Coronary heart disease risk screening: the community pharmacy Healthy Heart Assessment Service

Objectives We examined the characteristics and CHD risks of people who accessed the free Healthy Heart Assessment (HHA) service operated by a large UK pharmacy chain from August 2004 to April 2006. Methods Associations between participants’ gender, age, and socioeconomics were explored in relation to calculated 10-year CHD risks by cross-tabulation of the data. Specific associations were tested by forming contingency tables and using Pearson chi-square (χ2). Results Data from 8,287 records were analysable; 5,377 were at low and 2,910 at moderate-to-high CHD risk. The likelihood of moderate-to-high risk for a male versus female participant was significantly higher with a relative risk ratio (RRR) 1.72 (P < 0.001). A higher percentage of those in socioeconomic categories ‘constrained by circumstances’ (RRR 1.15; P < 0.05) and ‘blue collar communities’ (RRR 1.13; P < 0.05) were assessed with moderate-to-high risk compared to those in ‘prospering suburbs’. Conclusions People from ‘hard-to-reach’ sectors of the population, men and people from less advantaged communities, accessed the HHA service and were more likely to return moderate-to-high CHD risk. Pharmacists prioritised provision of lifestyle information above the sale of a product. Our study supports the notion that pharmacies can serve as suitable environments for the delivery of similar screening services.

How was patient empowerment portrayed in information leaflets describing the community pharmacy Medicines Use Review service in the UK?

Objective The Medicines Use Review (MUR) community pharmacy service was introduced in 2005 to enhance patient empowerment but the service has not been taken up as widely as expected. We investigated the depiction of the patient–pharmacist power relationship within MUR patient information leaflets. Methods We identified 11 MUR leaflets including the official Department of Health MUR booklet and through discourse analysis examined the way language and imagery had been used to symbolise and give meaning to the MUR service, especially the portrayal of the patient–pharmacist interactions and the implied power relations. Results A variety of terminology was used to describe the MUR, a service that aimed ultimately to produce more informed patients through the information imparted by knowledgeable, skilled pharmacists. Conclusion The educational role of the MUR overshadowed the intended patient empowerment that would take place with a true concordance-centred approach. Although patient empowerment was implied, this was within the boundaries of the biomedical model with the pharmacist as the expert provider of medicines information. Practice implications If patient empowerment is to be conveyed this needs to be communicated to patients through consistent use of language and imagery that portrays the inclusivity intended.

Uptake of a free coronary heart disease risk screening programme in community pharmacy: the Healthy Heart Assessment service

Introduction Health promotion (HP) aims to enhance good health while preventing ill-health at three levels of activity; primary (preventative), secondary (diagnostic) and tertiary (management).1 It can range from simple provision of health education to ongoing support, but the effectiveness of HP is ultimately dependent on its ability to influence change. HP as part of the Community Pharmacy Contract (CPC) aims to increase public knowledge and target ‘hard-to-reach’ individuals by focusing mainly on primary and tertiary HP. The CPC does not include screening programmes (secondary HP) as a service. Coronary heart disease (CHD) is a significant cause of morbidity and mortality in the UK. While there is evidence to support the effectiveness of some community pharmacy HP strategies in CHD, there is paucity of research in relation to screening services.2 Against this background, Alliance Pharmacy introduced a free CHD risk screening programme to provide tailored HP advice as part of a participant–pharmacist consultation. The aim of this study is to report on the CHD risk levels of participants and to provide a qualitative indication of consultation outcomes. Methods Case records for 12 733 people who accessed a free CHD risk screening service between August 2004 and April 2006 offered at 217 community pharmacies were obtained. The service involved initial self-completion of the Healthy Heart Assessment (HHA) form and measurement of height, weight, body mass index, blood pressure, total cholesterol and highdensity lipoprotein levels by pharmacists to calculate CHD risk.3 Action taken by pharmacists (lifestyle advice, statin recommendation or general practitioner (GP) referral) and qualitative statements of advice were recorded, and a copy provided to the participants. The service did not include follow-up of participants. All participants consented to taking part in evaluations of the service. Ethical committee scrutiny was not required for this service development evaluation. Results Case records for 10 035 participants (3658 male) were evaluable; 5730 (57%) were at low CHD risk (<15%); 3636 (36%) at moderate-to-high CHD risk (≥15%); and 669 (7%) had existing heart disease. A significantly higher proportion of male (48% versus 30% female) participants were at moderate- to-high risk of CHD (chi-square test; P < 0.005). A range of outcomes resulted from consultations. Lifestyle advice was provided irrespective of participants’ CHD risk or existing disease. In the moderate-to-high-risk group, of which 52% received prescribed medication, lifestyle advice was recorded for 62%, 16% were referred and 34% were advised to have a re-assessment. Statin recommendations were made in 1% of all cases. There was evidence of supportive and motivational statements in the advice recorded. Discussion Pharmacists were able to identify individuals’ level of CHD risk and provide them with bespoke advice. Identification of at-risk participants did not automatically result in referrals or statin recommendation. One-third of those accessing the screening service had moderate-to-high risk of CHD, a significantly higher proportion of whom were men. It is not known whether these individuals had been previously exposed to HP but presumably by accessing this service they may have contemplated change. As effectiveness of HP advice will depend among other factors on ability to influence change, future consultations may need to explore patients’ attitude towards change in relation to the Trans Theoretical Model4 to better tailor HP advice. The high uptake of the service by those at moderate-to-high CHD risk indicates a need for this type of screening programme in community pharmacy, perhaps specifically to reach men who access medical services less.

A follow-up study of characteristics of young people that dropout and continue psychotherapy: service implications for a clinic in the community

Background: The paper reports the findings from a follow-up study of the factors that contribute to whether young people dropout or continue once-weekly psychotherapy at a voluntary sector psychotherapy service for young people aged 12 to 21 years. Method: The study uses data from an ongoing audit of the psychotherapy service that started in 1993; 882 young people were included in the study. Premature termination of treatment was defined as dropping out before the 21st session. Continuation in treatment was defined as remaining in therapy after 20 sessions. Measures and areas of interest used in the study include diagnostic measures, the Youth Self Report Form and Young Adult Self Report Form, demographic characteristics and treatment related information. Results: Young people who continued in treatment were more likely to be older, have anxieties about sexual and relationship issues and have higher scores on self-reported anxiety-depression. Young people who dropped out of treatment were more likely to be younger, have higher self-reported delinquency scores, have a diagnosis of hyperactivity-conduct disorder and be homeless. Conclusions: The study of treatment termination has demonstrated the value of service audit and has led to a significant change in clinical practice.

Knowledge dissemination in the global service marketing community

Purpose– The evolution of the service marketing field was marked by the emergence of a global, vigorous and tolerant community of service marketing researchers. This paper seeks to examine the history of the service marketing community and argues that it may be an archetype for building the emergent global service research community. Design/methodology/approach– The study combines qualitative and quantitative approaches. The authors interviewed four pioneering service scholars and also collected descriptive data (e.g. Authorship, Affiliation, Title, Keywords) of all service related articles published in 13 top peer‐reviewed marketing and service journals over the last 30 years (5,432 articles; 6,450 authors). In a dynamic analysis the authors mapped global collaboration between countries over time and detected clusters of international collaboration. Findings– Findings suggest a growing international collaboration for the USA and the UK, while for other countries like Israel the global collaboration started from a high level and decreases now. Further, the service marketing community never became polarized and there were always contributions from researchers all over the world. Research limitations/implications– As the global service research community is developing, service marketing becomes a research neighborhood within the broader service research community. Simultaneously, other research neighborhoods are emerging within this new community (e.g. service arts, service management, service engineering, service science). Originality/value– Anchored on the social evolution and biological evolution metaphors, this study explains the evolution of the service marketing field from both qualitative and quantitative perspectives. Furthermore, it explains the development of the service marketing community as an archetype for building the global service research community.

How is the language of medicines use review leaflets symbolising the service?

Introduction The medicines use review (MUR), a new community pharmacy ‘service’, was launched in England and Wales to improve patients’ knowledge and use of medicines through a private, patient–pharmacist appointment. After 18 months, only 30% of pharmacies are providing MURs; at an average of 120 per annum (maximum 400 allowed).1 One reason linked to low delivery is patient recruitment.2 Our aim was to examine how the MUR is symbolised and given meaning via printed patient information, and potential implications. Method The language of 10 MUR patient leaflets, including the NHS booklet,3 and leaflets from multiples and wholesalers was evaluated by discourse analysis. Results and Discussion Before experiencing MURs, patients conceivably ‘categorise’ relationships with pharmacists based on traditional interactions.4 Yet none of the leaflets explicitly describe the MUR as ‘new’ and presuppose patients would become involved in activities outside of their pre-existing relationship with pharmacists such as appointments, self-completion of charts, and pharmacy action plans. The MUR process is described inconsistently, with interchangeable use of formal (‘review meeting‘) and informal (‘friendly’) terminology, the latter presumably to portray an intended ‘negotiation model’ of interaction.5 Assumptions exist about attitudes (‘not understanding’; ‘problems’) that might lead patients to an appointment. However, research has identified a multitude of reasons why patients choose (or not) to consult practitioners,6 and marketing of MURs should also consider other barriers. For example, it may be prudent to remove time limits to avoid implying patients might not be listened to fully, during what is for them an additional practitioner consultation.

Community strategies in England: reshaping spaces of governance?

The preparation of Community Strategies (CS) has been required of LSPs and Local Authorities in England since the passing of the Local Government Act 2000. This paper examines the process and content of two Community Strategies in southern England as part of an ongoing project to understand their impact and explore ways that CSs may be carried through in a meaningful and effective manner. The paper concludes that the two CSs studied illustrate the challenge faced by LSPs in producing Strategies that are meaningful, inclusive and which follow the spirit of the government CS guidance. LAs and LSPs are also posed with a difficult challenge of seeing through an implicitly required transition from a traditional representative democratic structure/process with a more fluid participatory model. Thus we detect that at least two forms of conflict may arise – firstly with elected councillors threatened by a loss of power and secondly between communities and the LAs who are encouraged to problematise local policy and service delivery in the context of limited resource availability.

The relationship between well-being, future planning and intentions to utilise intervention programmes: what can be learned from homeless service users?

There has been an increasing interest in the impact of individual well-being on the attitudes and actions of people receiving services designed to offer support. If well-being factors are important in the uptake and success of service programmes it is important that the nature of the relationships involved is understood by service designers and implementers. As a contribution to understanding, this paper examines the impact of well-being on the uptake of intervention programmes for homeless people. From the literature on well-being a number of factors are identified that contribute towards overall well-being, which include personal efficacy and identity, but also more directly well-being can be viewed as personal or group/collective esteem. The impact of these factors on service use is assessed by means of two studies of homelessness service users, comparing the implementation of two research tools: a shortened and a fuller one. The conclusions are that the factors identified are related to service use. The higher the collective esteem – esteem drawn from identification with services and their users and providers – and the less that they feel isolated, the more benefits that homeless people will perceive with service use, and in turn the more likely they are to be motivated to use services. However, the most important factors in explaining service use are a real sense that it is appropriate to accept social support from others, a rejection of the social identity as homeless but a cultivation of being valued as part of a non-homeless community, and a positive perception of the impact of the service.

A Web Map Service implementation for the visualization of multidimensional gridded environmental data

We describe ncWMS, an implementation of the Open Geospatial Consortium’s Web Map Service (WMS) specification for multidimensional gridded environmental data. ncWMS can read data in a large number of common scientific data formats – notably the NetCDF format with the Climate and Forecast conventions – then efficiently generate map imagery in thousands of different coordinate reference systems. It is designed to require minimal configuration from the system administrator and, when used in conjunction with a suitable client tool, provides end users with an interactive means for visualizing data without the need to download large files or interpret complex metadata. It is also used as a “bridging” tool providing interoperability between the environmental science community and users of geographic information systems. ncWMS implements a number of extensions to the WMS standard in order to fulfil some common scientific requirements, including the ability to generate plots representing timeseries and vertical sections. We discuss these extensions and their impact upon present and future interoperability. We discuss the conceptual mapping between the WMS data model and the data models used by gridded data formats, highlighting areas in which the mapping is incomplete or ambiguous. We discuss the architecture of the system and particular technical innovations of note, including the algorithms used for fast data reading and image generation. ncWMS has been widely adopted within the environmental data community and we discuss some of the ways in which the software is integrated within data infrastructures and portals.

A conceptual framework of patient satisfaction with a pharmacy adherence service

Background Patients do not adhere to their medicines for a host of reasons which can include their underlying beliefs as well as the quality of their interactions with healthcare professionals. One way of measuring the outcome of pharmacy adherence services is to assess patient satisfaction but no questionnaire exists that truly captures patients' experiences with these relatively new services. Objective Our objective was to develop a conceptual framework specific to patient satisfaction with a community pharmacy adherence service based on criteria used by patients themselves. Setting The study was based in community pharmacies in one large geographical area of the UK (Surrey). All the work was conducted between October 2008 and September 2010. Methods This study involved qualitative non-participant observation and semi-structured interviewing. We observed the recruitment of patients to the Medicines Use Review (MUR) service and also actual MUR consultations (7). We also interviewed patients (15). Data collection continued until no new themes were identified during analysis. We analysed interviews to firstly create a comprehensive account of themes which had significance within the transcripts, then created sub-themes within super-ordinate categories. We used a structure-process-outcome approach to develop a conceptual framework relating to patient satisfaction with the MUR. Favourable ethical opinion for this study was received from the NHS Surrey Research Ethics Committee on 2nd June 2008. Results Five super-ordinate themes linked to patient satisfaction with the MUR service were identified, including relationships with healthcare providers; attitudes towards healthcare providers; patients' experience of health, healthcare and medicines; patients' views of the MUR service; the logistics of the MUR service. In the conceptual framework, structure was conceptualised as existing relationships, environment, and time; process was conceptualised as related to recruitment and consultation stages; and outcome as two concepts of immediate patient outcomes and satisfaction on reflection. Conclusion We identified and highlighted factors that can influence patient satisfaction with the MUR service and this led to the development of a conceptual framework of patient satisfaction with the MUR service. This can form the basis for developing a questionnaire for measuring patient satisfaction with this and similar pharmacy adherence services. Impact of findings on practice * Pharmacists and researchers can access the relevant ideas presented here in relation to patient satisfaction with pharmacy adherence services. * Researcher can use the conceptual framework as a basis for measuring the quality of pharmacy adherence services. * Community pharmacists can improve the quality of healthcare they provide by realizing concepts relevant to patient satisfaction with adherence services.

Collaboration model for SSMEnetUK: a service science perspective

This paper aims to design a collaboration model for a Knowledge Community - SSMEnetUK. The research identifies SSMEnetUK as a socio-technical system and uses the core concepts of Service Science to explore the subject domain. The paper is positioned within the concept of Knowledge Management (KM) and utilising Web 2.0 tools for collaboration. A qualitative case study method was adopted and multiple data sources were used. In achieving that, the degree of co-relation between knowledge management activities and Web 2.0 tools for collaboration in the scenario are pitted against the concept of value propositions offered by both customer/user and service provider. The proposed model provides a better understanding of how Knowledge Management and Web 2.0 tools can enable effective collaboration within SSMEnetUK. This research is relevant to the wider service design and innovation community because it provides a basis for building a service-centric collaboration platform for the benefit of both customer/user and service provider.

From warfare to welfare: veterans, military charities and the blurred spatiality of post-service welfare in the United Kingdom

The military offers a form of welfare-for-work but when personnel leave they lose this safety net, a loss exacerbated by the rollback neoliberalism of the contemporary welfare state. Increasingly the third sector has stepped in to address veterans’ welfare needs through operating within and across military/civilian and state/market/community spaces and cultures. In this paper we use both veterans’ and military charities’ experiences to analyse the complex politics that govern the liminal boundary zone of post-military welfare. Through exploring ‘crossing’ and ‘bridging’ we conceptualise military charities as ‘boundary subjects’, active yet dependent on the continuation of the civilian-military binary, and argue that the latter is better understood as a multidirectional, multiscalar and contextual continuum. Post-military welfare emerges as a competitive, confused and confusing assemblage that needs to be made more navigable in order to better support the ‘heroic poor’.