Collaboration in chronic care: unpacking the relationship of pharmacists and general medical practitioners in primary care

Authors


Dr Sinthia Bosnic-Anticevich, Faculty of Pharmacy, University of Sydney, Science Road, Sydney, NSW 2006, Australia.
E-mail: sinthia.bosnic-anticevich@sydney.edu.au

Abstract

Objectives  The objective of this research was to gain deeper understanding of the expectations, experiences and perceptions of Australian general medication practitioners (GPs) and pharmacists around collaboration in chronic illness (asthma) management in the primary care setting.

Methods  A qualitative research methodology utilising a semi-structured interview guide, based on theory and an empirical approach, was used to fulfill the objectives of this study. Face-to-face interviews with pharmacists (n = 18) and GPs (n = 7) were recorded, transcribed and coded for concepts and themes. Relationships between concepts and themes were examined and used to describe the nature of collaborative relationships in the primary care setting.

Key findings  A relationship between GPs and pharmacists currently exists although there is minimal collaboration and there are several areas of practice and patient care in which the two professional groups are mismatched. At the same time, this research uncovered key aspects of the GP–pharmacist relationship, which could be used to develop more collaborative relationships in the future. The findings from this study were evaluated in light of the Collaborative Working Relationships model and published literature.

Conclusions  A model for the development of GP–pharmacist relationship has been postulated which articulates the dynamic nature of professional relationship in primary care and highlights a pathway to more collaborative practice. Future research should focus on further developing this model.

Introduction

Over the past decade, healthcare professionals (HCPs) have increasingly become overwhelmed by the burden and complexity of chronic disease care which has resulted in a high proportion of patients experiencing suboptimal disease management.[1] One of the concepts promoted in an attempt to improve chronic disease management in primary care includes ‘collaboration’ (research in the area of ‘collaboration’ is often referred to in terms of a variety of terms that include co-ordinated, interprofessional, interdisciplinary, multidisciplinary and team-based health care); that is, ‘the process in which different professional groups work together to positively impact health care’.[2]

The impact of collaboration on patient outcomes has been studied in many disease states and in various groups of patients. These include chronic and episodic diseases treated in both hospital and community settings. Improved outcomes have been linked to collaborative interventions in a variety of disease states, for example diabetes, heart failure and asthma.[3–14] Collaboration has also been shown to increase professional satisfaction of HCPs and cost savings for the healthcare system (e.g. decreased hospitalisation and more appropriate medication use).[15–20] Consequently, collaboration has been embraced by researchers, regulators and professional bodies. Practice frameworks and chronic care models, many of which include the concept of collaboration,[21–25] have also been developed. In fact, one of the most widely used models of chronic care illness, the Chronic Care Model, has recognised the importance of a team-based approached to health care for over a decade.[26,27]

In the primary care setting, pharmacist and physician collaborations have reported successful outcomes with regards to cholesterol lowering and cardiac risk reduction, blood-pressure control, diabetes management, heart-failure management, depression, pain, asthma control and palliative care.[28–38] In Australia, the importance of collaboration in primary healthcare delivery has been acknowledged by the Commonwealth Government through the availability of two funding models for collaboration:[39] (i) the Enhanced Primary Care (EPC) programme, which reimburses medical practitioners for developing care plans for chronically ill patients that involve at least two other HCPs and (ii) the Home Medication Review (HMR; also known as DMMR or Domiciliary Medication Management Review), which reimburses medical practitioners and pharmacists for, respectively, initiating and completing comprehensive medication reviews.

Despite the evidence supporting collaboration and the funding models available to enhance collaboration, international and Australian data indicate that minimal collaboration occurs in primary care and that links between general practice and allied health, including pharmacy, are poorly developed.[2,14,40–44]

The aim of this research was to unpack the concepts of collaboration to gain fundamental understanding of the expectations, experiences and perceptions on collaboration of Australian general medication practitioners (GPs) and pharmacists around chronic illness management in the primary care setting. In recognition of the advanced status of community pharmacists in the delivery of asthma disease-state management services in Australia,[45–49] the exemplary chronic disease of asthma was chosen as the chronic illness model around which to frame this research.

Method

A qualitative research approach was employed, utilising a theoretical framework and the collection of empirical data. Based on the literature and the Collaborative Working Relationships model,[15,50] a semi-structured interview guide was constructed (Table 1). The semi-structured interview guide was designed to elicit experiences and perceptions about professional relationships between GPs and pharmacists and collaboration around asthma management in the community. Note that the term ‘teamwork’ as well as ‘collaboration’ was used to gain feedback from the participants as the concept of teamwork was often found to be more intuitive for the participants. Following attainment of ethics approval from the University of Sydney Human Research Ethics Committee, purposive sampling based on location (i.e. GPs and community pharmacists working in Western Sydney) was used to target recruitment of participants. Seventy-four pharmacists and 69 GPs were identified using business addresses from the telephone directory, and invited to participate by mail. Follow-up phone calls were made to pharmacies and GP surgeries to arrange a convenient appointment time at the usual place of business. Participants were given an information sheet and were asked to sign a consent form before the interview occurred. Face-to-face interviews (conducted by RD) with pharmacists and GPs were recorded and transcribed. Following transcription of audio data, the following process of data analysis was undertaken: first-level coding was performed immediately after most interviews (RD and SBA), and concepts were identified from these interview transcripts by the researchers independently and later grouped into categories. Consensus of researchers was reached prior to finalisation of categories (RD and SBA). Selective coding then occurred as themes emerged from the conceptual categories. Recruitment continued until saturation of ideas and concepts was reached. Interviews took between 30 and 45 min and were conducted at the workplace of participating GPs and pharmacists at a time of their convenience.

Table 1.  Semi-structured interview guide
TopicsPrimary questionsSecondary questionsClarification
  1. GP, general medication practitioner; HCP, healthcare professional; QOL, quality of life.

DemographicsDescribe your business in terms of regular staff.
How long have you associated with this practice/business?
How far are you from local pharmacy/GP?
In this practice/business, who contributes to patient care?
How smoothly does this practice/business run compared with others (better/worse)?
Describe the relationship with GP/pharmacist.
Experience with other HCPs
Do other HCPs have impact on practice/business?
Is distance a factor in relationship between pharmacists and GPs?
Experience with asthma patientsWe're interested in all of your asthma patients/customers: how well do they manage their asthma?
Would asthma patients benefit from more regular educational intervention from HCPs?
Do any of your patients/customers, have problems with compliance, technique, inadequate use of steroids, poverty or lack of follow up?
Which HCP should perform this role?
In this practice, what are the reasons for suboptimal control in asthma patients?
Previous experience with collaboration in primary careApart from your present practice, describe any previous involvement with multidisciplinary care.What were the outcomes (plus and minus) for patients. you personally and your practice?If HCP was involved in past multidisciplinary care, what was the general feeling?
Barriers to collaborationWhat in your opinion are the barriers to teamwork?
What in your opinion would be the main barriers to asthma collaboration between pharmacists and GPs?
Which of these issues, as identified in literature, are important?
Poor communication
Territorialism, concern about roles or info ‘stealing’
Low morale
Expense
Lack of timeLack of guidelines
Lack of knowledge (who)
What could be done to overcome these barriers?
HCP's opinion (from personal experience or communication or reading as opposed to literature identified) of teamwork and barriers.
Qualities of ideal HCP for asthma collaborationHow would you describe your ideal pharmacist/GP?What about in a GP/pharmacist asthma collaboration?
Trust?
Relationship?
Qualifications?
Distance?
What changes need to occur to encourage HCPs to work together in an asthma collaboration?
Issues to enhance asthma collaboration between pharmacist and GPWhat makes teamwork successful? How could a GP/pharmacist asthma collaboration be enhanced, or made more successful?Which of these issues, as identified in literature, are important and practical?
Good rapport between team players
Common goal
Accepted protocols with job descriptions
Training
Regular progress meetings
PR to educate staff and patients about collaboration
HCP's opinion (from personal experience or communication or reading as opposed to literature identified) of teamwork and facilitators.
Which of these does HCP think are important for GP/pharmacist asthma collaboration?
Impact of successful asthma collaborationIn your opinion what are the potential benefits of a successful asthma collaboration forPatient?
Yourself?
Your business?
How do you think this would impact on:
other HCPs?
their practice?
Perceived potential benefits for:patient: increased QOL, fewer visits to GP, A&E and hospital;
GP: fewer visits, less concern;practice: PR? Satisfaction;pharmacist.

Results

Response rates and respondent demographics

HCPs were approached until saturation of data was achieved. In total 65 HCPs (25 pharmacists and 40 GPs) were approached to participate, with 25 interviews being were completed and analysed (saturation of data being reached with 18 community pharmacists and all seven willing GPs being interviewed). This corresponds to a response rate of 38% (25/65). Reasons for non-participation included lack of time or lack of interest. Some HCPs did not provide a reason, and others, mainly GPs, were unable to be contacted. Of the participants, eight were female. Most participants worked in excess of 50 h a week and over half the pharmacies were open 7 days per week. Pharmacies were located in a broad range of settings from small street shop fronts to large shopping complexes. Most GPs worked within group general medical practices. In terms of proximity, 80% of the HCPs interviewed either shared common buildings with their nearest HCP, or were in the same street. It was not possible to interview ‘adjoining’ HCPs; however, in each case, participants spoke about their relationship with their nearest HCP.

Themes

Analysis of data resulted in the generation of seven themes: perception of the interprofessional relationship, professional needs, perception of asthma care and patient needs in the community, barriers to teamwork, facilitators to teamwork and benefits of teamwork.

Perception of the interprofessional relationship

Most GPs and pharmacists perceived their current working relationship with the other HCP favourably, describing the relationship as a very good one.

For example ‘Oh they're great, very easy to get along with, I often call them up for questions. . . .’ (GP 3), ‘Very friendly, professional, we cooperate.’ (GP 6), ‘We've got quite a good relationship with a few of them. . . . they are approachable, they can be contacted. . . .’ (pharmacist 14).

However, further discussion revealed that while mostly perceived to be good, GPs and pharmacists had a basic/minimal relationship in terms of the extent to which they engaged professionally. They had limited understanding of each other's role and negative aspects to their relationship were present. It appeared that pharmacists were very conscious of the way in which they spoke to the GP, perhaps lacking confidence in the best way to approach the GP.

For example ‘Generally you don't see them unless there's a Doctor's Bag [see below]. They [GPs] don't know what's in the pharmacy and they don't know what's available in the outside world.’ (pharmacist 7), ‘. . . We've had problems with some doctors saying “No never call me again . . .”.’ (pharmacist 8), ‘. . . He's a GP who doesn't like to be questioned if something doesn't appear to be right . . . often recommend[ing] medications or doses which we may think is inappropriate . . . we have to be fairly diplomatic . . .’ (pharmacist 15).

Note: GPs are able to purchase medication deemed appropriate for Emergency Drug Supply at a subsidised price. These medications are often referred to as Emergency Drug (Doctor's Bag) Supply and are ordered through community pharmacy.

Professional needs

GPs and pharmacists also reflected on their needs/expectations of each other as HCPs. Overwhelmingly, they reported on the need to communicate with each other; however, expectations varied greatly between what GPs and pharmacists articulated as being their professional needs and expectations of one another.

For the GPs, communication, which related to facts about the patient (e.g. information about the patient such as inappropriate use of medication), was expected and valued. They wanted the pharmacist to report back to them, ensuring they had all the information about the patient.

For example ‘A pharmacist would definitely have to let me know if someone was using large amounts of Ventolin without a preventer. . . .’ (GP 1), ‘. . . the pharmacist's role would be to . . . keep the doctor and the patient up to date on. . . .’ (GP 2).

In contrast, for pharmacists, accessibility, style and nature of communication was a priority.

For example ‘The ideal GP would be . . . a good communicator and accessible.’ (pharmacist 3), ‘. . . willing to view us as an equal partner.’ (pharmacist 10), ‘. . . smart and care[ing] . . .’ (pharmacist 4), ‘. . . approachable, and available to speak with (me) . . .’ (pharmacist 8).

Perception of asthma care

GPs and pharmacists were also mismatched in their perceptions of asthma management. GPs felt that asthma was well managed in the community, that asthma care had improved significantly in the last decade and that although there may be room for improvement, acute/problematic asthma was rarely seen in GP surgeries. In contrast, pharmacists perceived asthma control to be variable, ranging from poor to good. Pharmacists recognised that some patients were readily identifiable as having poorly controlled asthma, identifying reasons such as poor adherence, self-management (e.g. lack of written self-management plan ownership) or reluctance to engage in care as the problem.

For example ‘it seems to be better managed nowadays, maybe with the new drugs . . .’ (GP 5). In contrast to ‘. . . [management of asthma control is] overall terrible. . . . I don't think that pharmacy has helped much.’ (pharmacist 11). With regards to why: ‘. . . a fear about steroids [medications] in the community . . .’ (pharmacist 18), ‘. . . They are either very well looked after or not at all.’ (pharmacist 3), ‘. . . most of them don't manage their asthma very well . . .’ (pharmacist 15).

Perception of patient needs

When it came to the needs of patients, GPs and pharmacists perceptions differed to some extent. Not all GPs were convinced that patients would benefit from receiving specialised and individualised education. Pharmacists recognised that while some patients are resistant to advice, patient education would result in patient benefits.

For example: with regards to receiving additional information, ‘. . . maybe newly diagnosed ones [patients] . . . it would enhance their understanding’ (GP 4), ‘benefits from education . . . definitely . . . [as] a lot become blasé . . .’ (pharmacist 10), compared with ‘. . . I don't know whether there's any extra benefit . . . they're not listening’ (GP 7) and ‘. . . there is that core element who will not conform, and it doesn't matter what you do. You can take a horse to water but you can't make it drink.’ (pharmacist 6).

With regards to who should be providing specialised support, GPs suggested that practice nurses should do this but as long as the HCP was trained, it could be the pharmacist. Pharmacists suggested all HCPs should be involved and the issue of reimbursement was raised.

For example ‘. . . doctors, nurses even pharmacists play a role, also the government needs to play a role in health care.’ (pharmacist 12). ‘It depends on who gets paid.’ (pharmacist 18).

Barriers to teamwork

GPs and pharmacists were asked about perceived barriers to collaboration. Some GPs didn't identify any barriers, others listed the expected issues; that is, time and poor communication. Several GPs and pharmacists mentioned payment as a potential issue. Pharmacists identified many more barriers which included time and poor communication but also lack of communication, GP attitudes, inaccessibility, lack of familiarity and motivation to interact.

For example ‘doctors are a bit insular, they tend to socialise with each other and that actually carries over to the workplace, that kind of barrier, an invisible barrier . . .’ (pharmacist 1). ‘You can't tell a doctor anything, he can't learn from anybody he's supposed to know it all . . .’ (pharmacist 7). ‘For some doctors, they look down on the pharmacist, they tell you what to do . . . they don't treat you equally. . . .’ (pharmacist 13).

Pharmacists also identified that GPs might feel threatened by pharmacist involvement or that there might be an element of territorialism involved.

For example ‘I went on a conference. . . . It got GPs and pharmacists together, you can see they are not very comfortable being together and in terms of providing health care for the patients, they think we are actually stealing their customers.’ (pharmacist 5).

For example ‘. . . the GPs might feel that they're a little bit under attack because they haven't put their patients on asthma plans, stuff like that.’ (pharmacist 18).

GPs negated this, describing it as their role or responsibility in patient care. Pharmacists recognised this as well.

For example ‘. . . the doctor should lead the team, that's got nothing to do with territorialism, it's . . .  accept[ing] responsibility . . .’ (GP 2). ‘. . . doctors still see themselves as the number one provider.’ (pharmacist 10). ‘For some doctors, they look down on the pharmacist, they tell you what to do . . . they don't treat you equally.’ (pharmacist 13).

Low morale of the GP was reported by some GPs and pharmacists and was clearly identified as a potential barrier to teamwork/improved relationships.

Universally, the patient was also perceived to be a barrier to a team approach.

For example ‘. . . some customers (patients), when you advise them something they never return to the GP or they go to the GP and they might have a different opinion . . . and that's the problem. . . .’ (pharmacist 5), ‘The patient, if they think its too much trouble [to follow your advice] . . . if you talk to the patient they'll say “I don't have time to go see the doctor” that's probably the main problem because they don't see asthma as one of the biggest health problems, even though they're using their puffer four or five times a day . . .’ (pharmacist 12).

Facilitators to teamwork

When it came to facilitators to collaboration, despite most of the HCPs being in close proximity to a GP or pharmacist, proximity was not considered particularly important. For the pharmacist it was more about ensuring they received feedback to help them know where the patient was at, or assist in addressing an issue. Face-to-face communication was seen as a way of ensuring this.

For example ‘. . . maybe a written, a short note from the doctor.’ (pharmacist 11), ‘. . . if you're not getting answers [over the phone] here you can actually go in [to their surgery] . . .’ (pharmacist 11).

Others also mentioned financial remuneration.

Benefits of teamwork

Despite all challenges, GPs and pharmacists felt that a collaborative approach delivered benefits to HCPs and patients. Both GPs and pharmacists felt that patients would benefit with improved asthma control, improved quality of life and reduced morbidity and mortality.

For example: ‘. . . the patients . . . are receiving more and more frequent information, that their asthma is better controlled, that they're getting the same information from multiple sources . . .’ (GP1), ‘. . . the whole concept of . . . better health . . . if we work together as a team the knowledge would get out there a lot quicker . . .’ (pharmacist 7), ‘. . . there would be far less hospital visits . . .’ (pharmacist 11), ‘better control of their asthma, better quality of life. They (the patient) would also have increased access to HCPs or perceived increased access to HCPs, it would also improve their relationship with the doctor and the pharmacist. . . . It might reduce mortality and that is a most desired outcome.’ (pharmacist 18).

Both professional groups believed that pharmacists would benefit with increased knowledge, increased patient rapport, increased professional fulfillment and improved professional image. When it came to benefits to the GP, pharmacists were more likely to see benefits for the GPs, while GPs thought the benefits were greater for the pharmacists, and they had less to gain. Benefits for GPs were perceived to be time savings and pharmacists believed that GPs would benefit with improved patient care delivery, professional relationships and respect from the patient.

For example ‘. . . the advantage is that for the GP we don't have to spend as much time on this sort of topic . . . it's been drummed into them by the nurses, pharmacists, physiotherapists, as well as GPs’ (GP1), ‘it would help the doctor too, because it would increase respect from the patient. Some patients say “oh the doctor just writes you a script”, some patients have got the feeling that the doctor doesn't care anymore . . . if we can help the patient . . . more respect for the pharmacist and the doctor. . . .’ (pharmacist 13).

Discussion

In this study we aimed to investigate the relationships between GPs and pharmacists in the primary care of asthma, in an attempt to further understand the fundamentals associated with these relationships and to identify a process by which these relationships could be further developed. In so doing, this research adds further context to and unpacks the complex interplay between GPs and pharmacists in chronic care management (of asthma) in Australia. Based on the results of this study, the literature and the theoretical framework of Collaborative Working Relationships,[51] a model for the development of collaborative relationships in primary care has been postulated (Figure 1), the relevance and implications of which will be discussed.

Figure 1.

Proposed relationship development between general practitioners and pharmacists in primary care as related to the theory of Collaborative Working Relationships.[15] Asterisks indicate stages in reference [15].

At this stage it is also important to acknowledge that the results of this study will be discussed in light of the strengths and limitations of this research. The strength of this study is that it has resulted in the postulation of a process for achieving collaboration in primary care, which is based on empirical data and a theoretical framework. It advances knowledge in this field, because to date, despite the abundance of data, understanding the process by which practising HCPs can develop collaborative relationships has not been postulated. The limitations of this study are that it focuses on GPs and pharmacists only and that it does not explore disease states other than asthma. Further it should be noted that although the overall response rate was 38%, even though saturation of data was achieved with 18 pharmacists (18/25, i.e. 72% response rate), only seven GPs (7/40, i.e. 18% response rate for GPs) were required to reach saturation of data. As recruitment continued until saturation was reached, it is not clear whether this is reflective of the current flux in the status of pharmacy in Australia (in which pharmacist's roles are evolving over a wide range of chronic and acute conditions) compared with the static status of general practice, or whether it is associated with the particular participants in this study. Further exploration of this model would help to articulate this as well as validate the model.

Despite any limitations, this research adds knowledge to this field of research and dovetails with the current published international literature. The following paragraphs explain the basis of the model postulated in light of this.

At the outset, it is important to recognise that a relationship between GPs and pharmacists in primary care in Australia currently exists. GPs and pharmacists have, overall, a favourable attitude towards one another and believe that ‘collaboration’ can result in benefits. Further, they both recognise that they might have a common barrier in the form of the patient who often presents challenges for both GPs and pharmacists. However, pharmacists and GPs, in particular, appear to have limited understanding/confidence in the breadth of knowledge of their cross-disciplinary colleagues, have differing needs and expectations of one another and even differ in their percepts of patient needs. Therefore, the starting point for our postulated model is Stage 1 of the Collaborative Working Relationships theoretical framework (professional recognition: GPs are aware that the pharmacist is able to provide information to the patient in addition to drug-specific issues).[51]

From this starting point, the results from this research suggest that the need to gain knowledge and understanding of each other's roles through effective communication, is important. The current research suggests that while pharmacists may have thought about the role of different HCPs in asthma management, the GPs have not considered a role for the pharmacist that is beyond medications. The results indicate that GPs would be open to a broader role for pharmacists, if they were confident that pharmacists had received the appropriate training. One way to gain confidence with one another is through interactions.

The extent and means by which interactions occur between GPs and pharmacists may be different at different stages of their relationship; however, having access to one another is obviously extremely important. In this research, a vast majority of participants were in close proximity to the nearest GP or pharmacist, but proximity was not specifically mentioned as an essential element to the relationship. However, pharmacists articulated face-to-face contact as an important enabler of the GP–pharmacist relationship. This is perhaps due to the heightened access/engagement that face-to-face contact provides[52] and the fact that it could be used as a means of ensuring engagement of both HCPs, rather than just ‘access’.

At the centre of the GP–pharmacist relationship was the act and nature of ‘communication’. It is clearly recognised by both HCP groups as an essential part of their relationship. Two clear aspects of communication were evident in this research: the clinical content of the communication and the nature/style of the communication. GPs acknowledged the importance of the clinical content of the communication while pharmacists focused on the more personal aspect of the communication as was displayed in the nature and the style of communication between the HCPs. In both instances, the communication was clearly evaluated by the HCPs (Stage 2: a fragile point in the relationship where roles are being explored and tested) and influenced future development of the relationship. It can be postulated that this particular point in the relationship is critical as the mismatch of expectations observed between GPs and pharmacists (in terms of the relationship, the purpose of communication, their respective roles in patient care, perceptions of the quality of disease management delivered and patient needs) could drive the relationship forwards or backwards. In fact, it might be at this point that the perceived barriers to collaboration, articulated both in this study and in the literature (including territorialism, attitudes, low morale, remuneration and patient engagement) may be most important[17,52–59] (Figure 1).

Despite these challenges, there is a need to look beyond this critical point. In this study, there is some evidence that for a minority of participants their relationship has the potential to progress to a more bi-directional model of communication. This is evidenced in an increase in interdependence; that is, with GPs seeking the advice of pharmacists in their decision-making (Stage 3). This was quite rare; however, it is postulated that at this point trust, good rapport, respect and common goals among the HCPs would be manifest and social interaction could enhance the professional relationship.[60–62] It is at this point that Stage 4 (i.e. commitment to collaboration and mutual cooperation) would occur.

Conclusion

The relationship between GPs and pharmacists in primary care in Australia remains complex and currently the level of collaboration between the two professions is low. There is a mismatch of attitudes and expectations between the two professions with regard to both their relationship and the management of the chronic disease state explored (asthma). However, some of the fundamental characteristics of collaboration, as reported in the literature, do exist to varying extents. With the right process these could potentially be harnessed to further develop professional relationships. This research has used these data and the theoretical framework of the Collaborative Working Relationships to postulate a model for the development of collaborative relationships between GP and pharmacists in primary care. Future research should focus on further developing this model within the primary care setting and across chronic disease management beyond asthma. In future, the further development of this model should be able to inform policy-makers of potentially effective strategies to be used to enhance collaboration in primary care.

Declarations

Conflict of interest

The Author(s) declare(s) that they have no conflicts of interest to disclose.

Funding

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sector.

Ancillary