of Surgeons in Ireland (RCSI), 123 St. Stephens Green, Dublin 2, Republic of Ireland; E-mail: barbaraclyne@rcsi.ie

Abstract
Background:  There is some evidence to suggest that pharmacists integrated into primary care
improves patient outcomes and prescribing quality. Despite this growing evidence, there is a lack
of detail about the context of the role.
Objective:  To explore the implementation of The General Practice Pharmacist (GPP) intervention
(pharmacists integrating into general practice within a non-randomized pilot study in Ireland), the
experiences of study participants and lessons for future implementation.
Design and setting:  Process evaluation with a descriptive qualitative approach conducted in four
purposively selected GP practices.
Methods:  A process evaluation with a descriptive qualitative approach was conducted in four
purposively selected GP practices. Semi-structured interviews were conducted, transcribed
verbatim and analysed using a thematic analysis.
Results:  Twenty-three participants (three pharmacists, four GPs, four patients, four practice nurses,
four practice managers and four practice administrators) were interviewed. Themes reported
include day-to-day practicalities (incorporating location and space, systems and procedures and
pharmacists’ tasks), relationships and communication (incorporating GP/pharmacist mode of
communication, mutual trust and respect, relationship with other practice staff and with patients)
and role perception (incorporating shared goals, professional rewards, scope of practice and
logistics).
Conclusions:  Pharmacists working within the general practice team have potential to improve
prescribing quality. This process evaluation found that a pharmacist joining the general practice
team was well accepted by the GP and practice staff and effective interprofessional relationships
were described. Patients were less clear of the overall benefits. Important barriers (such as
funding, infrastructure and workload) and facilitators (such as teamwork and integration) to
the intervention were identified which will be incorporated into a pilot cluster randomized
controlled trial.

Key words: Organization of health services, pharmacist, primary care, process evaluation, qualitative research, quality in health care

© The Author(s) 2020. Published by Oxford University Press. All rights reserved.
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Key messages
• Clinical pharmacists are increasingly part of general practice internationally.
• Positive impacts include improved clinical outcomes and reduced GP workload.
• We explored integrating pharmacists in general practice in Ireland qualitatively.
• GPs, pharmacists and practice staff cited good interprofessional relationships.
• GPs, pharmacists and practice staff were supportive of expanded pharmacist role.
• Barriers to future implementation included funding, infrastructure and workload.
Introduction
Clinical pharmacists are increasingly part of general practice teams
internationally, including in Canada, the UK and the USA (1).
Pharmacists in general practice can have positive impacts on clin-
ical outcomes (e.g. blood pressure and glycosylated haemoglobin)
and prescribing safety (2,3). Integrating pharmacists into primary
care may also reduce GP workload (particularly medication-related
administration), emergency department attendance and medication-
related hospitalizations and may also be cost-effective (1,4,5).
To obtain maximum benefits for patients, particularly those with
polypharmacy and multimorbidity, full integration of clinical phar-
macists into a primary care setting has been argued for (6). Although
there is growing evidence of the benefits to pharmacists working
within general practice, a recent realist review highlighted that there
is a lack of detail about the context of the role (3). Further research
on pharmacists’ experiences of starting and embedding this new role
in general practice and observational studies of the process of phar-
macy work is conducted in practice are required (3).
The General Practice Pharmacist (GPP) study was a non-
randomized pilot study investigating the integration of pharma-
cists into general practice in Ireland (described in more detail in the
methods section and in Supplementary Table 1). Unlike countries
like the UK and Canada, pharmacists in Ireland are not formally in-
tegrated into general practice, nor do they have prescribing rights. In
keeping with the international literature (2,4,6), the GPP study dem-
onstrated that pharmacists working within general practices could
improve prescribing quality, particularly medication appropriateness
(7). This paper describes a qualitative process evaluation, undertaken
to contextualize the quantitative results and aims to explore how the
intervention was implemented, the experiences of those participating
in the study and lessons for future implementation.
Methods
The process evaluation undertaken used a descriptive qualitative
approach.
GPP intervention
The detailed methods (8) and results (7) have been published else-
where (summarized in Supplementary Table 1.) Briefly, the study was
conducted in four purposively selected general practices, reflecting a
range of practice sizes and socioeconomic profiles, recruited from the
national Primary Care Clinical Trials Network Ireland. Following
practice enrolment, three pharmacists were integrated into the four
participating practices for a period of 6 months (one pharmacist de-
livered the intervention in two practices) working 10 hours per week
(September 2017 to March 2018). Configuration of time and activ-
ities in the practice were agreed between each practice and pharma-
cist. Each pharmacist was provided with a Study Intervention Manual
detailing the scope of activities to be delivered by the pharmacist,
Family Practice, 2020, Vol. XX, No. XX
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based on national guidance and previous research (9–12). Broadly,
this involved medications reviews (opportunistic and targeted, con-
ducted face to face with patients or using medical charts only), in-
volvement in the repeat prescribing process, conducting educational
sessions with staff and supporting clinical audits.
Study population
The lead GP, practice nurse, practice manager and practice admin-
istrator in all four practices were invited to participate in semi-
structured interviews by email or phone. One patient who had a
medication review with a pharmacist per practice was invited to par-
ticipate in an interview following their review. All three pharmacists
were also interviewed. The pharmacists had a mean of 15.7  years
clinical experience (range 4–26 years). See Table 1 for an overview
of practice characteristics.
Data collection
Semi-structured interviews were conducted by one of two female
interviewers (KC—pharmacist, BC—health services researcher) ei-
ther face to face (in practice) or via telephone, depending on partici-
pant preference. Telephone interviewing is generally used where time
or costs are issues, and evidence suggests there is little difference in
the answers obtained (13,14). The topic guide explored issues re-
lated to context and implementation of the intervention, as well as
participant experience (Supplementary Table 2). The framing of the
questions drew on concepts from Normalisation Process Theory
(NPT) (15) to understand how the intervention was (or was not)
embedded in routine clinical practice, and relational coordination
(16), a theory that identifies key concepts that underpin effective
interprofessional work (problem solving, timely, accurate and fre-
quent communication and relationships between professionals char-
acterized by shared goals, shared knowledge and mutual respect). All
interviews were audio recorded (loud speaker for telephone inter-
views) and were transcribed verbatim. Participants had the option to
review their transcripts however none availed of this.
Data analysis
Data were analysed using a thematic analysis following a six-step
process (17). Two researchers (OJ and BC) independently reviewed
the transcripts several times to familiarize themselves with the data.
Both are health services researchers without a clinical background.
Codes with common features were grouped together in themes (using
Microsoft Word), before being assigned to overarching themes by
one researcher (OJ) and the findings discussed with the second re-
searcher (BC) for further refinement. In analysing the data, the aim
was to utilize the concepts of NPT and relational coordination to
guide the development of the broad themes and sub-themes, how-
ever, due to the number and length of interviews, the data did not
fully allow for this approach across all stakeholders. All participant
data were pseudo-anonymized by assignment of a unique study ID.
General Practice Pharmacist (GPP) process evaluation
Table 1.  Characteristics of GP practices enrolled in the study (n = 4)
Characteristics
Number of GPs
Percentage full-time GPs
Number of GP sessions/week
Practice nurse sessions/week
Administrative staff sessions/week
Number of patients
Percentage of patients aged ≥65 years
Table 2.  Interviewee characteristics
Group Number of participants Gender
Pharmacists 3 2 female
1 male
GPs 4 2 female
2 male
Patients 4 3 female
1 male
Practice nurse 4 4 female
Practice manager 4 4 female
Practice administrator 4 4 female
Results
Interviews with the 23 participants (3 pharmacists, 4 GPs, 4 pa-
tients, 4 practice nurses, 4 practice managers and 4 practice ad-
ministrators) ranged in length across the participant groups
(Table  2). Findings are reported under the themes of day-to-day
practicalities (incorporating location and space, systems and pro-
cedures and pharmacists’ tasks), relationships and communication
(incorporating GP/pharmacist mode of communication, mutual
trust and respect, relationship with other practice staff and rela-
tionships with patients) and role perception (incorporating shared
goals, professional rewards, scope of practice and logistics).
Quotations are used as exemplars of key themes within the text
and in Table 3.
Day-to-day practicalities
Location and space were important considerations for the study
duration, and influenced the configuration of the 10 hours per
week. In three practices, pharmacists were based in available prac-
tice rooms. In one practice, the pharmacist was based either in the
administration office or in their own room, depending on room
availability (Table 3, Q1). As the individual joining the GP practice,
the pharmacists had to acquaint themselves with the practice sys-
tems and procedures. In particular, all pharmacists were required
to learn about practice software (not standard in Irish general prac-
tice) to access patients’ electronic medical records (Table 3, Q2).
Across all practices, there was similarity in the tasks undertaken
by the pharmacist (Table 4), however, there was variation in coord-
ination. All pharmacists conducted medication reviews, identifying
potential prescribing issues such as those pre-specified in the Study
Intervention Manual and others based on their clinical judgement.
Some reviews were conducted by the pharmacist with the patient
but the majority were conducted based on a chart review only (with
or without the GP). Universally, the GPs reported that the pharma-
cist reviewing medications increased their workload but this was not
viewed entirely negatively:
3
Mean per practice Range
4.25 2–9
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88.2 77.8–100
27 11–64
14.5 8–30
30 0–90
8830.5 1777–16 631
16.1 10.8–24.8
Average length of interview (minutes) Mode of interview
58 3 face to face
39 3 telephone, 1 face to face
15 4 telephone
11 3 telephone, 1 face to face
16 3 telephone, face to face
12 4 telephone
‘It had an impact on workload in that it increased that workload,
but that’s not to say it was a negative impact, the impact was
positive in that it identified various issues that we were able to
address. So from that perspective, although there was a workload
implication, it was a valuable workload implication.’ GP1
All pharmacists participated in practice audit and delivered practice-
based education. In addition, one pharmacist and GP developed
electronic prescribing tools on the treatment and management of
chronic obstructive pulmonary disease and type II diabetes mellitus,
which were adopted across that practice. Pharmacists occasionally
connected with community or hospital pharmacists in order to re-
solve prescription issues, or stepped into patient appointments to
give prescription advice.
One intervention component (management of repeat prescribing)
was not delivered by pharmacists at any recruited practice, as this
process had been largely standardized within practices and/or was
not feasible given the configuration of the pharmacists’ time.
Relationships and communication
The strongest on-going interaction in all practices was between the
pharmacist and the GP (Fig.  1) in the conduct of tasks (i.e. medi-
cation review, audits and education). Communication around these
tasks, particularly medication reviews, was frequent with the mode
of communication differing across practices (Table  3, Q3). Much
communication was face to face, with organized regular meetings
of varying length (Table 4). The length and structure of these meet-
ings evolved over the course of the study based on feasibility and
sustainability. In one practice, meetings were more opportunistic
due to differing timetables. Some communication was in email, and
some GPs preferred information to be noted in patients’ files to be
reviewed opportunistically as they presented, highlighting the time-
liness of the information. Any urgent cases of potentially inappro-
priate prescribing were emailed directly to the GP regardless of prior
communication arrangements.
Across each practice, there was universal feedback of teamwork,
mutual respect and trust (Table 3, Q4). The pharmacists were largely
4
Table 3.  Illustrative quotations
Theme
Day-to-day practicalities
Q1 Location and space
Q2 Practice systems and pro-
cedures
Relationships and communication
Q3 GP/pharmacist mode of
communication
Q4 Mutual respect and trust
Q5 Relationship with other
practice staff
Q6 Communication with
patients
Role perception
Q7 Shared goals (patient
safety)
Q8 Professionally rewarding
Family Practice, 2020, Vol. XX, No. XX
Illustrative quotation
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‘There weren’t difficulties because we had the space you know. In other practices there mightn’t have been a
room free for half a day every week, so in that way we were able to allocate one of the rooms, so that just took
a bit of moving around…we just changed the trainee to somewhere else.’ PM4
‘There are three GP offices, so I typically would be between [GP] office and they had a reg, so [registrar] was
off for their training on Wednesdays, but the chiropodist was there in the mornings so I would be there in the
afternoons, so I would split it between the two days’ PHARM 2
‘I was given a password and username on the [practice system] in both practices…it took me kind of a half an
hour to an hour to figure out how to start looking in it for data.’ PHARM3
‘So in the face to face meeting we’d come up with a plan in [GP Practice], the way the GP did it out there was
they created the note in the file for the medication review so…for medical legal reasons, they wanted to create
their own note in the file and next opportunity they had to chat to the patient, to do a medication review with
the patient. They’d often make note of them and then they’d call the patient in for a medication review. And
then the next time I go into the file and look at, see what had happened and what they’d done…’ Pharm3
‘So they [pharmacist] had no issue with pointing out things that you know might be a patient safety risk,
but the sense that they were our resource, that was really good and I think that’s the only way it could work.
So I think if it was to be rolled out, I use that phrase, I think it would have to be a very much you know
non-judgemental’ GP4
‘Like I never felt that [pharmacist] was there to overlook my prescribing or was negative in any way or that
I was being monitored. I never had that idea. It was always like “These here are a group of patients, do you
want to have a look at them?”, “There’s probably not much that we can change but you know I possibly
thought this and this”. And then I would look at that and say “Yeah you know maybe” or “Hm, we’ve tried
that before” or something like that. So you know it’s just a kind of collegial thing and I think he/she works
well as part of a team.’ GP3
‘I think I got a lot of respect from them certainly yeah. I think that they really valued me being at the practice,
I felt that they were happy for me to be there… there were often times whenever some of the GPs would have
come to me and said you know like, “Oh what do you think of this medication for this patient?” So I defin-
itely did feel that they had confidence in me and I was able to answer their questions’ Pharm 1
Administrators: ‘Well I mean we would get a lot of queries … say from hospitals about what medications the
patients are on. Now I mean that’s not something that I actually feel that I am capable of portraying that in-
formation. I think sometimes the doctors are too busy to actually take those calls at the time…we take a mes-
sage and by the time we get to the doctor with the message or by the time the doctor gets back to us could be
a fair few hours passing and you know it would be probably quicker and handier for somebody… who knows
what they’re talking about as opposed to us on the front desk who don’t know what we’re talking about.’ PM3
Nurses: ‘They [pharmacist] would have thought differently to me on a solution to that problem and their
solution definitely was more time efficient first of all, and secondly, probably was the direct line when you’re
looking at medication’ PN2
‘With my pharmacist, I find them most helpful but always very busy and I always feel “Oh I’m taking up their
time.” You know they haven’t got the same time. [Pharmacist], I felt relaxed completely with [Pharmacist] …
I can’t remember exactly how long, but I felt so relaxed and able to talk and I felt that it was a most helpful
operation.’ P4
‘I suppose I’m really very excited about what has been done. I can see immediately that it’s making the con-
sultation easier for the doctor and better for the patient so that, from the point of view of my job, quality
control, assuring people we want to give the best service we can, it all just stacks up.’ PM4
‘So there were a few that you felt you did actually make a difference em, and I suppose ultimately that’s what
you’re all about isn’t it.’ PHARM3
‘They identified problems that need to be solved, so that’s more work, it’s more time, it’s more energy, em but
I suppose at the end of it then maybe you hope that having gone through that process that you’re probably
going to be less likely to make mistakes, you’re going to be more quick to pick up stuff that you weren’t pick-
ing on before, you know? You’ve raised the bar of knowledge and hopefully that there’s an overall benefit that
feeds into your systems and to your practice I suppose.’ GP2
‘It has allowed me to use the clinical knowledge that I have…I didn’t feel like I was getting the opportunity
to use that knowledge and, yes I interacted with the patients and yes they would come to me if they had any
problems but you were kind of working with your hands behind your back because you didn’t have access to
the clinical information. You’d give them advice and you’d say you know “You should speak to your GP about
that,” or “I’ll ring your GP about that,” but you there was a limit as to what you could do.’ PHARM 1
‘That was us doing something not because the regulations said we had to do it, but because we wanted to do
it, that was very fulfilling professionally. And personally it was charming to work with [Pharmacist], they were
very easy to work with, so I learnt stuff. Also you had this feeling that you were not just going round in circles
with these two complex chronic diseases that you hadn’t really got to grips with. So you know that’s always
enjoyable when you solve a problem. And then I think from a practice point of view more generally, I think we
learned that we could integrate somebody like that into our work and it was an eye opener that you don’t have
to be a GP to be making these decisions and that was all very positive.’ GP4
General Practice Pharmacist (GPP) process evaluation 5

Table 3.  Continued

Theme Illustrative quotation

Q9 Inside scope of practice Education: ‘It’s all fine and well for reps to come in, but they’re just looking for their, specific drug, for their

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Q10 Debated scope of practice
Q11 Logistics
brand of drug. Whereas actually if a pharmacist was to come in and educate the staff a bit more in certain
areas’ PN1
‘So something like having them here might encourage me to do my nurse prescribing and it would be great
because then you’d have the support there…’ PN4
Repeat prescribing: ‘I don’t think it’s that people need a physician to re-diagnose them, but a clinician like a
pharmacist who could re-evaluate an ageing patient and establish their repeat prescribing every second or third
visit could de-bulk the work load to the GP, and certainly improve the quality of care for the patients. So if
you had a permanent pharmacist that’s where you’d be going I think.’ GP4
Chronic disease management: ‘So maybe you know the likes of diabetic patients, maybe pharmacists could be
facilitating clinics where they are reviewing those patients for the GP and then relaying any information or any
changes in prescribing that needs to be done, so I think the role could certainly be extended.’ PHARM 1
‘…their scope of expertise…they can’t prescribe for instance, they can advise, they can’t assess the patients
from the perspective of a clinical, medical perspective.’ GP1
Cost: ‘Well, if there was clinical funding through the GMS or through other means for having a clinical
pharmacist working with the team then we would sign up for it immediately.’ GP1

Table 4.  Characteristics of the pharmacist role

Practice characteristics GP1 GP2 GP3 GP4

Integration into the GP staff as team Yes Yes Yes Yes

member
Scheduled time with GP 60 minutes 60–120 minutes per week 30–60 minutes daily ‘an hour here
per session and there’
Pharmacist own room in surgery Yes No (based with practice Yes Yes
administrators)
Pharmacist conducted medicines reviews Yes Yes Yes Yes
Pharmacist participated in audits Yes Yes Yes Yes
Management of repeat prescribing No No No No

viewed by the GPs as being part of the team and non-judgemental
in their advice:
‘Professional colleagues who have skills, that are augmented by
our skills just as our skills augment theirs. So it’s very much a
professional environment where [Pharmacist] wasn’t working
for us…to our instructions, it was very much part of a team ap-
proach.’ GP1
Equally, the pharmacist reported feeling valued and respected within
the practices:
Patients were offered a medication review with the pharmacist,
however, uptake was low overall. For those who did participate in a
review with the pharmacist, conversations tended to involve medi-
cine information and managing symptoms in more affluent areas,
while in less affluent areas the conversations were more about what
each medicine did and why they were taking it. Overall, patient
interviews indicated that they did not clearly understand the role of
a non-dispensing pharmacist in a GP practice (despite receiving the
participant information leaflet) generally, but did personally find the
interaction pleasant (Table 3, Q6).

‘I think they appreciated my help…any questions I could answer,

advice I could give.’ Pharm2
Relationships between the pharmacist and other practice staff
were less strong (Fig.  1). The practice manager and administra-
tors mainly interacted with pharmacists in relation to the research
study practicalities, such as patient recruitment which in terms of
calling and scheduling patients. Additionally the pharmacist was in
a position to assist the administration staff addressing issues with
repeat prescriptions, calls from hospital or community pharma-
cists, or answering patient medication queries. Administrative staff
appreciated assistance with a task they felt unqualified to conduct
and noted the knock on effect that this was one less task for the GP
to attend to (Table 3, Q5). The practice nurses had very little pro-
fessional contact with the pharmacist. Only one of the four nurses
interviewed consulted the pharmacist in relation to medicines in-
formation directly, and reported finding the different perspective
useful (Table 3, Q5).
Role perception
In general, there was good agreement across the pharmacist and all
practice staff that during this study, the pharmacists within general
practice were beneficial in broadly supporting the shared goal of
improving patient care (Table 3, Q7). Both GPs and pharmacists re-
ported finding the process professionally rewarding and developed
their knowledge and skills (Table 3, Q8).
There was less clear agreement on the future role of the pharma-
cist in Irish general practice. There was broad agreement across the
practice staff and pharmacists that ‘patient review, medication re-
view, optimising prescribing, highlighting areas of potential inter-
actions…liaising with local dispensing pharmacists’ GP1, as well as
audit, and practice education would fall within the pharmacist scope
of practice. GPs also felt there was scope for a clinical pharmacist to
be involved in repeat prescribing and working with nursing homes
under the practice care (Table 3, Q9). Some of the pharmacists also
felt there was an opportunity for role expansion to include running
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Figure 1.  Diagrammatic representation of pharmacist interactions with GP staff through tasks. Staff are represented with ovals, tasks are represented with
rectangles. Pharmacist and GP: green. Pharmacist and patient: pink. Pharmacist and practice nurse: orange. Pharmacist and administrators: red. Pharmacist
and practice manager: purple.
disease management clinics, but some GPs were unclear about the
clinical responsibilities and implications of this in practice (Table 3,
Q10). As described above, patients were unclear on the role of a non-
dispensing pharmacist in a GP practice overall:
‘But I mean if you asked me would I see it as a benefit…I suppose
I’m not too sure that I’d say yes to that.’ P1
The logistics of the future role of pharmacist in practice was also
unclear. Space was identified as an issue, as was the time configur-
ation with some participants seeing a part‐time or sessional position
being the most realistic option. From the GP perspective, the cost of
employing a pharmacist and who should pay for that was identified
as a future challenge (Table 3, Q11), as was balancing the demands
of time and workload, although this was counterbalanced somewhat
against the potential for future efficiencies:
‘I suppose I went from having, alarmed “Oh my God why are we
doing this, it’s really hard work”, to “God it’s really interesting,
it’s really worthwhile, absolutely fascinating stuff”. And if people
could see that and put money behind it would be great…I mean
it definitely was a big commitment and staff knew that, you just
need to be prepared for that…’ GP2
There was also some disagreement as to whether or not a commu-
nity pharmacist could provide the same service as a clinical pharma-
cist amongst the pharmacists themselves:
‘…it doesn’t need to be done week in week out…in my view you
know a community pharmacy could be doing it if they had the
proper structure in place with the GP…’ Pharm 2
‘They’re just so different because community pharmacy is
dispensing driven whereas this was purely patient safety in rela-
tion to medications. Now community pharmacy is also that but
you wouldn’t have the same time to do it, or the same resources
to do it…they’re two very, very different things…the GP practice
pharmacist would be purely about patient safety and prudent pre-
scribing in terms of generics and things like that.’ Pharm 3
Family Practice, 2020, Vol. XX, No. XX
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Discussion
Summary of findings
This process evaluation highlighted that GPs and pharmacists per-
ceived the benefits to pharmacists working within general practice
(3). Perceived benefits included improved quality use of medicines,
improved medication knowledge and professional development.
Comparison with existing literature
The importance of strong relationships has been identified as a
key component of clinical pharmacists working in primary care
(3). A  central strength of this study was the universal feedback of
teamwork and strong relationships between the GPs and phar-
macists. Previous studies have highlighted the importance of rela-
tional coordination in the effective delivery of disease-management
programs by interprofessional teams in primary care (18–21). The
GP pharmacist relationship described in this pilot study arguably
demonstrated key characteristics of effective interprofessional work
(according to relational coordination theory) including timely, ac-
curate and frequent communication and relationships characterized
by shared goals, shared knowledge and mutual respect. The degree
of integration of pharmacists into primary care teams may impact on
overall effectiveness with a recent systematic review reporting that
a higher degree of pharmacist integration was associated with im-
proved health outcomes (6). Our participants were not in agreement
about the level of integration or the time commitment required for
such as role, however, given the importance of developing effective
interprofessional relationships, some degree of integration would be
required to make the transition work.
In keeping with international literature (22), there was enthu-
siasm and willingness among most of the pharmacists for new, ex-
tended roles in primary care. The development of extended roles
depends upon a number of factors, including role definition and pro-
fessional boundaries, particularly the willingness of local physicians
General Practice Pharmacist (GPP) process evaluation
(and nurses) to delegate tasks (23,24). Within this study, some of the
GPs and pharmacists themselves, hinted at professional boundaries
in relation to what was and was not within a pharmacist ‘scope of
practice’, but overall, GP, practice nurses and practice administra-
tion were collectively supportive a role for the pharmacist in gen-
eral practice. There was also uncertainty in relation to how such
extended roles would relate and be distinct to existing community
pharmacy.
Many of the barriers identified to the successful broad implemen-
tation of such a role in Irish general practice in this study mirror those
identified in previous studies, despite some of the unique features of
the Irish health care system (Supplementary Table 3). Funding, in-
frastructure and workload balance for this type of role appear to
be universal barriers to implementation. In this study, patients were
unclear of the benefit of the pharmacist role in general practice (3).
A lack of well‐defined roles has been identified as a barrier to patient
awareness, demand and uptake of pharmacist services in general
practice and community settings (3,25). We are now commencing a
pilot cluster randomized controlled trial (RCT) with revisions based
the valuable insights gained during this process evaluation. Based on
these findings and feedback from a ‘Public and Patient Involvement’
(PPI) panel of patients with multimorbidity, patient education and
awareness strategies such as posters and GP/patient communication
on the role will be employed in this RCT to inform patients.
Strengths and limitations of this study
This study should be interpreted in the context of its strengths and
limitations. This study included key stakeholders from the general
practice team and patients in the analysis. General practices reflected
a range of practice sizes and socioeconomic areas. However, there
was a small number of participants in each of stakeholder group
and interview length varied which may have affected the richness
of the data. Practices were recruited from a national research net-
work and it is likely that the agreeing practices had a pre‐existing
interest in research and were open to new initiatives which may not
be representative of all general practices in Ireland. Despite this, they
expressed varying views, highlighting the complex nature of the sub-
ject. Study constraints, including short duration, study data collec-
tion and fixed restricted pharmacist hours were limitations of this
evaluation. Furthermore, some of the pharmacists’ interactions, par-
ticularly with the administrative staff, were restricted to study pro-
cesses and may not reflect working relationship that would develop
organically over time.
Conclusion
This study highlighted that a pharmacist joining the general practice
team was well accepted by the GP and practice staff but patients
were less clear of the overall benefits. Implementation in practice
would require resourcing both for the GP pharmacist role, and
protection of GP time to allow communication and genuine team
working. Important barriers and facilitators to integration identified
will be addressed in a pilot cluster RCT.
Supplementary material
Supplementary material is available at Family Practice online.
Acknowledgements
The other members of the GPP Study Group are Michael Barry, Fiona Boland,
Sarah Clarke, Karen Finnigan, Maria Daly, Laura McCullagh, Emma Wallace,
Ciara Kirke, Catriona Bradley, Paul Gallagher, Edel Murphy, Andrew Murphy,
7
Patrick Byrne, Aisling Croke and Tom Fahey. We thank the GP practices and
the patients who participated in this study.
Declaration
Downloaded from https://academic.oup.com/fampra/advance-article-abstract/doi/10.1093/fampra/cmaa044/5831491 by Uppsala Universitetsbibliotek user on 12 May 2020
Funding: this study was funded by The Health Research Board (HRB) Re-
search Collaborative in Quality and Patient Safety (RCQPS) award. The spon-
sors of the study had no role in the study design, data collection, data analysis,
data interpretation, writing of the report or in the decision to submit the paper.
Ethical approval: this study was approved by our institutional research ethics
committee and informed consent was given by all pharmacists, GP practice
staff and patients.
Conflict of interest: none.
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