Abstract:Community pharmacy faces ongoing challenges to its economic and social standing. A concern to legitimate professional status explains the attraction of public health. Interventions currently advocated by UK State-sponsored health care seek to reconcile the autonomous 'entrepreneurial' patient with market-driven solutions. Engaging critically with recent Foucauldian sociological work on pharmacy as a conduit for disciplinary power, we explore how professional ambiguity is exploited to 'manage' the subjectivitie… Show more
“…This tension between meeting targets and the freedom to support clients resonates with the experiences of link workers in education (Fretwell, 2020) and of community pharmacists who were defined as much by policy as professional practice due to the ‘payments associated with contractual activity’ (Atkin et al., 2021, p. 339). Likewise, Sam described:For me it’s incredibly frustrating to be based in practices where, if we were outside the [intervention] I would be busy from 6:00 am in the morning to 6:00 pm at night, very, very happily working with some people who need it…That imbalance is a result of structural strategic issues rather than patient need and is incredibly frustrating to me.…”
Link worker social prescribing has become a prominent part of NHS England's personalisation agenda. However, approaches to social prescribing vary, with multiple discourses emerging about the potential of social prescribing and different interpretations of personalisation. The transformational promise of social prescribing is the subject of ongoing debate, whilst the factors that shape the nature of front-line link working practices remain unclear. Based on 11 months of in-depth ethnographic research with link workers delivering social prescribing, we show how link workers' practices were shaped by the context of the intervention and how individual link workers navigated varied understandings of social prescribing. Following the work of Mol, we showhow link workers drew differentially on the interacting logics of choice and care and trace a multiplicity in front-line link working practices within a single intervention. However, over time, it appeared that a logic of choice was becoming increasingly dominant, making it harder to deliver practices that aligned with a logic of care. We conclude that interpreting personalisation through a logic of choice could potentially undermine
“…This tension between meeting targets and the freedom to support clients resonates with the experiences of link workers in education (Fretwell, 2020) and of community pharmacists who were defined as much by policy as professional practice due to the ‘payments associated with contractual activity’ (Atkin et al., 2021, p. 339). Likewise, Sam described:For me it’s incredibly frustrating to be based in practices where, if we were outside the [intervention] I would be busy from 6:00 am in the morning to 6:00 pm at night, very, very happily working with some people who need it…That imbalance is a result of structural strategic issues rather than patient need and is incredibly frustrating to me.…”
Link worker social prescribing has become a prominent part of NHS England's personalisation agenda. However, approaches to social prescribing vary, with multiple discourses emerging about the potential of social prescribing and different interpretations of personalisation. The transformational promise of social prescribing is the subject of ongoing debate, whilst the factors that shape the nature of front-line link working practices remain unclear. Based on 11 months of in-depth ethnographic research with link workers delivering social prescribing, we show how link workers' practices were shaped by the context of the intervention and how individual link workers navigated varied understandings of social prescribing. Following the work of Mol, we showhow link workers drew differentially on the interacting logics of choice and care and trace a multiplicity in front-line link working practices within a single intervention. However, over time, it appeared that a logic of choice was becoming increasingly dominant, making it harder to deliver practices that aligned with a logic of care. We conclude that interpreting personalisation through a logic of choice could potentially undermine
“…We thus agreed Version 4 with the patient and pharmacy advisory groups, thus completing the planned intervention development process and proceeded with the pilot trial [ 49 ], which provided encouraging evidence of impacts, whilst identifying also the challenges involved in research participation for community pharmacists [ 50 ]. After we had completed the intervention development work we also examined in depth our experience of the nature of co-production with patients in the context of the relevant literature [ 51 ] and further analysed the nature of professionalism among pharmacists in respect of public health roles [ 52 ].…”
Background
Alcohol is challenging to discuss, and patients may be reluctant to disclose drinking partly because of concern about being judged. This report presents an overview of the development of a medications review intervention co-produced with the pharmacy profession and with patients, which breaks new ground by seeking to give appropriate attention to alcohol within these consultations.
Methods
This intervention was developed in a series of stages and refined through conceptual discussion, literature review, observational and interview studies, and consultations with advisory groups. In this study we reflect on this process, paying particular attention to the methods used, where lessons may inform innovations in other complex clinical consultations.
Results
Early work with patients and pharmacists infused the entire process with a heightened sense of the complexity of consultations in everyday practice, prompting careful deliberation on the implications for intervention development. This required the research team to be highly responsive to both co-production inputs and data gathered in formally conducted studies, and to be committed to working through the implications for intervention design. The intervention thus evolved significantly over time, with the greatest transformations resulting from patient and pharmacist co-design workshops in the second stage of the process, where pharmacists elaborated on the nature of the need for training in particular. The original research plans provided a helpful structure, and unanticipated issues for investigation emerged throughout the process. This underscored the need to engage dynamically with changing contexts and contents and to avoid rigid adherence to any early prescribed plan.
Conclusions
Alcohol interventions are complex and require careful developmental research. This can be a messy enterprise, which can nonetheless shed new insights into the challenges involved in optimising interventions, and how to meet them, if embraced with an attitude of openness to learning. We found that exposing our own research plans to scrutiny resulted in changes to the intervention design that gained the confidence of different stakeholders. Our understanding of the methods used, and their consequences, may be bounded by the person-centred nature of this particular intervention.
“…CPs were more able to use certain person-centred consultation skills in routine practice to varying degrees. However, long standing professional habits and the busy, dispensing-focused, practice context incentivised reverting to more transactional and less person-centred practice (see ( Atkin et al., 2021 )). Scrutiny of, and feedback on, actual practice with patients have been identified as being likely key mechanisms for further empirical study in the RCT.…”
Section: Discussionmentioning
confidence: 99%
“…A scoping review of the MUR and NMS literatures found that few studies evaluated outcomes of MURs or the NMS ( Stewart, et al, 2019 ). To date only one RCT (of NMS) has been conducted ( Elliott et al., 2016 ), in addition to a few qualitative observational studies ( Atkin et al, 2021 ; Morris et al, 2019 ). Most research is retrospective and based on recall of what happens in consultations.…”
In order to effectively evaluate complex interventions, there have been calls for the further integration of qualitative methods. Qualitative process studies of brief alcohol interventions and medicines reviews are notably lacking. This article provides a grounded example through the presentation of findings from an embedded qualitative process evaluation of a multi-site, pilot cluster RCT of a new intervention: the Medicines and Alcohol Consultation (MAC). MAC is designed to increase the capacity of community pharmacists (CPs) to conduct person-centred medicines reviews in which the subject of alcohol consumption is raised in connection with medications and associated health conditions. Participant-focused qualitative studies (interviews, observations, recorded consultations) sought to understand how CPs engaged with and implemented MAC in context. This article documents effects of the intervention on developing person-centred consultation practice and highlights how qualitative process studies can be used formatively to develop middle range programme theory and to optimise intervention design for testing in a definitive RCT.
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