Date Published: March 12, 2019
Publisher: Public Library of Science
Author(s): Zachariah Jamal Nazar, Hamde Nazar, Simon White, Paul Rutter, John Rovers.
The Healthy Living Pharmacy (HLP) project, launched in England, UK in 2009 was a novel approach of introducing public health services within community pharmacy to tackle local health inequalities. A national roll-out followed a reported successful pilot; subsequent local evaluations ensued.
To summarise reported outcomes and investigate contextual factors that indicate the presence, absence and maturity of implementation determinants, thus offering useful lessons to stakeholders in implementing future initiatives to achieve successful outcomes.
A systematic review was conducted to identify all publications reporting on the HLP project. All HLP articles and conference abstracts were considered for inclusion and were assessed for methodological quality. The Consolidated Framework for Implementation Research (CFIR) was utilised to identify potential implementation determinants reported. Each article was then analysed to identify reported economic, humanistic or clinical outcomes.
The review included six peer-reviewed journal articles and 12 conference abstracts. Joanna Briggs Institute Qualitative Assessment and Review Instrument indicated deficiencies in methodological quality. Through adoption of the CFIR framework, the implementation determinants relevant to the implementation of HLP into community pharmacy were identified. A resonating issue emerged in that the absence of adopting an evidence-based implementation process limited the ability to capture meaningful outcome data. This resulted in a lack of evidence to support sustainability and the failure to address many of the well cited barriers, e.g. lack of awareness amongst patients, public and other healthcare professionals, and weak support for future investment in resource for training and dissemination.
Healthcare systems are increasingly called on to adopt evidence‐based interventions that improve quality, control costs, and maximize value, thus offering opportunity to accelerate the implementation of clinical pharmacy services and programs aimed at improving patient care. Interventions, such as the HLP project require focused efforts on implementation and evaluation of those implementation efforts to produce effective and lasting changes in complex health care systems.
The 2008 White Paper: Pharmacy in England: building on strengths, delivering the future, described the role community pharmacy could play in supporting public health through becoming healthy living centres. Recommendations were made to increase pharmacy’s contribution to promoting better health, prevention and early detection of disease and managing patients with long-term conditions. The development of the concept of the “healthy living centres” was commissioned by the Department of Health (DoH) to Portsmouth Primary Care Trust in 2009. The project was named ‘The Healthy Living Pharmacy (HLP) project’.
The literature search resulted in twenty publications reporting on the implementation of the HLP or providing outcome data, which were published between 2013 and 2017 (Table 3); six peer-reviewed journal articles and fourteen conference abstracts. Studies were predominantly qualitative, involving case studies and interviews and/or surveys of the perceived impacts, success factors, barriers, or satisfaction among different stakeholder groups. Sixteen of these publications included reports of implementation determinants (Table 3).[17, 32–46] Four publications,[17, 32–34] reported on both implementation determinants as well as outcomes of HLP involvement; and two publications reported solely on various outcomes of HLP involvement.[47, 48] Two publications reported on the content of HLC training and therefore did not fall into the criteria since.[49, 50] Identified articles were placed in chronological order starting from 2013 to 2017.
Our appraisal of the published research has highlighted that the current body of literature has insufficiently addressed the possibility of bias in its design, conduct and analysis. Furthermore, a key review article which contributed to the evidence base for the national role-out of HLP contained a lack of both theoretical underpinnings and analysis transparency. It has been advocated that a formative, theory-based approach be taken in conducting evaluations of initiatives in pharmacy practice.[52, 53] This includes recommendations that evaluations account for the iterative nature of health care improvement work and are undertaken prospectively, generating learning applicable to ongoing improvement efforts and enabling midcourse adjustment to the initiative. Moreover, it has been recommended that such initiatives are resourced to include a trained programme evaluation researcher to conduct this work.[54, 55] The findings relating to the implementation determinants are discussed with reference to the relevant constructs within each domain.
This review has successfully collated the published literature relating to the Health Living Pharmacy model and provides detail of its reported evidence-base. With the exception of one study conducted by the research team in Portsmouth, the published studies do not include service delivery data from community pharmacies, but rather focus on the self-reported impact of introducing HLP. The majority of the literature consists of cross-sectional studies involving small samples of community pharmacy staff conducted in specific geographical areas of England. Recent changes to the community pharmacy contractual framework has seen the introduction of payments for meeting a set of defined quality criteria, one of which is designed around the HLP model. Further research is required to evaluate the impact these changes have made to community pharmacy. Most importantly, the need for robust outcome data is significant. Evidence for effectiveness will provide a powerful tool to bolster many of the implementation constructs, supporting future delivery and adoption of HLP.