Title: Investigating the organisational factors associated with variation in clinical productivity in community pharmacies
Funder: Department of Health (England)

Abstract: The overarching aim of this study is to inform the commissioning of NHS general pharmaceutical services in England by exploring variation in clinical productivity (levels of service delivery and service quality) in community pharmacy organisations and identifying the organisational factors associated with this variation.The objectives are to: (a)explore variation in levels of service delivery across a representative sample of community pharmacies in England; (b)investigate the relationships between organisational characteristics and levels of service delivery; (c)investigate the inter-relationships between organisational characteristics levels of service delivery and service quality; (d)examine the mechanisms by which organisational factors influence both levels of service delivery and service quality;(e)develop a toolkit to inform commissioning processes to improve clinical productivity in community pharmacy.The proposed study will be conducted in 2 stages over 27 months within a purposive sample of five geographical areas covering a range of affluent/deprived areas of dense/sparse populations.Stage 1: will combine analysis of existing datasets with primary data collection to examine variation in levels of service delivery across community pharmacies (objective a) and analyse associations between organisational characteristics and levels of service delivery (objective b). All community pharmacies in the five study areas will be approached to participate. Data will be obtained through three major sources: a) Community pharmacy returns (monthly dispensing volume; yearly volume of advanced; numbers and volume of enhanced services); b) socio-economic and health need data from secondary datasets (e.g. census indices of multiple deprivation); and c) a survey of community pharmacies (ownership-type organisational culture staffing and skill-mix working patterns management structure safety climate). Survey items will be developed from items validated through previous community pharmacy surveys conducted by the research team. Organisational culture will be measured using the Pharmacy Service Orientation (PSO) tool validated for use in community pharmacies. This short tool is scored on the basis of three 1 to 10 semantic differential scales whereby respondents are asked to rate their pharmacy’s ‘orientation’ (patient vs. product) ‘focus’ (quality vs. quantity) and ‘pharmacists’ work’ (professional vs. technical).Initially we will summarise the variation in our primary (monthly dispensing volume; yearly volume of advanced services) and secondary (yearly volume of enhanced services; safety climate) outcome measures using appropriate summary statistics. We will also report these measures by key organisational factors (e.g. ownership; culture; etc). Using STATA software we will then fit a series of fixed-effects linear regression models to determine whether these outcomes are associated with pharmacy-level organisational variables and/ or areal-specific demographic socio-economic and health-needs variables. Stage 2: Quantitative methods will examine the inter-relationships between organisational characteristics levels of service delivery and service quality (objective c). Qualitative methods will explore issues around levels of service delivery and service quality in community pharmacies their relationship and the mechanisms by which they are influenced by organisational characteristics (objective d). Forty community pharmacies – 2 of each ownership-type (supermarket multiple chain independent) from each NHS area – will be randomly selected from stage 1 respondents to participate in stage 2. A two-sided questionnaire will be distributed by the pharmacist/pharmacy staff in each of these pharmacies to two samples of 30 consecutive patients following receipt of a) dispensing and b) MUR services from each pharmacy (N=2400). The questionnaire will collect some background data (socio-demographic existing conditions medications received) in addition to including two self-reported measures of a) satisfaction with information about medicines (SIMS) and b) adherence to medicines (MARS). Both the SIMS and MARS are of proven reliability and validity and have been widely used in research studies in a number of settings (including pharmacy) across a range of conditions and in several countries. Initially we will tabulate the responses to each of the 17 items on the SIMS and the 5 items on the MARS. SIMS items can also be dichotomised to represent satisfaction and dissatisfaction (with medication information): we will report these overall and by ownership type. Individual binary ‘ratings’ can then be summed to give an overall assessment of satisfaction (ranging from 0 to 17). This ‘score’ will be used as the outcome in a multi-level linear regression model to determine which patient- (stage 2) and pharmacy-level (stage 1) independent variables are predictors of satisfaction with medication information. MARS item ratings can also be summed to produce an overall medication adherence ‘score’ which will be used as an outcome in a multi-level linear regression model. All regression models will be fitted using STATA.In addition semi-structured face-to-face interviews will be conducted with up to 50 pharmacy and commissioning representatives selected purposively to include one service commissioner and up to 8 pharmacy interviewees from each geographical area across all types of pharmacy. Topic guides developed from the aims of the research and the research literature will broadly explore the relationship between the quantity and quality of service provision in community pharmacies opportunities and barriers to increasing clinical productivity in this setting and the mechanisms by which different organisational characteristics may help or hinder this objective. Interviews will be audio-recorded with permission fully transcribed and thematically analysed using a framework approach using NVIVO qualitative analysis software. Finally we will develop a toolkit to help service commissioners improve their contracting processes with community pharmacies (objective e) to promote clinical productivity. To inform the development of the toolkit we will organise a half-day workshop to which we will invite community pharmacy/primary care commissioning leads from the new local commissioning structures.


Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE