Tesis doctoral
Departament de Medicina
Barreres i facilitadors de la comunicació i la col·laboració entre el metge d’atenció primària i el farmacèutic comunitari
Anna Maria Jové Massó
Directors Dr. Carlos Martín Cantera i Dra. Maria Rubio Valera Barreres i facilitadors de la comunicació i la col·laboració entre el metge d'atenció primària i el farmacèutic comunitari
Tesi doctoral
Anna Maria Jové Massó
Directors: Dr. Carlos Martín Cantera i Dra. Maria Rubio Valera
Programa de doctorat en Medicina
Departament de Medicina
Facultat de Medicina
Universitat Autònoma de Barcelona
Barcelona, juny de 2014
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4.2.2 Percepció neutra de la utilitat de la col·laboració...... 114
4.2.3 Percepció positiva de la utilitat de la col·laboració...... 114
4.2.3.1 Percepció positiva de la utilitat de la col·laboració a nivell del Sistema Sanitari...... 115
4.2.3.2 Percepció positiva de la utilitat de la col·laboració a nivell dels professionals...... 120
4.2.3.3 Percepció positiva de la utilitat de la col·laboració a nivell dels pacients ...... 122
4.3 Diferències en el discurs entre els MAP i els FC, entre Comunitats Autònomes i entre els professionals amb i sense experiència en col·laboració (objectiu secundari)...... 123
5 DISCUSSIÓ...... 125
5.1 Fortaleses i limitacions...... 127
5.1.1 Fortaleses...... 127
5.1.2 Limitacions...... 127
5.2 Resultats més rellevants i comparació amb d’altres estudis...... 129
5.2.1 Percepció d’utilitat...... 130
5.2.2 Opinió recíproca...... 134
5.2.3 Factors que canvien les opinions negatives...... 136
5.2.4 Assoliment dels objectius...... 139
5.2.5 Factors que influeixen en l’assoliment dels objectius...... 140
5.2.6 Altres factors rellevants de la col·laboració...... 142
5.3 Estratègies per a la col·laboració entre MAP i FC...... 145
5.3.1 Estratègies per a iniciar la col·laboració...... 145
5.3.2. Estratègies per a mantenir la col·laboració...... 146
5.3.3 Altres estratègies...... 146
6 CONCLUSIONS...... 147
REFERÈNCIES...... 153
ANNEX I: Protocol de treball per a les entrevistes individuals semiestructurades a metges d’atenció primària i a farmacèutics comunitaris...... i
ANNEX II: Publicacions derivades d'aquest estudi...... xi !"#$%&#$&).,/$-
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BMC Health Services Research 2012, 12:188 http://www.biomedcentral.com/1472-6963/12/188 RESEARCHARTICLE Open Access Factors affecting collaboration between general practitioners and community pharmacists: a qualitative study Maria Rubio-Valera1,2*, Anna Maria Jové2,3, Carmel M Hughes4, Mireia Guillen-Solà2,5, Marta Rovira2,5 and Ana Fernández1,2 Abstract Background: Although general practitioners (GPs) and community pharmacists (CPs) are encouraged to collaborate, a true collaborative relationship does not exist between them. Our objective was to identify and analyze factors affecting GP-CP collaboration. Methods: This was a descriptive-exploratory qualitative study carried out in two Spanish regions: Catalonia (Barcelona) and Balearic Islands (Mallorca). Face-to-face semi-structured interviews were conducted with GPs and CPs from Barcelona and Mallorca (January 2010-February 2011). Analysis was conducted using Colaizzi’s method. Results: Thirty-seven interviews were conducted. The factors affecting the relationship were different depending on timing: 1) Before collaboration had started (prior to collaboration) and 2) Once the collaboration had been initiated (during collaboration). Prior to collaboration, four key factors were found to affect it: the perception of usefulness; the Primary Care Health Center (PCHC) manager’s interest; the professionals’ attitude; and geography and legislation. These factors were affected by economic and organizational aspects (i.e. resources or PCHC management styles) and by professionals’ opinions and beliefs (i.e. perception of the existence of a public-private conflict). During collaboration, the achievement of objectives and the changes in the PCHC management were the key factors influencing continued collaboration. The most relevant differences between regions were due to the existence of privately-managed PCHCs in Barcelona that facilitated the implementation of collaboration. In comparison with the group with experience in collaboration, some professionals without experience reported a skeptical attitude towards it, reporting that it might not be necessary. Conclusions: Factors related to economic issues, management and practitioners’ attitudes and perceptions might be crucial for triggering collaboration. Interventions and strategies derived from these identified factors could be applied to achieve multidisciplinary collaboration. Keywords: Interprofessional Relations, Family Physicians, Pharmacists, Qualitative Research Background GPsandCPsisacauseofpreventable hospital admissions General practitioners (GPs) and community pharmacists [7]. However, during the implementation of a trial evaluat- (CPs) are encouraged to collaborate to improve patient care ing a complex intervention [8] we realized that GPs and [1,2] Pharmacists’ interventions within the healthcare team CPs had difficulties communicating with each other. Des- improve patient outcomes in physical [3-5] and mental con- pite working in the same geographical area and sharing ditions [6]. On the other hand, miscommunication between patients, some doctors and pharmacists used the study re- searcher to transmit information to the other professional * Correspondence: [email protected] or to obtain additional information about the participants. 1Research and Development Unit, Fundació Sant Joan de Déu, Calle Picasso Surveys have been conducted exploring this issue, 13, Sant Boi de Llobregat, Barcelona 08830, Spain 2Red de Investigación en Actividades Preventivas y Promoción de la Salud pointing out that exchange characteristics (i.e. trust- (RedIAPP), Barcelona, Spain worthiness or role specification) are the factors most Full list of author information is available at the end of the article © 2012 Rubio-Valera et al.;licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Rubio-Valera et al. BMC Health Services Research 2012, 12:188 Page 2 of 10 http://www.biomedcentral.com/1472-6963/12/188 frequently associated with GP-CP collaboration [9,10] but [17,18] which could affect the organization of primary quantitative work provides only a limited understanding of care health centers and pharmacies as well as the way in what promotes collaboration. Qualitative studies may which collaboration is manifested between GPs and CPs. untangle some of the deeper reasons preventing such col- Table 1 summarizes the main characteristics of Spanish laboration [11]. Qualitative work has been conducted in primary care, comparing the organization of the PCHCs the UK, Australia and USA to explore factors affecting and the pharmacies. GP-CP collaboration [12-15]. These qualitative works high- The aims of this study were: 1) to identify and analyse lighted the fact that professionals from each discipline were barriers and facilitators in collaboration between GPs not personally acquainted, territoriality, and the pharma- and CPs in Spain and 2) to explore whether differences cist’s conflict of interest with regard to selling medications exist between GPs and CPs based on the geographical re- as the barriers that most affected mutual trust and respect gion where they work and previous experience of between practitioners, thus impeding collaboration. Some collaboration. of these studies explored the factors affecting collaboration in areas where multiple chain pharmacies and single inde- Methods pendent pharmacies coexisted, reporting higher distrust Adescriptive-exploratoryqualitative study using face-to- and lack of interest among GPs towards collaboration with face, semi-structured interviews (January 2010-February chain pharmacists. However, the impact on collaboration 2011) was undertaken using a phenomenological approach. of publicly funded and privately managed PCHC in com- The study population comprised GPs and CPs from 2 parison with publicly funded and publicly managed PCHCs Spanish regions: Catalonia (Barcelona) and the Balearic has not been previously assessed. Nor did these studies ex- Islands (Mallorca). Commitment to primary care is plore the perception of the Primary Care Health Centers higher in Catalonia than in Balearic Islands and there is (PCHC) managers or the impact on the GP-CP relation- a greater investment of resources in primary care with ship of external agents that participate in the process such respect to total health expenditure [18] Consequently, in as the patient and the pharmacy assistant. comparison with Balearic Islands, there is a higher dens- Differences between the health systems and the model ity of PCHCs, a lower ratio of patients per GP, a greater of community pharmacy require a country-specific study number of services integrated within primary care (i.e. in Spain. The Spanish national health system (NHS) is dentistry) and better access to diagnostic procedures by publicly funded. The organization and provision of GPs in Catalonia. A further important difference be- health services depends on each of the 17 regional gov- tween the regions is the coexistence of the private and ernments through which Spain is governed [16]. This public model in Catalonia, which is reflected in the generates differences in health policies between regions presence of "Entidades de Base Asociativa” (EBAs) (see Table 1 Summary of the main characteristics of the PCHC and community pharmacies in Spain Primary care health centers Community pharmacies Owner Predominantly state-owned Privately owned (the pharmacy owner must be a licensed pharmacist and each pharmacy may own only Every PCHC contains several GP surgeries with few exceptions one pharmacy) in rural areas of Spain Funding Publicly funded Offers both publicly funded services (i.e. drugs that are financed by the state) and privately funded services (i.e. over the counter drugs) A large part of the profit derives from selling financed drugs. Management Predominantly publicly run (the manager is one of the GPs from Privately run (usually by the owner) the PCHC team that combines clinical activities with management activities) In some regions, privately managed PCHCs exist. This is the case with the "Entitades de Base Asociativa" (EBAs). EBAs are limited companies comprised of health professionals that establish a contractual relationship with the NHS to offer health services in exchange for capitation financing, a theoretical cost per person independent of the real costs incurred. Compensation Most GPs are employed by the public sector and receive fixed CPs are owners of the community pharmacy or salaries. employed in exchange of a fixed salary. Management by Objectives (MBO) has been introduced to improve quality of the service and reduce cost. For instance, GPs are paid a bonus if they prescribe a high percentage of generic drugs and/or those of proven efficacy. Rubio-Valera et al. BMC Health Services Research 2012, 12:188 Page 3 of 10 http://www.biomedcentral.com/1472-6963/12/188 Table 1) that do not exist in the Balearic Islands. In both Participants were recruited until each theorized cat- regions management by objectives (MBO) is used. The egory (professional group, previous experience and re- MBO system gives GP incentives (usually financial) if gion) independently achieved saturation of thematic they fulfill the objectives set by the health system (i.e. findings. prescription of drugs of proven efficacy). Electronic pre- Interviews were conducted in a place of convenience for scribing links the GP’s prescriptions with the community the participant by AMJ (GPs from Barcelona), MRV (CPs pharmacists and acts as a communication channel be- from Barcelona), MG (GPs from Mallorca) and MR (CPs tween the two professionals. The implementation of from Mallorca). The interview guide was developed by a electronic prescribing in the Balearic Islands began team of researchers and clinicians including AMJ, AF and in 2006, long before its introduction in Catalonia. By MRV taking into account their experience in the field as the time we conducted the study interviews, elec- well as the results of the only paper that had been pub- tronic prescription had long been established in the lished at the time the study was designed [13]. The inter- Balearic Islands while in Catalonia only GPs and CPs view guide was piloted with one GP and one CP. The from some areas were using it, primarily in rural interview guide is summarized in Table 2. Interviews were areas and small cities. In Barcelona, it was in the im- audiorecorded, fully transcribed and anonymized. plementation stage. In parallel with interviews, analysis assisted by Atlas-ti We also considered whether recruited practitioners software was conducted. The information obtained was had previous experience of collaboration (defined as hav- triangulated by the participation of three investigators [a ing had regular face-to-face contact with the other group GP (AMJ), a pharmacist (MRV) and a psychologist with of professionals). We theorized that practitioners from experience in using qualitative research (AF)] who inde- different regions and those with previous experience pendently analyzed the interviews [11]. In the Mallorca compared with those with none would have different interviews, a fourth analyst participated [a nurse and opinions towards collaboration thus maximizing the pos- sociologist (MG) from Mallorca]. sibility of finding disconfirming cases (theoretical sam- Analysis was conducted using Colaizzi’s method for pling [11]). analysis [20]. The following is a complete description of The PCHC manager in Spain is usually a GP from the the procedure. The process of generation of categories team of physicians who combines clinical work with the was largely inductive. Researchers became familiar with management of the PCHC. While in charge, the manager the interviews by listening, reading and re-reading them. officially represents the PCHC and he/she administers Themes were identified and coded independently by the human and financial resources allocated to the health each of the researchers involved in the analyses. center. Consequently, the PCHC manager is responsible Researchers then came together to compare and discuss for distribution of the resources necessary for collabor- differences in the analyses. Themes were then re-coded ation with the CP. Some of the GPs interviewed had ex- and classified, identifying common patterns and conver- perience as managers of the PCHC. gences and divergences in data through a process of con- We contacted key informants from the fields of pri- stant comparison. With the assistance of a fifth mary care (PC) and community pharmacy in Barcelona researcher, a pharmacist with experience in undertaking and Mallorca [the College of CPs, the Research Network qualitative research and collaboration between pharma- on Preventative Activities and Health Promotion cists and GPs (CMH), findings from the analysis were (RedIAPP) in PC and the School of Pharmacy-University integrated to formulate a theoretical model for the of Barcelona] to identify those professionals who phenomenon under investigation. Finally, respondent matched our sampling criteria. It was explained to the validation was conducted, comparing our interpretation key informants that we were seeking professionals with of the phenomenon with those who had participated. experience of collaboration so that we would be referred Participants were sent a summary of the findings and to professionals whom we knew in advance would take invited to a meeting where findings were presented and part. Thereafter, practitioners were contacted by tele- discussed. Fourteen out of thirty-seven professionals par- phone and invited to participate. At this time we estab- ticipated in this validation. Changes suggested by partici- lished a time for the interview but did not explain the pants were incorporated into the final description of the study objective in detail. We did, however, ask them phenomenon. some brief questions, including whether they collabo- In order to guarantee the validity of this research rated with any other health professionals. Once inter- [11,21] the study was externally audited from the begin- viewed, participants were asked if they knew other ning to its conclusion by a group of researchers from practitioners who matched our criteria (snowball sam- the "Qualitative Health Research Group" (led by Dr pling [19]). One general practitioner declined to Vázquez ML) of the "Consorci de Salut i Social de Cata- participate. lunya". Interviewers and main analysts kept a personal Rubio-Valera et al. BMC Health Services Research 2012, 12:188 Page 4 of 10 http://www.biomedcentral.com/1472-6963/12/188 Table 2 Topic guide for the interview Topic guide Suggested questions to help the interviewer Relationship nowadays How is your relationship with the CP/GP? - If there is no relationship: Why do you think that there is no relationship? - If the relationship is good/bad/regular: What do you think that makes the relationship good/bad/regular? Utility of the collaboration Do you think that it would be useful to potentiate the teamwork between the GP and CP? Why? What advantages do you see in working in collaboration with the CP/GP? And what disadvantages do you see in collaborating with the CP/GP? Opinion about the other What do you think about the CP/GP? group of professionals How do you think that CP/GPs see GP/CPs? Barriers for communication If you tried to get in contact with the CP/GP at any time, what difficulties did you have? You told me that when trying to get in contact with the CP/GP you had problems because... can you think of any others? Barriers for collaboration What do you think makes collaborative work difficult? Facilitators for communication What steps do you think could be taken to improve communication with CPs/GPs? Facilitators for collaboration How do you think collaborative work could be promoted or strengthened? Impact from the National Health Is there any aspect in the organization of the health system that you think is affecting the System relationship between GPs and CPs? In what sense? GP = General practitioner; CP = Community pharmacist. research diary in which any reactions to events occurring of the theoretical model were central in facilitating or during the research were recorded. All participants gave impeding the initiation of collaboration between the two informed consent and the study was approved by the professions. Foundation Sant Joan de Déu Clinical Research Ethics During collaboration, a successful relationship between Committee. doctors and pharmacists has been established and the Results Table 3 Characteristics of the participants A total of 37 interviews were conducted that lasted 5–99 minutes (mean: 23 minutes) (Table 3 shows the sample Characteristics of participants (n = 37) Barcelona Mallorca characteristics). Nine GPs and nine CPs had had previ- General practitioners, n 99 ous experience in collaboration with the other group of Sex, n professionals and 4 of the GPs belonged to an EBA. Male 6 4 In the group of participants with previous experience Female 3 5 the collaborative experiences differed from one another. Mean age (range), years 48.7 (35–60) 47.6 (37–60) Some examples of activities were: interdisciplinary pro- Mean clinical work experience 21.8 (8–31) 19.6 (8–30) fessional training, detection and resolution of medication (range)*, years related problems, carrying out tests or clinical analysis Previous experience in GP-CP (e.g., glycemia) at the pharmacy for patients who require collaboration, n regular monitoring, rationalization of expenses, special With previous experience 4 5 care for people with mobility problems, personalized Without previous experience 5 4 medication dosage system (weekly blister packs for Community pharmacists, n 10 9 patients taking a variety of medications) and public Sex, n health education, and so on. Male 4 4 Female 6 5 Factors affecting GP-CP collaboration Mean age (range), years 50.4 (30–64) 47.7 (29–56) The factors affecting the relationship varied depending on Mean clinical work experience 23.7 (5–40) 17.2 (1–30) the timing in relation to the collaboration: 1) Before col- (range), years laboration started (prior to collaboration) and 2) Once the Previous experience in GP-CP collaboration had been initiated (during collaboration). collaboration, n Prior to collaboration, GPs and CPs worked on their With previous experience 5 4 own. This first phase was a process of team-building that Without previous experience 5 5 allowed collaboration to begin. The factors identified * Three general practitioners from Barcelona and four from Mallorca also had assigned to this first stage in the process of generation experience as Primary Care Health Center managers. Rubio-Valera et al. BMC Health Services Research 2012, 12:188 Page 5 of 10 http://www.biomedcentral.com/1472-6963/12/188 factors affecting that relationship changed. The challenge we look for something more we will have problems. from this point on is to maintain and consolidate collab- [CP2: Community pharmacist without experience in oration to ensure continuity. collaboration from Barcelona (CP WO BCN)]. Practitioners from the group which had experience of collaboration provided data which was rich in the identifi- However, participants stated that there were some fac- cation of collaboration facilitators. GPs and CPs without tors that could influence a positive perception of useful- experience who had tried to collaborate without success ness. GPs and CPs with previous experience reported that provided information about barriers which prevented or evidence supporting positive outcomes of collaborative limited collaboration. Finally, GPs and CPs without experi- GP-CP relationships could make professionals change ence who had never engaged in collaboration reported bar- their mind about collaboration. Similarly, professionals sta- riers related to attitudes and preconceived perceptions. ted that sometimes the NHS introduced strategies that affected both groups of professionals, e.g., the introduction Prior to collaboration of electronic prescribing, which could force a collaboration Prior to the process 4 key factors were identified which to start. affected collaboration: A) perception of usefulness, B) PCHC manager’s interest, C) attitude, and D) geography But thanks to electronic prescribing, given that just like and legislation. Figure 1 shows the conceptual model of any implementation of a system in which we are forced factors affecting the initiation of the collaborative rela- to work together ... has forced this exchange, this tionship between GP and CP. feedback with the medical team ... we have established a series of courses of action with the aim of Perception of usefulness having more fluid communication to solve this A positive perception of usefulness was necessary in problem. [CP10: Community pharmacist with order to start the collaboration. Conversely, the percep- experience in collaboration from Barcelona (CP W tion of usefulness was negative when GPs and CPs BCN)] believed that there were no advantages in collaborating or that collaboration would cause problems. Only profes- PCHC manager interest sionals without previous experience from Barcelona To collaborate it was necessary that the PCHC manager thought that collaboration would be troublesome. was interested in promoting collaboration. I think we shouldn’t tamper with it (the relationship I think that a lot depends on the will of the manager of with the doctor) because I think that it’s correct ... if the PCHC; whether the manager of the PCHC is in Figure 1 Factors affecting collaboration between general practitioners and community pharmacists prior to collaboration. PCHC: Primary Care Health Center; EBA: type of privately managed PCHC; GPs: General practitioners; CPs: Community pharmacists. Rubio-Valera et al. BMC Health Services Research 2012, 12:188 Page 6 of 10 http://www.biomedcentral.com/1472-6963/12/188 favor or not. So far I have had a PCHC manager sometimes the other professional was performing tasks against (cooperation). Now they have changed this and that should not be done by him/her. This concern was she is already waiting for me. [CP1: CP WO BCN] generated by the fact that the roles of professionals were not well defined. The interest of the PCHC manager was influenced by his/her own perception of usefulness and by the initial cost We have the experience of seeing a productive cough, a in terms of infrastructure and human resources required dry cough, some mucosity. I think we can recommend to trigger the collaboration. EBA-type PCHCs in Barcelona a medication ...a doctor will tell you: “but well, we were a good example of this (see Table 1). GPs and CPs are doctors and it is us who have to (prescribe)” and, suggested that collaboration was easier for two reasons: well, he/she is right, on the one hand they’re right, but because the PCHC manager would be interested in collab- where is the line where we end and the doctor begins, oration as a strategy to reduce costs and improve out- you know? [CP7: CP WO BCN] comes for the center and because these PCHCs had smaller teams which were easier to coordinate. GPs and CPs believed that patients generated conflict by relaying biased information or directly criticizing pro- The advantage of centers like this (EBA) is that this fessionals. health center is a small center. ... There is more flexibility and greater speed when we want to get a (The patient) is a tell-tale (laughs). Sometimes they project going. [GP8: General Practitioner with also tell lies, you know? ...They tell lies to both groups experience in collaboration from Barcelona (GP W (the doctors and the pharmacists). This is also true, BCN)]. eh? They are blackmailers, they blackmail to get what they want. [CP6: CP W BCN] A barrier influencing the manager’s interest was the per- ception that the NHS did not incentivize collaboration. Pharmacy assistants created conflict by assuming roles of the pharmacist. This affected quality of patient care Attitude of the professionals and the relationship with the doctor, who preferred to Attitude was strongly influenced by opinions held communicate with the pharmacist. about the other professional. A good opinion would lead to respect and trust; key factors for collaboration. For some years, anybody could start off being the A negative opinion might be due to the perception pharmacy guy (pharmacy assistant) ... He then started that a “public-private” conflict existed. GPs and CPs dispensing and ends up putting on a white coat and believed that, through MBO (see Table 1) doctors finally he acts as a pharmacist ... the boss, the were encouraged to prescribe cheaper drugs and less licensed pharmacist, he is almost always there but if of them while the pharmacist, through selling medica- he/she is not there, and I need to talk about something tions, had a greater interest in non-rational use of and I need his/her knowledge [GP8: GP W BCN] medicines. However, the view about the other profession changed (Pharmacists must think) that we are forced by the when practitioners knew each other. Stigmatized views health policies that reward or punish some prescription and conflicts were resolved. styles ...There are many doctors that (say) “I’m not giving (prescribing) this, do you know why? Because I’ll The main advantage when collaboration is established get into trouble, because they’ll penalize me”...They is that it breaks a series of stereotypes that exist from (CP) must think, “Here, it’s my money that’s at stake, the doctor towards the pharmacist, that there is because I have a business and the doctor is a state intrusiveness, this or that... and the opposite, from the employee and nothing’s going to happen to him/her pharmacist towards the doctors, that they are and he/she doesn’t care.”... And they must compare arrogant, that they do this or that, all these things stop this difference of their feeling of responsibility, that they when two professionals with similar knowledge, or even have a business and they must pay a salary to their a similar age, see each other, a lot of barriers are assistants, that there are things to pay for. They have broken. [CP16: Community pharmacists with an element of the entrepreneur that we don’t have. experience from Mallorca (CP W MLL)] [GP8: GP W BCN] Another factor that may contribute to improving the Overlapping responsibilities generated a negative opin- physician’s opinion of the pharmacist is the existence of ion of the other professional. GPs and CPs believed that shared goals to improve service, preferably if they are Rubio-Valera et al. BMC Health Services Research 2012, 12:188 Page 7 of 10 http://www.biomedcentral.com/1472-6963/12/188 clinical. Put bluntly, GPs and CPs felt that collaboration In the current system, pharmacy income is mainly cen- was only possible if the pharmacists involved in the team tered on the payment for dispensing medications. were highly trained and clinically competent. Pharmaceutical care services which do not involve the Initiating collaboration involved extra work for these busy sale of medications are, therefore, not remunerated so professionals who received no additional remuneration for that doctors and pharmacists think that the system pro- it. GPs and CPs stated that their attitude would be even motes an economic conflict of interest that makes it dif- worse if the NHS forced them to collaborate without releas- ficult for the pharmacist to collaborate on clinical tasks. ing them from other duties or offered economic incentives. What we want is what is right for the patient. And, of To attend to a patient, time is needed and this time is course, earn our living with the medications ... if only also money. And trained people are needed. For they paid me differently. That is a problem. I mean, I training, time and money are needed, you see? think that a problem that our relationship could have Everything until now has been paid by the pharmacist (the doctor with the pharmacist) is the idea that the him/herself. ... If fewer human resources are available, doctor has that the pharmacist makes a profit from the then somewhere we will have to make cuts. [CP10: CP medication. And I think that, well, we are earning a W BCN] living, of course, and at the moment we earn a living with medications. It’s a handicap we have. [CP4: CP Geography and legislation WO BCN] Legislative and geographical factors had the potential to increase the effort required to coordinate collaboration, Some doctors and pharmacists suggest that one pos- which in turn also affected the professionals’ attitudes. In sible solution is a change in the organization of the phar- poorly defined geographic areas with no clear neighbor- macy, integrating it into the health center itself. hood divisions, there were a large number of pharmacies and/or some of them were far from the PCHC. By law, One possible solution which is not totally unviable is to patients can choose any pharmacy to fill their prescrip- create pharmacies inside the health center. So that tion and can switch from one to another in successive there is a pharmacy service like there is in the visits, making collaboration difficult. Therefore, profes- hospitals. ... De-privatize the pharmacies. [GP17: GP sionals felt that working together was easier in small W MLL] areas or when pharmacists in the area worked together and coordinated the delivery of services between them. During collaboration Once collaboration had successfully started, the factors What happens is that I have the advantage that I am that influenced the relationship changed. Two key fac- in a basic unit where I have a single reference tors were identified at this stage: A) achievement of pharmacy. So, of course, there is only one pharmacy objectives and, B) change in the PCHC management. with which I have regular contact ... which is a very Figure 2 shows the relationship between the factors big advantage. [GP17: General practitioner with affecting GP-CP collaboration once collaboration had experience from Mallorca (GP W MLL)] begun. According to GPs and CPs, another barrier is caused Achievement of objectives because pharmacies are privately owned and pharmacists For the relationship to be maintained over time, both are not seen as part of the health system structure. professionals and the PCHC manager had to recognize the benefit of this collaboration. There were a number of I consider that the structure clearly leaves the factors that could help to fulfill the goals. According to pharmacist outside the national health system. That’s GPs and CPs, it seemed essential to have a coordinator why the pharmacists don’t know which entity they are (s) or reference person(s), responsible for leading the col- part of. We are private centers with an agreement with laboration and linking the two professional groups. the administration. Yes, we are obliged to follow all the GPs and CPs felt that meetings needed to be held administration guidelines ...because we are regularly so that professionals could discuss shared dispensing national health system prescriptions but objectives. Meetings between GPs and CPs usually take then we are not considered as being part of the health place in the PCHC at lunch time, when the pharmacies system in any way. Not structurally, organizationally, are usually closed and the GPs change shifts so when legally, nowhere. If one is not considered (as part of the food was provided it encouraged attendance. While this system) it is very difficult to be part of it. [CP16: CP is not an ideal arrangement, the option of combining W MLL] lunch with meetings is the most practical solution in a Rubio-Valera et al. BMC Health Services Research 2012, 12:188 Page 8 of 10 http://www.biomedcentral.com/1472-6963/12/188 Figure 2 Factors affecting collaboration between general practitioners and community pharmacists once the collaboration has been started. PCHC: Primary Care Health Center; CPs: Community pharmacists. country where the midday meal is a social occasion and CPs’ interests) are so divergent that we don’t have many business premises, including pharmacies, close be- points in common. I mean, they (CPs) have their tween 2-5 pm. It was important to share a clinical chart interests, that if their stock, that if I don’t know what so that both professionals could have access to complete ... When we are having these meetings and you say: patient information. Standardized working methods as “but if we (GPs) really don’t mind that the stock of well as standardized communication channels facilitated generics is this brand or another”...Sometimes they collaboration. For non-urgent consultations, a referral speak about things that we don’t understand [GP13: form assisted in information transmission. General practitioner without experience from Mallorca (GP WO MLL)] One of the things that we had is that we phoned the health center to have direct access to the doctor’s Change in PCHC management surgery. We had the switchboard number,...each If the new management team was not in favor of collabor- doctor had a switchboard number and we dialled it. I ation, practitioners would no longer have time or support mean we went in directly. This meant that any to conduct meetings, collaborative work, etc. problem we had could be solved straight away. [CP6: CP W BCN] The most important handicap appeared when they (EBA’s managers) left... No other company was However, a positive attitude might change as a conse- contracted; they (the people of the NHS) decided to quence of the increased burden or lack of financing that manage the center by themselves. They designated a made collaboration impossible. new manager and, at the beginning, we explained to her everything we had been doing and everything As we already have a lot of work, it couldn’t work and looked fine to her “very good, very good, very good” but it was cancelled. Because we all have enough work ... we had neither meetings, nor health controls, nor...I I don’t think there was any other reason, there was no mean, everything diminished. [CP7: CP W BCN] misunderstanding or anything else. It was just this, the pressure they were under and ours too. [GP4: GP W Discussion BCN] Summary of main findings This study highlights two stages associated with collabor- In addition to workload, wasting time with personal ation: prior to and during collaboration. Key factors prior complaints in meetings could make GPs and CPs unwill- to collaboration were perception of usefulness, PCHC man- ing to collaborate. Pharmacists needed to work with each ager interest, attitude, and geography and legislation. At other and could be demotivated if they were unable to co- this stage there was a process of team building that corre- operate with their colleagues. Finally, if GPs and CPs were sponded to the first stages of the model of development of unable to agree on new objectives, collaboration would Collaborative Working Relationship (CWR) [22] (Profes- end. sional Awareness; Professional recognition; Exploration and Trial). During collaboration, which corresponded to Sometimes we (GPs and CPs) have meetings in the the last stages (Professional expansion; Commitment to the health center and the differences (between GPs’ and CWR), achievement of common objectives and PCHC Rubio-Valera et al. BMC Health Services Research 2012, 12:188 Page 9 of 10 http://www.biomedcentral.com/1472-6963/12/188 management stability were the main factors to consider in Comparison with existing literature perpetuating collaboration. Results from this study are consistent with previous re- The most important difference between regions in search [12-15]. The importance of mutual knowledge, terms of collaboration was due to the presence of EBAs, role definition, CPs’ conflict of interest and the territori- which only exist in Barcelona. Practitioners from this ality of the GP concurs with previously reported results type of privately managed center were more motivated [12-15] although in our study a problem with territorial- to initiate collaboration with the community pharmacies ity was also reported by pharmacists who felt that GPs and, once initiated, the relationship seemed to be easily were assuming pharmacist roles. Since some GPs in maintained over time. Spain are incentivized through MBO, a stereotypical Negative perception of usefulness was only reported by view of the GP being too worried about meeting targets GPs and CPs without experience in collaboration from and being rewarded by the health system was also Barcelona. The fact that this particular view was only demonstrated in our study. reported by professionals without previous experience in Both professions had to perceive collaboration as eco- collaboration could be a consequence of previous bad nomically profitable. However, as highlighted by our experiences when having contact with the other profes- study, the PCHC manager also had to be motivated to sional. Although we consider that it could be the other promote this collaboration. In privately managed way around and, in fact, it is the negative perception, or PCHCs, practitioners stated that collaborative care had prejudice against collaboration, that prevents it. Regional led to a reduction in expenses, which could have been a differences cannot be explained with the information we motivation for managers to collaborate. This could be an have at present. It is possible that the search for negative important factor to consider when implementing collab- cases (i.e. disconfirming cases) was more intensive in orative relationship in areas or countries where PCHCs Barcelona than in Mallorca although it is also possible are privately managed. that the variance really is due to regional differences. Pharmacists in Spain only receive public funding for This issue will require further exploration. providing prescription medicines. Consequently, barriers GP and CP speech were similar and they agreed on the related to lack of incentives from the NHS to initiate majority of factors affecting collaboration. Although there and maintain collaborative work were highlighted. Previ- are differences in the factors which affect each type of pro- ous studies have reported pharmacists’ concerns about fessional (i.e., the pharmacist’sconflictofinterestisrelated potential increases in workload and adequacy of remu- to an incentive to sell the greatest number of products while neration when new services are introduced [23] seemed that of the doctor is connected with offering a service in to be a crucial factor in building multidisciplinary teams which cutting costs results in salary bonuses) both profes- [12,14,15]. When professionals meet, preconceptions sionals express them, being aware that this is the view about the others can be overcome and shared aims, others have of them which, in turn, affects collaboration. strategies and tools to enhance communication and lead to an improvement in services can be discussed. To maintain collaboration, it is preferable to share clinical Strengths and limitations objectives [14]. If only administrative issues are To the best of our knowledge, this is the first qualitative addressed, physicians are not interested and pharmacists study conducted by a multidisciplinary team and the first feel frustrated. Working on clinical issues implies shar- conducted in Spain. Moreover, this is the first study that ing patient clinical information [14]. Ethical and security compares samples from two regions with different geo- considerations need to be taken into account when col- graphical characteristics and health policies. Taking into laborating and the need for patient consent must be account distinct contexts improves the relevance of this considered [22]. study. A series of quality control measures were used to guarantee the trustworthiness of the conclusions. Conclusions Nevertheless, those who participated in the study were A better understanding of the GP-CP relationship more likely to be interested in this topic. However, we enables us to develop strategies and interventions to recruited professionals without experience in collaboration promote collaboration. The most relevant strategies to and who held negative views regarding collaboration. implement are the encouragement of positive attitudes Interviews were conducted by a number of investigators, and the perception of usefulness on the part of the perhaps resulting in biased information, but an interview health administrators and professionals to take advan- guide was used and recorded interviews were audited. tage of the new changes or strategies imposed by the However, CPs were interviewed by a pharmacist, and GPs health system as an opportunity to initiate collabor- were interviewed by a GP or a nurse, encouraging openness ation (common objective); to promote face-to-face rela- and honesty. tionship development to overcome prejudices and enable Rubio-Valera et al. 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DOI: 10.3109/13561820.2014.898621 ORIGINAL ARTICLE Perceptions of collaboration between general practitioners and community pharmacists: findings from a qualitative study based in Spain Anna Maria Jove´1, Ana Ferna´ndez2, Carmel Hughes3, Mireia Guille´n-Sola`4, Marta Rovira4 and Maria Rubio-Valera2 1Catalan Health Service (ICS), Barcelona, Spain, 2Fundacio´ Sant Joan de Deu´, Barcelona, Spain, 3Department of Pharmacy, Queen’s University Belfast, Belfast, UK, and 4Healthcare Services of Balearic Isles, Mallorca, Spain Abstract Keywords According to the theory of reasoned action (TRA), collaboration is only possible when it is Content analysis, interprofessional perceived as useful by the participants involved. This paper describes a qualitative study using collaboration, interviews, professional semi-structured interviews to explore the preceived usefulness of general practitioner (GPs)- boundaries, qualitative method community pharmacists (CPs)’ collaboration from these professionals’ perspectives based in two Spanish regions. Thirty-seven interviews were conducted with GPs and CPs with and History without previous experience of collaborating with the other groups of professionals. Analysis of the data indicated that the GPs and CPs considered that collaboration between practitioners Received 10 April 2013 and pharmacists to have different forms of usefulness, ranging from positive to negative Revised 5 November 2013 perceptions of usefulness. Negative and neutral opinions (collaboration generates conflict Accepted 24 February 2014 and/or is not benefitial) could prevent practitioners from initiating collaboration with the other Published online 13 March 2014 group of professionals, which is explained by the TRA. These perceptions were only found among those participants without experience in collaboration. When collaboration was perceived as advantageous, it could be beneficial on three levels: health system (i.e. provision of integrated care, increased efficiency of the system), GPs and CPs (i.e. increased job For personal use only. satisfaction and patient loyalty) and patients (i.e. improved patient safety). Although GPs and CPs with experience identified benefits using a range of examples, GPs and CPs who had never collaborated also believed that if collaboration was undertaken there would be benefits for the health system, patients and health professionals. These results should be considered when developing strategies to encourage and improve the implementation of collaborative working relationships between GPs and pharmacists in primary care. Introduction GPs and CPs also consider that better collaboration brings greater satisfaction and professional development for both the GP Primary healthcare and community pharmacies are the main J Interprof Care Downloaded from informahealthcare.com by 90.163.160.253 on 03/14/14 and the CP (Howard et al., 2003) while making the healthcare access points for healthcare services. Users perceive the pharmacy system more consumer-friendly (Bajramovic et al., 2004). as a trustworthy, local healthcare resource that is occasionally Despite the evidence underlining the potential benefits of visited before or even instead of the general practitioner (GP) collaboration, it is still not common practice in primary care (Hassell, Noyce, Rogers, Harris, & Wilkinson, 1997). Community (Herrera-Carranza, 2002; McGrath et al., 2010), although there pharmacists (CPs) are expected to cooperate with the GP in have been initiatives which encourage it (Van, Mitchell, & Krass, pharmaceutical care interventions and participate in the rational 2011). Factors which influence collaboration are diverse and use of medication (Bajramovic, Emmerton, & Tett, 2004; World range from time and funding to those which depend on approach, Health Organization, 1993). Patients appreciate CP/GP collab- such as trust and respect (Bradley, Ashcroft, & Noyce, 2012; orative work (Howard et al., 2003) and have expressed the need Hughes & McCann, 2003; Rubio-Valera et al., 2012). One for GPs and CPs to establish relationships with the aim of of the most relevant factors in promoting or initiating the producing a better, user-friendly healthcare system (Bajramovic GP–CP relationship is the perception that these professionals et al., 2004). have regarding the usefulness of the collaboration (Bryant GPs and CPs believe that cooperation can be useful in et al., 2010a). improving service efficiency and quality, as well as overcoming In accordance with the theory of reasoned action (TRA), when problems related to medication (Bryant, Coster, & McCormick, a person forms beliefs about an action, in this case, initiating 2010a,b; Howard et al., 2003; McGrath et al., 2010; Montgomery, collaboration, the person automatically acquires an attitude Ka¨lvemark-Sporrong, Henning, Tully, & Kettis-Lindblad, 2007). towards it (Fishbein & Ajzen, 2010). This attitude influences the intention to carry out this action and the final behavior. Based Correspondence: Maria Rubio-Valera, Fundacio´ Sant Joan de Deu´, on this theory, the importance of understanding GPs and CPs’ Barcelona, Spain. E-mail: [email protected] perception of usefulness is clear as this will affect their attitude 2 A. M. Jove´ et al. J Interprof Care, Early Online: 1–6 towards collaboration and, consequently, their intention to Table I. Characteristics of the participants. collaborate and to carry it out. GP and CP’s belief that Characteristics of participants (n 37) Mallorca Barcelona collaboration will have positive effects (e.g. as improved medi- ¼ cation adherence or use of cost-effective pharmaceuticals) is a Community pharmacists, n 9 10 strong predictor of attitude, intention and willingness to work in Female, n 56 collaboration with each other (Bryant et al., 2010a,b; Laubscher, Male, n 44 Evans, Blackburn, Taylor, & McKay, 2009). Mean age (range), years 47.7 (29–56) 50.4 (30–64) The aim of this study was to assess the perceptions of GP–CP Mean clinical work experience 17.2 (1–30) 23.7 (5–40) collaboration from these professionals’ perspectives. One way to (range), years CP with previous experience in 55 approach this issue is through qualitative research methodology GP-CP collaboration, n which permits exploration, awareness and understanding of GPs General practitioners, n 99 and CPs’ opinions and motivations (Popay & Williams, 1998). Female, n 53 Male, n 46 Methods Mean age (range), years 47.6 (37–60) 48.7 (35–60) Mean clinical work experience 19.6 (8–30) 21.8 (8–31) This paper presents findings secondary analysis (Long-Sutehall, (range), years Sque, & Addington-Hall, 2011) of an exploratory study that GP with previous experience in 54 aimed to describe factors affecting collaboration between the GP GP-CP collaboration, n and CP (Rubio-Valera et al., 2012). During this initial analysis, researchers acknowledged that the GPs and CPs’ perception of usefulness emerged as a key and complex topic, deserving a secondary analysis of this data set. Therefore, we included GPs and CPs from the Balearic Islands and Catalonia with and without previous experience of collabor- ation. We contacted key informants from the fields of primary Setting and participants care and community pharmacy [the College of CPs, the RedIAPP The political organization of the Spanish state is made up of the Research Network in Primary Care and the School of Pharmacy- central state and 17 highly decentralized regions with their University of Barcelona] to identify those GPs and CPs who respective governments and parliaments. The devolution of matched our sampling criteria. Practitioners were then contacted responsibilities for health services to the regions can generate and invited to participate. A total of 37 interviews were conducted differences in health policies between regions (Reverte-Cejudo & (Table I). Once interviewed, participants were asked whether they Sanchez-Bayle, 1999). The study population consisted of GPs and knew other practitioners who matched our criteria (snowball CPs from two distinct Spanish regions: Catalonia (Barcelona) and sampling). One GP declined. the Balearic Islands (Mallorca). The main difference between the two regions is the degree of Data collection commitment to primary care which is greater in Catalonia than in the Balearic Islands (Navarro-Lopez & Martı´n-Zurro, 2009). Semi-structured face-to face interviews were conducted in convenient setting for the participant by AMJ (GPs from For personal use only. As a consequence, the investment of resources in primary care with respect to total health expenditure is higher in Catalonia. Barcelona), MRV (CPs from Barcelona), MG (GPs from Accordingly, the density of Primary Care Health Centres Mallorca) and MR (CPs from Mallorca) (January 2010– (PCHCs), the access to diagnostic procedures by GPs and the February 2011). To encourage openness and honesty, CPs were number of services integrated within primary care is higher in interviewed by a pharmacist, and GPs were interviewed by a GP Catalonia than in the Balearic Islands while the ratio of patients or a nurse. The interview guide was developed by a team of per GP is lower. researchers and clinicians including AMJ, AF and MRV and was In some Spanish regions there is a coexistence of the private piloted with one GP and one CP. and public model. While in the Balearic Islands only publicly Data analysis managed PCHCs can be found, some of the PCHCs are privately J Interprof Care Downloaded from informahealthcare.com by 90.163.160.253 on 03/14/14 managed in Catalonia. These private PCHCs establish a contrac- The secondary analysis of data was conducted using the Colaizzi tual relationship with the National Health System to offer public method (Wojnar & Swanson, 2007) with the support of Atlas-ti health services in exchange for capitation financing. software. The information obtained was triangulated through the Another difference between the two regions relates to the stage participation of three researchers with different professional of implementation of electronic prescribing. The main objective backgrounds: a GP (AMJ), a pharmacist (MRV) and a psycholo- of electronic prescribing was to link the GP’s prescriptions with gist with experience in qualitative research (AF). A fourth the pharmacy. However, it can be used as a communication researcher, CH, collaborated as an external advisor in discussion channel between the pharmacist and the GP and it has been the of the results of the analysis. first formal electronic link between GPs and CPs in Spain. The The process of generation of categories was largely inductive. Balearic Islands government initiated its implementation in 2006, The researchers became familiar with the interviews by listening, long before its introduction in Catalonia. Thus electronic reading and re-reading them. Themes were identified and coded prescription had long been established in the Balearic Islands independently by each of the researchers involved in the analysis. by the time we conducted the interviews, while in Catalonia it was Researchers then came together and compared and discussed being used exclusively in rural areas and small cities, excluding differences. Themes were then re-coded and classified, identify- Barcelona where the interviews were conducted. ing common patterns and convergences and divergences in data, We also considered whether recruited practitioners had through a process of constant comparison. Finally, respondent previous experience of collaborating with the other groups of validation was conducted for the main results of study comparing professionals (regular face-to-face contact). We theorized our interpretation of the findings with the subjects who had that practitioners with previous experience would have differ- participated. Participants were sent a summary of the findings ent opinions to those without such experience (theoretical and invited to participate in a meeting where these findings were sampling). presented and discussed to gauge if they agreed with our DOI: 10.3109/13561820.2014.898621 Perceptions of pharmacist-physician collaboration 3 interpretation. Fourteen out of thirty-seven participants attended relationship and if we need something, there can be one-off to the meeting. Changes suggested by the participants were contact but I don’t see the need for regular contact. (GP incorporated into the final description. without collaboration experience) In order to guarantee the trustworthiness of this research (Popay & Williams, 1998), the study was externally audited from On the other hand, the CPs thought that it was the GPs who did the beginning to its conclusion by a group of researchers from a not perceive the usefulness of collaboration and therefore had no qualitative health research group of the Consorci de Salut i Social interest in collaborating: de Catalunya. Interviewers and main analysts (AMJ, AF, MRV and MG) kept a personal research diary in which any reactions to The doctor will never take the initiative because he/she cannot events occurring during the research were recorded. see the possible benefits to be gained or the, that is, the performance (benefits) that they can get from a relationship Ethics with the pharmacist, the doctor is unaware of this. (CP with All participants gave informed consent and the study was collaboration experience) approved by the Foundation Sant Joan de De´u Clinical Research Ethics Committee. Positive perception of usefulness of collaboration Results Collaboration was perceived as beneficial by GPs and CPs independently of prior experience of collaboration and region. The GPs and CPs interviewed considered that collaboration According to them, collaboration had positive impacts on the between GPs and CPs could have different forms of usefulness, health system, the GPs and CPs, and the patients. At the health ranging from positive perceptions of usefulness (collaboration had system level, GPs and CPs believed that collaboration allowed the a positive impact on patients, GPs and CPs, and the health system) professionals to share patients’ clinical information and results, to negative perceptions of usefulness. facilitated the provision of integrated care, increased the number We classified the GPs’ and CPs’ differing perspectives into of services offered (especially in the community pharmacy) and three categories: negative perception of usefulness of collabor- the efficiency of the health system, reduced the number of ation; neutral perception of usefulness of collaboration and problems related to medication and promoted the rational use of positive perception of usefulness of collaboration. medications. The benefits for GPs and CPs included an increase in their job satisfaction, professional image and patient loyalty. GPs Negative perception of usefulness of collaboration and CPs thought that the management of the pharmacy was easier Some of the GPs and CPs interviewed stated that GP-CP when collaboration existed and that the relationship between collaboration could give rise to more problems or could generate pharmacists in the area was improved. Also, the GPs and CPs conflicts and that, for these reasons, collaboration between these believed that collaboration facilitated the definition of the two groups of professionals should not be encouraged. As the professional roles which could prevent conflicts between the following interview extract indicates: GPs and the CPs. Finally, it was perceived that patients benefited from improved For personal use only. I think we shouldn’t tamper with it (the relationship with the outcomes and safety and reduced number of visits to the PCHC. GP) because I think that it’s correct (...) if we look for They were also reassured by receiving consistent health messages something more we will have problems. (CP without collab- from the GPs and the CPs. oration experience) Although it was the GPs and CPs with experience who identified benefits using a range of examples, GPs and CPs who Opinions of this type were only found among those GPs and had never collaborated believed that if it was undertaken, it could CPs from Barcelona without experience of collaboration: bring multiple benefits. There is no relationship whatsoever (between her and the Positive impacts on the health system pharmacist(s)) (...) on the only two occasions in all the years GPs and CPs expressed the opinion that collaboration would J Interprof Care Downloaded from informahealthcare.com by 90.163.160.253 on 03/14/14 I was working (that I was in contact with the pharmacist) it was facilitate their involvement in training activities such as sessions because I prescribed a particular product and they changed it or courses that already take place or that could include the other for a product that did not even have the same active drug. (...) group of professionals and that this could be done jointly, offering But, now, as there is no relationship, I think that it (the a better, integrated service: relationship) is good. (GP without collaboration experience) They (pharmacists) deal better with banal pathologies (mild and/or self-limiting diseases), for instance, lice in children, in Neutral perception of usefulness of collaboration treatments with dietary supplements, vitamin supplements, etc. A neutral perception of usefulness was identified in those who that sometimes we don’t know about whether it’s because considered that it was neither beneficial nor necessary to of training because the information doesn’t reach us and encourage or improve GP–CP collaboration. Making contact or they know more and many times they explain things to us. (GP cooperating to solve specific problems was considered sufficient, with collaboration experience) and, as such, making the effort to initiate and maintain a closer relationship was unnecessary. In contrast with the negative This would also lead to clinical improvement as both GPs and perception, it was not considered that additional problems CPs could agree on the way to treat the patient and share the would be generated. Such opinions were only found in those patient’s results and clinical information: GPs and CPs without experience of collaboration: It’s not exactly the clinical history but the blood tests, Neither advantages nor disadvantages (...) I don’t consider additional tests that can clarify things, sometimes, for example, that it’s necessary. I think that there has to be a normal I have a diabetic who comes to do a capilliary glycemia test in 4 A. M. Jove´ et al. J Interprof Care, Early Online: 1–6 the pharmacy and it’s found to be high; if I had the patient’s implementation of new measures related to taking medication: the glycosylated haemoglobin, I could probably say to him/her: introduction of generics, the electronic prescription, repeat ‘‘well, today it’s high but the haemoglobin has been going fine dispensing: for three months’’ and I wouldn’t do anything else as I know that the doctor is monitoring him/her. (CP without collabor- This (the change of medication to generics) has brought about ation experience) drastic changes compared with the patients’ previous medica- tion. And these changes, bearing in mind that for patients, 80% GPs and CPs gave many examples about how health services of their prescriptions are for chronic illnesses and they only go could be improved. It is interesting to observe that most of to see the doctor once a year, to make the prescription changes examples that GPs and CPs gave, implied strategies to be carried for all these people we would have needed a year. And, in out by the CP, such as education programmes for patients, health contrast, what we did is that with the clinical guides and the promotion, illness prevention, detection of health problems, clinic sessions with us, on top of choosing between all the aims greater resolution of minor problems in the pharmacy, control that would have come up and changes that would have of chronic illnesses, detection of drug duplication, interaction and/ happened, we were told what changes they would like to make or errors in posology, and pharmacological treatment follow-up: with the patients and there was no need for them to visit the doctor. (...) We (pharmacist) made it easier for them to do All the medication that the patient takes and that I don’t know it all in one go, you know? This means that in the first year, about as it’s not covered by the insurance like contraceptives I think the primary care centre’s pharmaceutical expenses went that I have not registered but have important interactions with down by 26%. (CP with collaboration experience) things that I can give, but the pharmacist does know, or the ‘‘para-pharmacy’’ (over- the-counter drugs and other products that do not require a prescription), the homeopathy ...Taking Positive impact on the GPs and CPs advantage of the confidence that the patient has in the The GPs and CPs saw the usefulness of collaboration at a personal pharmacist, many things could be completed jointly and not level in that it would increase their job satisfaction and improve only inform us of the side-effects. For instance, arterial their image. Participants expressed the opinion that collaboration tension, the patient’s weight, whether antismoking advice has facilitated pharmacy management and patient loyalty. Moreover, been given, whether she is taking contraceptives, whether they being able to offer new and/or improved services provided added take herbal remedies, if they do homeopathy. (GP with value to the CP as a healthcare professional and reducing the collaboration experience) perception of them as sales staff: On a more organizational level, the GPs and CPs expressed the Like a robot, they carry on dispensing medication, full stop. opinion that collaboration prevented the emergence of adminis- And, well, they have these collaborations with the primary care trative errors and would help to manage them in a more flexible centre and I think we make this professional figure bigger, we way should they arise: give it greater importance. (CP with collaboration experience) For personal use only. Having direct contact with the health center is good for us (...) The GPs and CPs stated that as a result of the good GP–CP Many times it’s a help to us and the patient because frequently relationship, the doctor was more highly valued by patients. they come with a badly filled-in prescription, a thousand Having to coordinate the various pharmacies with the medical things. Of course before we had any relationship, we had to tell team also had consequences in terms of an improvement in the them: ‘‘look madam, this has to go back because it hasn’t been relationship between the pharmacists in the area: done properly’’. Well, not now, having this good relationship we can solve the problem and later sort it out it for us. (CP with One of the things that the pharmacies have really appreciated is collaboration experience) having these meetings (monthly meetings in the PCHC with GPs and CPs from the area) and so the thing is, since we The GPs and CPs commented that due to all the above, the started this, they have improved their relationship with each J Interprof Care Downloaded from informahealthcare.com by 90.163.160.253 on 03/14/14 quality of the service would increase: other (...) each year, they have a lunch, a ‘‘gathering’’, them, all of them, the pharmacy managers, but in reality they have It is a really complicated system (the electronic prescription) been doing it since they started to meet each other here with (...) sometimes it doesn’t work well and provokes incidents, us. (GP with collaboration experience) you know, on the weakest link that is the patient. This forced the exchange ...the feedback with the medical doctors at Finally, the GPs and CPs thought that collaboration would PCHC NAME and the answer was absolutely positive. I mean, allow them to define everyone’s role, avoiding potential conflicts: in this respect, we established a series of strategies in order to have a fluid communication, you know, to solve these They are pharmacists and they don’t have to give medicines of problems since it is obvious that the common objective is to any kind without a prescription, that’s my opinion. I think that improve the care quality, you know, for the patient. (CP with is the most important basis (the pharmacist avoiding giving collaboration experience) medicines without a prescription is key) and I think that if we talked they would have to understand it. (GP without Efficency of health services arose from a decrease in collaboration experience) appointments with doctors and nursing staff for consultations whether they were for prescriptions, carrying out tests to monitor Positive impacts on the patients chronic pathologies or the detection and resolution of health problems which were not severe or are self-limiting. Similarly, it According to the GPs and CPs, the health service improvements was perceived that collaboration could reduce problems related to described above would have a positive impact on patient medication, encourage the rational use of medications and the outcomes. Furthermore, the GPs and CPs expressed the opinion DOI: 10.3109/13561820.2014.898621 Perceptions of pharmacist-physician collaboration 5 that the GP and CP providing consistent messages and giving the quality of healthcare (Dieleman et al., 2004; Howard et al., 2003) same information to patients would avoid contradictions, confu- and would increase patient trust (Montgomery et al., 2007). sion and conflicts and potentially improve patient safety. In Another perceived benefit from collaboration was that it would addition, coordinated work would avoid unnecessary visits to the improve the image of the practitioners, especially the CP. Those primary healthcare centre to solve, for instance, administrative collaborating with physicians may be recognized for his/her problems: clinical work which coincides with the findings of other studies (Dieleman et al., 2004; Montgomery et al., 2007), perhaps This good understanding between the doctor and the pharma- because collaboration highlights the clinical aspect of their cist solves plenty of problems for the patient so that they are profession more prominently. not running backwards and forwards, or feeling confused In addition, the fact of perceiving collaboration as useful not or that things are complicated. (CP with collaboration only influences the willingness to initiate collaboration, but also experience) its continuity (Bryant et al., 2010b). Various studies have indicated that health professionals who collaborate wish to continue doing so as they feel more comfortable in the interaction, communication improves (Dieleman et al., 2004) and an Discussion improvement in results is perceived (Laubscher et al., 2009; To the best of our knowledge, this is the first qualitative study Teinila¨ et al., 2011). Conversely, poor experiences of collabor- focused on exploring the GPs and CPs’ perceptions of ation can mean that collaboration is perceived as bad or interprofessional collaboration in Spain. Our study includes a unnecessary. sample of participants with different backgrounds with respect to One strategy to change the perception on the usefulness of collaboration and from two different regions with differing collaboration from the very beginning could be related to geographical characteristics and health policies. Involving differ- interprofessional education (IPE). According to the WHO ent contexts improves study relevance. Additionally, a series of (2010), IPE occurs ‘‘when two or more professions learn about, quality control measures were used to strengthen the trustworthi- from and with each other to enable effective collaboration and ness of the conclusions (i.e. field diary, triangulation of analysis, improve health outcomes’’. The integration of IPE within the member checking and external audit). Schools of Pharmacy and Medicine’ (or health-related profes- In accordance with the TRA, to be able to carry out sions) curricula would provide learning opportunities for students collaboration between the GP and CP, one of the main conditions in an environment which prepares them to practice. Although IPE is that this collaboration be perceived as useful by all the central seems a promising strategy, evidence about its effectiveness for figures involved. Beliefs contribute to the creation of attitudes that promoting future interprofessional collaboration is still required will subsequently lead to particular behavior, in this case, (e.g. Reeves, Perrier, Goldman, Freeth, & Zwarenstein, 2013). collaboration (Fishbein & Ajzen, 2010). In fact, a previous Nevertheless, a recent study suggests that workshops conducted study reported that physicians’ beliefs that collaborating with CPs with first year Pharmacy and Medical students to foster under- would result in improved medication adherence was the strongest standing of the other professionals’ roles in health care improved predictor of attitude toward collaboration (Bryant et al., 2010a,b; students’ attitudes toward interprofessional collaboration. For personal use only. Laubscher et al., 2009). In our study, negative attitudes were only However, it should be noted that medical students’ collaboration detected among those from Barcelona without experience of scores remained significantly lower than those of pharmacy, collaboration, suggesting that it is the perception of limited suggesting that more effort may be needed to convince medical benefits that impedes the initiation of collaboration. On the other students of the benefits of collaboration (Van Winckle et al., hand, according to Allport’s contact hypothesis (Allport, 1954) 2012). the fact that the primary care and GP were not in contact could However, some limitations should be mentioned when inter- contribute to the maintenance of erroneous beliefs or prejudices preting the findings. Firstly, this paper presents secondary analysis that they have towards collaboration, providing feedback which of another study whose main aim was to explore the opinions reinforces the perception that it is not necessary (Hewstone & of CPs and GPs on collaboration (Rubio-Valera et al., 2012) and, Swart, 2011). This lack of knowledge of the other professional as such, the study interview did not focus on the perception of J Interprof Care Downloaded from informahealthcare.com by 90.163.160.253 on 03/14/14 could mean that value is not given to the knowledge, skills and usefulness as a primary objective. Nevertheless, ‘‘usefulness of added value contributed by the other group and, as such, collaboration’’ was one of the themes in the topic guide. Secondly, collaboration is not perceived as necessary or beneficial. the participants may have felt obliged to be positive about Negative perceptions of usefulness reported were not reported collaboration in order to please the interviewers (social desirabil- by GPs an CPs from Mallorca. This is the most important ity). However, opinions opposed to collaboration were also difference between regions but it is difficult to explain with the fielded. Moreover, the fact that CPs were interviewed by a available information. The search for disconforming or negative pharmacist and GPs were interviewed by a GP or a nurse cases may have been more intensive in Barcelona than in should have encouraged openness and honesty. On the other hand, Mallorca. Further exploration will be necessary to ascertain if the the fact that interviews were conducted by different researchers difference is due to contrasting regional health policies. may have resulted in biased information. To overcome this, an With respect to the perceived benefits of collaboration, interview guide was used and recorded interviews were audited. independently of prior experience, GPs and CPs believed that it would improve service quality and efficiency, leading to increased satisfaction on the part of the professional and the patient. Other Declaration of interest studies which have explored different issues related to CP and GP The authors report no declarations of interest. The authors alone are collaboration have found similar results, indicating that this would responsible for the writing and content of this paper. improve the quality of the prescription (Bryant et al., 2010a; Montgomery et al., 2007; Teinila¨, Kaunisvesi, & Airaksinen, 2011) appreciation of the other professional (Dieleman et al., References 2004; Montgomery et al., 2007; Morris, Cantrill, & Weiss, 2001), Allport, G.W. (1954). The nature of prejudice. 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Y ? ?+P K 5 A $ 5 AHN AA % L5 IH% L aoorS_a/EE,p`aoqN 9 &I ` + L Q LL A I` + A I Q I+'H& I & + & $9 +H HN & + L H $ + A ` +'I Q LA A m Q L ' ` EqErXaoEoQ Eq = 5 L Q =I L L MH 5M nI Q 9)I+ Q + InI N 5! & & IL L = &=M A= &3N EqQ EoEb ## H&; A == I# M% L5 &=H L &A H% Gao`E`aoEEBN &5MLI; 5 AH I# % L A HI AH& ML == AH=/ =n=H 5 H& L ;& 2 A 5 ` H A +n=&=N A A X_XE,rVQ ap L&+Q A L + % L5 I H% LN aoEES_pGEB/b,`_rN A& N I+ H'A #& & + + =H I AC Eoa ` E,rV `Eo_,, Ga,`_`E,rV BN N I 2 L Q ; Ln Q &== ++ / 9= = I # ML ; AH + L9$`L + H %I=M&H + 5&==&IA=/ + A = ILL = Q L $3A W Q &++ LI 09 +&H H&; =H9 nN 9 + # +H% L 9&AH A Q LH'A 'I= N > L + AHLI aoorSEq/Eo,`EV N = +9 I ) L + # L5 & P = I #& &A = # L5 & I5I L 9L=I H A &3A ML&5 L& N L + n Q =% LI#H Q In / H A L&5 L& N aoooSaV/EE`pN AH $L H&IA A &## L AH& H&IA/ IA MH9 + 5I + I# $ A L + ML H&H&IA L A I559A&Hn == ++ Q I n Q I $ L= Q LL&= Q M% L5 &=H I++ IL H&IA N = I & + 5 &+*&A=IA N M H%2 n HI H% / H% % L5 aoEaSr/bV `_V N M% L5 9H& + IA=9+H H&IA = #&L=H MILH I# ++ &A ML&5 Ln +H% L N 5 L N E 9$% = Q AA / L &; E,,qSE_GVB/_,r`poaN &AH LMLI# ==&IA + LL& L= H2 A I559A&Hn M% L5 &=H= A $ A L + ML H&H&IA L=/ n a,XaooV aV )9+&I $ L AH' = n 9=I 09 +&H H&; == ==5 AHN L A L H aoobQ L &IA + +I= 5 & 5 AHI= n MLI 9 HI= pb/Voo`VN = A&H L&I=N Eqr aqXoqXaooVN A Q &H % ++ Q L == / A L + + M M + + # L5 f9H& I A + =&=H 5 ML H&H&IA L`M% L5 &=H &AH L H&IA= &A H A &3A = +9 N A#IL5 + 9A&3A + MLI # ==&I A + M% L5 n = L;& =N A H LMLI # L N I*&IQ M3AN bE $I=HI a aoEESap/bVV `qaN = MH& 5 L E,,bN A n L Q &++& % Q L&5 * Q H +/ % I Q ) L Q 9mmI Q &A L=IA "M+IL&A$ =9 ==#9+ I559A&Hn M% L5 &=H` / A=&H&;&Hn I# M H& AH I9H I5 = HI M%n=& & A I++ IL H&; 2 IL*&A $ L + H&IA =%&M= M% L5 &=H &AH L; AH&IA=N LH / n=H 5 H& 9=&A$ 5&" 5 H%I =N = I & + 5 % L5 L ;& 2 A 5 H ` A +n=&= &A %nM LH A=&IA aoEoSV/boq`abN 5 A $ 5 AHN AA % L5 IH% L aooqS_E/Eqqo`rEN 9 &I ` + L Q I ;f Q 9$% = Q 9&++ A` I + Q I ;&L Q LA A m N HI L= N % I Q ) L Q 9mmI Q &A L=IA / ## H&A$ I++ IL H&IA H2 A $ A L + A=&H&;&Hn I# M H& AH I9H I5 = HI M% L5 &=H ML H&H&IA L= A I559A&Hn M% L5 &=H=/ &AH L; AH&IA=N LH / =n=H 5 H& L ;& 2 A 09 +&H H&; =H9 nN +H% L; =N aoEa 5 H ` A +n=&= &A & H = 5 A $ 5 AHN AA 9+ qSEa/ErrN I &/ EoNEErV XE_qa`V ,Vb`Ea`ErrN % L5 IH% L aooqS_E/EpV ,`raN % I Q ==IL Q ) L Q 9mmI Q &A L=IA / A=&H&;&Hn I# M H& AH I9H I5 = HI M% L5 &=H &AH L; AH&IA=N LH / =n=H 5 H& L ;& 2 A 5 H ` A +n=&= &A %nM L+&M& 5 & q =Y8