This short report presents an example of the use of IMPACT, a new method of service evaluation, which was used to evaluate prescription owings in the same pharmacy described in part 1. IMPACT stands for the stages of the process: Issue, Method, Perspectives, Analysis of themes, Conclusion and Targets. It is based on a simplified methodology that was used to explore the interaction of prescribing policy and patient perspectives.
It is a service evaluation tool that aims, literally, to increase the impact of audits. This is done by incorporating the views of patients and other stakeholders, in a systematic manner, into the audit process.
The stages of IMPACT are presented as a preliminary step (section 1), followed by the audit results (section 2).
Section 1: IMPACT
The contractual framework for community pharmacy in England and Wales “Essential service: clinical governance” document (available at www.psnc.org.uk) specifies that “medicines owed to patients or out of stock should be monitored”. The Royal Pharmaceutical Society guide to owings audit (available at www.rpharms.com) sets acceptable standards and criteria to monitor. These criteria appear to be from the perspective of the pharmacy profession. In this example, IMPACT was used to elicit perspectives from a variety of stakeholders in order to design an audit that reflects the wider healthcare setting.
The stakeholders affected by prescription owings were identified. One of each of these stakeholders was interviewed about their perspective on owings. Stakeholders were given information sheets and consent forms. (It is important to note that this process was not research. The aim was to elicit typical perspectives to aid service evaluation at a local level, not to generate representative data as part of adding to the body of knowledge through research.) Individual interviews were used rather than brainstorming in a group so that the stakeholders could freely identify their own perspectives, without any tendency to be influenced by more dominant perspectives. Themes were identified and analysed using qualitative data analysis techniques. Indicators for the audit were selected for each of the themes. Data collection took place over one week.
A patient received half of her tablets, which was acceptable. Had she not received any of them she would have taken the prescription to another pharmacy. From the patient perspective the themes of “proportion of prescription owed”, “delivery”, “loss of business” and “adherence” were identified.
The counter assistant thought that many patients did not collect their owings and that offering to deliver owings helped to minimise loss of prescriptions. This highlights the themes of “delivery” and “adherence”.
The dispenser’s perspective focused on the reasons for items being out of stock, and a distinction was made between acceptable and unacceptable reasons for this. From the dispenser’s perspective the theme of “reason for stock problems” was identified.
The pharmacist was aware of patients’ expectations that they would get all their medicines immediately and that owings could potentially result in loss of prescriptions. However, the business had been growing and this had caused problems with the electronic stock system causing “unacceptable” owings. The themes of “reason for stock problem” “loss of business” and “drug substitution” were identified from the pharmacist’s perspective.
The GP reported that if there was an immediate need for a medicine that was out of stock then he might consider changing the prescription, but generally he prescribed the drug that he considered to be the most appropriate with the view that it would be obtainable from one of the pharmacies in the area. The themes of “loss of business” and “drug substitution” were identified from the GP’s perspective.
Analysis of themes
Analysis of the themes revealed that reasons for stock problems could be categorised as “acceptable” or “unacceptable”. It was perceived that owings could lead to less clinically appropriate care if prescriptions were changed. However, the GP was reluctant to change prescriptions. This then raises the issue of owings causing a potential loss of business.
From the patient themes, it can be seen that owings could lead to loss of business. An influencing factor here is whether the owing is for the whole amount or only a proportion of the prescription, with patients being more likely to go elsewhere for the whole prescription. Another influencing factor was if the pharmacy offered to deliver the owing; it appeared that this prevented many prescriptions from being lost. The fact that many owings were never collected suggests that there may adherence issues.
The main consequences of owings therefore appear to be potential loss of business and clinical threat to patients caused by non-adherence or substitution of a less appropriate drug.
From the above analysis appropriate target indicators were selected. Data for these targets were collected over one week in the pharmacy.
Section 2: Audit results
Reason/circumstances of owings
It was found that 0.6 per cent of prescription items were dispensed incompletely. Reasons were identified for stock problems and 0.7 per cent of owing items were caused by “unacceptable stock problems”.
Handling of owings
Fourteen per cent of owings were delivered. The cost of these deliveries was calculated to be an average of £1.90 per delivery, which equates to £19 a week and £988 per year. No prescriptions were lost because of owings and no prescriptions were changed as a result of owings.
Consequences of owing — non-collection
After 10 days, three items remained uncollected (Keppra, Salazopyrin and Marvelon), at a total cost of £92.22. This indicates that there may be adherence issues with potential adverse clinical outcomes, in addition to wastage of NHS resources (potentially up to £3,366 a year).
The number of owings exceeded the specified RPS standards. The consequences of the owings were an effect on business through the cost of delivering owings and a potential cause of adherence problems, which could lead to adverse effects clinically and wastage of NHS resources.
 Solomon J. An exploration of the relationship between prescribing guidelines and partnership in medicine taking. PhD Thesis, University of Leeds, 2009.