Problems associated with the inefficient or ineffective use of medicines at the interface between primary and secondary health care are well recognised and remain largely unresolved. Attempts to resolve difficulties at the interface have, to date, focused on national guidance with a view to improving communication between health care professionals. The research presented in this thesis examines the root causes of problems with the management of medicines with a view to reappraise traditional definitions of the interface and to learn of the perspectives of the main stakeholders - community phannacists, hospital phannacists, general medical practitioners and hospital medical consultants. The objectives of the research were: 1. To describe and categorise problems relating to the care transfer process that lead to a deterioration in medicines management, 2. To critically appraise the local interpretation and implementation of health policy, 3. To describe staff communication and decision-making processes and 4. To explore reasons why guidance is not put into practice. The research was conducted in a district general hospital whilst the researcher was employed as an Interface Phannacist. Qualitative methods of data collection were deployed as follows. First, 87 case study examples of interface issues were collected from reports made by doctors and phannacists in primary and secondary care and those identified by the researcher. A root cause analysis of each case showed how deficiencies in medicines management processes could contribute to problems and difficulties. The medicines management processes relevant when patients are transferred between primary and secondary care, together with the root causes of interface issues were mapped. The next stage ofthe research involved conducting focus group and semi-structured interviews with seven community phannacists, sixteen hospital pharmacists, nine general practitioners and two hospital medical consultants. Content analysis, based on qualitative research theory, showed participants' perspectives of medicines management across the interface. The perspectives of patients were gained through semi-structured interviews with 101 patients attending hospital outpatient clinics and eight medical inpatients. Patients were followed up after the hospital episode to detennine whether they had experienced any difficulties with their medicines. Three key outcomes emerged from the research. First, an improved understanding of the types of medicines management issues that arise when patient care is transferred across the interface. Second, four causes of sub-optimal medicines management across the interface were identified, a lack of awareness or misunderstanding of policy, inadequate inter- or intra-professional collaboration, impracticable or inflexible policy or flagrant violation of policy. Change management theory was utilised in order to confirm the presence of barriers that prevent medicines from being managed effectively at the interface and demonstrate why guidance has failed to improve the situation. Finally, this research has led to an improved understanding of the interface and its constituent dimensions which helps appreciation of the type of interventions that may be necessary in order to improve seamless care.

Continued pressure to reduce costs and manage healthcare delivery in risk-based reimbursement environments, has, internationally, resulted in hospitals adopting different methods to manage pharmaceutical and surgical consumable products. An initial review of systems of management of these products showed that the trend is to manage them separately. Pharmaceutical products are managed using dedicated resources and structures in each hospital, which may be difficult to establish and sustain in smaller, non-academic hospitals. Amongst other factors, the absence of a classification system and a lack of utilisation information hindered the development of management systems for surgical consumable products. In addition, traditional materials management processes applied to these products, often do not adequately address the impact that these products have on clinical care. In this study, the decision was made to develop an integrated system for both pharmaceutical and surgical consumable products and to adopt a systems approach in which all hospitals in the group were included as a single system. The study was multi-methodological with the design being contextual and qualitative and the research strategy, exploratory and descriptive. A multi-phased, action research approach was used, comprising of three (3) cycles, two (2) in which the integrated system was developed and enhanced and a third in which it was independently tested in 19 newly acquired hospitals. The result of the three (3) cycles was an implemented integrated system across 43 acute-care hospitals in the group comprising six (6) processes namely: a product selection process, information technology (IT) support system, a hospital implementation process, measurement and management tools, pharmacy capability and a supplier strategy and interface process. These processes included several key unique features, such as one (1) product selection team for all hospitals, a surgical classification system based on functional therapeutic uses, a single IT system and utilisation review capability for all products, extending the role of pharmacy departments in hospitals to include the management of surgical consumable products and an integrated quality assessment process for both types of products. By the end of the three (3) cycles (September 1999), the product selection process covered 66,5% of value of product spend, the percentage reduction in the number of products used was 68% and the value of products purchased that complied with specified products and suppliers was 90%. Ongoing and further application showed that the integrated system could be sustained in existing hospitals, applied to a further four (4) newly acquired hospitals and expanded to include specialised pharmaceutical and surgical consumable products in cardiac catheterisation laboratories. By September 2003, the total spend on pharmaceutical and surgical consumable products had reached R1,7 billion. The product selection process covered 67,6% of total spend, the compliance value reached 95% and there were additional financial improvements realised. Following a further literature review, limitations and improvements to the approach were identified and further adaptations were added as concepts in the graphic representation of system. One (1) of these was to show the integrated system as an open system. The second adaptation highlighted the systems-based input-process-outcomes feedback concept that is critical to continuous improvement of the system. In the final progression, a systems approach to strategic planning and management was incorporated in order to provide a structured approach for adapting to the rapid and ongoing changes in healthcare and aligning the system of management of pharmaceutical and surgical consumables to the overall business strategy. Overall, this research study succeeded in bringing new perspectives and an innovative approach to the management of pharmaceutical and surgical consumable products by developing and implementing an integrated system for both products, establishing essential processes with key unique features and tools, and the application of a systems thinking approach. Four (4) areas of further research are suggested, namely testing the integrated system in other contexts, improved methods of measurement of quality of care, extension to other areas of healthcare and use of the systems approach in other areas of the business.