Farmasi Sosial

Nama : Yusril Ahmad Fadhilah
NIM : 1708010030
Saat ini, profesi apoteker di apotek komunitas tidak begitu dihargai sejak saat itu visi
komersial dari profesi yang dibuat untuk apoteker mencakup citra penjaga 1ega.Beberapa
apoteker di beberapa 1egara tidak lagi terlibat dalam pemberian, tetapi hanya dalam penyediaan
obat dan memberi saran. Terlepas dari pelatihan penting mereka, apoteker komunitas adalah
hanya para 1egara1ional kesehatan yang tidak diberi imbalan utama karena memberikan
perawatan kesehatan. Masyarakat apoteker dapat berperan dalam mengurangi ADE dan
meningkatkan kepatuhan pengobatan, yang pada gilirannya dapat membantu dalam
menurunkan kunjungan penyedia yang tidak perlu dan rawat inap sambil memperkuat
terintegrasi pemberian perawatan primer di seluruh 1egara kesehatan. Selanjutnya, persepsi
terhadap farmasi profesi di apotek komunitas semakin berisiko, terutama karena dampak dari
internet di masyarakat. Dengan menggunakan sarana komunikasi buatan ini, komunikasi
pribadi antara apoteker dan pasien telah berkurang atau bahkan menghilang. Karena salah satu
peran utama apoteker di apotek komunitas adalah 1egar pada konseling, komunikasi sangat
penting bagi apoteker untuk memenuhi tugas etika utamanya. Komunikasi juga sangat
diperlukan bagi pasien untuk menerima semua informasi yang diperlukan tentang penggunaan
obat secara interaktif, langsung, jelas, dan terperinci, dan untuk memperoleh pengetahuan
dapatkan manfaat maksimal dari terapi yang akan dilakukan. Karena itu komunikasi adalah
kuncinya dan elemen penting untuk membangun hubungan interpersonal yang solid dengan
pasien untuk pertahankan dia, untuk membuat proses konsultasi efektif, dan untuk memperkuat
masa depan apoteker profesi di apotek komunitas. Dalam perspektif masa depan, untuk
merevitalisasi peran apoteker komunitas dan meningkatkan spesifiknya keterampilan
komunikasi yang berpusat pada pasien dan melek kesehatan, penting untuk menerapkan yang
memadai dan perubahan umum dalam kurikulum akademik, yang perlu dipantau secara teratur
dan terkini. Pengantar yang lebih luas dari studi mendalam dan pelatihan 1egara1ional dalam
perilaku, metodologi dan teknik komunikasi, pendidikan, dan sosiologis akan menjamin
bahkan lebih efektif dalam praktik konseling farmasi. Mulai dari pengalaman praktis dianalisis
(khususnya, PaCT dan MPC), mempelajari komunikasi standar yang berpusat pada pasien
metode dapat memungkinkan apoteker menggunakan bahasa yang lebih sederhana, lebih
langsung, dan jelas dalam dirinya latihan sehari-hari.(Sir et al., 2014)
Penelitian yang saya ambil mengenai pelaksanaan good pharcmacist practice yaitu
Negara Lebanon. Adapun hambatan atau barrier yang terjadi pada pelaksanaan good
pharmacist practice di 1egara Lebanon antara lain seperti
1. memberikan obat tanpa indikasi atau tanpa resep yang tepat

2. kurangnya konseling pada pasien, manajemen terapi obat-obatan serta monitoring efek
samping obat;
3. sebagai pelayan kesehatan dituntut harus menjaga komunikasi yang efektif dengan
pasien serta menindaklanjuti perawatan lanjutan untuk pasien untuk meningkatkan
kesehatan dan keberhasilan pengobatan namun dalam hal ini komunikasi antar pelayan
kesehatan dengan pasien masih kurang; sarana dan prasarana atau fasilitas yang
memadai;
4. ketidak mampuan pasien dalam segi ekonomi untuk mendatangi dokter serta kendala
waktu;
5. permasalahan SDM farmasi yang masih kurang;
6. masih minimnya pengetahuan, kesadaran, keterampilan dan pemahaman apoteker itu
sendiri.(Badro et al., 2020)
Sedangkan manfaat atau benefit dari penerapan good pharmacist practice pada apotek
komunitas di Lebanon yaitu dapat sebagai materi pendukung yang berubah-ubah serta untuk
materi pendukung system perawatan yang semakin kompleks dari standar praktik. Beberapa
decade terakhir ini banyak 2egara yang membuat praktik farmasi semakin sulit. Oleh karena itu
penting dilakukannya pemantauan good pharmacist practice terutama pada beberapa 2egara
berkembang karena memberikan antibiotic tanpa resep dokter adalah praktik umum; kemudian
permasalahan kesehatan yang lainnya adalah tingkat kejadian merokok yang tinggi; cara
pembuangan obat-obatan yang tidak baik dan benar atau tidak sesuai; maraknya produksi obat
palsu; keterbatasan kesiapan pada manajemen terapi pengobatan yang memadai; serta pelaporan
mengenai ADR yang sedikit.(Badro et al., 2020)
Pada penerapan good pharmacy practice komunitas ataupun apotek di Kanada, Inggris
dan Amerika Serikat memiliki benefit atau manfaat nya sendiri yaitu:
1. Meningkatkan profesi farmasi, mempromosikan keunggulan dalam perawatan pasien

dan pengembangan ilmiah serta mampu mengatur dan menyediakan manajemen terapi
obat yang efisien.
2. Meminimalisir kejadian medication error sehingga dapat meningkatkan layanan dan
kualitas farmasi komunitas.
3. Apoteker dalam praktik umumnya memiliki dampak positis pada hasil klinis (misalnya
seperti tekanan darah dan hemoglobin glikosilasi) serta keamanan resep.
4. Meningkatkan prosefi farmasi, mempromosikan keunggulan dalam perawatan pasien
dan melakukan pengembagan ilmiah serta mampu mengatur dan menyediakan
manajemen terapi obat yang efisien.
5. Mengintegrasikan apoteker ke dalam perawatan primer juga dapat mengurangi beban
kerja dokter umum (terutama yang berhubungan dengan pengobatan), kehadiran gawat
darurat dan rawat inap terkait obat dan mungkin juga hemat biaya.
6. Mengatur, menyiapkan, memperoleh, melindungi, mendistribusikan serta membuang
dan menyediakan produk medis.
7. Menyediakan manajemen terapi obat yang efisien sesuai dengan masalah farmakoterapi
serta meningkatkan control klinis penyakit.
8. Meningkatkan kinerja professional apoteker serta berkontribusi meningkatkan kinerja
professional tenaga kesehatan dan efektivitas system perawatan dan system kesehatan
masyarakat. (Oskar james, 2020)
DAFTAR PUSTAKA
Badro, D. A. et al. (2020) ‘Good pharmacy practice assessment among community pharmacies
in Lebanon’, Pharmacy Practice, 18(1), p. 1745. doi: 10.18549/PharmPract.2020.1.1745.
Oscar James, Karen Cardwell, Frank Moriarty, Susan M Smith,Barbara Clyne. Pharmacists in
general practice: a qualitative process evaluation of the General PracticePharmacist
(GPP) study. Family Practice, 2020, 1–8
Badro DA, Sacre H, Hallit S, Amhaz A, Salameh P. Good pharmacy practice assessment among community pharmacies in
Lebanon. Pharmacy Practice 2020 Jan-Mar;18(1):1745.
https://doi.org/10.18549/PharmPract.2020.1.1745
Original Research
Good pharmacy practice assessment among
community pharmacies in Lebanon
Danielle A. BADRO , Hala SACRE , Souheil HALLIT , Ali AMHAZ, Pascale SALAMEH .
Received (first version): 11-Nov-2019 Accepted: 23-Feb-2020 Published online: 16-Mar-2020
Abstract
Objective: This study aims to assess good pharmacy practice (GPP) aspects and compare GPP scores among community pharmacies in
Lebanon, using a tool developed jointly by the International Pharmaceutical Federation (FIP) and the World Health Organization (WHO)
to improve and maintain standards of pharmacy practice.
Methods: Data collection was carried out between July and October 2018 by a team of 10 licensed inspectors who work at the
Lebanese Order of Pharmacists (OPL) and visited community pharmacies across Lebanon. The questionnaire was adapted to the
Lebanese context and included 109 questions organized under five sections: socio-demographics, Indicator A (data management and
data recording), Indicator B (services and health promotion), Indicator C (dispensing, preparation and administration of medicines),
and Indicator D (storage and facilities). The value of 75% was considered as the cutoff point for adherence to indicators.
Article distributed under the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 Unported (CC BY-NC-ND 4.0) license
Results: Out of 276 pharmacies visited, a total of 250 (90.58%) pharmacists participated in the study with one pharmacist being
interviewed in every pharmacy. Results showed that 18.8% of pharmacists were generally adherents to GPP guidelines (scores above
the 75% cutoff): 23.3% were adherent to indicator A, 21.6% to indicator B, 14.8% to indicator C and 13.2% to indicator D. Moreover,
comparison of GPP scores across geographical regions revealed a higher adherence among community pharmacists working in the
Beirut region compared to the North region, the South region, Mount Lebanon, and the Bekaa.
Conclusions: Our study shows that community pharmacists in Lebanon do not fulfill GPP criteria set by FIP/WHO, and that this poor
adherence is a trend across the country’s geographical regions. Therefore, efforts should be made to raise awareness among
pharmacists about the necessity to adhere to GPP guidelines and standards, and train them and support them appropriately to reach
that goal. This is the first indicator-based comprehensive pilot assessment to evaluate GPP adherence in community pharmacies across
Lebanon. Working on the optimization of this assessment tool is also warranted.
Keywords
Pharmacies; Professional Practice; Quality of Health Care; Pharmacists; Pharmaceutical Services; Health Promotion; Goals;
Management Audit; World Health Organization; Reference Standards; Lebanon
INTRODUCTION continuous improvement of professional knowledge and

performance, and the contribution to improving
“The mission of pharmacy practice is to contribute to
effectiveness of community health.
health improvement and to help patients with health
1
problems to make the best use of their medicines”. In an The updated GPP guidelines served as supporting material
effort to standardize pharmacy practice, the International to community pharmacists practicing in continually
Pharmaceutical Federation (FIP) and the World Health changing healthcare systems and increasingly complex
Organization (WHO) published a joint document in 2011 standards of practice. Over the past few decades, a number
1
about Good Pharmacy Practice (GPP). The document of factors have directly or indirectly contributed to
delineated sets of standards that would guide national complicating the initially rather streamlined mission of
pharmacy professional organizations through the pharmacy practice. Therefore, the monitoring of GPP is
establishment of their own national GPP guidelines, and crucial, particularly in developing countries such as
broke down pharmacists’ practice under four roles and Lebanon where dispensing antibiotics without prescription
1
specified the minimum standards required to meet GPP. is common practice, alongside other public health issues,
Roles included the preparation, storage, distribution, including high prevalence of smoking, inappropriate
administration and disposal of medications, the provision disposal of medicines, dispensing of counterfeit medicines,
of effective medication therapy management, the poor generic substitution, readiness for but limited
adequate medication therapy management, and lack of
2-9
reporting of adverse drug reactions (ADRs). Moreover, a
Danielle A. BADRO, PhD *. Faculty of Health Sciences, American
University of Science and Technology. Beirut (Lebanon).
report published by the WHO in 2014 indicated that non-
dbadro@aust.edu.lb communicable diseases (NCDs) account for 85% of total
Hala SACRE, Pharm.D*. National Institute of Public Health, Clinical deaths in the country, thus emphasizing the importance of
Epidemiology & Toxicology (INSPECT-LB). Beirut (Lebanon).
halasacre@hotmail.com the pharmacist’s involvement in the prevention of chronic
10
Souheil HALLIT, Pharm.D, MSc, MPH, Ph.D. Faculty of Medicine diseases.
and Medical Sciences, Holy Spirit University of Kaslik (USEK).
Jounieh (Lebanon). souheilhallit@hotmail.com Pharmacists in Lebanon have become exposed to activities
Ali AMHAZ, MSc. Faculty of Health Sciences, American University
that were not within the primary scope of their practice,
of Science and Technology. Beirut (Lebanon).
ali001_1993@hotmail.com leading to a new role for Lebanese pharmacists that goes
Pascale SALAMEH, Pharm.D, MPH, Ph.D. Faculty of Pharmacy, beyond their regular duties (as per the minimum legal
Lebanese University, Hadat (Lebanon).
pascalesalameh1@hotmail.com
requirement). Indeed, the emergence of local healthcare
*These authors equally contributed to this work crises consequent to refugee displacements and the
www.pharmacypractice.org (eISSN: 1886-3655 ISSN: 1885-642X) 1

resulting spread of communicable diseases are only a few in the Decree No. 2622 issued in 1992 that briefly describes
among numerous other critical aspects that have severely the location, inner layout, fixtures, materials, and
11-13 20
impacted community health. All these roles have to be supplies.
practiced within well-managed settings to guarantee
In Lebanon, as in many developing countries, law
quality of medications and pharmaceutical services while
enforcement is limited, and the introduction of new laws is
minimizing errors and malpractice. In Lebanon, to be
slow and thus laws of 1950 are still enforced. Moreover,
allowed to practice, pharmacists must register with the
inspection visits to community pharmacies are sporadic and
Lebanese Order of Pharmacists (OPL, is the official
penalties differ according to the breach of the law
pharmacists’ association), as per the Lebanese law of
14 identified. Consequently, and to improve the quality of
1950. To maintain their registration, pharmacists should
pharmacy practice and practice evaluation, GPP standards
pay an annual fee and enroll in the mandatory continuing
14,15 were suggested by the OPL and published in 2019. These
education program. Moreover, pharmacists’ practice is
standards were based on those suggested by the FIP/WHO
overseen by inspectors from the OPL in collaboration with
and those in application in the United States, Europe, and
inspectors from the Ministry of Public Health (MOPH);
regional countries, and adapted to the Lebanese context.
however, a standardized tool for pharmacy practice
The GPP requirements applicable to Lebanon were defined
evaluation is not yet available in the country.
and categorized into fifteen sections that set standards for
Figures retrieved from the OPL indicate that at the end of various aspects of pharmacy practice, including pharmacy
2017, 2,968 pharmacies, harboring 3,762 pharmacists settings, handling of stock, supply of non-prescription
(employers and employees), were distributed across a medicines, health promotion, and research and
2 21
territory of 10,452 Km as follows: 232 (7.8%) in Beirut, 431 professional development.
(14.5%) in the North region, 553 (18.7%) in the South
The leading authority entitled to evaluate GPP is the MOPH
region, 463 (15.6%) in the Bekaa region, and 1,289 (43.4%)
in collaboration with the OPL. However, the process of
in the Mount Lebanon region. The evaluated ratios of
monitoring pharmacists’ professional activities is neither
pharmacies and community pharmacists were 6.61 and
16 standardized nor quantitative and might be subjective due
8.36 per 10,000 inhabitants, respectively. The latter was
to the lack of a quantitative tool. A pre-requisite for
higher than the mean density of 3.73 pharmacists per
efficient and fair evaluation of GPP in the community is the
10,000 inhabitants identified within the WHO Eastern
establishment of an indicator-based tool that can be used
Mediterranean region in a study conducted by the FIP in
reliably for the assessment. Studies conducted among
2016. Moreover, the average density of community
community pharmacists in Lebanon have already reported
pharmacists per 10,000 inhabitants in Lebanon (8.36) was
about GPP performance; however, these studies were
higher than the mean ratio (3.31 per 10,000 inhabitants)
limited in number and focused on some but not all aspects
across all WHO regions and in the higher range of the ratios 9
of GPP.
(1.92 to 11.82) found in some neighboring WHO countries
17
(United Arab Emirates, Bahrain, Jordan, Egypt, Kuwait). In To implement the GPP standards already defined by the
Lebanon, the easy access to pharmacies and familiarity OPL, and since no validated tool is available in Lebanon, it is
with pharmacists, the distant location of hospitals, essential to start by assessing the current situation using
particularly in remote regions, the expensive international tools. Thus, the objective of this pilot study
clinical/medical consultation fees, and the possibility to was to assess GPP aspects as recommended by the FIP and
obtain medication without prescription are all contributing the WHO, and compare GPP scores among community
factors that have made pharmacists the first healthcare pharmacists in Lebanon based on pharmacies’ geographical
18
professionals to be consulted by patients. distribution and pharmacists’ characteristics, using a
1
FIP/WHO-developed tool.
In this context, the aspects of pharmacy practice that
require particular attention or urgent intervention are not
clearly identified, in particular the common practice in METHODS
Lebanon of dispensing medications without prescription or
Data collection
appropriate indications of use. This haphazard practice that
started during the Lebanese civil war still prevails, despite Data collection was carried out between July and October
efforts of regulatory authorities to enforce article 43 of law 2018. Data were prospectively collected by a team of 10
367/94 of 1994, requiring that the dispensing of licensed OPL inspectors who were designated by the OPL
19
medications be done upon physician’s prescription. In and visited community pharmacies across all Lebanese
fact, the only two classes of medications strictly regulated geographic areas, namely Beirut, Mount Lebanon, North,
in Lebanon are psychotropic agents and narcotics, where South, and Bekaa. Based on the list of pharmacies available
the pharmacist is required by law to keep the physician’s in the OPL, inspections were scheduled by the OPL
prescription and record it in specifically designed registers; administration in regular rounds, following specific routes
other medications are not subject to law enforcement. of visits outside of their district of origin.
Other practice items are also addressed in the law (such as
the prohibition to perform any medical act or injecting In preparation for data collection, OPL inspectors received
medications and vaccines); however, no mention is made a one-day training session on the use of the inspection tool.
about the majority of other practice issues, such as Pharmacies to be visited were randomly selected and were
counseling to the patient, medication therapy not informed beforehand of the OPL inspector’s visit. In
management, reporting adverse effects, etc. Regarding the every visited pharmacy, only one licensed community
technical specifications of the pharmacy, they are featured pharmacist (employer or employee) was approached; if

more than one was on duty at the time of the visit, then All 35 questions administered by OPL inspectors were
the OPL inspector would choose one of them randomly. excluded from their specific indicator section and grouped
Those who refused to participate were excluded from the into an “OPL-administered group” (OAG). Those questions
study. No unlicensed staff were approached. It is were considered as indicators and taken into account when
noteworthy to highlight that in Lebanon, pharmacists have estimating Cronbach’s alpha.
the legal obligation to comply with OPL inspectors’
The questionnaire was available in both Arabic and English
demands during visits; however, this does not include filling
languages, and participants chose their preferred language.
out surveys.
It was initially developed in English, then translated into
Institutional Review Board (IRB) approval was granted by formal Arabic language and reverse translated into English
the American University of Science and Technology to [See Online appendix 1 for the questionnaire].
conduct the study (IRB request number AUST-IRB-
Specific items of the FIP/WHO document were purposefully
20180518-01). The study was anonymous and verbal
excluded from our questionnaire, such as the role of
approval of participation was obtained from all
pharmacists in vaccination campaigns, in the writing of
participating pharmacists. Anonymity was ensured by
standard operating procedure for referral to appropriate
analyzing the data after removing any pharmacist related
healthcare providers, and in the implementation of new
identifier.
technologies in pharmacy services. Those aspects of
Indicators and scale pharmacy practice were not used to evaluate GPP scores
since they do not rely on the professional capacities of the
The FIP/WHO document described four roles in pharmacy
pharmacist or their standard of practice solely and require
services and identified 15 functions under those roles.
support by other healthcare professionals as well as
Using the FIP/WHO document and the questions published
ministries. Therefore, our indicator-based tool specifically
by Trap et al. (2010), a 109-item questionnaire was
focused on the items of the FIP/WHO document that
designed; it included one section detailing demographics
evaluated efficacy and standards of practice for the items
and characteristics of the community pharmacist, and four
22 that can be managed by the pharmacists unilaterally in the
indicators. Indicator A was labeled “Data management
Lebanese context and where no external intervention or
and data recording” and was designed to evaluate data
support is required or needed.
management and data recording, such as the systems used
to record medications dispensed. Indicator B was labeled Statistical analyses
“Services and facilities” and measured items related to
Data entry was performed by two people not involved in
services and health promotion, including health campaigns
the data collection process. Data were analyzed using IBM
and services available to patients such as vaccinations.
SPSS Software version 23. After weighting for the
Indicator C evaluated “Dispensing, preparation,
community pharmacists’ geographical distribution
administration and distribution of medicines” by assessing
according to the OPL official figures, frequencies were
the quality of dispensing, preparation and administration of
calculated for all categorical variables, while means and
medicines by pharmacists. Indicator D focused on “Storage”
standard deviations were calculated for continuous
and addressed power supply, contingency plans, and other 23
variables. GPP indicators were analyzed as continuous
storage-related aspects. Additional questions about facility
variables and as dichotomous variables, where adherence
details and medication disposal were added to indicator D.
to an indicator was considered positive in case the score
24
The questionnaire was designed to fit requirements and was above the passing grade set at 75%.
standards of pharmacy practice in Lebanon. Some of the
Since our sample included more than 100 participants, the
questions were self-administered by the community
data was considered normally distributed, whereby non-
pharmacist, while others were answered by the OPL
normal distributions have no significant consequences in
inspector since they required direct observation and visual 25
the case of samples greater than 100. The Student’s t-test
verification. All of the eight questions under Indicator A
was used to investigate differences between two groups,
were self-administered. Eight of the 20 questions under
while ANOVA was used to compare means of adherence
Indicator B were self-administered, while 12 were
scores between three groups or more. A post-hoc analysis
answered by the OPL inspector after direct observation.
using the Bonferroni test was also applied to study
Thirty-two of the 33 questions under Indicator C were self-
differences between variable modalities taken two by two.
administered, while one was assessed by the OPL inspector,
No multivariable analyses were conducted since the
and 14 of the 36 questions under Indicator D were self-
majority of bivariate tests were non-significant. A p-value
administered, while 22 were answered by the OPL
of 0.05 was considered significant and 95% confidence
inspector. The maximum possible score is 26, 32, 55 and 16
intervals were used.
for indicators A, B, C, and D, respectively. The Cronbach’s
alpha was 0.833, 0.301, 0.119, and 0.526 for indicators A, B,
C and D, respectively. The GPP adherence total score was RESULTS
calculated by summing the scores of the four indicators. In
A total of 250 pharmacies participated in the study,
addition, overall adherence to an indicator was assessed
whereby one pharmacist was surveyed in every pharmacy.
using a cut-off value of 75%: for every indicator, the
Most pharmacies were located in the Mount Lebanon
pharmacist had to have appropriate behavior/answer on
region (44.50%), while Beirut included the lowest
more than 75% of items to be considered adherent to the
percentage (12.60%). Across demographic regions, 138
FIP/WHO indicator.
(57.20%) participating pharmacists were females and most

Table 1. Sociodemographic and other characteristics of the Finally, most pharmacies offered services such as flu
participants.
vaccination, blood pressure, and glycemia checks (Online
Variable N (%)
appendix 2 - Table 2).
Gender
Male 103 (42.80%) All pharmacists had dispensed more than one prescription
Female 138 (57.20%) per day (Online appendix 2 - Table 3), and almost all of
Level of education
them had encountered prescription errors and provided
BS Pharmacy 145 (60.60%)
PharmD 76 (31.60%)
information regarding adherence to treatment and
Master’s 14 (5.70%) antibiotic resistance (98%). Less than half of them had to
PhD 5 (2.10%) call back patients because of a wrong delivery of
Governorate medication or wrong dosage prescription after patients had
Beirut 31 (12.60%) left the pharmacy (41%), while 88% acknowledged
Mount Lebanon 109 (44.50%) dispensing medications without prescription. Those
North 32 (13.20%) medications included NSAIDs (95%), antibiotics (60%),
South 41 (16.70%) steroids (27%), benzodiazepines (14%), gastrointestinal
Bekaa 32 (13.10%)
drugs (67%), hormones and contraceptives (48%).
Number of patients per day
<50 106 (45.20%) Moreover, 88% declared explaining to patients the purpose
50-100 95 (40.30%) of switching to a generic and less than 40% made
>100 34 (14.50%) extemporaneous preparations in a suitable area using
Years of practice appropriate equipment. The vast majority did not have a
Less than a year 8 (3.20%) clear recall procedure for dealing with products suspected
1 year to less than 3 years 28 (11.20%) to be adulterated, unlicensed, spurious, falsely labeled,
3 years to less than 6 years 37 (14.90%) falsified, or counterfeit, while almost all pharmacists
6 years to less than 12 years 72 (29.50%)
declared that patients could consult them for unusual
12 years or more 101 (41.20%)
adverse events. Most of the pharmacists interviewed had
Hours of work per week
Less than 31 hours 19 (7.60%) access to documentary and information resources, mainly
32-40 hours 31 (12.40%) through the internet (63%). More than 90% counseled
>40 hours 199 (79.90%) patients and checked medications before dispensing, while
Position in the pharmacy one-quarter did not check for contraindications, drug
Owner/Employer 197 (80.50%) interactions, or prescribed doses (Online appendix 2 - Table
Staff/Employee 48 (19.50%) 3).
Family monthly income *
<1000 USD 8 (4.20%) With regard to the management of medication stock
1000-2000 USD 58 (30.20%) (Indicator D), around 7% of pharmacists stated that there
2000-3000 USD 51 (26.60%) was no electric power supply available overnight, 9%
>3000 USD 75 (39.10%) indicated that they did not have adequate inventory
Mean (SD) management and expiration date monitoring systems, 85%
Age (in years) 39.01 (10.19) did not encourage patients to return expired or unwanted
House crowding index 0.94 - 0.47
products, and 68% did not have a specific procedure to
*The mean family income in Lebanon is 1833 USD
dispose of expired products (Online appendix 2 - Table 4).
had at least 12 years of experience in pharmacy practice Regarding items that were directly checked by OPL
(41.20%). The mean age of pharmacists was 38.88 years (SD inspectors, the evaluation of Indicator B showed that
10.06), with 64.80% having a Bachelor of Science (BS) around 60% of community pharmacies did not have
degree and most (77.30%) working more than 40 hours a drinking water or toilet facilities available for customers.
week. Additional descriptive results are summarized in The evaluation of Indicator D showed that 3% of
Table 1. pharmacists did not protect their stock of medications from
Descriptive results related to indicators’ items are direct sunlight. However, most pharmacies were equipped
presented in Online appendix 2 - Tables 1 to 5. Almost all with cooling and heating systems, 88% had a refrigerator
pharmacists made use of a computerized data where, in 22% of cases, products other than medications
management system (99%) mainly for stock management were stored. In 52% of pharmacies, pharmacists did not
(92%), but rarely for clinical services and medication label shelves, and in 58% of the cases medicine
management. Around one-quarter (27%) of the bottles/containers were stored on the floor in the storage
pharmacists interviewed used log books, but only a few area (Online appendix 2 - Table 5). Finally, half of the
used them for clinical services. Three-quarters of pharmacists surveyed declared that they did not use pest
pharmacists kept copies of prescriptions for non-controlled control services at the pharmacy (Online appendix 2 - Table
medications (76%) (Online appendix 2 - Table 1). 5).
The majority of pharmacies (83%) employed a licensed The mean GPP adherence score was 4.62 (SD 1.36) for
pharmacist for patient services and health promotion, and indicator A, 9.39 (SD 4.05) for indicator B, 14.02 (SD 2.27)
offered a suitable place to discuss confidential information for indicator C, and 9.35 (SD 2.02) for indicator D; for the
(93%). Furthermore, less than a third of pharmacists full scale, the results were 33.90 (SD 3.95) (Figure 1).
declared participating in awareness campaigns against Moreover, in the absence of a cutoff point for the GPP
most common diseases, and half of them made information adherence total scale score, the value of 75% was adopted
24
of various types and health resources available for patients. as the cutoff point. Results were presented as percentage

Figure 1. Spidograph depicting mean score and percentage of adherence per indicator and for the full scale
of adherence to GPP; 41 (18.80%) of the pharmacists were and the Bekaa regions. Doctor of Pharmacy (PharmD)
considered adherent to GPP guidelines (all scores above holders demonstrated better adherence to GPP guidelines
75%), 57 (23.30%) were considered adherent to indicator A, in comparison with BS Pharmacy holders. All other
53 (21.60%) to indicator B, 36 (14.80%) to indicator C, and characteristics did not affect the adherence to GPP
32 (13.20%) to indicator D (Figure 1). guidelines (Table 3).
The bivariate analysis was used to examine GPP adherence
for each of the demographics and characteristics of the DISCUSSION
pharmacists (Table 2). The results of the ANOVA test
This study sought to assess the level of adherence to GPP
showed significantly higher adherence score to indicator D
guidelines of community pharmacists in Lebanon. The
in Beirut (11.25; SD 0.50); also the highest GPP overall
results showed that 18.80% of pharmacists were generally
adherence score (37.75; SD 0.50) for the four indicators
adherent to GPP guidelines (scores above the 75% cutoff):
altogether was found in Beirut (Table 2). Post-hoc analysis
23.30% were adherent to indicator A, 21.60% to indicator
results identified a significantly higher mean GPP
B, 14.80% to indicator C, and 13.20% to indicator D. The
adherence total score in Beirut compared o other regions.
use of indicators rather than other measurement tools was
Concerning indicator D, a significantly higher mean score
deemed most appropriate because, despite its limitations,
was found in Beirut compared to the Bekaa (p=0.036), in
it is a well-accepted “measurable element of practice
the Mount Lebanon compared to the Bekaa (p=0.010), and
performance for which there is evidence or consensus that
in the North compared to the Bekaa (p=0.024).
it can be used to assess the quality, and hence change in
26-28
No significant difference was found between the GPP the quality of care provided”.
adherence total score and all indicators and gender, years
of practice, number of weekly working hours, and total Moreover, comparison of GPP scores across geographical
family income per month (p>0.05 for all variables). A regions revealed a higher adherence among community
significantly higher indicator D score was found in pharmacists working in the Beirut region compared to the
employees compared to employers (p=0.049), whereas North region, the South region, Mount Lebanon, and the
there was no significant difference between the two groups Bekaa. The data collected can be used as a baseline in
and the GPP total score, indicators A, B, and C. Finally, a future GPP evaluations over the years, across geographical
significantly higher indicator A mean score was found in locations, and according to the demographic characteristics
pharmacists receiving between 50 and 100 patients per of pharmacists, particularly if the assessment tool is
day, whereas significantly higher indicators C and D mean improved in future studies.
scores were found in pharmacists receiving more than 100 Furthermore, it is important to point out that FIP
patients per day (Table 2). encourages national pharmacy professional associations to
In the multivariable analysis, a significantly lower evaluate pharmacy practice by adapting the FIP/WHO
adherence was found in the South as compared to Beirut guidelines to the national context. Indeed, they state that

Table 2. Mean scores and standard deviations for all indicators univariate analysis
GPP adherence
Indicator A Indicator B Indicator C Indicator D
total score
Region
Beirut 37.75 (0.50) 5.50 (0.57) 12.50 (4.36) 14.25 (2.22) 11.25 (0.50
Mount Lebanon 34.78 (3.07) 4.52 (1.37) 9.51 (3.77) 13.61 (2.25) 9.35 (2.13
North 30.00 (9.90) 4.71 (0.99) 9.36 (4.84) 14.35 (2.24) 10.07 (1.77
South 31.00 (3.84) 4.57 (1.29) 8.77 (3.86) 14.57 (2.30) 9.19 (1.82
Bekaa 34.01 (4.58) 4.70 (1.71) 9.04 (4.21) 14.48 (2.35) 8.37 (1.75
p-value <0.001 0.318 0.403 0.076 <0.001
Gender
Male 33.79 (4.08) 4.67 (1.51) 9.43 (4.20) 14.33 (2.33) 8.99 (2.07)
Female 33.40 (4.22) 4.57 (1.41) 9.14 (3.88) 14.05 (2.33) 9.09 (1.87)
p-value 0.483 0.627 0.575 0.354 0.700
Years of practice
Less than 6 months 31.16 (3.06) 4.50 (1.73) 10.00 (1.15) 13.25 (1.50) 9.50 (2.38)
6 months to less than a year 33.62 (6.67) 4.25 (1.71) 11.50 (3.42) 15.00 (2.00) 9.50 (1.73)
1 year to less than 3 years 33.09 (4.44) 4.86 (1.24) 9.46 (3.78) 13.75 (2.34) 9.39 (2.02)
3 years to less than 6 years 34.23 (4.36) 4.62 (1.59) 9.70 (3.98) 14.51 (2.43) 9.19 (2.09)
6 years to less than 12 years 34.18 (3.49) 4.64 (1.32) 9.52 (4.34) 14.21 (2.44) 8.98 (2.05)
12 years or more 33.92 (3.95) 4.53 (1.56) 8.74 (4.02) 14.10 (2.25) 9.01 (1.89)
p-value 0.644 0.927 0.569 0.708 0.919
Hours of work/week
1-16 hours 32.67 (2.59) 5.33 (0.52) 9.00 (1.41) 14.67 (0.82) 9.00 (0.89)
17-31 hours 31.20 (4.88) 5.00 (1.00) 8.92 (3.25) 14.62 (2.10) 10.23 (1.88)
32-40 hours 34.65 (3.25) 4.52 (1.61) 9.10 (4.02) 13.97 (2.85) 9.03 (2.14)
>40 hours 34.01 (3.99) 4.58 (1.47) 9.31 (4.17) 14.13 (2.28) 9.03 (1.97)
p-value 0.052 0.543 0.978 0.799 0.205
Position in pharmacy
Owner/Employer 33.72 (3.82) 4.64 (1.46) 9.16 (3.93) 14.14 (2.29) 8.98 (1.88)
Staff/Employee 34.61 (4.41) 4.57 (1.39) 9.89 (4.71) 14.19 (2.56) 9.68 (2.40)
p-value 0.186 0.794 0.313 0.892 0.049
Family income/month
<1000 USD 32.54 (4.46) 4.12 (1.73) 7.75 (2.60) 12.62 (1.51) 9.13 (1.64)
1000-2000 USD 33.46 (4.13) 4.64 (1.45) 9.19 (4.50) 14.14 (2.35) 9.22 (1.99)
2000-3000 USD 34.83 (3.70) 4.59 (1.69) 9.53 (3.91) 14.04 (2.46) 8.78 (1.84)
>3000 USD 34.17 (3.78) 4.60 (1.35) 9.76 (3.96) 14.40 (2.24) 9.48 (1.88)
p-value 0.256 0.839 0.557 0.218 0.254
Number of patients per day
<50 2.32 (1.14) 1.78 (0.75) 2.26 (1.02) 2.11 (0.99) 2.18 (1.08)
50-100 2.30 (1.13) 2.04 (0.73) 2.48 (1.08) 2.38 (0.94) 2.29 (1.03)
>100 2.76 (1.01) 1.76 (0.77) 2.34 (1.25) 2.60 (1.17) 2.85 (0.85)
p-value 0.106 0.026 0.375 0.027 0.005
“The minimum national standards for each activity are into” the “system”. Therefore, instead of evaluating them
based on processes that need to be relevant and defined on their ability to control quality of products at the time
appropriately according to the local needs of the pharmacy they are allowed into the system, community pharmacists
practice environment and national profession aspirations. were evaluated on their readiness to report in case of
All national pharmacy professional associations should also suspicion over the quality of products beyond the time
adapt these roles and functions in accordance with their point when those medications were allowed into the
own requirements. The activities listed below can be system, which is the time those products are being
further defined and measured by setting indicators of good delivered to patients (see questions C16-C18 in Online
practice within a national context and can be weighted by appendix 1).
1
actual practice-setting priorities”. Accordingly, items of our
The geographical distribution of pharmacies into Beirut,
indicator-based tool were adapted to the Lebanese
Mount Lebanon, Bekaa, North, and South was
context. For instance, in the FIP/WHO joint document,
representative of the OPL distribution of pharmacies.
under Role 1/Function B/2nd requirement, it is indicated
Expectedly, pharmacists were predominantly females
that “Pharmacists who are responsible for procurement
(57.2%) and overall, degrees earned were BS (60.6%),
should ensure that procurement is supported by strong
Pharm.D. (31.6%), Master’s (5.7%), and PhD (2.1%). These
quality assurance principles to assure that substandard,
findings are contradictory with the data published recently
adulterated, unlicensed and spurious/falsely-
by Bizri et al., possibly due to the slightly varying
labelled/falsified/counterfeit medicines are not procured or 29
1 geographical distribution of the participating pharmacists.
allowed into the system”. While we trust in the MOPH and
Nevertheless, our data are in line with the official national
their strict control of the pharmaceutical products
figures available in the OPL databases, thus our study
imported into the country, we believe that pharmacists, as sample can be considered representative of Lebanese
healthcare providers, do not have any tangible power in 23
community pharmacists. However, some confidence
assuring that counterfeit medicines are not being “allowed intervals are extremely wide, showing that for some

Table 3. Univariate analysis of different factors associated with the adherence vs. non-adherence to the GPP guidelines.
Variables p-value Unadjusted OR Confidence Interval
Age 0.310 1.02 0.99 1.04
Gender (males* vs females) 0.063 0.60 0.36 1.03
Education level 0.094
BS Pharmacy - 1
Pharm.D. 0.048 1.89 1.01 3.56
Master’s degree 0.274 0.57 0.21 1.56
PhD 0.581 0.60 0.10 3.69
Governorate <0.001
Beirut 1
Mount Lebanon 0.859 1.08 0.46 2.53
North Lebanon 0.492 0.50 0.07 3.61
South Lebanon <0.001 0.15 0.05 0.43
Bekaa 0.730 0.83 0.30 2.35
Years of experience 0.213
Less than 6 months - 1
6 months to less than a year 0.178 9.00 0.37 220.92
1 year to less than 3 years 0.706 1.59 0.14 17.56
3 years to less than 6 years 0.268 3.80 0.36 40.34
6 years to less than 12 years 0.251 3.87 0.38 39.05
12 years or more 0.197 4.54 0.46 45.22
Number of working hours / week 0.241
1-16 hours - 1
17-31 hours 0.711 0.67 0.08 5.68
32-40 hours 0.278 2.77 0.44 17.46
>40 hours 0.252 2.73 0.49 15.30
Position in the pharmacy (employer* vs employee) 0.791 1.10 0.53 2.28
House crowding index 0.788 0.92 0.51 1.66
Number of patients per day 0.169
<50 - 1
50-100 0.802 0.93 0.51 1.69
>100 0.089 2.11 0.89 4.97
*Reference group
analyses, the sample size was small. Studies with larger solutions yet to be approved and implemented by the
30
sample are recommended to overcome this drawback. MOPH.
Overall, our results showed that pharmacy practice in Indicator B served to identify services and facilities
Lebanon is not compliant with GPP standards, with less available at the pharmacies. A licensed pharmacist was
than a fifth of pharmacists meeting the requirements of all employed at most pharmacies (83%) for patient services
four indicators. The highest adherence score detected was and health promotion, which means that 17% are
for indicator A (23.3% of pharmacists). It is noteworthy that breaching the law by not having a pharmacist on a
indicator A consisted of eight questions in total and that continuous basis (besides during the interview where the
none of those questions were subjected to direct pharmacist was present); thus, it is suggested to enforce
verification by the OPL inspectors, thus possibly allowing the law on the pharmacist's continuous presence in the
the pharmacists to have a better adherence score for that pharmacy. There was a suitable place to discuss
indicator specifically. Pharmacists scored poorly on confidential information in almost all pharmacies.
indicators C and D, with less than 15% of pharmacists However, less than a third of pharmacists declared
properly adhering to GPP standards, respectively. Those engaging in awareness campaigns about most common
indicators are critical in a healthcare context since they diseases. In fact, the participation of pharmacists in
relate to the dispensing, preparation, and storage of outreach activities organized by the MOPH is still weak, and
medications. Importantly, the adherence levels were not higher levels of collaboration between the OPL and the
related to the pharmacy or the pharmacists’ characteristics. MOPH are recommended to improve pharmacists’
involvement. Nevertheless, half of the pharmacists had
The analysis of Indicator A showed that almost all information of various types and sources available to
pharmacists surveyed used a computerized system for data patients, which impact on patients’ health needs to be
management (99%), mainly for stock management (92%), assessed in future studies. The majority of pharmacists
and rarely for clinical services and medication offered services such as flu vaccination, blood pressure,
management. Since the electronic patient profile is not and glycemia checking; these activities can be considered
mandatory yet, this result was expected but not in as a satisfactory involvement in health promotion and their
8,21
accordance with the suggested Lebanese GPP guidelines. extension to other preventive measures would be
Moreover, only three-quarters of pharmacists kept copies encouraged to optimize pharmacists’ implication in health
of prescriptions for non-controlled medications, although awareness.
31
required by law. Issues concerning the unified prescription

– a new prescription system implemented in Lebanon – are Indicator C was of particular importance since it aimed to
still unresolved, and the OPL had already suggested related investigate the dispensing, preparation, and administration
of medicines. Our results showed that all pharmacists had

dispensed more than one prescription per day, most of dispose of expired products. This is another major issue
them identified errors in prescriptions, and engaged in that the competent authorities must address, because of its
awareness by providing information about adherence to environmental and health consequences, particularly in
treatment and antibiotic resistance. These figures are Lebanon where pollution of ecosystems linked to the waste
41,42
considered appropriate. Less than half of the pharmacists crises has been lasting for years.
had to call back patients after leaving the pharmacy, which
With regard to the items confirmed by the interviewer,
is relatively low, while almost all pharmacists declared that
serious hygiene problems were identified, with half of the
patients could consult for unusual adverse events.
pharmacists declaring that they do not use pest control
Although more than 90% declared counseling patients and
services. In addition, 88% had a refrigerator (confirmed by
checking medications before dispensing, one-quarter did
the interviewer), but 22% used it to store products other
not check for contraindications, drug interactions, or
than medications. Another major issue is that 7% of
prescribed doses; more efforts should be deployed by
pharmacists stated that the pharmacy was not supplied
relevant authorities to optimize these practices through
32 with electrical power during the night, while 3% did not
continuing professional development.
store medication stocks away from direct sunlight, which
43
Moreover, although the majority of pharmacists have may alter their quality. GPP adherence scores by region
access to literature and information resources for their own were low for each of the four indicators except for
education, mainly through internet, pharmacists should Indicator D (Storage) in Beirut.
broaden their knowledge and acquire better dispensing
33 Comparison across regions revealed a higher overall GPP
practices. They should also be encouraged to maintain
adherence score in Beirut. The underlying explanation is
effective communication with their patients, and follow up
34 yet to be identified and requires confirmation by larger
on their treatments to improve health outcomes. Indeed,
studies. It is hypothesized that an urban status of Beirut
a study in Lebanon had revealed that 40 to 50% of
dwellers (and thus pharmacists) would allow pharmacist to
Lebanese patients were asking for better communication
have more assets and better apply standards that require
with pharmacists, and enhanced pharmacy services.
resources at the human or financial levels, which may not
Pharmacists are also encouraged to improve their
be the case in other regions. This finding corroborates
communication with prescribing physicians in cases of
18,35,36 those of a previous situation analysis of pharmacists in
identified unnecessary medical prescriptions.
Lebanon conducted recently, showing that a substantial
Additional questions within Indicator C showed that almost percentage of Lebanese pharmacists have financial
44
all pharmacists declared dispensing medications without difficulties and cannot afford hiring assistant pharmacists.
prescription (NSAIDs [95%], antibiotics [60%], steroids
While pharmacists may proactively and actively work on
[27%], benzodiazepines [14%], gastrointestinal drugs [67%],
improving their adherence to GPP guidelines, the quality of
hormones and contraceptives [48%]), despite laws
pharmacy practice can be affected by involuntary factors
prohibiting it. This high rate of dispensing medications
unrelated to the pharmacist’s skills or standards of practice,
without prescription was found across all geographical
such as the patients’ load or the educational level of
areas. The undermining reasons found in previous studies
patients in the geographical area of the pharmacy. Indeed,
were mainly patients’ inability to visit a physician due to
2,37 a heavy load of patients means that the pharmacist can
financial constraints and lack of time. Therefore, it is
only dedicate a limited amount of time explaining to each
imperative to strengthen law enforcement through
patient the proper use of medications, or providing health
collaborative actions between the OPL and the MOPH,
awareness information to patients with a possibly low level
taking appropriate measures to improve the system,
of knowledge. Therefore, patient load, patient education
protect patients’ health, and reduce antibiotic
38,39 level, and the socioeconomic status of the pharmacist must
resistance. Furthermore, 88% of pharmacists declared
be included in GPP assessment tools to ensure a fair
explaining to patients the purpose of switching to a generic,
evaluation of pharmacists’ adherence to GPP. Our results
knowing that there are no evidence-based guidelines in
revealed that most pharmacies were visited daily by 10 to
Lebanon (similar to the book Approved Drug Products with
50 patients (44.66%) and many were visited by 50 to 100
Therapeutic Equivalence Evaluations, commonly known as
patients (40.30%). Moreover, the majority of pharmacists
the Orange Book in the US) to drive the pharmacist’s choice
(79.90%) declared working more than 40 hours per week.
and define a clear legal framework; the OPL had already
Taken altogether, these data indicate that the load of visits
suggested to the MOPH appropriate guidelines for safe
does not always provide enough room for the pharmacist
substitution of medications, allowing pharmacists to use
30,40 to discuss with every patient and abide by the
generic substitution whenever adequate and safe.
requirements of the FIP/WHO to explain the purpose of use
Within Indicator D, results showed an obvious problem of medication and indications of use, collect information
with the disposal of expired medications and about their medical history and provide health habits tips,
pharmaceutical waste. Moreover, the vast majority of especially if the pharmacist is not assisted by an additional
pharmacists did not have a clearly designed recall staff at the pharmacy. Adherence to GPP requires further
procedure for products they suspected to be adulterated, study since the multivariable analysis did not demonstrate
unlicensed, spurious, falsely labeled, falsified, or that the number of weekly working hours and the daily
counterfeit. In addition, 9% did not have an adequate stock patient load were associated with poor adherence to GPP
management and expiry date monitoring system, 85% did standards; this could be due to a lack of power in the
not encourage patients to return expired or unwanted analysis, or to a real absence of association in the Lebanese
products, and 68% did not have a specific procedure to context. Since previous studies in both developed and

developing countries had demonstrated the importance of national study will be important for statistical significance
the adequacy of the number of pharmacists compared to and appropriate comparison across geographical regions
the patients load in terms of quality of care, future studies over time. Finally, the validity was not assessed and
28,45,46
are warranted to further assess this issue. reliability results of the standardized tool we used was
suboptimal; this may be due to the fact that respondents
It is suggested that competent authorities, mainly the
better understood the question in one indicator than the
MOPH and the OPL, discuss solutions to improve the
others. We suggest further studies to better adapt the tool
financial situation of community pharmacists by
to the Lebanese context and prove its validity and improve
remunerating the services they might provide (particularly
its reliability characteristics, particularly in a constantly
the ones that were shown to be cost-effective), such as 51
changing healthcare system. Since the tool we used was
medication therapy management, medication
8 not previously validated, using it in a standardized way
reconciliation, and others. Improving the situation of
might still lead to a non-differential information bias,
pharmacists might allow them to better adhere to GPP
underestimating some associations. Improving the tool may
standards, which is expected to improve patients’ health as
show additional associations and further precise the
demonstrated in developed countries; additional studies
results, although we do not have reasons to believe that
are necessary to confirm these ideas. Furthermore,
the overall direction (i.e., suboptimal pharmacy practice)
continuing education related to this topic would also
would change. Another limitation is related to the
consolidate pharmacists’ knowledge, improve their attitude
assessment of Indicators B, C, and D since those were
towards the importance of GPP, and motivate them to
measured by combining together two distinct
spend resources towards improving the quality of their
47,48 measurement methods namely, self-reporting and visual
services. In addition to education, research has shown
evaluation by OPL inspectors. We suggest that in future
that multi-interventions might improve pharmacy practice
studies only one measurement method is used or that self-
in developing countries: regulatory enforcement,
reported items are evaluated separately from items
education, and peer influence were useful in specific
49 evaluated by OPL inspectors. Finally, for the accurate
aspects of pharmacy practice, when applied together.
assessment of those GPP items that are of critical
Finally, our results and recommendations could be importance for patients’ health, we could envisage using
52
extrapolated to other developing low- and middle-income specific measurement models.
countries; they can however be also useful for high-income
countries in rural areas, where several pharmaceutical
CONCLUSIONS
services are not available. This point was clearly highlighted
by the WHO European region report on legal and This study aimed at designing an indicator-based tool to
regulatory framework for community pharmacy in assess the level of adherence to GPP among community
50
Europe. pharmacists in Lebanon, and compare scores across
geographical regions. To our knowledge, this is the first
Limitations and strengths of the study indicator-based comprehensive pilot assessment study that
This pilot study has several limitations including a evaluates GPP adherence in community pharmacies across
possibility of information bias. Indeed, 80.5% of the Lebanon. It showed that community pharmacies in
pharmacists interviewed owned the pharmacy: they may Lebanon do not fulfill GPP criteria. Efforts should be made
have feared sanctions or penalties by the visiting OPL to support pharmacists with appropriate measures, make
inspector and may have altered their answers to meet GPP them aware of the importance of GPP adherence, and train
standards and protect the interests of their businesses. them on GPP guidelines and standards. Working on the
Therefore, we suggest evaluating pharmacists anonymously optimization of the assessment tool is also imperative. It
and have all answers pooled by geographical location. must be validated and adapted to the Lebanese context,
Similarly, items that require direct evaluation by the OPL thus leading to more precise assessment results and better
inspector would be answered electronically on site, which implementation of GPP standards in community practice.
decreases the risk of errors. However, we note that the
inspectors involved in this validation study were selected CONFLICT OF INTEREST
based on their experience; in addition, there was a high
number of completed questionnaires that were returned. Prof. Pascale Salameh was Chair of Scientific Committee at
the OPL at the time of this research work.
Moreover, there is a risk of error during data entry that was
done electronically and checked at three different time
points by three different individuals. Therefore, we believe FUNDING
that data entry mistakes are minimal if not absent. Also, None.
increasing the population size for the purpose of a cross-
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Family Practice, 2020, 1–8
doi:10.1093/fampra/cmaa044
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Qualitative Research
Pharmacists in general practice: a qualitative

process evaluation of the General Practice
Pharmacist (GPP) study
Oscar James, Karen Cardwell, Frank Moriarty , Susan M Smith and
Barbara Clyne*, , on behalf of the General Practice Pharmacist (GPP)
Study Group
HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland (RCSI),
123 St. Stephens Green, Dublin 2, Republic of Ireland
*Correspondence to Barbara Clyne, HRB Centre for Primary Care Research, Department of General Practice, Royal College
of Surgeons in Ireland (RCSI), 123 St. Stephens Green, Dublin 2, Republic of Ireland; E-mail: barbaraclyne@rcsi.ie
Abstract
Background: There is some evidence to suggest that pharmacists integrated into primary care
improves patient outcomes and prescribing quality. Despite this growing evidence, there is a lack
of detail about the context of the role.
Objective: To explore the implementation of The General Practice Pharmacist (GPP) intervention
(pharmacists integrating into general practice within a non-randomized pilot study in Ireland), the
experiences of study participants and lessons for future implementation.
Design and setting: Process evaluation with a descriptive qualitative approach conducted in four
purposively selected GP practices.
Methods: A process evaluation with a descriptive qualitative approach was conducted in four
purposively selected GP practices. Semi-structured interviews were conducted, transcribed
verbatim and analysed using a thematic analysis.
Results: Twenty-three participants (three pharmacists, four GPs, four patients, four practice nurses,
four practice managers and four practice administrators) were interviewed. Themes reported
include day-to-day practicalities (incorporating location and space, systems and procedures and
pharmacists’ tasks), relationships and communication (incorporating GP/pharmacist mode of
communication, mutual trust and respect, relationship with other practice staff and with patients)
and role perception (incorporating shared goals, professional rewards, scope of practice and
logistics).
Conclusions: Pharmacists working within the general practice team have potential to improve
prescribing quality. This process evaluation found that a pharmacist joining the general practice
team was well accepted by the GP and practice staff and effective interprofessional relationships
were described. Patients were less clear of the overall benefits. Important barriers (such as
funding, infrastructure and workload) and facilitators (such as teamwork and integration) to
the intervention were identified which will be incorporated into a pilot cluster randomized
controlled trial.
Key words: Organization of health services, pharmacist, primary care, process evaluation, qualitative research, quality in health care
© The Author(s) 2020. Published by Oxford University Press. All rights reserved.
1
For permissions, please e-mail: journals.permissions@oup.com.
2 Family Practice, 2020, Vol. XX, No. XX
Key messages
• Clinical pharmacists are increasingly part of general practice internationally.
• Positive impacts include improved clinical outcomes and reduced GP workload.

• We explored integrating pharmacists in general practice in Ireland qualitatively.
• GPs, pharmacists and practice staff cited good interprofessional relationships.
• GPs, pharmacists and practice staff were supportive of expanded pharmacist role.
• Barriers to future implementation included funding, infrastructure and workload.
Introduction based on national guidance and previous research (9–12). Broadly,

this involved medications reviews (opportunistic and targeted, con-
Clinical pharmacists are increasingly part of general practice teams
ducted face to face with patients or using medical charts only), in-
internationally, including in Canada, the UK and the USA (1).
volvement in the repeat prescribing process, conducting educational
Pharmacists in general practice can have positive impacts on clin-
sessions with staff and supporting clinical audits.
ical outcomes (e.g. blood pressure and glycosylated haemoglobin)
and prescribing safety (2,3). Integrating pharmacists into primary
care may also reduce GP workload (particularly medication-related Study population
administration), emergency department attendance and medication- The lead GP, practice nurse, practice manager and practice admin-
related hospitalizations and may also be cost-effective (1,4,5). istrator in all four practices were invited to participate in semi-
To obtain maximum benefits for patients, particularly those with structured interviews by email or phone. One patient who had a
polypharmacy and multimorbidity, full integration of clinical phar- medication review with a pharmacist per practice was invited to par-
macists into a primary care setting has been argued for (6). Although ticipate in an interview following their review. All three pharmacists
there is growing evidence of the benefits to pharmacists working were also interviewed. The pharmacists had a mean of 15.7 years
within general practice, a recent realist review highlighted that there clinical experience (range 4–26 years). See Table 1 for an overview
is a lack of detail about the context of the role (3). Further research of practice characteristics.
on pharmacists’ experiences of starting and embedding this new role
in general practice and observational studies of the process of phar- Data collection
macy work is conducted in practice are required (3). Semi-structured interviews were conducted by one of two female
The General Practice Pharmacist (GPP) study was a non- interviewers (KC—pharmacist, BC—health services researcher) ei-
randomized pilot study investigating the integration of pharma- ther face to face (in practice) or via telephone, depending on partici-
cists into general practice in Ireland (described in more detail in the pant preference. Telephone interviewing is generally used where time
methods section and in Supplementary Table 1). Unlike countries or costs are issues, and evidence suggests there is little difference in
like the UK and Canada, pharmacists in Ireland are not formally in- the answers obtained (13,14). The topic guide explored issues re-
tegrated into general practice, nor do they have prescribing rights. In lated to context and implementation of the intervention, as well as
keeping with the international literature (2,4,6), the GPP study dem- participant experience (Supplementary Table 2). The framing of the
onstrated that pharmacists working within general practices could questions drew on concepts from Normalisation Process Theory
improve prescribing quality, particularly medication appropriateness (NPT) (15) to understand how the intervention was (or was not)
(7). This paper describes a qualitative process evaluation, undertaken embedded in routine clinical practice, and relational coordination
to contextualize the quantitative results and aims to explore how the (16), a theory that identifies key concepts that underpin effective
intervention was implemented, the experiences of those participating interprofessional work (problem solving, timely, accurate and fre-
in the study and lessons for future implementation. quent communication and relationships between professionals char-
acterized by shared goals, shared knowledge and mutual respect). All
interviews were audio recorded (loud speaker for telephone inter-
Methods views) and were transcribed verbatim. Participants had the option to
The process evaluation undertaken used a descriptive qualitative review their transcripts however none availed of this.
approach.
Data analysis
GPP intervention Data were analysed using a thematic analysis following a six-step
The detailed methods (8) and results (7) have been published else- process (17). Two researchers (OJ and BC) independently reviewed
where (summarized in Supplementary Table 1.) Briefly, the study was the transcripts several times to familiarize themselves with the data.
conducted in four purposively selected general practices, reflecting a Both are health services researchers without a clinical background.
range of practice sizes and socioeconomic profiles, recruited from the Codes with common features were grouped together in themes (using
national Primary Care Clinical Trials Network Ireland. Following Microsoft Word), before being assigned to overarching themes by
practice enrolment, three pharmacists were integrated into the four one researcher (OJ) and the findings discussed with the second re-
participating practices for a period of 6 months (one pharmacist de- searcher (BC) for further refinement. In analysing the data, the aim
livered the intervention in two practices) working 10 hours per week was to utilize the concepts of NPT and relational coordination to
(September 2017 to March 2018). Configuration of time and activ- guide the development of the broad themes and sub-themes, how-
ities in the practice were agreed between each practice and pharma- ever, due to the number and length of interviews, the data did not
cist. Each pharmacist was provided with a Study Intervention Manual fully allow for this approach across all stakeholders. All participant
detailing the scope of activities to be delivered by the pharmacist, data were pseudo-anonymized by assignment of a unique study ID.
General Practice Pharmacist (GPP) process evaluation 3
Table 1. Characteristics of GP practices enrolled in the study (n = 4)
Characteristics Mean per practice Range
Number of GPs 4.25 2–9

Percentage full-time GPs 88.2 77.8–100
Number of GP sessions/week 27 11–64
Practice nurse sessions/week 14.5 8–30
Administrative staff sessions/week 30 0–90
Number of patients 8830.5 1777–16 631
Percentage of patients aged ≥65 years 16.1 10.8–24.8
Table 2. Interviewee characteristics
Group Number of participants Gender Average length of interview (minutes) Mode of interview
Pharmacists 3 2 female 58 3 face to face

1 male
GPs 4 2 female 39 3 telephone, 1 face to face
2 male
Patients 4 3 female 15 4 telephone
1 male
Practice nurse 4 4 female 11 3 telephone, 1 face to face
Practice manager 4 4 female 16 3 telephone, face to face
Practice administrator 4 4 female 12 4 telephone
Results ‘It had an impact on workload in that it increased that workload,

but that’s not to say it was a negative impact, the impact was
Interviews with the 23 participants (3 pharmacists, 4 GPs, 4 pa- positive in that it identified various issues that we were able to
tients, 4 practice nurses, 4 practice managers and 4 practice ad- address. So from that perspective, although there was a workload
ministrators) ranged in length across the participant groups implication, it was a valuable workload implication.’ GP1
(Table 2). Findings are reported under the themes of day-to-day
practicalities (incorporating location and space, systems and pro- All pharmacists participated in practice audit and delivered practice-
cedures and pharmacists’ tasks), relationships and communication based education. In addition, one pharmacist and GP developed
(incorporating GP/pharmacist mode of communication, mutual electronic prescribing tools on the treatment and management of
trust and respect, relationship with other practice staff and rela- chronic obstructive pulmonary disease and type II diabetes mellitus,
tionships with patients) and role perception (incorporating shared which were adopted across that practice. Pharmacists occasionally
goals, professional rewards, scope of practice and logistics). connected with community or hospital pharmacists in order to re-
Quotations are used as exemplars of key themes within the text solve prescription issues, or stepped into patient appointments to
and in Table 3. give prescription advice.
One intervention component (management of repeat prescribing)
was not delivered by pharmacists at any recruited practice, as this
Day-to-day practicalities process had been largely standardized within practices and/or was
Location and space were important considerations for the study not feasible given the configuration of the pharmacists’ time.
duration, and influenced the configuration of the 10 hours per
week. In three practices, pharmacists were based in available prac- Relationships and communication
tice rooms. In one practice, the pharmacist was based either in the The strongest on-going interaction in all practices was between the
administration office or in their own room, depending on room pharmacist and the GP (Fig. 1) in the conduct of tasks (i.e. medi-
availability (Table 3, Q1). As the individual joining the GP practice, cation review, audits and education). Communication around these
the pharmacists had to acquaint themselves with the practice sys- tasks, particularly medication reviews, was frequent with the mode
tems and procedures. In particular, all pharmacists were required of communication differing across practices (Table 3, Q3). Much
to learn about practice software (not standard in Irish general prac- communication was face to face, with organized regular meetings
tice) to access patients’ electronic medical records (Table 3, Q2). of varying length (Table 4). The length and structure of these meet-
Across all practices, there was similarity in the tasks undertaken ings evolved over the course of the study based on feasibility and
by the pharmacist (Table 4), however, there was variation in coord- sustainability. In one practice, meetings were more opportunistic
ination. All pharmacists conducted medication reviews, identifying due to differing timetables. Some communication was in email, and
potential prescribing issues such as those pre-specified in the Study some GPs preferred information to be noted in patients’ files to be
Intervention Manual and others based on their clinical judgement. reviewed opportunistically as they presented, highlighting the time-
Some reviews were conducted by the pharmacist with the patient liness of the information. Any urgent cases of potentially inappro-
but the majority were conducted based on a chart review only (with priate prescribing were emailed directly to the GP regardless of prior
or without the GP). Universally, the GPs reported that the pharma- communication arrangements.
cist reviewing medications increased their workload but this was not Across each practice, there was universal feedback of teamwork,
viewed entirely negatively: mutual respect and trust (Table 3, Q4). The pharmacists were largely
Table 3. Illustrative quotations
Theme Illustrative quotation
Day-to-day practicalities

Q1 Location and space ‘There weren’t difficulties because we had the space you know. In other practices there mightn’t have been a
room free for half a day every week, so in that way we were able to allocate one of the rooms, so that just took
a bit of moving around…we just changed the trainee to somewhere else.’ PM4
‘There are three GP offices, so I typically would be between [GP] office and they had a reg, so [registrar] was
off for their training on Wednesdays, but the chiropodist was there in the mornings so I would be there in the
afternoons, so I would split it between the two days’ PHARM 2
Q2 Practice systems and pro- ‘I was given a password and username on the [practice system] in both practices…it took me kind of a half an
cedures hour to an hour to figure out how to start looking in it for data.’ PHARM3
Relationships and communication
Q3 GP/pharmacist mode of ‘So in the face to face meeting we’d come up with a plan in [GP Practice], the way the GP did it out there was
communication they created the note in the file for the medication review so…for medical legal reasons, they wanted to create
their own note in the file and next opportunity they had to chat to the patient, to do a medication review with
the patient. They’d often make note of them and then they’d call the patient in for a medication review. And
then the next time I go into the file and look at, see what had happened and what they’d done…’ Pharm3
‘So they [pharmacist] had no issue with pointing out things that you know might be a patient safety risk,
but the sense that they were our resource, that was really good and I think that’s the only way it could work.
So I think if it was to be rolled out, I use that phrase, I think it would have to be a very much you know
non-judgemental’ GP4
Q4 Mutual respect and trust ‘Like I never felt that [pharmacist] was there to overlook my prescribing or was negative in any way or that
I was being monitored. I never had that idea. It was always like “These here are a group of patients, do you
want to have a look at them?”, “There’s probably not much that we can change but you know I possibly
thought this and this”. And then I would look at that and say “Yeah you know maybe” or “Hm, we’ve tried
that before” or something like that. So you know it’s just a kind of collegial thing and I think he/she works
well as part of a team.’ GP3
‘I think I got a lot of respect from them certainly yeah. I think that they really valued me being at the practice,
I felt that they were happy for me to be there… there were often times whenever some of the GPs would have
come to me and said you know like, “Oh what do you think of this medication for this patient?” So I defin-
itely did feel that they had confidence in me and I was able to answer their questions’ Pharm 1
Q5 Relationship with other Administrators: ‘Well I mean we would get a lot of queries … say from hospitals about what medications the
practice staff patients are on. Now I mean that’s not something that I actually feel that I am capable of portraying that in-
formation. I think sometimes the doctors are too busy to actually take those calls at the time…we take a mes-
sage and by the time we get to the doctor with the message or by the time the doctor gets back to us could be
a fair few hours passing and you know it would be probably quicker and handier for somebody… who knows
what they’re talking about as opposed to us on the front desk who don’t know what we’re talking about.’ PM3
Nurses: ‘They [pharmacist] would have thought differently to me on a solution to that problem and their
solution definitely was more time efficient first of all, and secondly, probably was the direct line when you’re
looking at medication’ PN2
Q6 Communication with ‘With my pharmacist, I find them most helpful but always very busy and I always feel “Oh I’m taking up their
patients time.” You know they haven’t got the same time. [Pharmacist], I felt relaxed completely with [Pharmacist] …
I can’t remember exactly how long, but I felt so relaxed and able to talk and I felt that it was a most helpful
operation.’ P4
Role perception
Q7 Shared goals (patient ‘I suppose I’m really very excited about what has been done. I can see immediately that it’s making the con-
safety) sultation easier for the doctor and better for the patient so that, from the point of view of my job, quality
control, assuring people we want to give the best service we can, it all just stacks up.’ PM4
‘So there were a few that you felt you did actually make a difference em, and I suppose ultimately that’s what
you’re all about isn’t it.’ PHARM3
‘They identified problems that need to be solved, so that’s more work, it’s more time, it’s more energy, em but
I suppose at the end of it then maybe you hope that having gone through that process that you’re probably
going to be less likely to make mistakes, you’re going to be more quick to pick up stuff that you weren’t pick-
ing on before, you know? You’ve raised the bar of knowledge and hopefully that there’s an overall benefit that
feeds into your systems and to your practice I suppose.’ GP2
Q8 Professionally rewarding ‘It has allowed me to use the clinical knowledge that I have…I didn’t feel like I was getting the opportunity
to use that knowledge and, yes I interacted with the patients and yes they would come to me if they had any
problems but you were kind of working with your hands behind your back because you didn’t have access to
the clinical information. You’d give them advice and you’d say you know “You should speak to your GP about
that,” or “I’ll ring your GP about that,” but you there was a limit as to what you could do.’ PHARM 1
‘That was us doing something not because the regulations said we had to do it, but because we wanted to do
it, that was very fulfilling professionally. And personally it was charming to work with [Pharmacist], they were
very easy to work with, so I learnt stuff. Also you had this feeling that you were not just going round in circles
with these two complex chronic diseases that you hadn’t really got to grips with. So you know that’s always
enjoyable when you solve a problem. And then I think from a practice point of view more generally, I think we
learned that we could integrate somebody like that into our work and it was an eye opener that you don’t have
to be a GP to be making these decisions and that was all very positive.’ GP4
Table 3. Continued
Theme Illustrative quotation
Q9 Inside scope of practice Education: ‘It’s all fine and well for reps to come in, but they’re just looking for their, specific drug, for their

brand of drug. Whereas actually if a pharmacist was to come in and educate the staff a bit more in certain
areas’ PN1
‘So something like having them here might encourage me to do my nurse prescribing and it would be great
because then you’d have the support there…’ PN4
Repeat prescribing: ‘I don’t think it’s that people need a physician to re-diagnose them, but a clinician like a
pharmacist who could re-evaluate an ageing patient and establish their repeat prescribing every second or third
visit could de-bulk the work load to the GP, and certainly improve the quality of care for the patients. So if
you had a permanent pharmacist that’s where you’d be going I think.’ GP4
Q10 Debated scope of practice Chronic disease management: ‘So maybe you know the likes of diabetic patients, maybe pharmacists could be
facilitating clinics where they are reviewing those patients for the GP and then relaying any information or any
changes in prescribing that needs to be done, so I think the role could certainly be extended.’ PHARM 1
‘…their scope of expertise…they can’t prescribe for instance, they can advise, they can’t assess the patients
from the perspective of a clinical, medical perspective.’ GP1
Q11 Logistics Cost: ‘Well, if there was clinical funding through the GMS or through other means for having a clinical
pharmacist working with the team then we would sign up for it immediately.’ GP1
Table 4. Characteristics of the pharmacist role
Practice characteristics GP1 GP2 GP3 GP4
Integration into the GP staff as team Yes Yes Yes Yes

member
Scheduled time with GP 60 minutes 60–120 minutes per week 30–60 minutes daily ‘an hour here
per session and there’
Pharmacist own room in surgery Yes No (based with practice Yes Yes
administrators)
Pharmacist conducted medicines reviews Yes Yes Yes Yes
Pharmacist participated in audits Yes Yes Yes Yes
Management of repeat prescribing No No No No
viewed by the GPs as being part of the team and non-judgemental Patients were offered a medication review with the pharmacist,
in their advice: however, uptake was low overall. For those who did participate in a
review with the pharmacist, conversations tended to involve medi-
‘Professional colleagues who have skills, that are augmented by
cine information and managing symptoms in more affluent areas,
our skills just as our skills augment theirs. So it’s very much a
while in less affluent areas the conversations were more about what
professional environment where [Pharmacist] wasn’t working
for us…to our instructions, it was very much part of a team ap-
each medicine did and why they were taking it. Overall, patient
proach.’ GP1 interviews indicated that they did not clearly understand the role of
a non-dispensing pharmacist in a GP practice (despite receiving the
Equally, the pharmacist reported feeling valued and respected within participant information leaflet) generally, but did personally find the
the practices: interaction pleasant (Table 3, Q6).
‘I think they appreciated my help…any questions I could answer,

advice I could give.’ Pharm2 Role perception
In general, there was good agreement across the pharmacist and all
Relationships between the pharmacist and other practice staff practice staff that during this study, the pharmacists within general
were less strong (Fig. 1). The practice manager and administra- practice were beneficial in broadly supporting the shared goal of
tors mainly interacted with pharmacists in relation to the research improving patient care (Table 3, Q7). Both GPs and pharmacists re-
study practicalities, such as patient recruitment which in terms of ported finding the process professionally rewarding and developed
calling and scheduling patients. Additionally the pharmacist was in their knowledge and skills (Table 3, Q8).
a position to assist the administration staff addressing issues with There was less clear agreement on the future role of the pharma-
repeat prescriptions, calls from hospital or community pharmacist in Irish general practice. There was broad agreement across the
cists, or answering patient medication queries. Administrative staff practice staff and pharmacists that ‘patient review, medication re-
appreciated assistance with a task they felt unqualified to conduct view, optimising prescribing, highlighting areas of potential inter-
and noted the knock on effect that this was one less task for the GP actions…liaising with local dispensing pharmacists’ GP1, as well as
to attend to (Table 3, Q5). The practice nurses had very little pro- audit, and practice education would fall within the pharmacist scope
fessional contact with the pharmacist. Only one of the four nurses of practice. GPs also felt there was scope for a clinical pharmacist to
interviewed consulted the pharmacist in relation to medicines in- be involved in repeat prescribing and working with nursing homes
formation directly, and reported finding the different perspective under the practice care (Table 3, Q9). Some of the pharmacists also
useful (Table 3, Q5). felt there was an opportunity for role expansion to include running

Figure 1. Diagrammatic representation of pharmacist interactions with GP staff through tasks. Staff are represented with ovals, tasks are represented with
rectangles. Pharmacist and GP: green. Pharmacist and patient: pink. Pharmacist and practice nurse: orange. Pharmacist and administrators: red. Pharmacist
and practice manager: purple.
disease management clinics, but some GPs were unclear about the Discussion
clinical responsibilities and implications of this in practice (Table 3,
Q10). As described above, patients were unclear on the role of a non-
Summary of findings
dispensing pharmacist in a GP practice overall: This process evaluation highlighted that GPs and pharmacists per-
ceived the benefits to pharmacists working within general practice
‘But I mean if you asked me would I see it as a benefit…I suppose (3). Perceived benefits included improved quality use of medicines,
I’m not too sure that I’d say yes to that.’ P1 improved medication knowledge and professional development.
The logistics of the future role of pharmacist in practice was also

unclear. Space was identified as an issue, as was the time configur-
Comparison with existing literature
ation with some participants seeing a part‐time or sessional position
The importance of strong relationships has been identified as a
being the most realistic option. From the GP perspective, the cost of
key component of clinical pharmacists working in primary care
employing a pharmacist and who should pay for that was identified
(3). A central strength of this study was the universal feedback of
as a future challenge (Table 3, Q11), as was balancing the demands
teamwork and strong relationships between the GPs and phar-
of time and workload, although this was counterbalanced somewhat
macists. Previous studies have highlighted the importance of rela-
against the potential for future efficiencies:
tional coordination in the effective delivery of disease-management
‘I suppose I went from having, alarmed “Oh my God why are we programs by interprofessional teams in primary care (18–21). The
doing this, it’s really hard work”, to “God it’s really interesting, GP pharmacist relationship described in this pilot study arguably
it’s really worthwhile, absolutely fascinating stuff”. And if people demonstrated key characteristics of effective interprofessional work
could see that and put money behind it would be great…I mean (according to relational coordination theory) including timely, ac-
it definitely was a big commitment and staff knew that, you just curate and frequent communication and relationships characterized
need to be prepared for that…’ GP2
by shared goals, shared knowledge and mutual respect. The degree
There was also some disagreement as to whether or not a commu- of integration of pharmacists into primary care teams may impact on
nity pharmacist could provide the same service as a clinical pharma- overall effectiveness with a recent systematic review reporting that
cist amongst the pharmacists themselves: a higher degree of pharmacist integration was associated with im-
proved health outcomes (6). Our participants were not in agreement
‘…it doesn’t need to be done week in week out…in my view you about the level of integration or the time commitment required for
know a community pharmacy could be doing it if they had the such as role, however, given the importance of developing effective
proper structure in place with the GP…’ Pharm 2
interprofessional relationships, some degree of integration would be
‘They’re just so different because community pharmacy is
required to make the transition work.
dispensing driven whereas this was purely patient safety in rela-
tion to medications. Now community pharmacy is also that but In keeping with international literature (22), there was enthu-
you wouldn’t have the same time to do it, or the same resources siasm and willingness among most of the pharmacists for new, ex-
to do it…they’re two very, very different things…the GP practice tended roles in primary care. The development of extended roles
pharmacist would be purely about patient safety and prudent pre- depends upon a number of factors, including role definition and pro-
scribing in terms of generics and things like that.’ Pharm 3 fessional boundaries, particularly the willingness of local physicians
(and nurses) to delegate tasks (23,24). Within this study, some of the Patrick Byrne, Aisling Croke and Tom Fahey. We thank the GP practices and
GPs and pharmacists themselves, hinted at professional boundaries the patients who participated in this study.
in relation to what was and was not within a pharmacist ‘scope of
practice’, but overall, GP, practice nurses and practice administra- Declaration

tion were collectively supportive a role for the pharmacist in gen- Funding: this study was funded by The Health Research Board (HRB) Re-
eral practice. There was also uncertainty in relation to how such search Collaborative in Quality and Patient Safety (RCQPS) award. The spon-
extended roles would relate and be distinct to existing community sors of the study had no role in the study design, data collection, data analysis,
pharmacy. data interpretation, writing of the report or in the decision to submit the paper.
Many of the barriers identified to the successful broad implemen- Ethical approval: this study was approved by our institutional research ethics
tation of such a role in Irish general practice in this study mirror those committee and informed consent was given by all pharmacists, GP practice
identified in previous studies, despite some of the unique features of staff and patients.
Conflict of interest: none.
the Irish health care system (Supplementary Table 3). Funding, in-
frastructure and workload balance for this type of role appear to
be universal barriers to implementation. In this study, patients were References
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INTRODUCTION continuous improvement of professional knowledge and

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required by law. Issues concerning the unified prescription

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Pharmacists in general practice: a qualitative

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Introduction based on national guidance and previous research (9–12). Broadly,

Table 1. Characteristics of GP practices enrolled in the study (n = 4)

Characteristics Mean per practice Range

Number of GPs 4.25 2–9

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Table 2. Interviewee characteristics

Pharmacists 3 2 female 58 3 face to face

Results ‘It had an impact on workload in that it increased that workload,

Table 3. Illustrative quotations

Theme Illustrative quotation

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Table 3. Continued

Theme Illustrative quotation

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Table 4. Characteristics of the pharmacist role

Practice characteristics GP1 GP2 GP3 GP4

Integration into the GP staff as team Yes Yes Yes Yes

‘I think they appreciated my help…any questions I could answer,

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The logistics of the future role of pharmacist in practice was also

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