Introduction

Healthcare systems in the world are facing significant challenges as a result of severe funding pressure, a growing ageing population, societal changes, rising demand and a limited supply of some healthcare professional groups [1,2,3]. This is compounded by the increasing prevalence of long-term conditions (LTC), in particular, people having two or more conditions which are being supported by different parts of the healthcare system [4]. The UK is home to the National Health Service (NHS), one of the largest healthcare systems in the world. In the UK, LTCs account for 70% of the NHS healthcare budget [4]. With the continued demands in the NHS, the current models of dealing with long-term conditions are not sustainable; the need to innovate in order to continue to deliver world-class healthcare outcomes within a limited financial envelope is critical [5]. Care needs to be provided in the right place and at the right time to ensure that the healthcare system meets the current and future needs of a nation’s healthcare provision [6]. In response to this new normal, care must not be fragmented between healthcare systems, e.g. pre-hospital, hospital and specialist care [7].

This is of particular importance in countries where healthcare systems are well developed where care needs to move seamlessly from the gatekeeping primary care systems to the hospital and specialist services for the benefit of patient care [8]. Effective communication and cooperation between primary and secondary care are critical to making the best use of limited resources [9] and to ensure the patient receives high-quality joined-up care [8, 10, 11]. A tool that has been used in the literature to support effective integrated care between primary and secondary care is the shared care agreement (SCA) [12,13,14]. The SCA was designed to provide a framework for the seamless sharing of care and to facilitate the passage of hospital-prescribed medication or a consultant-managed patient into primary care.

The term shared care agreement has various definitions, none of which is universally agreed on [14,15,16,17,18]. The primary description to describe shared care was by Hickman et al. in their seminal paper on the taxonomy of shared care in 1994 [15]. The original definition of shared care described shared care as The joint participation of general practitioners and hospital consultants in the planned delivery of care for patients with chronic inflammatory musculoskeletal disorders, informed by an enhanced information exchange over and above the routine clinic, discharge and referral letters [15]. A more recent evolved definition describes these arrangements as the joint participation of primary and speciality care practitioners in the planned delivery of care for patients with a chronic condition, informed by enhanced information exchange, over and above routine discharge and referral notices [16]. This evolved definition takes into account the changes in primary care since the primary definition was described.

Since the introduction of an executive letter EL (91) 127 by the NHS in 1991 described SCA to support prescribing between hospitals and GPs [19], several problems have marred the integration of SCA into primary care, and in 2017, the British Medical Association (BMA) stated that shared care is still not working effectively [20]. General practitioners have expressed concern about poor communication between primary and secondary care, lack of follow-up and monitoring and the medico-legal responsibilities for the prescriber when they accept shared care [16, 21,22,23]. After 30 years, EL (91) 127 has been superseded by the new national guidance released in 2018 for England [24]. The guidance was designed to overcome the challenges of shared care that have been exhibited in the healthcare system over the last 30 years [21]. The document has described a role for the pharmacist in general practice in supporting joint working and collaboration to ensure that primary care prescribers have access to information on new or less familiar medicines and how they can support the introduction of medicines into primary care [21]. Evidence indicates that pharmacists have a significant role in medicine optimisation and improving safe and effective medication use in primary care [25]. In addition, the literature has shown that pharmacists in general practice are increasingly playing a central role in managing medicines [26], such as setting up systems for safe monitoring and prescribing high-risk medicines such as direct oral anticoagulants, lithium, non-steroidal anti-inflammatory drugs (NSAIDs) prescribing and medicine safety requirement in general practice. With the support of government initiatives to increase the number of pharmacists in general practice to support new models of care, the pharmacist could be seen as a vital component in bridging the transfer of care from secondary to primary care settings [4, 27, 28]. This paper aims to review the literature on the role of a pharmacist in general practice with regard to SCA support, their roles and identify the potential benefits, barriers and facilitators to their potential integral role.

Aim of the review

This study aimed to identify activities and assess the interventions provided by pharmacists in primary care on SCA provision. The specific objectives were to determine the following:

  • The types of interventions/activities being provided by pharmacists in supporting SCA in a general practice setting

  • The effectiveness of these interventions/activities on health-related quality of life (HRQoL) for patients, to consider the impact of clinical pharmacist supporting shared care agreement in a general practice setting.

Method

Study registration

The review protocol was registered with the International Prospective Register for Systematic Review (PROSPERO database; registration number CRD42020165363). The review was guided by the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions [29]. The reporting of the review complies with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement and checklist (refer to supplementary information S2 and S3) [30].

Eligibility criteria for study inclusion

The search was focused on locating studies eligible for inclusion or excluded based on the criteria below.

Inclusion criteria

The following are the inclusion criteria:

  1. 1.

    Only primary studies (qualitative, quantitative and mixed studies)

  2. 2.

    Studies which have tested an intervention and/or have obtained views of stakeholders (pharmacists, GPs, medical specialists, practice staff and patients) related to SCA in the primary care setting

  3. 3.

    Studies in which a pharmacist has input within a primary care setting to provide non-dispensing care

Exclusion criteria

The following are the exclusion criteria:

  1. 1.

    Studies in which the intervention has been provided only in secondary or tertiary care settings (hospitals, specialist clinics and national and regional specialist centre)

  2. 2.

    Studies written in a language other than English

  3. 3.

    Studies presented as editorials, protocols and commentaries

Information sources and search strategy

Specific search strategies were developed with expert information specialists and included broad and narrow, free-text and thesaurus-based terms. The term pharmacist was used as a general term to allow greater scope to find multiple roles provided by pharmacists, which included prescribers. Boolean operators and truncation were used to ensure we maximised our search strategy. The following eleven databases were systematically searched from date of inception to November 2021: Allied and Complementary Medicine Database (AMED®) (1985 to 07.11.2021) Platform: Ovid®; Cumulative Index to Nursing and Allied Health Literature (CINAHL®) (1950 to 07.11.2021) Platform: EBSCO®; Cochrane Database of Systematic Reviews (CDSR) (accessed on 07.11.2021) Platform: Wiley® online library; Excerpta Medica database (EMBASE®) (1974 to 07.11.2021) Platform: Ovid®; EMCARE® (1995 to 07.11.2021) Platform: Ovid®; Google Scholar (accessed on 07.11.2021) Platform: Google UK®; Healthcare Management Information Consortium (HMIC®) (1979 to November 2021) Platform: Ovid®; Medical Literature Analysis and Retrieval System Online (MEDLINE®) (1946 to 07.11.2021) Platform: Ovid®; PsycINFO®, Psychology and Behavioural Sciences Collection, Health Business Elite, Biomedica Reference Collection: Comprehensive Library, Information Science & Technology Abstracts (1967 to 07.11.2021) Platform: EBSCOhost®; and Scopus (2004 to 07.11.2021) Platform: Elsevier, Web of Science® Core Collection (1970-07.11.2021) Platform: Clarivate Analytics®. The search was adapted according to the respective database-specific search tools. It was searched using a combination of Medical Subject Heading terms (MeSH) where available, free-text search terms and Boolean operators. Refer to supplementary information S1 ‘Search terms’ for the specific detail of the search used for each database. Search results in languages other than English were noted, but for practical reasons, only search results in English or translated into English were included in this review. In an effort to identify unpublished studies, a search of grey literature was performed (http://www.opengrey.eu/ on 07.11.2021) to identify studies not indexed in the databases listed above. The term grey literature in this paper refers to sources used to describe a wide range of information produced outside of traditional publishing and distribution channels and which is often not well represented in indexing databases.

Data collection and analysis

All references from database search were downloaded into EndNote® X8.2 [31] reference manager, which was used to collate and remove duplicate records, to screen titles and abstracts and to store the full text of retrieved studies. Citations from OpenGrey could not be uploaded to EndNote® reference manager and therefore were uploaded to a Microsoft Excel® 2016 spreadsheet. Duplicate citations were removed by the automatic de-duplicating option in EndNote®X8.2 and were supplemented by hand-searching. Two researchers (NI and CH) examined the titles and abstracts of all eligible articles according to the inclusion and exclusion criteria listed above. References to be screened were allocated into groups and was divided into ‘include’, ‘exclude’ and ‘potential’ groupsets. The full-text articles of any abstracts classified as potentially meeting the inclusion criteria were retrieved and analysed independently by two authors (NI and CH) against the predefined inclusion and exclusion criteria with differences between reviewers resolved by consensus. The principal authors of all included papers were contacted to explore the potential for any studies considered vital to them that may have been missed in the search strategy. A data extraction form from the Cochrane collaboration was utilised to extract data from eligible papers [32]. Raw data from quantitative studies were extracted onto Microsoft Excel® 2016 spreadsheet. If data could not be pooled for meta-analysis, the plan was to undertake a narrative synthesis of results. The qualitative data synthesis methodology was decided upon after the quantity, quality, conceptual richness, and contextual thickness of the qualitative studies were determined. The intended results and data synthesis were to be conducted by authors NI and CH independently to assure the data extraction integrity.

The Mixed Method Appraisal Tool (MMAT) 2018 version was used to appraise and describe the methodological quality of included quantitative, qualitative and mixed-method studies. A pilot test of two articles was conducted to ensure consistent interpretation between the two authors (NI and CH). Discrepancies were resolved through discussion and consensus with the research team. If further information was required to appraise a particular study, an attempt was made to contact the authors by phone or email. Quality scores will be calculated using the MMAT tool. However, this did not solely determine if studies were of “low” or “high” quality, as a descriptive summary using MMAT criteria was considered [33]. If a study received a low score, it was compared with those with a higher score (higher quality studies) to consider if this modifies the outcome and interpretation of our synthesis.

Results

The database search yielded 7727 citations. After duplicates were removed, the database search identified 3908 citations. Based on the title and abstract information, 3844 citations were ‘excluded’, leaving 64 citations identified as ‘potentially relevant’ articles requiring a full-text article text review. In addition to the 3908 citations that were yielded by the databases, 1336 additional citations were retrieved from http://www.opengrey.eu/ and were screened separately as they could not be uploaded onto EndNote® X8.2 [31] reference manager. After screening, no pertinent articles that met the inclusion and exclusion criteria were extracted from grey literature sources.

On the examination of the full text of the 64 studies in the ‘potentially relevant’ category, no publications addressing evidence to identify activities and to assess interventions provided by pharmacists in primary care on SCA provision were identified (see Table 1, which includes a tabulated list of the 64 excluded studies along with reasons for exclusion, with some articles having more than one reason for exclusion). Out of the 64 excluded studies, one study (a conference proceeding) could not be found, and an attempt was made to contact the author to obtain further information (full set of results). The author did not respond; hence, this article was excluded from our review as the reviewers could not assess the eligibility based on the information from the abstract. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flow chart (Fig. 1) shows the identification, screening and selection of papers for this review. There were no included studies for which to assess the risk of bias or to apply for evidence synthesis.

Table 1 List of excluded studies along with reasons for exclusion
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Fig. 1
figure 1

Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flow chart

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Discussion

This paper aimed to systematically assess the pharmacist’s role in general practice in supporting the implementation of SCA in primary care. No articles met our inclusion criteria. Several studies have tried to define the role of pharmacists in general practice, but the working definition has not been defined by healthcare organisations or the research community [98, 99]. Another reason for there to be no studies available is because the GP pharmacist’s role is still a relatively new role in healthcare and little existing literature in role evolution is available [100].

Comparison with other studies

There is an agreement in the literature that the pharmacist role is developing at pace within the general practice setting and recent international systematic reviews and meta-analyses demonstrate positive effects on medication use and clinical outcomes [99, 101]. Pharmacists integrated into general practice teams can perform a variety of roles. This includes direct patient care, medicines reconciliation and education to members of the healthcare team and in the detection and resolution of medication-related problems [102,103,104]. A recent review of the impact of integrating pharmacists into primary care teams on health systems indicators on healthcare utilisation by Hayhoe et al. did highlight the activities provided by pharmacists in general practice. Still, it failed to discover activities to support SCA in the published literature [105]. Internationally, other terminologies and contexts vary, giving one example being collaborative care agreements by Stuhec et al. in Slovenia [106,107,108,109]. The focus has been aimed in this international context as clinical pharmacists share a role within their own heterogeneous setting and sharing this with various physicians in managing a patient with chronic conditions, not necessarily in the same setting such as GP surgery in the UK where the GP is seen anecdotally as the main gatekeeper and first point of contact for all medication issues related to the patient. The observational studies by Stuhec et al. have focused on older patient and psychiatric patients. Further research would be required to homogenise and formalise an internationally recognised term for shared care agreements.

The most recent Cochrane systematic review, which assessed the effectiveness of shared care across the interface between primary and speciality care in the management of long-term conditions, did not consider models of integrating care between pharmacists and primary care physicians [18]. The authors of the Cochrane review stated that this limited its generalisability to all types of collaborative care due to the contextual specificity. The review did note that several other models of shared or collaborative care should be considered for review. This systematic review has highlighted that the model of care involving a pharmacist in primary care supporting SCA is not currently present in the literature and should be considered for further investigation.

Implications of the review findings on clinicians and decision-makers in healthcare and future studies

The changing needs of the population make it increasingly important that the patient’s multiple needs are met in a well-coordinated way. To respond effectively to these changing needs, healthcare teams need to utilise the skills available across our healthcare teams. To help alleviate these pressures, it has been recommended that the NHS should maximise the opportunities offered by pharmacists [9, 110, 111]. Pharmacists can take on significant amounts of work currently done by GPs and other staff in general practice [111]. To explore whether shared care management could be implemented successfully by the pharmacist in general practice, we need to understand the relevant and important pharmacist related barriers and facilitators concerning the implementation of this role. The influence of these factors needs to be recognised and considered and how this can inform further research into this area.

Decision-making

Collaboration between pharmacists and the healthcare team is of paramount importance, and understanding the skills of multiple healthcare professionals will help support an integrated system [112]. We need to understand the role in which pharmacists will support SCA and how general practitioners are willing to integrate pharmacists within this process. A finding from earlier research has shown that general practice has a positive experience of pharmacist recommendations in a range of conditions [113,114,115]. However, how would this apply to SCA when patients and healthcare staff need to understand the role of the pharmacist and agree to the SCA? Would patients accept pharmacists undertaking this new role within the general practice?

Funding and workload

General practice continues to be concerned with the inappropriate funding associated with supporting shared care medication [21]. Commissioners have always stated that the funding of specialist’s drugs has been agreed so cost should not be an issue. General practitioners have expressed concerns that the additional workload required to support the integration of specialised medication is a factor they believe has not been appreciated [116]. This has been exacerbated by the COVID-19 pandemic, which has seen a rise in how general practice is expected to manage care which would typically be carried out in a hospital setting which in turn has contributed to a growing workload in primary care [117]. Previous studies have suggested that the impact of practice-based pharmacists will not be on workload but quality and safety [118]. It is reasonable to ask whether GPs would support pharmacists taking on this role without appropriate funding and whether this intervention will reduce workload in general practice.

Working definition and liability

We need to consider a working definition of the practice pharmacist role in shared care. The differences in pharmacists’ primary care roles have been identified in the international literature. The lack of clarity and knowledge of this primary care role can negatively affect their potential integration into the primary care team [119]. The knowledge, skills and attitudes required to support SCA should be made readily available to practice pharmacists, primary care teams and the general public. This would enable SCA management to be developed and applied nationally across primary care. The rapid emergence of new professional roles for pharmacists also means that arrangement in respect of liability needs to keep up with the changing nature of pharmacy practice within this more complex intervention.

This empty review can act as a platform to inform policymakers in healthcare that there is a lack of robust evidence that evaluates the role and potential value of pharmacists supporting SCA in general practice. Healthcare systems must seek out the best possible evidence to support patients within this new healthcare environment. However, the absence of research in this area does not justify the rejection of this intervention [120]. As the role is relatively new, there is still work to be done to develop the evidence base of pharmacists working in general practice to support SCA and the benefits of this role within the healthcare system.

Limitations

A limitation of this review is that the search strategy included a literature search of articles only in the English language. Other articles may have been published on pharmacists supporting SCA in general practice in non-English journals. Personal commentaries, blogs and opinion pieces were excluded from this systematic review due to the research design. This may have excluded observations that are occurring in general practice but have not been critically appraised. Another limitation is that the term SCA may be used as an alternate term from an international perspective. Despite the use of 12 healthcare-related bibliographical databases and the extensive use of keywords to maximise the sensitivity of relevant studies, after removal of duplicates, this yielded a low number of citations of titles and abstracts, another limitation. This systematic review used database word stock to establish standard search terms; however, it cannot be discounted that this may not have retrieved all articles relating to this intervention. Another limitation that needs to be considered is that abstracts from conference proceedings were not included in the synthesis, which could account for the empty return due to the high evidence bar for the systematic review.

Conclusion

This systematic review identified no eligible studies on the interventions provided by a pharmacist in supporting SCA in general practice. It is not possible to formulate what the role pharmacists can play in supporting SCA in general practice based on scientific evidence. There is an urgent need for studies that identify, observe and evaluate GP-based pharmacists’ roles concerning SCA that currently occur in clinical practice. Comparing and contrasting each general practice’s approach will ensure the development of a consensus for the role of GP pharmacists on SCA based on the current SCAs occurring in general practice, and how to implement this intervention consistently. The role of the pharmacist is expanding in general practice, and interventions which prove beneficial for patients and the healthcare system are required to meet the ever-changing demand in healthcare and to ensure that these new interventions follow the evidence. This empty systematic review serves as a starting point for further clinical research in this area.