title: A multisite ethnographic study of patients, carers & interprofessional relationships & roles in polypharmacy reviews
titleType: Other
Creators: name: Mair, Alpana R.
Publisher: name: University of Dundee
Year: 2022

description: Background: Polypharmacy has been defined as taking four or more daily prescription medicines. Reviews were introduced by the Scottish Government (2012) with the purpose of these reviews being to undertake a person centred seven step review to aim for optimal polypharmacy where the risks and benefits of medicines are assessed so that the process cannot be protocolised.

Aim: This was a multisite ethnography to understand to understand patients, healthcare professionals and carers’ perceptions and experiences of polypharmacy medication reviews for patients with multimorbidity.

Methods: This multisite ethnography took place in two health boards and four GP practices across Scotland, who were early adopters of the policy on delivering polypharmacy reviews using a multidisciplinary team (MDT). The analysis draws on Abbotts (1988) theory of jurisdictional boundaries, sociological theories of professional boundaries (Fournier, 2000; Strauss 1978; Nancarrow and Borthwick, 2005) and how work is transferred and negotiated between professionals and Lipsky’s (2010) concept of street level bureaucracy.

Results: In both health boards, the drivers for the reviews were safety, quality and financial drivers and the priority of these changed over time and strongly influenced by medical or finance senior managers. Implementation of policy was felt to take time, because of the complexity of implementing new kinds of team working and so there was a view that policy should be in place for longer. When protocol led work is transferred from the more dominant profession there is horizontal transfer of the work. This research was to understand how autonomous work that provides professional status and prestige is transferred from one professional group to another in the context of polypharmacy reviews that requires autonomous decision-making.

How policy was implemented in practice varied being adapted to address local issues, with GPs having more influence over this than other healthcare professionals. The reviews across the practice were always pharmacist led but there was variation in the autonomy given to pharmacists to make decisions and role of the geriatrician, GP and pharmacist MDT review depending on the patient group. The pharmacist doctor boundary is still evolving but has been accelerated in the local arena by workforce pressures to manage patients with complex medication issues and to work autonomously to make decisions for these patients despite the publically maintained position that the pharmacist undertakes routine reviews. Many doctors were inviting pharmacists to do the work, and while most of the work was transferred through horizontal substitution, some GPs tried to maintain supervisory activity so introducing the concept of “diagonal transfer” to explain the substitution. The conceptual models provide a framework to understand how autonomous work is being transferred between doctors and pharmacists leading to substitution of this work, accelerated by increased workload, as well as geriatricians and pharmacy technicians.

Patients thought reviews were to address active medication-related problems rather than prevention of medication-related harm. The most important factor to patients was that they had a relationship with the professional doing the review, that they were listened to, and that there was continuity of care. GPs could influence public and cultural acceptance of pharmacists’ role in some practices.

Conclusion: The pharmacist doctor boundary is still evolving and is likely to change in both the local and public arena. The acceptance of the pharmacists’ role in primary care changed after patients had seen the pharmacists and this may affect wider public and cultural acceptance of the pharmacists’ role as the lead in the polypharmacy reviews with GPs and geriatricians adopting an advisory role.
Key words: professional relationships, polypharmacy reviews, boundaries, street level bureaucrats, professional autonomy