Title: Study title: 'Listening to seldom heard voice communities': A service-user, co-produced education intervention for community pharmacists and pharmacy support-staff to improve the provision and delivery of Medicine Use Reviews (MURs) to under-served populations.
Funder: Health Education England

Abstract: Introduction: Medicine Use Reviews (MURs) form part of the Government's strategy to improve medicine adherence, optimise health gains and reduce medicine waste. In light of the well known problems patients experience with medicine taking, the MUR provides an opportunity to address these concerns and facilitate medicine taking. However, certain groups are not receiving the service and questions have been asked of pharmacists' consultation skills. There is potential for an educational intervention to address the sub-optimal delivery of MURs. Reusable Learning Objects (RLOs) are e-learning tools that have an established track record in educating professionals and improving health-related behaviours. This study aims to investigate whether a co-developed educational intervention can deliver maximum health benefits to patients in most need of the service.Study Objectives: Primary objectives: 1. Co-produce with patients (from under-served communities), pharmacists and support-staff an e-learning educational intervention (series of RLOs). 2. Evaluate their impact on pharmacist and support-staff's reported attitudes and behaviour scores of delivering MURs to under-served communities. 3. Characterise pharmacist and support-staff's experience of the educational intervention, acceptability and explore barriers and facilitators to its successful implementation. Secondary objectives: 1. Inform and support future implementation. Plan of investigation: This is a feasibility study and will involve two stages. Stage 1: Co-production of RLOs. This will involve patients from under-served groups (seldom heard voice communities and other vulnerable groups), pharmacists and their support-staff. Anticipated topics to be included in the intervention will be: understanding the needs of under-served communities; effective targeting strategies and how to tailor consultation skills. RLOs will be informed by theoretical frameworks around learning, behavioural change and social identity. Stage 2: Implementation and evaluation of the educational intervention. All pharmacists and support-staff who are involved with MURs and working within Nottinghamshire Clinical Commissioning Groups (CCGs) will be invited to take part in the evaluation. There will be two workstreams: Stage 2-Workstream 1: Single cohort, pre-post study design. The RLOs and data collection tool will be piloted using ten undergraduate pharmacy students to test the functionality of the RLOs and face validity of the data collection instrument. Then pharmacists and pharmacy support-staff will be invited to complete an initial baseline questionnaire (accessible through an electronic platform) to assess their attitudes and behaviour scores in delivering MURs to under-served community groups. Following an on-line, baseline data collection questionnaire, the e-learning educational intervention will be made available on-line. A follow-up post-intervention, on-line questionnaire will then be sent. The primary outcome measure will be changes in pharmacist / pharmacy support-staff attitudes and behaviour scores. Stage 2-Workstream 2: Process evaluation (qualitative study) involving one-to-one interviews with a purposive sample of pharmacists / support-staff (n = up to 40) or focus group discussions (n = 2) about their experience of using the RLOs and impact on practice. Analyses: Questionnaire data will be subject to descriptive and inferential analyses (comparison of baseline and post-intervention data scores). Qualitative data will be analysed thematically. Potential patient benefits and impact on the NHS: With over 3 million MURs conducted in England in 2013-14, the e-learning intervention will aim to focus pharmacy teams to target MURs at population groups that potentially would benefit most, as opposed to targeting populations that are perceived as simple' or convenient to reach. This will promote equity of access to care for all. The intervention will enhance pharmacist's consultation skills, specifically identifying non-adherence and resolving patients' problems with medicines. MURs will be more responsive to under-served communities, more effective at identifying and resolving patient problems with medicines and through this, deliver a more effective service at optimising patient's use of medicines and thereby securing improved health and wellbeing.

Lay abstract: Background:There is growing awareness that patients experience difficulty following complex medicine regimens. These are often prescribed to an aging population affected by multiple long-term medical conditions. The consequence of not taking medicines as prescribed can contribute towards poor health, unnecessary hospitalization and medicine waste. One independent report evaluating the scale, causes and costs of waste medicines, estimates that in England alone the annual cost of NHS prescription medicines wastage is 300 million, including 90 million worth of unused prescription medicines that are retained in individuals' homes and 110 million returned to community pharmacies. To tackle these problems, community pharmacists are being asked to take on new responsibilities to help patients and lessen the growing demands on family medical centres and hospitals. Medicine Use Reviews (MURs) have been funded by the English NHS since 2005. MURs are designed to help patients use their medicines more effectively and reduce medicine waste. They are normally carried out by the pharmacist in a private consultation room in the community pharmacy. During an MUR, the pharmacist will talk to the patient about their medicines in order to identify and resolve any problems they may have with them. Pharmacists are required to train and take a test before offering the service. However, this training mainly focuses on checking whether the pharmacist knows about the process of delivering the service i.e. knowing how to complete the paperwork. Problems have been identified with delivering MURs to those most in need and over the quality of the patient-pharmacist consultation.Our previous investigations have found there are two main problems with the MUR service: (i) MURs are offered less to those in greatest need, and (ii) pharmacist's skills during consultations could be greatly improved. One way to rectify these problems and so make the service better for patients is to provide pharmacists with solutions to address these problems. Reusable Learning Objects (RLOs) are on-line educational tools to support learning. In practice, RLOs are small, 'bite-sized' chunks of e-learning focusing on a particular narrow topic. They can be freely available on-line and involve assessment of the user's learning. As such, these resources are uniquely placed to address the type of clearly-defined knowledge gaps present in the case of MUR provision among pharmacists. Project aims and methods:This project aims to co-produce with patients from under-served communities (i.e. people who are housebound, who have English as a second language, those with a disability etc) and with pharmacy teams, an on-line e-learning training package (RLOs). There will be close involvement with patient and public representatives when designing the training package to ensure that this is relevant to the genuine needs of the public. Anticipated topics will include, understanding the needs of under-served communities' 'effective MUR targeting to those who benefit most' and improving pharmacists' communication skills'. Two workshops will be used to co-develop the e-learning training package: an initial development' workshop that aims to capture ideas and experiences so the e-learning training package can be developed and a later feedback' workshop that will refine the package to ensure it addresses the identified learning needs of pharmacy teams. Once developed, we will evaluate the impact the e-learning package will have on pharmacist and support-staff's attitudes and behaviours in delivering MURs to under-served patients. This will happen in two steps: 1. A before and after' evaluation study will be conducted. All pharmacies located within Nottingham Clinical Commissioning Groups (CCGs) will be invited to take part in an evaluation study. They will be invited to complete an initial questionnaire to assess attitudes and behaviours. They will then be provided with the on-line e-learning training package for 30 days and then sent a follow-up questionnaire. 2. A selection of pharmacists and pharmacy support-staff will be invited to a one-to-one interview to explore their experience of using the on-line training package and explore whether this has impacted on their practice.Once the project is complete, plans will be made to make the findings publicly available. Because the pharmacist's educational materials are accessible on-line, they will be made freely available and accessible to all pharmacy teams nationally. In addition, they will be made available to those responsible for training pharmacists to do MURs. This strategy will allow the benefits of the research to be implemented in practice and ensure they have an impact on patient care. Also, the results will be published in relevant research journals, and the findings made available to the patients and organisations involved at various stages of this project and to the wider public.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES;7.1 INDIVIDUAL CARE NEEDS
Health categories: GENERIC HEALTH RELEVANCE