The aim of this research was to investigate the structures and processes of pharmacist prescribing in Great Britain, focusing on primary care settings. A ‘sequential-mixed methods’ was employed in the conduct of the research. The first phase was a cross-sectional postal questionnaire of all pharmacist prescribers (n= 1654 in January 2009), to quantify the extent and nature of prescribing and key factors associated with prescribing practice. Response rate was 42.3% (n=695). The pharmacy practice setting was significantly associated with prescribing (those in hospital or general medical practice were more likely to have prescribed (p< 0.05), than respondents in community practice). Factor analysis of attitudinal statements on prescribing implementation revealed factors, grouped as: ‘administrative structures and processes’, ‘perceptions of pharmacists’ prescribing role’ and ‘facilities for prescribing’. Scores for ‘facilities for prescribing’ varied depending on practice setting. Respondents in community practice recorded lower median scores compared with those in general medical practices. However, there were no statistically significant differences in median scores between respondents based in GP and hospital settings. In-depth qualitative work undertaken in the second phase further explored facilitators of, and challenges to prescribing practice (e.g. the lack of defined prescribing roles) identified in phase one. Semi-structured interviews were conducted with a purposive sample of 34 prescribers. Prescribers were selected from diverse settings, including secondary care from England and Scotland, to highlight key factors contributing to prescribing success which could potentially inform extrapolations of successful practice from one setting to the other. The ‘framework’ approach to qualitative data analysis was rigorously applied, revealing that the professional isolation and issues around access to clinical data and administrative support in the community setting may have negatively impacted on prescribing implementation. Notably, a perceived lack of clarity and definition of the pharmacist prescribing role was a key theme in hindering prescribing practice of pharmacists irrespective of setting. Participants described ‘ideal’ roles which they perceived as potentially providing clarity, definition and direction to facilitate implementation. The original data generated through this research highlights that prescribing implementation is less than desired, especially in community pharmacies. Pharmacist prescribing appears to have progressed little since supplementary prescribing developments in 2004, even with the much heralded arrival of independent prescribing in 2006. Interestingly, phase 2 participants suggested a ‘hybrid supplementary/independent’ prescribing model, as more likely to succeed. In this model, pharmacist prescribers favour a cooperative practice arrangement in which doctors diagnose and pharmacists prescribe. The implication of these findings and specific recommendations for policy makers, other key stakeholders and practitioners are discussed in detail within the thesis.

<p>This study proposes that poor understanding of the structures, processes and outcomes of organisations seriously hampers collaboration between professional groups in care organisations. Three care settings were investigated: follow-up of patients with heart disease, an intensive care unit and care services for older people.</p><p>The overall aim was to investigate how people understand structures, processes and outcomes in care organisations. The participants were patients, patient representatives, healthcare professionals, managers and politicians.</p><p>A qualitative approach was used. Thematic analysis and grounded theory were employed in analysing the data.</p><p>Despite considerable efforts, no major changes took place over a 7-year period as to how cardiac follow-up services were understood. The system of cardiac follow-up services was found fragmented in its organisation and in the way individuals understood it. The results indicate that care professionals, patients and leaders have dissimilar understandings. The data suggest that care is organised from a professional-centred perspective rather than from a holistic worldview of the patients’ total context. Leaders in intensive care perceive their organisation as a learning organisation. However, in daily work healthcare tends to function to what can be described as a mass production approach to care. This state of conflict caused confusion and chaos among the leaders. The municipal elderly care services and the county council’s geriatric organisation had difficulties in co-ordination. Older people were perceived as passive recipients of healthcare, rather than as consumers whose well being and outcome were a reflection to the quality of the service.</p><p>The study concludes that despite the major changes that have taken place in the Swedish health and elderly care organisations over the past years, healthcare professionals’ understanding of their work has gone largely unchanged. Their understanding of care structures and processes did not change despite outside pressures. Lack of understanding of what others understand hampers development with the result that care organisations risk stagnation.</p>

This study proposes that poor understanding of the structures, processes and outcomes of organisations seriously hampers collaboration between professional groups in care organisations. Three care settings were investigated: follow-up of patients with heart disease, an intensive care unit and care services for older people. The overall aim was to investigate how people understand structures, processes and outcomes in care organisations. The participants were patients, patient representatives, healthcare professionals, managers and politicians. A qualitative approach was used. Thematic analysis and grounded theory were employed in analysing the data. Despite considerable efforts, no major changes took place over a 7-year period as to how cardiac follow-up services were understood. The system of cardiac follow-up services was found fragmented in its organisation and in the way individuals understood it. The results indicate that care professionals, patients and leaders have dissimilar understandings. The data suggest that care is organised from a professional-centred perspective rather than from a holistic worldview of the patients’ total context. Leaders in intensive care perceive their organisation as a learning organisation. However, in daily work healthcare tends to function to what can be described as a mass production approach to care. This state of conflict caused confusion and chaos among the leaders. The municipal elderly care services and the county council’s geriatric organisation had difficulties in co-ordination. Older people were perceived as passive recipients of healthcare, rather than as consumers whose well being and outcome were a reflection to the quality of the service. The study concludes that despite the major changes that have taken place in the Swedish health and elderly care organisations over the past years, healthcare professionals’ understanding of their work has gone largely unchanged. Their understanding of care structures and processes did not change despite outside pressures. Lack of understanding of what others understand hampers development with the result that care organisations risk stagnation.