Practice pharmacists in the primary healthcare team in Aotearoa New Zealand: a national survey

Introduction

Most pharmacists internationally work in community pharmacy settings. However, in recent years, there has been much exploration, discussion and appetite for the integration of pharmacists into general practice in many jurisdictions, including in the United Kingdom (UK),^1–3 Australia,^4–6 Canada⁷ and the United States.^8,9 The speed at which the role has developed has varied; it is currently well-established in the UK.^10,11

Pharmacist roles in general practice can include individual patient care (eg medicines education and optimisation), providing support for other clinicians (eg medicines information) and undertaking practice-level activities such as medicines audits.^4,9 Extant evidence suggests that pharmacist services in general practice are highly effective; for example, in improving medicines adherence and some clinical outcomes for patients, reducing prescribing errors and easing workload pressures in general practice.^12–14

In Aotearoa New Zealand (NZ), the ‘practice pharmacist’ role has experienced ad hoc regional development, with some areas enjoying greater local support and investment in the role. In mid-2019, the role scope became explicit at a professional strategic level, with the Pharmacy Council NZ (PCNZ) publishing a position statement on expectations for pharmacists practising clinically in general practice.¹⁵ A toolkit to support role development is maintained by the Clinical Advisory Pharmacists Association (CAPA), a leading professional support and advocacy network.¹⁶

Traction for further development of practice pharmacist roles transpired at the health sector level with the 2020 Health and Disability System Review, which explicitly recognised the value ‘clinical pharmacists’ offered in medicines optimisation.¹⁷ This was followed in 2023 with the Primary, Community & Rural Early Actions Programme, a partnership between the then Te Aka Whai Ora–Māori Health Authority and Te Whatu Ora–Health NZ to strengthen care in these parts of the health system.¹⁸ A priority area identified was Comprehensive Care Teams, with funding for new roles, including pharmacists, to improve access and the breadth of care delivered to local communities. A position description for the practice pharmacist role (which may be tailored following discussion with the postholder) is now publicly available.¹⁹

Clear gains have been made at health policy levels, but scant empirical evidence exists about pharmacists in these roles in NZ, the tasks they undertake, the way in which they work and barriers and facilitators to undertaking the role effectively. A 2017 survey provided brief demographic data on some newer pharmacist roles emerging in primary health care (PHC), but it focused predominantly on medicines information provision tasks.²⁰ In 2018, pharmacists working collaboratively from or within a general practice to improve the quality of medicines use for patients were surveyed.²¹ This research identified a broader picture of practice pharmacist roles, and perceptions on their integration into general practice. Boyina et al.²² took a different approach, retrospectively reviewing medical notes (2015–2018) to determine patient-related tasks undertaken by clinical pharmacist facilitators in a single geographical region (Southern District Health Board), and the characteristics of the patients concerned. In 2023, general practices with a practice pharmacist were surveyed about the services these pharmacists were providing and the value they added to the practice, finding that they were viewed as adding ‘significant value’ to clinician support (93%), patient outcomes (92%) and patient safety (89%).²³

Survey results reported here form part of wider work around enhancing PHC services to improve healthcare delivery in NZ. This paper describes in detail the current status of pharmacists working in PHC settings other than community pharmacy, how these roles operate in practice, and the challenges faced.

Methods

The survey (Supplementary file S1) was developed based on previous literature and other research about practice pharmacists already being undertaken by the authors. Survey topics covered employment characteristics, services pharmacists currently offered or were intending to offer, patient consultations, relationships with other local health professionals and organisations, costs and benefits of pharmacists’ services, and demographics. Two of the authors are pharmacists (TNO and CM) and they contributed to the drafting of survey questions, which were tested with and refined by other research team members. Advice was also provided by a practice pharmacist on our research advisory group. The survey, hosted online on the Qualtrics platform,²⁴ was piloted with two pharmacists, with final changes made in response to suggestions.

Ethical approval was given by the Human Ethics Committee of Te Herenga Waka–Victoria University of Wellington (#0000030080). Information about the study was provided at survey commencement and participants gave informed consent before they began the survey. Respondents were offered the opportunity to enter a prize draw for one of five NZD$100 gift vouchers.

The survey was live between late May and the end of August 2022. An initial invitation to participate was circulated through PCNZ and Pharmaceutical Society of NZ (PSNZ) newsletters, with an electronic link to the survey. PSNZ sent three reminder notices to members by email. Information was also circulated via CAPA and other channels directed at pharmacists to improve response rates.

The survey was open to all pharmacists and intern pharmacists working in community pharmacy or other PHC settings. Those working in community pharmacy answered one survey section (these results will be reported in another paper). Practice pharmacists (ie pharmacists working in other PHC settings (solely, or in addition to community pharmacy work)), were routed to a second section, of which the results are reported here. Interns were not eligible to complete this section because no general practices were approved as training sites. Due to the way national workforce statistics are captured and reported, and inconsistent definitions applied, the precise number of pharmacists working in PHC roles nationally is unknown. It was estimated at September 2022 that there were 83 pharmacists and 28 pharmacist prescribers (total: 111) working in general practice and Primary Health Organisations (PHOs) settings (pers. comm., Bob Buckham, Te Whatu Ora–Health New Zealand, 25 July 2023).

Survey questions included single and multiple response options. Some used Likert scales and some had free-text options. Descriptive statistical analyses were undertaken, including numbers and percentages of participants agreeing with each option. Values were regrouped where possible or were withheld when a grouping contained fewer than four respondents, to reduce potential identifiability. Missing values were reported in tables but were not used to calculate percentages. Free-text responses were analysed thematically.

Results

Forty-nine people participated in the primary healthcare arm of the survey. Of these, nine did not answer further questions beyond stating that they were a pharmacist, and one was an intern, so are excluded. The results are, therefore, based on 39 practice pharmacists, an estimated response rate of 35%.

Respondents’ characteristics are set out in Table 1. They were more likely to be female (84%), New Zealand European (81%) and slightly older than the median practising age compared with the national demography of pharmacists in June 2022.²⁵ Fewer than four of the participants identified as Māori and none were Pacific. Most (89%) had postgraduate clinical pharmacy qualifications and 37% had a pharmacist prescriber qualification.

The 39 respondents recorded 51 separate jobs, with 23% having two or three jobs. Table 2 provides the respondents’ employment characteristics. Three-quarters of respondents worked at least partly within general practice and about half had roles in PHOs. About one-third worked in roles funded through each of the then District Health Boards (DHB), PHOs or general practices. Almost three-quarters of respondents were salaried, with most of the remainder being self-employed and fewer than four were paid through a mixture of salary and self-employment. About half of the pharmacists worked full-time, defined as ≥36 h per week across all roles. Almost 90% of respondents were based in main centres or other sizeable urban areas; few worked in smaller urban centres, and none defined their workplace as rural.

Practice pharmacists offered varied services. Those with more than one employment place were asked to answer with respect to their main role. Supplementary Table S1 shows that the three most common services were responding to medicines information queries from other health professionals (87%), advice and updates about medicines (85%), and liaison with community pharmacists (82%). Most also offered one or more medicines management services (medicines use review (44%), medicines therapy assessment (62%), medicines optimisation (69%)) and one-third were involved in prescribing. Immunisation was offered by 36%. Those not already offering one of the listed services were asked about their future intentions; strongest interest was shown in taking up repeat prescribing (to review and continue previously prescribed medication; 46%) and prescribing (initiating new medication; 42%).

Most practice pharmacists (n = 32, 86%) reported having patient consultations as part of their work (Table 3). Nearly half were undertaking fewer than 11 consults weekly. The reported capacity for additional consultations was a median of five (interquartile range 2–10), suggesting that many were working at or near capacity. Seven (22%) pharmacists reported that their patients directly funded the consultation; the remainder were funded by one or a combination of general practice, PHO and/or DHB. The amount paid by patients for consulting with a practice pharmacist was generally in line with standard fees for general practitioner consultations, which ranged from NZD$19.50 maximum for adults at Very Low Cost Access (VLCA) practices, and NZD$20–$51 for other practices.^26,27 One respondent stated that patients paid the standard script fee, rather than a consultation fee. Lack of funding and lack of consultation space were the two biggest perceived limitations to seeing more patients; cost to the patient was also a common limitation to offering more consultations. Other reasons given included being too busy with other work, a lack of referrals from other health practitioners, and limited time in a practice.

The lattermost constraint may be reflected by the fact that half of the pharmacists spent ≤10 h per week consulting with patients (Table 4). However, in addition to direct consultation time with patients, time was spent on consultation preparation and follow-up. Among those undertaking consultations, most conducted these alone; the remainder were completed jointly with doctors, nurse practitioners, or registered nurses.

Survey respondents ranked improved health outcomes, improved understanding of their medicines, and medicines optimisation as the most important benefits of their role for patients (Table 5). Supporting doctors’ or nurse practitioners’ workload, changes in prescribing, and additional workforce capacity were ranked as the most important benefits for their workplace. The pharmacist’s salary, office space and resources, and consultation space were ranked by respondents as the main costs to the workplace. Additional workload for general practitioners, nurses or other practice staff were not ranked as major costs.

Respondents were asked to rate their professional relationships with other people and organisations in their area on a five-point scale. Supplementary Table S2 shows the proportion of pharmacists reporting ‘very good’ or ‘good’ relationships. The highest percentages were with other PHC team members (eg practice nurses (95%), general practitioners (92%)). Relationships with pharmacists were strongest with others working in PHC settings (92%) and community pharmacists (84%), whereas it was slightly lower with hospital pharmacists (66%). Relationships with ‘your community’ were rated as ‘good’ or ‘very good’ by 76% of respondents; for iwi or Māori health providers, this was 55% and for Pacific health providers, 52%. The lowest rated relationships were with public health services (46% ‘good’ or ‘very good’).

Discussion

Conclusions

In summary, we have described in detail the practice pharmacist role in NZ, which continues to expand and develop. The inclusion of a pharmacist in the primary healthcare team may address some of the ongoing workforce issues facing PHC, but careful planning is required to ensure support and appropriate infrastructure is available for practice pharmacist roles to succeed.

Supplementary material

Supplementary material is available online.