Competencies required for General Practice Clinical Pharmacists providing the Scottish Pharmacotherapy Service: A modified eDelphi study

Due to work load pressures in primary care, increasing efforts are being made inter nationally to implement pharmacists working alongside general practitioners. While there is wide interest in the contributions pharmacists can make within primary care, there is limited research which explores the competencies pharmacists need to safely and effectively provide care in this arena. Therefore, a modified eDelphi study was conducted between July 2019 and January 2020 among pharmacists working in General Practice in Scotland in order to (a) generate a list of competencies required to undertake pharmacotherapy tasks within General Practice using content analysis; and (b) establish consensus regarding the importance of these competencies using a rating scale ranging from 1 (“not important”) to 10 (“very important”). A framework of competencies was developed, containing eight competency categories with a total of 31 individual competency items. Overall, study participants considered all eight com petency categories as being important, with


| INTRODUC TI ON
Pressure within General Practice has been increasing globally in recent years (Avery, 2017;Bradley et al., 2018). A main contributor is the rise of multi-morbidity and polypharmacy in ageing populations, resulting in cases becoming more complex (Barnes et al., 2017;Maskrey et al., 2018;Stewart et al., 2020). Alongside this, there has been a shift in workload from secondary care to primary care, which may also increase pressure by causing additional workload for general practitioners (GPs). High levels of dissatisfaction among GPsnot least due to increasing workload-have had a negative impact on both recruitment and retention, with many GPs choosing to leave practice (Owen et al., 2019).
To help alleviate the pressure in primary care, efforts have been made to introduce pharmacists into General Practice, working together with GPs and other practice staff-for instance, in Australia and the Netherlands (Hazen, de Groot, de Bont, et al., 2018;Polasek et al., 2015). Research from Australia found a positive reception to this move, with GPs believing that pharmacists facilitate effective pharmacotherapy, despite earlier research highlighting a possible lack of GP support Tan et al., 2014).
Pharmacists working within General Practice is not a new role within the UK (Bush et al., 2018); however, recently there has been increased funding and a drive to develop this role (Bradley et al., 2018;Stewart et al., 2020). Within the National Health Service (NHS) England, a pilot programme in 2015 saw the introduction of 1,000 pharmacists in practice-based roles (NHS England, n.d.;NHS England, 2015), while the Scottish Government funded the recruitment of 140 full-time equivalent General Practice Clinical Pharmacists (GPCPs) (Matheson et al., 2020). The GPCPs' role was operationalised in 2018 with the introduction of a national "Pharmacotherapy Service" within the General Medical Services Contract, which detailed a series of tasks GPCPs and other pharmacy staff should deliver (Scottish Government, 2017). The service comprises three levels of pharmacotherapy tasks: core tasks (e.g. medicines reconciliation and medication safety reviews); advanced tasks (e.g. resolving high-risk medicines problems); and specialist tasks (e.g. specialist clinics). Core tasks may be carried out by pharmacists, or other qualified staff (e.g. pharmacy technicians) under supervision, while higher level tasks are carried out by pharmacists only. The pharmacotherapy service is being introduced over a 3-year period, with the goal of Scotland-wide implementation by April 2021 (Scottish Government, 2017).
While there is wide interest in the contributions pharmacists can make within primary care, there is limited research which explores the competencies pharmacists need to safely and effectively provide care in this arena. In Australia, a literature review was conducted in order to gain an understanding of the tasks, competencies and training needs of pharmacists within General Practice. The review highlighted areas such as medicines management, patient examination and screening, and chronic disease management, and was used to map specific training needs for pharmacists working in General Practice (Benson et al., , 2020. In the Netherlands, research has highlighted the importance of educational support and continuous professional development in order to develop pharmacists' competencies within the role. This led to the development of a 15-month inter-professional training framework based on competencies identified by screening clinical pharmacy courses and frameworks, and focused on consultation skills, clinical reasoning, and inter-professional collaboration skills (Hazen, de Groot, de Bont, et al., 2018;.
In Scotland, a competency-based educational resource-the What is known about this topic • Pharmacists are being introduced into General Practice in order to alleviate pressure in primary care in several countries.
• There is wide interest in the contribution pharmacists can make, and increasing support by the UK government for pharmacists working alongside General Practitioners.

What this paper adds
• Pharmacists working in General Practice in Scotland require a wide range of competencies, including skills related to the use of IT systems and wider healthcare procedures.
• Training programmes should emphasise clinical and consultation skills, while also providing ongoing support with regards to more generic skills.
• The developed methodology can easily be adapted to accommodate other settings in order to gain an understanding of important competencies regardless of context.

| Aim
The aim of this study was to identify the competencies required for GPCPs in Scotland to deliver the Pharmacotherapy Service in General Practice, with the overarching goal of supporting the ongoing, Scotland-wide implementation of this service and informing further developments of the existing educational resource.

| Ethics approval
Ethical approval was granted by the Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde.

| ME THODS
The study was split into two phases, as depicted in Figure 1. Each research activity conducted within each phase informed subsequent research activities in an iterative manner.
Phase 1 applied an eDelphi design and consisted of three steps: an initial participant selection questionnaire to identify an expert panel; followed by two eDelphi rounds. Each step involved online questionnaires designed and hosted on Qualtrics. The Delphi technique was chosen because it is a commonly used method for gathering information and providing consensus, particularly in complex areas such as healthcare and education; however, to accommodate the busy schedules of participants, the original Delphi method was modified to exclude a third round (enabling panellist to review their initial responses). The sampling strategy was designed to recruit participants who were knowledgeable about the GP setting as well as the Pharmacotherapy Service, and were qualified to make valid judgements on the specific topics presented (Boulkedid et al., 2011;Holloway, 2012;Hsu & Sandford, 2007;Thangaratinam & Redman, 2005).
Phase 2 sought to validate the results of the eDelphi and used a paper-based questionnaire with a larger sample of participants.
Details are presented in Table 1.

| Pharmacotherapy tasks
The Scottish "National Pharmacotherapy Service Specification (2018) Table 2. Based on feedback during the piloting phase with regards to the time required to complete the first F I G U R E 1 Process flowchart-research phases and related outputs eDelphi, questionnaires for both Phase 1 and Phase 2 were split into two groups, each covering seven of the pharmacotherapy tasks.

| Preparation of materials
Three Phase 1 questionnaires-covering demographics (to enable participant selection based on GP practice experience); free-text fields to collect ideas regarding competencies/required skills (eDelphi-1); and a rating scale to establish consensus with respect to the importance of competencies (eDelphi-2)-were developed incrementally between May and September 2019 (Table 1). The eDelphi-2 was designed based on the competencies identified from the eDelphi-1 results.
For Phase 2, minor layout changes were made to the participant selection questionnaire and eDelphi-2 in January 2020 Questionnaires included a participant information sheet (PIS) and a Privacy Notice, and were configured so that participant consent was required in order to proceed. The PIS, consent form and Privacy Notice used for all data collection approaches were based on standard University of Strathclyde templates and adapted where appropriate for the purpose of this study. All materials were piloted by experienced pharmacists and revised based on feedback received prior to being disseminated to participants, and can be found in Appendices S1-S6.

| Ethical considerations
Participants were informed that participation in this study was voluntary, and all data provided would be kept confidential; all participants consented to taking part. Electronic data were stored in a password-protected file on a secure University server. Paper-based materials were stored under lock-and-key on University premises, with only authorised researchers having access to these.

| FINDING S
Twenty-six participants completed the initial participant selection questionnaire; since the response rate to this questionnaire was low and all respondents had GP practice experience, all were invited to participate in the study. Of the 26 invited participants, 10 completed the eDelphi-1 (with four complete and one partial response in group 1, and five complete responses in group 2) and 11 the eDelphi-2 (with seven responses in group 1, and four in group 2). The paperbased validation exercise was completed by 20 participants (10 in each group).
The majority of participants were female and independent prescribers. Age and experience within GP practice varied across the different questionnaires; details are presented in Table 3.

| Competencies required to conduct the Pharmacotherapy Service (eDelphi-1)
Based on content analysis of eDelphi-1 responses, a framework of competencies required to undertake the pharmacotherapy tasks was developed, containing eight competency categories with a total of 31 individual competency items (Table 4).

| Pharmacotherapy Service overall
Across the pharmacotherapy service, all eight competency categories were considered important, with a mode of 10 and a median >8.
Agreement among participants was high with >75% of answers between 8 and 10 for approximately half of the categories, albeit with minor differences observed between eDelphi-2 and the validation exercise (Table 5). Results from both eDelphi-2 and the validation exercise are presented together to allow for comparison; results from the validation exercise were used to order the tasks (with eDelphi-2 results presented in brackets).

| By pharmacotherapy task
All competency categories were considered important for the advanced and specialist pharmacotherapy tasks, with modes and medians all ≥8; in contrast, modes and/or medians were below 8 for several competency categories across four of the core tasks (medicines reconciliation; medicines safety reviews/recalls; medication compliance reviews and formulary adherence). Levels of agreement were high across competency categories for most pharmacotherapy tasks, but was relatively low (with <60% of answers between 8 and 10) for a number of core tasks (medicines reconciliation; monitoring high-risk medicines; medication compliance reviews; medication safety reviews/recalls; immediate discharge letters; repeat prescribing requests and formulary adherence). Main results from the validation exercise are presented in Figure 2; see also Table A1 and Figure A1 in Appendix S7 for additional details, including results from eDelphi-2.

| D ISCUSS I ON
To the best of our knowledge, this is the first study to use a bottom-up consensus method to determine the competencies required when working as a pharmacist in General Practice, drawing on the experiences of those working within the field. As such, it offers valuable insights into the variety of competencies necessary for pharmacists working in this setting.
Analyses of free-text responses received during eDelphi-1 and the subsequent ratings of the importance of competencies in both eDelphi-2 and the following validation exercise offered a range of interesting and, occasionally, rather unexpected findings. While most of the competency categories mentioned were to be expected-the ability to work as part of a multi-disciplinary team and communicate with patients, for instance-the emphasis on generic skills and IT skills was unexpected. The focus on pharmacological knowledge was also unanticipated, since all participants were fully trained and qualified pharmacists. It is, however, unclear whether this reflected the general requirements for pharmacological knowledge while practicing as a pharmacist, regardless of the work environment, or the need for specialised pharmacological knowledge above and beyond what has been acquired through an initial Pharmacy degree. It may be that the knowledge base acquired through undergraduate pharmacy studies is not sufficient for working in General Practice.
The prominence of generic/IT skills within the developed framework highlights the importance of basic skills due to the complexity of healthcare systems. This supports previous research which found that working efficiently requires IT proficiency and pre-existing knowledge of wider systems, alongside cognitive, social and collaborative work processes (Berg, 1999;Holden et al., 2013). as clinical reasoning, consultation skills and inter-professional collaboration  Note: Rating scale 1-10; 1 = "not important at all" and 10 = "very important". a Per cent of ratings for competency items with a score of 8-10, aggregated by competency category.

F I G U R E 2
Rating of importance of competency categories by pharmacotherapy task-median (validation exercise, n = 20). Rating scale 1-10; 1 = "not important at all" and 10 = "very important". IT, information technology; MDT, multi-disciplinary team is its adaptive design, using both online as well as paper-based questionnaires in order to accommodate participants' circumstances.
However, the size of the study population was quite small, and results might therefore not be reflective of the entire population of GPCPs working in Scotland; plans for a second cohort of participants in Phase 2 could unfortunately not take place due to COVID-19.
Disappointingly, no GPs or nurses agreed to participate in the study and therefore responses were only available from pharmacists, indicating that certain aspects of working in GP practice might not have been captured.
Findings have been discussed with the funder (NHS Education for Scotland), and might be used to update and/or refine the existing educational resource (the CCF) and potentially inform forthcoming iterations of this framework. Future work will include repeating the validation exercise with a larger cohort of GPCPs to further refine interpretations of the importance of individual competencies for specific pharmacotherapy tasks; including additional details with regards to pharmacists' background (e.g. whether they previously worked in a hospital setting or community pharmacy) would be beneficial. It would also be interesting to adopt the same methodology within a different clinical setting; replicating this study in other countries would enable comparisons across different healthcare systems. This would foster our understanding of those competencies that are independent of geographical and/or cultural setting, and those competencies that are context specific.

| CON CLUS ION
Based on input received from pharmacists currently working in General Practice, this setting requires a broad set of competenciescovering areas such as the use of IT systems; clinical knowledge and communicating with patients and other healthcare professionals.
The applied methodology can easily be adapted to accommodate other settings to offer a universal method to gain an understanding of important competencies regardless of context.

ACK N OWLED G EM ENTS
We thank all participants and pilot material reviewers for their engagement. We appreciate the funding received from the Scottish Government, and the support provided by NHS Health Boards and NHS Education for Scotland.

CO N FLI C T O F I NTE R E S T
There are no conflicts of interest to declare.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.