Themes
Four main themes were identified: (1) Variations in perceptions and knowledge about RA: (2) The role of the pharmacy in increasing public awareness about RA. (3) The role of the pharmacy staff in facilitating access to the GP. (4) Practical considerations for pharmacy based interventions.
1.Variations in perceptions and knowledge about RA: This theme covers pharmacy staff’s perceptions and knowledge of RA, its symptoms and possible treatments. Several interviewees gave an accurate description of RA as a progressive inflammatory disease (Table3, Quote 1, further referred to as T3Q1), mentioned the fact that RA is an autoimmune disease and accurately identified some of the main symptoms associated with it including joint pain and swelling (T3Q2-Q3). Some interviewees were further able to accurately describe the wide age range of patients affected with inflammatory arthritis (T3Q4). However, others indicated not knowing much about RA (T3Q5) or held misconceptions about RA, for example stating that uric acid accumulation caused RA pain (T3Q6). Moreover, some interviewees could distinguish between RA and other MSK conditions such as osteoarthritis (OA)(T3Q7), others could not (T3Q8). Further, not all interviewees were aware of the increased incidence rate of RA in women compared to men (T3Q9).
Table 3
Quotes related to theme 1: Variations in perceptions and knowledge about RA.
Quote No. | Quotes |
1 | “It’s a progressive, degenerative disorder that we know will become worse if you don’t look at halting the disease progression; hence, the need for disease modifying anti-rheumatic drugs.” P03*, Pharmacist. |
2 | “So rheumatoid arthritis, it's an auto-immune disease so the main symptoms we're looking at are joint pain, swelling, redness, warmth, maybe some fatigue, and fever.” P16, Pre-registration in placement year. |
3 | “Obviously, if their joints are swollen or quite obviously red and inflamed; even symmetrical swellings maybe that indicate rheumatoid arthritis of the joints, if there are any deformities. Any other symptoms that flag along with it, like feeling unwell, fever, etcetera.” P04, Pharmacist. |
4 | “I think the typical patient is probably over 50 but it can happen to a child. A child can have it and the parents are not aware. It doesn’t get diagnosed for a long time, I don’t think, in children because it’s not something you associate with children...” P02, Pharmacy technician |
5 | “I don’t really have that much knowledge about it.” P13, Pharmacist |
6 | “I think it's to do with the uric acid and stuff like that, when it's higher you get these joint pains and stuff.” P12, Pharmacy dispenser |
7 | “The rheumatoid, is that autoimmune, is that right? So you want, more so get pain and swelling of the joints […] more so than osteoarthritis where that’s more wear and tear over years.” P09, Pharmacy manager. |
8 | Hold on, osteoarthritis, that’s just the general term and rheumatoid arthritis is the more specific term that talks about the joints, mainly the fingers and everything. It’s an interchangeable term as far as I know”. P19, Pre-registration in placement year. |
9 | “I don’t think it’s specifically between men or women either, from my knowledge.” P04, Pharmacist. |
10 | “100% yes of course, I think arthritis is definitely a serious condition, it’s affecting your day-to-day life, you’re in pain, you have to constantly rely on painkillers to go about your day.” P14, Pre-registration in placement year. |
11 | “Generally, in all honesty, if they come to me for RA, they’ve probably suffered for months, so another week or two is neither here nor there really, is it? I’m aware of the pressure on GP practice appointments.” P01, Pharmacy manager. |
12 | “Yeah, I’d say the earlier you’ve started treating it the, it’s good ‘cause you can slow down like the progression.” P10, Pharmacy manager. |
13 | “With rheumatoid arthritis, if the inflammation gets to a peak then the medication won’t have as much of an effect. Also, because it is physically debilitating, we always aim for prevention. So, in that way, I would say early treatment is preferred.” P19, Pre-registration in placement year. |
14 | “I don’t know whether other people are probably in the same boat as me but they probably weren’t as knowledgeable on rheumatoid arthritis and how important it is to intervene early.” P04, Pharmacist. |
15 | “You’ve got things like Methotrexate, which seems to be the main thing. They also use NSAIDs and things like Sulfasalazine. Methotrexate would be the main one that springs to mind for rheumatoid arthritis. But they have to have blood level checks and toxicity checks for that.” P05, Pharmacy manager. |
16 | “In terms of medication for that in particular, so we offer NSAIDs. Maybe a corticosteroid if it's an acute – maybe if we're injecting into the joint or DMARDs, so anything like methotrexate, Leflunomide, things like that. Or any biologic treatment after that, so Etanercept, Abatacept, that kind of stuff.” P16, Pre-registration in placement year. |
*P03 refers to participant 1 as described in Table 2. Idem for the other participant numbers |
While some interviewees perceived RA as a serious condition associated with a reduced quality of life and an impact on physical functioning (T3Q10), others did not perceive RA to be serious or in need of urgent attention, stating that waiting a few more weeks before seeking medical attention for these symptoms would not be problematic (T3Q11). Whereas some interviewees readily recognised the need for early DMARD treatment (T3Q12-Q13), others did not (T3Q14). Several interviewees were able to describe the treatment of RA once it was diagnosed including DMARDs and non-steroidal anti-inflammatory drugs (NSAIDs) (T3Q15-Q16).
2. The role of the pharmacy in increasing public awareness about RA. Various interviewees shared their thoughts on the causes of patient delay in help-seeking and described a lack of public awareness of RA. Interviewees recognised that the public’s lack of knowledge about the seriousness of RA and misperceptions around it being a disease of the elderly might be why symptomatic patients delayed seeking help (Table 4; T4Q1-Q2). Some indicated that patients might believe their condition was not serious enough to see a GP (T4Q3-Q4) and would only seek help if symptoms were so severe that they interfered with daily activities, thus delaying seeking help from their GP with early symptoms. Others thought patients may be embarrassed about seeking help for ‘a little bit of pain’ (T4Q5-Q6) or that they may find it difficult to get a GP appointment (T4Q7).
Table 4
Quotes related to theme 2: The role of the pharmacy in increasing public awareness about RA
Quote No. | Quotes |
1 | “I suspect for the public perception there isn’t a whole lot. And when you say arthritis, they’re immediately thinking that they’re not old. I don’t think that the general public know much about rheumatoid arthritis.” P05, Pharmacy manager. |
2 | “I think that’s something we’ve definitely seen. I mean we’ve [yeah] actually had one patient that just said, ‘Yeah, we, it’s, yeah, I thought it was actually part of getting old’.” P10, Pharmacy manager. |
3 | “When it is early enough, it’s not severe enough for them to take action. And that is a problem that we have. That … even if there is a serious condition, what really would motivate someone to take some action, so clearly it really should start affecting their life. They don’t do anything.” P08, Pharmacy manager. |
4 | “They don’t want to bother their GP. They don’t think the symptoms, particularly in the early stages, are specific enough to make them go the GPs.” P05, Pharmacy manager. |
5 | “Yeah, they can’t be bothered to make another appointment at the doctors, and they feel like they might be embarrassing themselves just going for a little bit of pain you know in the joints.” P07, Pharmacist. |
6 | “A lot don’t want to bother the GPs if they’re only having paracetamol.” P05, Pharmacy manager. |
7 | “I know it’s hard for people to get a doctor’s appointment, which is what they keep saying.” P02, Pharmacy technician. |
8 | “So it’s just a case of making sure that the conversations are happening so you don’t want to miss things so often it’s the case that the patient is seeking advice for the first time and if it is something like rheumatoid or something it is spotted and you are referring the right patients so I think we now have a bigger role in terms of awareness of arthritis and things, I'm not too sure how aware people are so… “ P06, Pre-registration in placement year. |
9 | “I think we’ve still got some of our leaflets. Yeah, national osteoporosis society. Am I at risk at osteoporosis and fractures? I mean any sort of learning materials like that, we go through them first in-house before we, you know, put them on the shelves for the patients ‘cause obviously we needed to get sourced up with everything.” P09, Pharmacy manager. |
10 | “And also these posters and leaflets you can post to the different pharmacies and also we can give some leaflets and posters to, we can stick the posters inside the pharmacy and the people they can read and they can say and also they can have leaflets where they read information.” P11, Pharmacy dispenser. |
Several interviewees indicated ways in which they could be instrumental in increasing public awareness and informing their clients about RA (T4Q8). For example, they referred to leaflets and posters they have received for other diseases and suggested that equivalent materials would be useful for both increasing their own and their clients’ awareness of RA. (T4Q9-10).
3 The role of pharmacy staff in facilitating access to the GP: This theme focused on the potential roles of community pharmacy staff in making positive interventions to signpost new onset RA patients towards GP consultations. Some interviewees explained they would identify a potential new onset RA patient by assessing symptoms and asking about family history, referring patients towards their GPs if RA was suspected (Table 5; T5Q1-Q3). Some discussed how the role of pharmacists has changed with the focus being increasingly placed on clinical interactions with patients and not “just dispensing the medication” (T5Q4), but others indicated that there was a lack of public awareness about pharmacists’ clinical knowledge (T5Q5) and that they are underutilized.
Table 5
Quotes related to theme 3: The role of the pharmacy in facilitating access to the GP
Quote No. | Quotes |
1 | “If I did suspect rheumatoid arthritis in a patient, although I would offer to treat symptoms there, I would recommend that they saw a doctor” P01, pharmacy manager. |
2 | “Yes, I'd ask if they'd been diagnosed with - do they have any other medical conditions, things like that. So maybe if they have a history of it in the family.” P16, Pre-registration in placement year. |
3 | “Initially it’s just ruling out if the stiffness is worse in the mornings, those sorts of things.” P06, Pre-registration in placement year. |
4 | “I think it’s changed a lot recently because it’s kind of moved from us staying in the back just dispensing the medication, checking, to actually being out the front and making sure that we’re picking up things so it’s just a case of making sure that the conversations are happening so you don’t want to miss things so often it’s the case that the patient is seeking advice for the first time and if it is something like rheumatoid or something it is spotted and you are referring the right patients so I think we now have a bigger role in terms of awareness of arthritis.” P06, Pre-registration in placement year. |
5 | “I think it's about public perception as well because obviously I think they forget that we're also clinical pharmacists and we're trying to obviously change that and we - I think the public don't realise how much obviously we learn and we know so we are an important port of call for things like that.” P16, Pre-registration in placement year. |
6 | “I would say personally you don’t get referred that often because the actual counter assistants have the training now and so they’re like a filter. If somebody does come in to the pharmacy they’ll speak to those people first and if they can’t answer the questions they’ll actually refer it to the pharmacist.” P07, Pharmacist. |
7 | 1. “I mean we usually like access the symptoms first and then obviously we refer it to the pharmacist and then like if he thinks that there’s anything more serious then he would always refer it to their GP.” P13, Pharmacist. |
8 | “In terms of stiffness in their hands or joint pain anywhere else in the body, at that point obviously I would […] just to keep an eye on generally what the patient is buying over the counter and spotting signs and clues as to there may be an underlying condition here.” P15, Pre-registration in placement year. |
9 | “So regarding joint pain the conversation I might have is more when I’m handing out pain medication and I strike up a conversation with the patient as to whether they’ve had the medication before and then it might go further into a conversation regarding their pain management.” P07, Pharmacist. |
10 | “This is what you have to do’ but as long as people can get some pain relief until they see their own doctor.” P02, Pharmacy technician. |
11 | “Yes in terms of giving medication OTC, that's just a temporary base, so what we can do, we can talk to the patient and get all the information and if we think this patient needs more than what we can do we can refer to the GP.” P12, Pharmacy dispenser. |
12 | “Sometimes people come and they ask for more medication even though the doctors prescribe something and then they ask for more tablets or more for example they just come for Co-codamol so many times even though they take medication at home they want some more tablets.” P11, Pharmacy dispenser. |
Furthermore, interviewees identified the role pharmacy technicians and counter assistants have as they are often the first to speak to patients. When technicians and counter staff are unsure about the cause of the symptoms a patient is presenting with, they refer to a pharmacist who can further assess the patient (T5Q6-T5Q7) and potentially suggest a GP visit.
Joint pain is the most common symptom of early RA and patients may seek advice about pain management from pharmacy staff. Indeed interviewees indicated that this is when they are most likely to see a patient with inflammatory arthritis (T5Q8). Some interviewees described the considerations they would make when offering medications for the management of joint symptoms (T5Q9). Some interviewees explained that OTC medications should only be used temporarily to relieve symptoms while patients await their GP consultation (T5Q10-Q11). Others highlighted how they could flag patients asking repeatedly for OTC medication for symptoms of RA and refer them onto the GP (T5Q12).
4. Practical considerations for pharmacy based interventions: This theme focused on the potential need for training of pharmacy staff and any other considerations needed in order to enhance opportunities for pharmacy staff to identify and signpost new onset RA patients. Whereas, some interviewees had undertaken training on (rheumatoid) arthritis fairly recently as part of their continuing professional development (CPD), and felt they had a good level of knowledge about RA (Table 6; T6Q1), others indicated that although they had recently graduated and their current knowledge about RA was good, they were aware they would need more training in the future (T6Q2). Some interviewees highlighted that there is currently no specific training requirement in relation to RA or other MSK conditions (T6Q3). Others stated that it was hard to find the time to do extra training (T6Q4).
Table 6
Quotes related to theme 4: Practical considerations for pharmacy based interventions
Quote No. | Quotes |
1 | “We have to do CPD, professionals do we have to do CPD don’t we and also I did a community pharmacy diploma about three or four years ago and they have a section in that that you cover on arthritis and on pain management.” P07, Pharmacist. |
2 | “Yes, absolutely. I think really for us the reason that I probably feel more confident and know a bit more is just because I've come out of university and we studied it. But I couldn't say confidently that five years down the line I'd know as much as I did now.” P16, Pre-registration in placement year. |
3 | “Yes but only nine CPD’s a year. So, it might not even be musculoskeletal, it might be something different. So, it’s not something that says we have to learn musculoskeletal, it’s down to the pharmacist, so they might neglect it.” P17, Pre-registration in placement year. |
4 | “Yeah, obviously, I love training but I think it’s tricky … I’ve got three kids and I work 43 hours a week. It’s tricky to fit it in.” P01, pharmacy manager. |
5 | “I mean the dispensers or the healthcare counter staff are not really trained or aware of things that they should be picking up so they do refer to us”, P06, Pre-registration in placement year. |
6 | “If healthcare counter staff are just sending them away with pain relief and then they leave it there's always that downfall that they're not getting treated”, P06, Pre-registration in placement year. |
7 | “It’s very varied because pharmacists have very little training in actual clinical examination” P01, pharmacy manager. |
8 | “I think it's really good because it's like with the inhaler technique with us, once that came out about 10% of patients actually knowing how to use their inhaler and then pharmacists didn’t really know so then where is the knowledge coming from when they're prescribed it? So that was a big thing, I think things like this need to happen” P06, Pre-registration in placement year. |
9 | “A lot of other people would have the same situation where they can’t always attend. An e-learning course, promoted by CPPE, would be my preference, or something like that, because they promote emails and everybody uses those on a daily basis. That would be something to highlight this e-learning package. It’s got to be simple and it’s not very long.” P04, Pharmacist. |
10 | “I would think a more face-to-face kind of approach. It’s a lot more useful. I mean you would need to do some preliminary work first and in the face-to-face interaction you might not cover all the ground at that stage but I think face-to-face is needed to consolidate it.” P19, Pre-registration in placement year. |
11 | “CCGs have a good, important role as well and so they could roll that out across the area; whether it’s in GP practices or community pharmacies. I’m sure they could. I don’t know whether they can promote that.” P04, Pharmacist. |
12 | “Yes, we see people on a regular basis. We can see deterioration in some people and that goes for lots of other medical issues going on as well.” P05, Pharmacy manager. |
13 | “We’re a village pharmacy, I’ve been there 25 years and so have half my staff, so we know the individual people that walk in, so we might initiate a conversation with somebody… You’ve initiated the conversation and given them the opportunity to speak to somebody about something that is occurring with them.” P05, Pharmacy manager. |
14 | “If you're a locum and you're only in there for a day it’s very difficult to even get an idea of how often this patient comes in so it can be missed” P15, Pre-registration in placement year. |
15 | “It’s usually a verbal recommendation that I give and I go back to notes and if the patient is one of our patients then I would go to their notes and write down that I’ve had interaction with the patient, I told them to go and see the doctor, they were feeling this, this, this, I’ll make a note of it so that it’s in my record as well and kind of like for all purposes as well. But more importantly to know that I have referred them and I know what’s happening now.” P14, Pre-registration in placement year. |
16 | “I tend to do formal referrals when I think it’s urgent and so it helps to ease people through the system because sometimes, a letter from a pharmacist actually does carry a little bit of clout that would get you past Reception. When I’ve felt that someone needs to be seen quite urgently, I have given people referral letters to take to the Walk-In Centre.” P01, Pharmacist |
17 | “Sometimes if it’s like a medication review, so like an MUR … that we’ve done, we can do a referral letter … or normally it’s just, ‘Oh, you just need to make an appointment […] with your GP so they can’, you know, we leave that with the patient to do themselves […] arrange themselves. Or if we find it an emergency or often not an emergency, if it’s something that we can do for them that they feel involved, ‘Actually I know your surgery quite well or I know the girls at XXX and that’s our local doctor’s surgery, we can just pass them a message or we can just give them a call’, especially the times if it’s elderly patients or housebound patients maybe that have popped in on the off chance. I will give them a call, say, ‘You know, a doctor probably wants to […] his patient’, we’ve done that in the past as well.” P09, Pharmacy manager |
Interviewees further stated that interventions made by pharmacy staff may vary depending on their clinical skills, and that technicians or counter staff did not have the clinical training to identify potential RA patients. They highlighted the importance of training for pharmacy technicians, dispensers and counter assistants in addition to that for pharmacists, to ensure they are able to identify potential new onset RA patients requiring further referral (T6Q5-6). The lack of training of pharmacists themselves in clinical examination was also highlighted (T6Q7).
Some interviewees gave examples of training they had received in other disease areas, such as the inhaler technique service, which had led to improved patient outcomes (T6Q8). They also explained that their preferred training format would be interactive online learning platforms although some preferred face-to-face teaching (T6Q9-Q10). Interviewees further suggested how training could be advertised to pharmacy staff to ensure training was delivered effectively to all community pharmacies (T6Q11).
Interviewies identified that the setting of a pharmacy may influence the likelihood that patients with new onset RA would be identified. Smaller local pharmacies see people on a regular basis and therefore pharmacy staff can initiate conversations to recognise new symptoms (T6Q12-Q14).
There was some discussion about the practicalities of how pharmacy staff might refer an individual they suspected of having RA to see their GP. Many would advise their client to consult their GP (T6Q15). However, some pharmacists described using a referral form when they believed the patient’s symptoms to be serious enough to require an urgent medial opinion (T6Q16 ) or instead approaching the GP surgery directly if, for example, dealing with a vulnerable patient they believe needs to be seen urgently (T6Q17).