Patient and public perspectives of community pharmacies in the United Kingdom: A systematic review

Abstract Background The United Kingdom has been at the forefront of enhancing pharmacist roles and community pharmacy services, particularly over the past decade. However, patient and public awareness of community pharmacy services has been limited. Objective To identify and synthesize the research literature pertaining to patient and public perspectives on: existing community pharmacy services, extended pharmacist roles and strategies to raise awareness of community pharmacy services. Search strategy Systematic search of 8 electronic databases; hand searching of relevant journals, reference lists and conference proceedings. Inclusion criteria UK studies investigating patient or public views on community pharmacy services or pharmacist roles from 2005 to 2016. Data extraction and synthesis Data were extracted into a grid and subjected to narrative synthesis following thematic analysis. Main results From the 3260 unique papers identified, 30 studies were included. Manual searching identified 4 additional studies. Designs using questionnaires (n = 14, 41%), semi‐structured interviews (n = 8, 24%) and focus groups (n = 6, 18%) made up the greatest proportion of studies. Most of the studies (n = 28, 82%) were published from 2010 onwards and covered perceptions of specific community pharmacy services (n = 31). Using a critical appraisal checklist, the overall quality of studies was deemed acceptable. Findings were grouped into 2 main themes “public cognizance” and “attitudes towards services” each with 4 subthemes. Discussion and conclusions Patients and the public appeared to view services as beneficial. Successful integration of extended pharmacy services requires pharmacists’ clinical skills to be recognized by patients and physicians. Future research should explore different approaches to increase awareness.


| INTRODUCTION
Health-care organizations find themselves facing new challenges to keep up with growing health-care demands of the public. 1 Many of these challenges are associated with improving the economical, humanistic and clinical outcomes for individuals with long-term conditions. 1,2 These demands have led policymakers to seek alternative ways to optimize the health-care system and enhance patient care.
It has been argued that for health-care services to be more efficiently utilized, all members of the health-care team need to collaborate and reassess their roles and contributions. 3 Better collaboration could reduce medical errors and improve patient outcomes 4 by combining skills, expertise and resources. 5 Community pharmacies are part of the primary care system, yet there has been scepticism about pharmacist collaboration with other health-care professionals due to their isolated roles and the commercial environments in which they operate. [6][7][8] Yet the importance of such integration, particularly with physicians, has now been recognized. 9 In recent decades, the advancement of the pharmacy profession has seen a movement away from a traditional supply function towards more clinically orientated activities. 10 Community pharmacies are the most frequently visited health-care destinations, 11,12 leading policymakers to recognize the importance of extending community pharmacists' roles to meet growing public demands. 11,13,14 This has led to novel reimbursement structures being implemented across many health-care systems, including Australia, Canada, New Zealand and the United States, 15 In England, the revised contracts specify 3 levels of service.
Essential services cover traditional roles such as dispensing medications/appliances, repeat dispensing and signposting whilst advanced services focus on pharmacist medication reviews. Locally commissioned services include a wide range of medication and public health services, such as minor ailments (assessment and management of minor ailments by pharmacists), smoking cessation, lifestyle advice, emergency hormonal contraception, substance misuse, screening and vaccinations. 12,15 Moreover, consultation rooms became mandatory and subject to certain requirements ensuring patient privacy and confidentiality.
In England, there are 2 medication review services, medicines use reviews (MUR) and new medicine service (NMS). Both aim to improve patient understanding and adherence to regular or newly prescribed medication through pharmacist consultations. 17 Similar MUR services exist in Wales 18 and Northern Ireland; 19 Wales also has a Discharge Medicines Review. 20 In Scotland, pharmacists develop and prioritize pharmaceutical care plans as part of the Chronic Medication Service. 21 Comparable services have been developed in other countries such as the medication therapy management in the United States, 22 MedsCheck in Canada and Australia, 23 Home Medicines Review in Australia 24 and Long Term Conditions service in New Zealand, 25 all of which focus on improving patient medication outcomes through pharmacist consultations.
Whilst evidence has demonstrated positive outcomes from community pharmacy services, 26-30 uptake [31][32][33] and awareness 12,34-37 of some of these services have been low. A systematic review of uptake and patient outcomes of remunerated pharmacy services revealed low uptake despite improved clinical and financial outcomes, 16 but this study did not explore patient perspectives. Two systematic reviews covering patient and public views on public health services provided in community pharmacies reinforced low awareness. The earlier review covered publications from 1990 to 2002, 34 including studies preceding the revised UK contractual framework; the other review covered 2001-2010. 12 However, only 9 UK studies reported patient perspectives, and only 4 were within the time frame of the revised pharmacy contract (2005 onwards). All of the above-mentioned reviews focussed on particular service(s) rather than community pharmacy more generally. So insight into reasons for low public and patient awareness and uptake remains limited, yet understanding patient views is important to ensure optimal design and provision of community pharmacy services that meet patients' needs and public expectations.
The UK government has recently announced new plans to innovate community pharmacy services by introducing reward systems for high-quality services, integration funds to improve health-care collaboration and expanding current services to those who need urgent care. 38 In the light of this push to further extend community pharmacy services, it is important to identify how patients and the public view community pharmacy services and pharmacist roles, and whether these have changed due to recent policy changes.
The aim of this article is to review current evidence on patient and public perspectives regarding existing community pharmacy services, extended pharmacist roles and strategies to raise awareness of community pharmacy services in the United Kingdom.

| METHODS
The development and reporting of this review followed the key principles for systematic reviews. 39 Based on the recommendations by Mays et al 40 for synthesizing disparate evidence to inform health-care policymaking, a narrative synthesis was undertaken, to provide a descriptive account of both qualitative and quantitative findings.

| Definitions
In this review, the term "patients" refers to participants who have experienced the service(s) examined whilst "public" refers to participants who may not have experienced service(s).  Table 1).

| Information sources and search
Specific search strategies for each database are provided in Appendix S1. Alterative screening techniques were also employed: reference lists of included studies were scanned and relevant abstracts from UK pharmacy practice conferences published since 2005 scrutinized to explore whether they had been followed up with a full paper publication. The search took place in November/December 2016.

| Data screening
Titles and abstracts were initially screened against the inclusion/ exclusion criteria by the lead author (see Table 2). One or both of the co-authors were consulted where queries arose. Subsequent screening involved full-text application of the inclusion/exclusion criteria.

| Data extraction and synthesis
Data from all included articles were extracted by the lead author and then reviewed with co-authors. The data extracted were collated via a grid to summarize study characteristics (see Table 3): author(s), year of publication, study design, number of participants, type of pharmacy service(s), study aim, key findings and themes. Themes were identified using the following steps: Findings that demonstrated commonality were combined under a potential theme. Potential themes were compared among all studies to identify trends and patterns. Themes demonstrating a trend were collated and further analysed to interpret underlying meanings which were labelled as initial themes and subthemes. The formation of an initial thematic map adapted from Braun and Clarke 41 was used to evaluate the strength and uniqueness of initial themes/subthemes. Any subthemes/themes that were not unique were added to broader subthemes/themes (see Figure 2).

| Critical appraisal
Study quality was assessed using the nine-item checklist developed by Hawker et al 42 for appraising disparate studies, including abstract and title, introduction and aims, method and data, sampling, data analysis, ethics and bias, results, transferability or generalizability, implications and usefulness. Critical appraisal was conducted by the lead author and results discussed with co-authors. Each study was given a rating of "Good" (4), "Fair" (3), "Poor" (2), "Very poor" (1) for each of the 9 items. The total score (min = 9, max = 36) was used to compare quality among studies, and scores for individual items allowed insight into the contribution of components to scores. Studies were not excluded based on quality, but served to critically appraise findings.

| Study selection
A total of 3260 papers were identified for initial screening after duplicates were removed. Following title and abstract screening, 321 papers were assessed for eligibility via full-text reading, with 30 studies included in the review. Manual searching of reference lists identified 4 additional studies ( Figure 1). (n = 13) would not otherwise have been tested. 80% of questionnaire respondents were "very satisfied" and 14% were "satisfied." All felt "very comfortable" or "comfortable" discussing sexual health with the pharmacist. Clients valued the speed and convenience of the service and the friendly, non-judgemental approach of the pharmacist. Confidentiality when asking for the service at the counter was suboptimal. At follow-up, intervention patients were more likely than control patients (P < .01) to rate the service provided by their pharmacist with a higher level of satisfaction, and most intervention patients stated a preference for seeing their physician to discuss their medications, although this was less marked than in control patients (76% vs 85%; P < .01). these and the range of potential pharmacy-based public health services Only 23% considered that pharmacies were the best place from which to seek general health advice, irrespective of frequency of pharmacy use. About 49% of respondents considered general practitioners to be the best source of public health advice, but 23.0% selected pharmacies. There was a general lack of awareness of pharmacy capacity and role in public health. However, most supported the provision of specific services by pharmacies, especially among frequent pharmacy users. Access and long opening hours were the main facilitating factors mentioned, together with pharmacist knowledge. A significant proportion of respondents said they would not use pharmacy as a source of public health advice, due to issues around confidentiality, privacy, space and busyness. Focus groups 20 problematic drug users Problematic drug users To qualitatively explore the feasibility and desirability of further developing community pharmacy services to meet the wider health needs of problematic drug users Many of the service users in the study were not aware of services beyond needle and syringe programmes and substitution therapy. Many service users perceived existing services to be suboptimal especially with regard to privacy, as a major concern. Good rapport between users and regular staff was highlighted as an important factor in good quality services. Pharmacies were consistently identified as having key opportunities to make useful health interventions within a range of therapeutic areas. The most widely supported roles were based around information provision and signposting. was the main concern of the public, but 80% were comfortable discussing alcohol in a pharmacy. Ten service users interviewed all considered the experience positive and all would recommend the service, but most wanted the service to be delivered in a private area.

| Critical appraisal
Using the nine-item checklist, 42

| Thematic analysis
Two main themes emerged: "public cognizance" and "attitudes towards services"; each with 4 subthemes (see Figure 2). These 2 themes were used to characterize patient and public views of community pharmacy services as the former provides insights into expectations from these services whilst the latter focuses on experiences of using these services. Meeting the demands of patients and members of the public requires a better understanding of both expectations and experiences.

| Public cognizance
The theme public cognizance concerned how community pharmacies are held within the mindset of patients and the public. Public cognizance encapsulated the subthemes: "awareness and use of pharmacy services," "perceptions of pharmacists," "physicians' supremacy" and "promotional strategies." Views on pharmacies were influenced by people's awareness and use of existing pharmacy services as well as perceptions of pharmacists' roles in health care. In addition, the comparison of pharmacists to physicians affected views of pharmacy services.

| Awareness and use of pharmacy services
Low public or patient awareness of extended pharmacy services was a common finding. 45,46,48,52,55,58,60,63,[65][66][67][68][69][70][71][72][73][74] The pharmacy setting appeared to be portrayed as a dispensary (medicines supply) and place for medicines purchase 46 as well as advice on minor ailments. 74 Nearly half (48.3%) of participants in one study chose dispensing as the most common reason for using pharmacies followed by the purchase of medicinal (22%) and non-medicinal products (17.7%). 46 In another survey assessing public views, when participants were asked how often they utilized pharmacies for certain purposes, a high proportion rated "always" for dispensing prescriptions (85.1%) and the purchase of medications (79.2%). 55 The public and patients in qualitative studies expressed their unfamiliarity with the range of pharmacy services available 60,65-70,72,73 whilst a survey of the general public indicated low awareness for MUR (18.2%) and NMS (8.6%) services. 55 A study eliciting views of MUR service users discovered a mismatch between their expectations of MUR benefits and those of policymakers. 74 In a study of patients experiencing a pharmacist prescribing service, participants indicated they were unsure about what to expect at the start of the service. 58 Lack of awareness was accompanied by lack of exposure to, or low utilization of, pharmacy services. In a study comparing pharmacy consumers' experiences between Australia and England, only 15.6% (24/155) of English participants had experienced a pharmacy-based programme for weight loss, 52 and few members of the public in another study had experienced any of 7 public health services investigated (2.1%-12.7%). 73 Participants in one study indicated that an influential factor for lack of awareness was pharmacy services not being publicized. 69 In a study piloting a chlamydia testing service, the vast majority of survey respondents would not have tested, or tested elsewhere, prior to the study. 71 Moreover, only one participant in a study preferred the pharmacy as their first choice for

| Perceptions of pharmacists
Patient and public perceptions of pharmacists seemed to influence their preferences for pharmacy-led services. There appeared to be resistance to acknowledge the pharmacist as an essential member of the health-care team. 46,60,68,70 Members of the public rated the importance of pharmacist roles with regard to certain public health issues relatively low in a questionnaire study, whilst activities linked to their traditional roles such as advice on medication usage, side-effects and disposal were rated highest. 46 Women in a study assessing the acceptability of pharmacies providing sexual and reproductive health services questioned whether it was the pharmacist's role to supply emergency contraception. 64 In another, patients expressed their preferences for nurses over pharmacists due to the perception that pharmacists were "behind the counter" health-care staff. 60 In 2 focus group studies, pharmacist roles were perceived to be limited to dispensing and minor conditions. 68,70 Only 1% of patients in a survey chose "trust in the pharmacist" as a reason to visit the pharmacy, 68 yet in another survey, trust in pharmacists was high. 56 Three studies showed that patients and the public were suspicious of pharmacist commercial affiliations and financial motives. 50,57,67 Moreover, concerns were identified regarding the pharmacist's lack of knowledge and training to conduct services beyond dispensing. 50,67,75 However, participants in one study were supportive of pharmacists providing advice, referrals and recommendations. 54 Despite reluctance in supporting pharmacists to carry out extended roles, their expertise in medications was acknowledged. 60,73,75 Participants in pharmacist prescribing studies were generally supportive of, and confident in, pharmacist prescribing roles. 44,47,58,66

| Physicians' supremacy
Whilst the scope of these studies was specific to pharmacies, patient and public perceptions of the roles and standing of physicians influenced their views on pharmacists and pharmacy services. In survey studies, the majority of respondents preferred physicians to pharmacists regardless of the service provided. 43,44,46,54 In a study focusing on public health services, physicians (49%) were preferred to pharmacists (23%), 46 whilst both the intervention and controls (76% and 84%, respectively) in an RCT investigating the effect of a community pharmacy-led medicines management service on patients attitudes preferred physicians for health discussions and enquiries. 43 Regarding prescribing, 65% of patients would prefer to consult a doctor 44 and 78% of participants in another study preferred to discuss alcohol consumption issues with physicians. 54 In contrast, the participants in one survey indicated a preference for pharmacists (69%) over physicians (25%) regarding medication advice 55 and 97% in another survey preferred pharmacists regarding prescribing. 49 Physicians were viewed as superior to pharmacists in knowledge and training, 50,60 and their perceived authority affected patients' views on pharmacists making medication recommendations. 57 This hierarchical portrayal created a division for patients between both healthcare providers, with physicians considered for diagnostic roles and more serious conditions whilst minor issues were deemed more suitable for pharmacists. 66,74 In 2 studies, this hierarchical structure led to increased accessibility of pharmacy services, as patients preferred to see the pharmacist when conditions were perceived to be not serious enough or worthy of physicians' time. 61,63 Of particular interest was how the dynamics of the patientphysician relationship influenced the patients' perceived need of pharmacists. Good relationships or experiences with physicians reduced the need to seek pharmacist advice and vice versa. 68 In one study, the physicians' influence extended to the point that patients required physicians' authorization or recommendation to convince/reassure them to utilize pharmacy services. 68 In fact, members of the public in one study claimed that their trust in pharmacists would be inspired by physicians' confidence in pharmacists. 67 Even if the pharmacist was accessed as the first port of call, their advice required physicians' confirmation before being acted upon. 68 Similarly, the majority of members of the public in one study preferred a general practitioner to supervise and review pharmacist prescribing. 50

| Promotional strategies
Despite numerous studies showing a lack of awareness for pharmacy services, there was a shortage of studies discussing strategies that could effectively promote pharmacy services. Only 2 papers (by the same author) elicited public views regarding effective promotional schemes. 56,69 One questionnaire-based study demonstrated word of mouth to be the most effective promotional strategy, either from a health-care professional, or family members or friends. 56 Focus group discussions with members of the public did not reveal specific preferences but identified various approaches that could enhance service utilization such as posters, media and physicians' support. 69

| Attitudes towards services
The theme "attitudes towards services" pertained to the actual service experience and covered 4 subthemes: "service vs non-service users," "perceived impact," "facilitators" and "barriers." Patient and public attitudes were influenced by frequency of service usage and the perceived impact or benefit from using these services. Utilizing pharmacy services was associated with a number of facilitators and barriers which affected preferences for using such services.

| Service vs non-service users
The extent of support for pharmacy services was dependent upon the frequency of their usage by patients. More frequent service users tended to favour extended pharmacy services and revealed more support for pharmacists performing numerous different roles. Six surveys that measured this all demonstrated that patients more acquainted with the pharmacy setting were more supportive of extended pharmacy services. 43,46,48,52,55,73 Four of these studies compared more frequent users to less frequent users 46,52,55,73 whilst the other 2 compared service users to non-service users. 43,48

| Perceived impact
The majority of studies suggested that patients and members of the public perceived pharmacy services to be beneficial. With the exception of one study, 65 most participants were positive and satisfied with pharmacy services. 43,44,48,49,57,61,65,66,71,72 Of specific interest was how services were perceived to be beneficial. Pharmacy services provided reassurance for patients in some studies. 57,74 Patients in another study believed that pharmacist discussions boosted their knowledge and confidence in medication usage which consequently enhanced future patient-physician discussions. 61 Another perceived benefit was that pharmacists provided assessments whether patients required visits to the physician. 61,62 In some studies, patients simply appreciated having an alternative source of information available to them. 57,64,68 Open-ended comments in a survey revealed that patients believed medicines optimization services had enhanced their appreciation of pharmacists' knowledge and understanding. 55 Conversely, negative remarks in some studies involved pharmacy services being perceived as unnecessary 57 since physicians provided all the information patients needed. 74

| Facilitators
This subtheme focused on the features that enhanced the use of pharmacy services from the patient and public perspective. Ease of access and convenience were the most commonly mentioned advantage accredited to pharmacy services. 44,[46][47][48][49][50]54,60,62,65,[67][68][69][70]72,73,75 Participants in 3 of these studies made specific reference to the non-appointment based nature of community pharmacies. [61][62][63] In 2 surveys, most respondents selected access and convenience as the main reasons for accessing pharmacy services. 51,53 The open-ended questions in 3 other surveys 46,48,50 as well as a nominal group discussion 72 also identified access and convenience as the most advantageous aspect.
Pharmacists' professionalism was also influential to patients' satisfaction and was attributed to them being friendly, approachable, nonjudgemental and possessing excellent communication skills. 57,66,71 Pharmacists' mannerisms were seen as the cornerstone of building the patient-pharmacist relationship, 63 Other less commonly mentioned advantages in studies were signposting and referral, 65 service quality, 58,75 collaboration with physicians. 47,50 Older people in one study indicated preference of independent pharmacies over large pharmacy chains. 70
In addition, 2 studies revealed the specific dissatisfaction of service users with supermarket pharmacies in terms of privacy. 56 55 Participants in 2 further studies revealed low awareness of private consultation rooms 63,68 whilst members of the public in another study avoided using them as they associated their usage with substance misuse services. 67 Interestingly, participants in 2 studies mentioned the lack of use or availability of private rooms. 65,69 Participants in one study argued that privacy remained an issue even when using consultation rooms. 59 In contrast, patients in one pharmacist prescribing study were aware and reassured by the presence of private rooms. 50 In several studies, participants perceived the pharmacist's lack of access to medical records, 50 [66][67][68][69] which may lead to a lack of continuity for service provision. 69 Lack of continuity was also raised as a barrier in another focus group study suggesting that pharmacy services were not always conducted by the same staff which reduced patient-pharmacist rapport and confidentiality. 73

| DISCUSSION
To the authors' knowledge, this is the first systematic review that has focused on patient and public perspectives specific to UK community pharmacy services. The past decade has seen the initiation of novel services and extended roles within a revised community pharmacy contractual framework. This review focused on gaining a deeper understanding of how these recent policy changes may have influenced patient and public views. Findings will also help to identify barriers to providing community pharmacy services which effectively meet patients' needs, enhancing recommendations to policymakers.
The current review builds upon and extends the findings of 2 previous systematic reviews. 12,34 There was similarity with these earlier reviews in that the perceived impact of pharmacy services was high despite low awareness. However, the current review provides a detailed account of the factors facilitating the use of pharmacy services and physicians' influence on the public's view of pharmacy services. In addition, the current review has provided evidence specific to MURs, the NMS and pharmacist prescribing, none of which have been explored previously. Furthermore, the substantial increase in qualitative studies within the last decade allowed for a comprehensive understanding and description of findings in this review.
This review focused on the United Kingdom, which was effective in reducing studies to those conducted in a single administrative and organizational context. However, this served as a possible limitation in that other countries may have provided pertinent findings, particularly ones with similar advancements in community pharmacy such as the United States, Canada, Australia and New Zealand. Another limitation was the omission of independent multiple-author study selection and data extraction to reduce bias. However, data extraction was reviewed and discussed thoroughly with the co-authors. Although not an exclusive community pharmacy role, the perceptions of pharmacist prescribing provided additional depth to the review and were applicable to community pharmacy services more generally.
International literature addressing the first theme, "public cognizance," confirms that low public awareness is not exclusive to the United Kingdom. [77][78][79][80][81][82][83][84][85][86] The considerable lack of awareness of extended pharmacy services and pharmacist roles suggests that more could be done to promote the pharmacy setting as an attractive venue for health-care delivery. Nevertheless, little has been done in the way of promoting pharmacy services or enhancing public understanding of pharmacists' knowledge and skills. 69,87,88 In relation to promotional strategies, patients in a Canadian study perceived word of mouth from pharmacy staff as the most effective method 77 which correlated with findings in this review. 56,69 However, international literature exploring effective promotional methods is also lacking. Moreover, pharmacists' low confidence or unwillingness to perform non-traditional roles, together with the belief that balancing dispensing duties with extended services is unachievable, 6,8,12,69,89,90 also needs to be addressed.
Perceptions of physicians being at the top of the health-care hierarchy were also common in other countries, including Australasia, 84 North America, 78 Europe 91 and Middle East. 82 This is borne out in evidence where physician-pharmacist collaboration in clinical settings has been shown to significantly improve patient outcomes. [92][93][94][95] However, physicians have shown a reluctance to support pharmacist integration due to their unawareness of extended services. 90,96,97 Moreover, physicians believe that clinical roles are better suited for themselves, 98,99 that pharmacists lack the training or ability to carry out extended roles, 6,78,99 and have suspicion of pharmacists' financial motives. 99 Physicians have also been concerned that extending pharmacist roles and granting them more access to patient information would compromise patient confidentiality 99 and threaten physicians' health-care authority. 8,99 In order to achieve better recognition and integration of physician and pharmacy services, it will be crucial to develop a better understanding of each other's knowledge, skills and potential contribution to patient care. In England 105 has gone some way to overcoming this, integration within the wider primary care team remains crucial.
The introduction of "summary care records," a scheme introduced in 2016, 106 which permits a range of health-care professionals, including pharmacists and pharmacy technicians, to access core clinical and medication information, with the patient's consent, may prove to be another important step towards integration and autonomy.

| CONCLUSION
This systematic review provides an update of patient and public perceptions of community pharmacy services since the introduction of a revised contractual framework for community pharmacy in the United Kingdom, which introduced funding for cognitive services.
Whilst the majority of literature suggests that patient and public opinions about community pharmacy services are positive, awareness of pharmacy services beyond medicines supply remains low.
Patients still look to their physicians, so successful integration of pharmacy services into the primary care pathway will be essential.