7 Reasons for the lower than expected take-up of service provision
7.1 Feedback from pilot pharmacies who had not yet claimed for services by January
2012
In order to investigate the reasons for lower than anticipated service provision, the evaluation team organised telephone interviews with 100 pharmacists from 100 pharmacies that had not yet claimed for a service. The interviews were conducted during
18 The initial expectation was that pharmacies would be able to deliver five MedsCheck services and one Diabetes MedsCheck service per week. Over 30 weeks, this equates to 51,480 services delivered by 286 pharmacies.
76
February 2012. The main objective of the interviews was to determine why these pharmacies had enrolled in the pilot, but decided not to proceed or else had been unable to proceed with service delivery and the point where this occurred in the program implementation pathway.
7.1.1 Interview sample
Of the 229 pharmacies which had not claimed for services during the first five months of the pilot program, 154 pharmacies were contacted with a view to completing 100 interviews. Pharmacies were randomly selected for interview. Pharmacies contacted for interview and reasons for non-participation are detailed in Chart 7.1.
Chart 7.1: Pharmacies contacted for interview and reasons for non-participation (N=154)
Pharmacy distribution by State/Territory
In terms of their location by States or Territory, the pharmacists interviewed were broadly representative of pharmacies eligible for interview. Victoria had the largest variation in proportional representation where 11% of pharmacies had not claimed for a service whereas 15% of pharmacists interviewed were from Victoria.
0 20 40 60 80 100 120
Sample duplicate contact name Unusable - Fax machine / modem Out of scope - Claims to have done survey Out of scope - Away f or duration Out of scope - Denies registered f or pilot Out of scope - SmartForm successf ully submitted Interview completed Unresolved contact - Appointment Number not initiated
Number of pharmacies
77
Table 7.1: Total population of eligible pharmacies and pharmacists interviewed State Pharmacies that had not claimed
for a service by 31st January 2012 (N=229)
Pharmacists interviewed (N=100)
Number Distribution Number Distribution Variation in percentage
In terms of their SEIFA decile, the pharmacists interviewed were from pharmacies that were broadly representative of pharmacies eligible for interview. The lowest four SEIFA deciles had a higher proportion of pharmacies that did not claim for services (45%) compared to the highest four deciles (29%). In terms of the pharmacists interviewed, the lowest four SEIFA deciles had a higher proportion of pharmacies at 49% compared to the highest four deciles at 21%.
Table 7.2: Distribution of pharmacies that had not claimed for a MedsCheck or Diabetes MedsCheck by 31st January 2012 and pharmacies that were interviewed
SEIFA decile Pharmacies that had not claimed for a
78
Some pharmacists in the sample provided services but were unable to claim for payment Of the 100 pharmacists interviewed, 83 had not yet provided a MedsCheck or Diabetes MedsCheck service, 15 had provided a service but were not able to successfully submit the SmartForm to claim for payment and two did not know whether a service had been provided in the pharmacy or not (Figure 7.1).
Figure 7.1: Pharmacists interviewed
Do the pharmacies which had not provided services plan to provide services in future?
Of the 85 pharmacists who had not yet provided a service or did not know whether a service had been provided in the pharmacy:
77 stated that their pharmacy intended to start providing MedsCheck and Diabetes MedsCheck services in future;
five stated that their pharmacy would not be providing services in the future; and
three did not know whether they would provide services in future.
7.1.2 Pharmacy size
In this section, the size of pharmacies participating in the interviews (ie pharmacies which had not successfully provided or claimed for any services) is compared with pharmacies
79
FTE pharmacists
Pharmacists interviewed (N=100) reported that their pharmacy had an average of 1.8 FTE pharmacists with a median of 1.65, a minimum of 1 and a maximum of 8. Table 7.3 shows that most pharmacies (89%) had fewer than 3.0 FTE pharmacists and around half the pharmacies had between 1.0 and 2.0 FTE pharmacists.
Table 7.3: Number of FTE pharmacists working at pharmacies
FTE pharmacists Number of pharmacies (% of total) (N=100)
≥1.0 < 2.0 51 (51%)
≥2.0 <3.0 38(38%)
≥3.0 11(11%)
In comparison, pharmacies which had commenced MedsCheck and Diabetes MedsCheck consultations and responded to the online survey reported a slightly higher number of FTE pharmacists (average of 2.3, median of 2 and maximum of 9.5), (Table 7.4). Just over three quarters of respondents to the Pharmacist Survey (78%) said they had fewer than 3.0 FTE pharmacists and 38% had between 1.0 and 2.0 FTE pharmacists. Overall, it appears that pharmacies which had commenced service delivery employed more pharmacists on average than pharmacies which had not commenced service delivery and which participated in the interviews.
Table 7.4: Number of FTE pharmacists at businesses which responded to the online survey(a)
FTE pharmacists Number of pharmacies (% of total)(N=50)
≥1.0 < 2.0 19 (38%)
≥2.0 <3.0 20(40%)
≥3.0 11(22%)
(a) Number of FTE pharmacists before the commencement of the MedsCheck program was reported
Dispensing volume
Table 7.5 shows that over one third (37%) of pharmacies that never provided or claimed for a MedsCheck or Diabetes MedsCheck service dispensed over 1,500 prescriptions per week and close to one half (49%) dispense over 1,250 prescriptions per week. Table 7.5 also shows that larger proportion of pharmacies that never provided a service or never successfully claimed for a service dispense more than 1,500 prescriptions compared to the pharmacies that have successfully claimed for a service provided, Table 7.5.
80
Table 7.5: Comparison between prescriptions dispensed per week for pharmacies that have not successfully provided or claimed for a MedsCheck or Diabetes MedsCheck
service and pharmacies that have prescriptions with slightly lower number of FTE pharmacists relative to weekly prescription volume than pharmacies that had commenced service provision, see Table 7.6.
Table 7.6: Mean number of FTE pharmacists and relative prescription volumes Number of prescriptions per
7.1.3 Main barriers to program implementation and subsequent service delivery
Pharmacists were asked to describe the main reasons why they had not provided services.
All pharmacists (N=100) responded, with a total of 163 reasons. These were categorised into 28 separate codes. The top ten codes (75% of the total number of responses) were as follows.
The pharmacy was too busy or the program takes too long to set up and/ or implement (30 responses).
It was too difficult/complicated to register or obtain an AUSkey (22 responses).
There was not enough staff or the staff turnover was too high (20 responses).
It was too difficult/complicated to install the AUSkey/make the AUSkey work (13 responses).
There was no computer/consultation area available (7 responses).
There were problems/difficulties with the AUSkey (7 responses).
81
It took too long to install the software (6 responses).
The pharmacy didn’t receive enough/clear information about the program in general (6 responses).
It was too difficult/complicated to install the software (6 responses).
The pharmacy had trouble with the digital signature/submitting the SmartForm online
(5 responses).
Close to half the responses under these top ten reasons (48%) concerned an IT related issue. Of the 163 responses in total, 83 (51%) specifically related to IT issues, while other responses may or may not reflect IT issues (for example, the 30 responses where the pharmacist indicated that ‘the pharmacy was too busy or the program takes too long to set up and/ or implement’). Other reasons are provided in Table 7.7.
Table 7.7: Non-computer related reasons for not providing MedsCheck and Diabetes MedsCheck services under the pilot program
Reason Number of responses
The pharmacy was too busy/the program takes too long to set up/implement
30
Not enough staff/staff turnover too high 20
No computer/consultation area available 7
Didn’t receive enough/clear information about the program in general
6
Other 4
Difficult to recruit patients 4
Already providing several HMRs which would preclude several customers from MedsCheck services
2
Moving stores/selling stores 2
Too much paperwork 2
Had trouble filling out forms 1
Confusing/incorrect information provided 1
Didn’t receive CD 1
7.1.4 Barriers to service provision — the point in the service delivery chain at which pharmacies stopped
Pharmacists who had not provided a MedsCheck or Diabetes MedsCheck service (N=83) or did not know if their pharmacy had provided either service (N=2) were asked where their pharmacy “is currently up to” in implementing service delivery processes, or at which point in the implementation process they “decided not to proceed”. The implementation process for successful service delivery was broken down into six steps and pharmacists’ progression through those steps was mapped. The six steps were:
Step 1: Received the Pilot Resource CD with the MedsCheck program software;
Step 2: Successfully located the pharmacy’s existing AUSkey/attained a new AUSkey;
82
Step 3: Successfully installed the AUSkey and the SmartForm Signing Utility software from the CD;
Step 4: Successfully downloaded the SmartForm Assessment Tool from the Department or the Guild website;
Step 5: Offered/promoted MedsCheck services to eligible patients;
Step 6: Delivered MedsCheck services, including completing the SmartForm Assessment Tool; and
Step 7: Successfully submitted the SmartForm Assessment Tool to the Department to claim payment using the AUSkey.
During piloting, it became evident that pharmacies who claimed they had provided a service but had unsuccessfully submitted their claim for payment or did not know if their submission had been successful, (N=15), had completed step 6 but not step 7. Therefore, no further pharmacists from these pharmacies were asked this question and it was assumed that these 15 pharmacies had completed step 6.
The findings presented here are designed to inform the design of any future electronic tools used to deliver professional pharmacy services. Chart 7.2 shows the cumulative number of pharmacies quitting at each step.
For pharmacies that never provided a service or did not successfully claim for a service provided:
more than half (53%) of the 100 pharmacies stopped at step 3;
only 1% of pharmacies stopped at step 4;
once the IT requirements had been met (steps 2,3 and 4), work flow and or promotion provided further barriers to the implementation of the program. Sixteen per-cent were unable to offer/promote MedChecks to eligible patients (step 5) and a further 15% were unable to deliver a MedsCheck including completing the SmartForm Assessment Tool (step 6); and
although 30 pharmacies reached and completed step 5, it appears that only half these pharmacies completed step 6. It is possible that their promotion of services did not make traction with customers and they were unable to deliver any MedsCheck or Diabetes MedsCheck services or they did not have time to schedule appointments, hence did not complete steps 6 and 7; and
15% of pharmacies reached step 7, but did not complete as they were either unable to submit their SmartForm for payment or were unsure if it was successfully submitted.
As can be seen Appendix O, a relatively small number of pharmacies did not know whether they had completed or not completed each step, hence these have been added to pharmacies that stated they did not complete the step.
83
Chart 7.2: Proportion of pharmacies that discontinued program implementation at each step (N=100)
Further descriptions of steps
Linking into the question about the point at which service delivery was stopped, pharmacists who had not provided any services i.e. not able to complete step 6 (N=85) were asked to further describe the steps they could and could not complete. The barriers steps 2 and 3 posed for pharmacies in implementing the MedsCheck and Diabetes MedsCheck pilot program were further emphasised by these descriptions. All 85 pharmacists provided 126 responses which were categorised into 26 separate descriptions.
Of those, the most frequently quoted description with 15 responses was that it was
‘difficult/complicated to register/get an AUSkey’ which would have occurred at Step 2. The second most frequently quoted descriptions were:
it was ‘too busy/program takes too long to set up/implement’; and
it was ‘difficult/complicated to install/set up the AUSkey’, each with 11 responses.
Out of the 26 types of descriptions for the steps that pharmacists could and could not complete, there were ten outlining AUSkey problems with a total of 47 responses.
The top ten descriptions (out of the 26 coded descriptions) accounted for 70% of the total responses (88 responses out of 126 responses in total). The ten most frequent descriptions and the frequency of responses for each as a proportion of total responses, N=88, is represented in Chart 7.3. When asked for a further description of the step they did not complete, pharmacists frequently described that they were too busy and that the program took too long to set up. This may be linked with the difficulties that pharmacists experienced in obtaining, registering and installing the AUSkey. Another popular
0%
5%
10%
15%
20%
25%
30%
35%
Step 1 Step 2 Step 3 Step 4 Step 5 Step 6 Step 7
Proportion of pharmacies
Step in program implementation
84
description was not receiving enough/clear information about the program in general. This also featured in the top ten main reasons as to why the pharmacy had not started providing the program.
Chart 7.3: The ten most frequent descriptions of the step not completed and their proportional frequency of responses (N=88 responses)
7.1.5 The impact of other 5CPA programs on MedsCheck service delivery
Ninety-seven per-cent of the 100 pharmacists interviewed offered a range of other services under the 5CPA with only 2% of pharmacies offering no other services and 1% not sure of other services offered. The 5CPA services provided included:
recording of Clinical Interventions (95% of pharmacies);
supply of dose administration aids (92% of pharmacies);
staged supply of medicines (84% of pharmacies);
HMRs (68% of pharmacies);
working with others (68% of pharmacies);
primary health care (53% of pharmacies);
community services support (44% of pharmacies);
residential Medication Management (26% of pharmacies); and
other (7% of pharmacies).
Overall, 82% of pharmacists who worked in pharmacies that had not implemented the MedsCheck program did not see the other 5CPA programs as a hindrance. However, 18%
Difficult/complicated to
85
of pharmacists stated that the other 5CPA programs they offered took up too much time or there was no time to implement the MedsCheck service.
Integration between the MedsCheck program and other 5CPA programs was recognised as advantageous by a minority of pharmacists with 11% reporting that the MedsCheck and Diabetes MedsCheck program complements the other programs. Pharmacists also recognised that the other programs available would
help them identify suitable patients for MedsCheck;
highlighted a general need for/the importance of MedsCheck; and/or
complemented the MedsCheck program.
7.1.6 Additional support that would assist in delivering services
In a question enabling an open ended response, pharmacists were asked about the different types of support, educational materials and promotional materials that would help them implement and deliver MedsCheck and Diabetes MedsCheck services. Ninety two pharmacists responded that some kind of additional support would help them implement MedsCheck and Diabetes MedsCheck services, two responded that they did not know of any supports that would be useful and six responded that the program is currently fine.
Of those with suggestions for additional supports, a total of one hundred and twenty-three responses were received from 92 pharmacists and were distributed into 11 separate categories. Twenty-three pharmacists responded that an instructional/educational/step-by-step guide/manual/booklet/information sheet on implementing the program would be helpful. The next most common, with 20 responses, was promotional brochures/leaflets/flyers on the program for customers (Chart 7.4).
86
Chart 7.4: Additional support and materials that would help pharmacies implement MedsCheck and Diabetes MedsCheck services and number of pharmacies (N=100)