Self-care of long-term conditions: patients’ perspectives and their (limited) use of community pharmacies
Self-care of long-term conditions: patients' perspectives and their (limited) use of community pharmacies
Oladapo J. Ogunbayo 0 1 2
Ellen I. Schafheutle 0 1 2
Christopher Cutts 0 1 2
Peter R. Noyce 0 1 2
0 Centre for Pharmacy Postgraduate Education (CPPE), Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester , Stopford building, Oxford Road, Manchester M13 9PT , UK
1 Centre for Pharmacy Workforce Studies (CPWS), Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester , Stopford building, Oxford Road, Manchester M13 9PT , UK
2 & Ellen I. Schafheutle
Background Self-care support is an 'inseparable' component of quality healthcare for long-term conditions (LTCs). Evidence of how patients view and use community pharmacy (CP) to engage in self-care of LTCs is limited. Objective To explore patients' perspectives of engaging in self-care and use of CP for self-care support. Setting England and Scotland. Method Qualitative design employing semi-structured interviews. LTCs patients were recruited via general practitioners (GPs) and CPs. Interviews were conducted between May 2013 and June 2014; they were audio-recorded, transcribed verbatim and analysed thematically. Results Twenty-four participants were interviewed. Three main themes emerged: engaging in selfcare, resources for self-care support and (limited) use of community pharmacy. Participants' LTC 'lived experience' showed that self-care was integral to daily living from being diagnosed to long-term maintenance of health/ wellbeing; self-care engagement was very personal and diverse and was based on beliefs and experiences. Healthcare professionals were viewed as providing information which was considered passive and insufficient in helping behavioural change. Non-healthcare sources (family, carers, friends, internet) were important in filling active support gaps, particularly lifestyle management. Participants' use of, and identified need for, community pharmacy as a resource for self-care support of LTCs was limited and primarily focussed on medicines supply. There was low awareness and visibility of CPs' potential roles and capability. Conclusion CP needs to reflect on patients' low awareness of its expertise and services to contribute to self-care support of LTCs. Rethinking how interventions are designed and 'marketed'; incorporation of patients' perspectives and collaboration with others, particularly GPs, could prove beneficial.
Community pharmacy; Healthcare professionals; Long-term conditions; Patient perspective; Qualitative interviews; Self-care; United Kingdom
Impact of findings on practice
Patients’ low awareness and limited use of community
pharmacy as a self-care resource may be indicative of
community pharmacists’ professional identity as
‘dispensers’ of medicines.
The ‘patient voice’, often ‘unheard’ in community
pharmacy research, needs to be recognised and
incorporated into new and existing community pharmacy
research, interventions and service design.
Community pharmacy needs to demonstrate evidence
of its value in the management and self-care support of
LTCs, alongside effectively ‘marketing’ this value to
Long-term conditions (LTCs) like diabetes, cardiovascular
diseases (CVD), chronic respiratory diseases and cancers
are now recognised as the greatest challenge facing
twentyfirst century healthcare . This recognition has led many
governments, policymakers and researchers globally to
develop strategies to efficiently manage limited healthcare
resources to meet future demands of people with LTCs. In
the United Kingdom (UK), healthcare professionals
working in the National Health Service (NHS) have been
encouraged to develop evidence of effective models of care
that improve the effectiveness and cost-effectiveness of
healthcare for people with LTCs [2, 3]. Self-care support
(also self-management support) is one model of care that
has been recognised as a potential paradigm shift in how
healthcare is provided to people with LTCs as it aims to
empower and support patients to take control and enable
them to self-care for their own health and well-being .
The UK government’s NHS Five-Year Forward View 
published in 2014 makes a strong case for patients,
particularly those with LTCs, to be given more control of their
own care. There is ample evidence that self-care support
works  and because of these well-documented benefits in
improving patient outcomes and being resource-efficient
[7–10], health policy and research now place great
emphasis on healthcare adopting the principles of self-care
support in their routine practice.
Self-care support in primary care has been described as
an inseparable component of high quality healthcare for
LTCs . It is an essential part of the chronic care model
(CCM)  which emphasises active engagement and
empowerment of patients before, during and after
consultations with healthcare professionals [13–15]. Self-care
support is now regarded as a distinct model of care for
LTCs but there is some ambiguity in the main components
of a clinically effective programme for self-care support
. What is however clear is that self-care support of
LTCs in primary care is multifaceted, with research
evidence suggesting that multilevel interventions such as
those that target healthcare professionals, patients and
organisational structures at the same time are more
effective than those that target simple or single components
. Self-care support requires a fundamental shift in the
healthcare professional-patient consultation with
patientcentred interactions that involve shared decision making,
personalised care planning, goalsetting, and proactive
Self-care is an activity of daily living for people,
whether healthy or with a LTC, and ranges from simple
activities to promote health such as exercising and eating
healthily, to more complex actions to restore health such as
receiving medical treatment and rehabilitation activities
. Patients with LTCs engage in self-care activities to
achieve normality in their everyday lives, maintain social
relationships and participate in meaningful activities in the
community [18–20]. Examples of these activities include
lifestyle modification such as stopping smoking, taking
medications, self/symptom-monitoring and seeking more
information and support about living with LTCs [4, 16].
Factors such as personal and lifestyle characteristics, health
status, resources, environmental factors and the healthcare
system affects how people engage in self-care .
Patients will often seek support for self-care from both
healthcare and non-healthcare sources based on their
instrumental, psychosocial and relational needs .
Studies have shown that non-healthcare sources (family,
friends, peers) play a more significant role in supporting
many aspects of self-care including emotional and lifestyle
support, although patients still rely on healthcare
professionals for support with the medical aspect of their LTCs
[18, 20, 23]. Among healthcare professionals, community
pharmacy teams are least considered for ongoing support
although the reasons for this is not clearly evident .
Community pharmacy is often described as the
healthcare profession that is most accessible to patients with
LTCs when collecting prescribed medicines [24–27].
Community pharmacy is also available to offer advice to
patients who need help and to signpost them to other
support services. Internationally, community pharmacy’s
contribution to the ongoing care of LTCs is largely
restricted by a focus on dispensing-related reimbursement
mechanisms which stifles the recognition and
incentivisation of other support activities that community pharmacists
could provide . In 2005, community pharmacy in the
UK moved to more innovative remuneration models that
reimburse community pharmacists for providing a whole
range of services . For patients with LTCs, these
include public health services such as healthy living advice
and support for lifestyle changes, and medicines-related
services which aim to help improve patients’ medicines
knowledge, understanding and adherence .
Medicinesrelated services, the English Medicines Use Review
(MUR) and New Medicine Service (NMS) and the Scottish
Chronic Medication Service (CMS), have, however, been
criticised as focussed on quantity rather than quality
[30, 31]. A study exploring community pharmacy’s views
on, and contributions to, holistic self-care support of LTCs
suggests a medicines-focussed approach, rather than a
patient-centred one . Currently, the evidence of the
impact of community pharmacy’s roles in improving
patient outcomes and reducing healthcare utilisation
remain inconclusive and ineffective in influencing
The majority of the research literature on the
management of LTCs in community pharmacy describes
interventions that target specific patient outcomes such as
medicines adherence , improvements in quality of life
 and uptake/utilisation of services [36, 37]. The views
and perspectives of patients with LTCs are usually
incorporated in research that focus on interventions such as
specific services [30, 38], LTCs-specific intervention
[39, 40], medicines management services [41, 42]
adherence-improving interventions , and lifestyle and public
health interventions [44, 45]. However, these focus on
patients’ preferences, experiences and satisfaction with
these services and interventions. While many of these
studies generally report favourable patient perspectives,
experience and satisfaction, there are few qualitative
studies that have examined a holistic perspective of how
patients with LTCs view and utilise community pharmacy
for their LTCs in their everyday lives. Indeed, qualitative
research that has explored patients’ perspectives of the
holistic care that they receive from healthcare
professionals in general is also limited [46–49]. The few studies
that exist are usually driven by agendas and priorities set
by healthcare professionals, which may lead to a
mismatch between the research undertaken and the actual
needs of patients [50, 51]. Patients’ needs are paramount
in any research that recommends changes to services or
interventions, and incorporating the views and
perspectives of patients has been described as morally desirable
as well as having the potential to improve the intervention
The overall aim of this study was to explore patients’
perspectives of the current and potential contributions of
community pharmacy to self-care support of LTCs. The
To explore and describe patients’ perspectives of how
they engage in self-care of LTCs and the resources they
access for self-care support.
To understand how patients view and use community
pharmacy in the ongoing management of their LTCs for
The study received NHS Research Ethics Committee and
local NHS Research and Development approvals in
England and Scotland.
This study employed a qualitative research design,
underpinned by descriptive phenomenology  which
focusses on understanding the ‘lived experience’ of
people from a first person point of view through the
interaction of the researcher and the participants .
Participants were patients living with LTCs in England
and Scotland, and included people that had at least one of
diabetes mellitus (type 1 and 2), chronic respiratory
diseases (asthma; COPD) and cardiovascular diseases
(hypertension; hypercholesterolemia; heart conditions).
Participants were sampled conveniently and purposively
to allow for maximal variation  in the type of LTCs
and demographic characteristics (age, gender, ethnicity,
Participants were recruited between May 2013 and June
2014. The initial recruitment strategy was to identify
patients from their general practitioner (GP) practices.
However, poor participation of GP practices led to a
change of strategy to include recruiting patients by
pharmacists. In England, one GP practice and ten community
pharmacists supported patient recruitment; in Scotland one
GP practice, two practice pharmacists and one community
pharmacist helped with patient recruitment. The researcher
attended GP diabetic and asthma clinics, where patients
were approached and provided with the recruitment pack
and verbal explanation of what the study entailed. The
pharmacists identified and approached eligible patients and
provided them with the same written and verbal study
information. Interested patients provided their contact
details and consent to the researcher directly (in the GP
practices) or to the pharmacists, who passed these onto the
researcher. Interested patients were contacted by telephone
and/or email and the interview date and venue were
This study used semi-structured one-on-one
interviewing of participants as its primary method of data collection.
Participants also completed a pre-interview questionnaire
collecting demographic data. The interview topic guide
was developed from the literature and evolved iteratively
as interviewing progressed. The topic guide focussed on
extending current knowledge on patients’ self-care
behaviours and activities and factors affecting their use of
healthcare and non-healthcare sources for support. While
previous studies have explored these topic areas in detail,
this study focussed on building on these studies and
gaining deeper insight into patients’ self-care behaviours in
relation to their use of community pharmacy for self-care
support. Hand written notes were taken during and after
each interview to record any important observations,
additional statements and the researcher’s reflections.
Interviews were conducted face-to-face with participants,
at their homes and in two cases at an alternative location
(coffee shops). Interviews lasted between 15 and 40 min
(average of 33 min). Following written/signed consent, all
interviews were audio-recorded and transcribed verbatim.
Data analysis was undertaken thematically 
underpinned by the philosophical stance of descriptive
phenomenology , which is characterised by a reflection of
an experience by the researcher based on the descriptions
provided by participants. The researcher gathered concrete
descriptions of specific experience from participants,
adopted the attitude of ‘phenomenological reduction’ to
understand the experience and sought to capture the
‘essential structure’ of the experience within the context of
the participants . The process of phenomenological
reduction and capturing of the essential structure of entire
and individual interviews undertaken in this study followed
the steps described by Todres .
Twenty-four patients were interviewed, 15 in England and
nine in Scotland. Fifteen were female and participants’
mean age was 62 years (SD = 20.1, Range = 24–92
years). Participants’ ethnicity was predominantly White
(n = 19), although Black (n = 3), Asian (n = 1) and other
ethnic groups (Mixed race, n = 1) were also represented.
Thirteen participants were educated up to high school
level, the remaining 11 had higher education qualification.
Seventeen participants were retired, two were unemployed,
and the rest were in full-time or part-time work (n = 5).
Most participants (n = 20) had multiple LTCs that
included asthma/COPD (n = 11), cardiovascular diseases
(n = 7) and diabetes (n = 6). The age at which
participants had been diagnosed with their LTC(s) ranged from
birth to 40 years, and they took an average of five regular
medicines (range 1–24).
Engaging in self-care
Interviews explored participants’ ‘lived experience’ where
it was found that self-care was ingrained in all stages of the
LTC trajectory; from diagnosis, through the acute
management of physical and emotional aspects, to long-term
maintenance of health and wellbeing. Table 1 summarises
some of the key themes on how participants engaged in
self-care, following this trajectory and illustrated with
exemplar quotes. Participants described self-care as a
complex range of behaviours and activities which were
diverse and shaped by their individual illness experiences,
beliefs and personal circumstances. For example, one
participant described how he adjusted his drinking lifestyle
based on information he had previously received and his
experience of self-monitoring his condition. While
participants’ sources of support to engage in self-care varied and
were driven by variable factors, it was generally agreed
that there were unmet self-care support needs along their
LTC trajectory, particularly in relation to managing
emotions and lifestyle behaviours (see Table 1).
Resources for self-care support
While describing their lived experience, participants were
probed about the support and resources they accessed to
engage in self-care. Participants identified healthcare and
non-healthcare resources with most indicating they
combined multiple sources. In the context of gaining the
knowledge and understanding about their particular LTCs,
most participants suggested they got more information
from non-healthcare resources such as family/friends,
reading books and websites, because some healthcare
professionals provided insufficient information.
I think I pieced together bits of information; I
probably did look online a little bit and then GPs and
nurses and just got combined information…the
education I got wasn’t that fantastic, to be honest, …I
mean I think the doctor at the hospital should have
given me more information, I was just sort of given a
bag of insulin pads and just told to go away… So I
sort of had to just learn it on my own what worked
and what didn’t work really….But also actually a lot
of stuff that I found out was from another diabetic
person, like, one of my friends that I met, like, he was
very helpful and very informative
EP4 (26 year old male with diabetes)
Most participants indicated that their prescribing
healthcare professional (mainly GPs) provided them with
medicines information and advice, although many also
indicated that they read the patient information leaflets
that came with the medicines. Despite obtaining their
prescribed medicines from community pharmacy, they did
not mention community pharmacy as a source of
information on medicines use, except occasionally when they
had been prescribed a new medicine. While participants
affirmed that they were aware they could obtain
medicines-related information from the pharmacy, they felt they
did not have the need to do so since they already obtained
this from GPs. Some participants admitted that they were
Table 1 Engaging in self-care—broad and specific themes and illustrative quotes
Broad themes—aspects of Specific themes: engaging in a
self-care along LTC trajectory self-care activity
Being diagnosed with a LTC
Taking/adhering to prescribed
medications as a habit/ritual
Seeking information after being I was in hospital for an asthma attack, a really bad asthma attack and it took
diagnosed ages to get over it and the doctors there said I had COPD but I didn’t know
what it was then so I had a look myself what it was. (EP12 – 70 year old
female with COPD and asthma)
Changing/modifying lifestyle to
cope with physical demands
Staying positive and hopeful
counselling and support
Yeah, when I was first diagnosed I pretty much stopped drinking completely
because I was kind of misinformed really but now I started drinking a lot
more, and I just monitor it. (EP4 – 26 year old male with diabetes)
Taking your medications, well, that just comes automatic now. Once you’ve
been taking it for years its habit now, its habit and you know exactly what
you’re doing. (SP4 – 77 year old male with asthma, CVD and arthritis)
Well, I mean in the past I used to be very active and played tennis and
hockey, but I haven’t done that for a long time. My husband and I fished,
that was our hobby, but nowadays my main exercise is the garden. (EP5 –
85 year old female with asthma, CVD and diabetes)
I was in the supermarket and I was feeling horrible [hypoglycaemic]….I bought
one of those little orange juices. I wouldn’t normally because it does shake your
blood sugar up, but I drank some of that and the pure juice, of course it shoots
your blood sugar up. (SP2 – 65 year old female with diabetes and CVD)
I mean we all worry as we get older you know, we are getting nearer to the
end you know [laughs]….But its, um, you know, when you see people that
are sick, it’s upsetting, you know, um, when you are hoping that those kind
of things don’t happen to you, but you know, nobody knows. (EP1 –
70 year old male with CVD and gout)
Yes, when I was going through university, I did actually see a counsellor
because one or two things became too heavy to deal with I did see a
counsellor about the emotional side, but I must have only had about four
sessions before I realised I can deal with this on my own… (EP6 – 26 year
old male with a heart defect)
Well, sometimes it [blood sugar] goes high, like, stress makes it just go up a
lot, but, because I was very paranoid of going to sleep with low blood
sugar. So, yeah, I’d say that my good control came probably, like, about
four years ago when I started to realise how important your health actually
is and if you just pay a little bit of attention to it, then it can be fine. (EP2 –
26 year old female with diabetes)
Making healthy lifestyle choices I take the tablets and I try and take as much exercise as possible. I could do
with losing more weight. I’ve stopped smoking a long, long time ago. Um,
and am trying on having a reasonable diet, ye. (EP8 – 78 year old male
with asthma and CVD)
Well, I’ve a fair idea, you know your own body better than anybody else and I
have a fair idea of when I feel out of sorts and something isn’t right and if
there’s something bothering me I won’t wait too long before I go to the
doctor if it’s worrying me. (SP9 – 73 year old female with CVD and COPD)
Yes. Recently, maybe two or three months ago, I was having hypos which
meant I was in the supermarket and I was holding on to the shelf, because I
thought I was going to [faint]. So I made an appointment to see the nurse
and she said, you definitely have to see the doctor. As far as she was
concerned everything was fine apart from that. So the doctor changed my
tablets. (SP2 – 65 year old female with diabetes and CVD)
unsure whether community pharmacy could deal with
problems relating to the use of prescription medicines.
I: And when you had the issue why did you go back
to the doctor, did you think about going to the
chemist rather than going to the doctor’s?
R: No, I didn’t actually, no, because I didn’t think a
chemist…well, I just didn’t think, that maybe a
With regards to making lifestyle changes, many
participants indicated that they had been offered information and
advice from healthcare professionals, primarily doctors and
nurses in their GP practices/hospitals, about making lifestyle
changes. However, most patients acknowledged that
healthcare professionals provided lifestyle information and advice
mostly passively rather than being more proactive in
supporting behaviour change or referring them to other
services which offered more proactive support. Again, most
patients resorted to non-healthcare professional sources to
help them make the lifestyle changes for their LTCs.
I wanted to lose weight anyway and that’s what I was
doing before the asthma flared up last year [laugh]
and then all of a sudden I couldn’t do anything.
…The doctors were like, well, you know, swimming
and stuff, do something gentle, but you don’t lose
weight doing gentle exercise. I’ve got a personal
trainer at the gym to help me.
EP7 (24 year old female with asthma)
Community pharmacy as a resource for self-care support
The majority of participants talked about the primary
purpose of community pharmacy to them being the supply
of medicines; mainly prescribed medicines for their LTCs
but also over-the-counter (OTC) medicines for minor
ailments. All participants were taking regular medicines for
their LTCs and most indicated that they had an established
supply system set-up with the community pharmacy. After
participants discussed their use of community pharmacy
for collecting their prescribed medicines, they were probed
further to discuss any other reasons when they made use of,
or interacted with, their community pharmacy for
managing their LTCs. Most participants struggled to come up
with anything and none of them mentioned any of the main
LTCs-specific services such as the MURs, the NMS and
the CMS or lifestyle interventions such as the smoking
cessation and healthy lifestyle services. Some participants
however indicated that they were aware that community
pharmacy offered a range of services but indicated that
they did not feel the need to use these.
I know the pharmacy offers a lot of services, in terms
of, like, free checks for this, checks for that and
checks for this, I’ve never felt the need to go in and
see them, like, one of them is a free check for your
diabetes risk, which I feel is a bit unnecessary and,
yeah, I know they do offer advice on prescriptions,
but I’ve never felt the urge to take advantage. So I
know that they do offer a lot, but, for me, my first
port of call would be my doctor. EP13 (45 year old
female with diabetes and CVD)
Participants were probed further on their awareness and use
of any services or interventions in the community
pharmacy for self-care support of LTCs. While most
participants indicated awareness of community pharmacy
as a potential self-care resource, some routinely returned to
their GP, and others simply did not consider the community
pharmacist as an option. When probed about this, some
participants indicated that it was because their GPs was
their first point of call, while some others suggested that
community pharmacy was not readily visible to them.
I don’t know, it’s just my perception, I’ve always just
gone to the doctor’s for advice and never the
pharmacist, and it’s just the way that it’s always been for
me; I’ve never really thought to question it with
them; I don’t really know why, to be honest.
SP1 (62 year old female with diabetes and CVD)
This topic was explored further with participants asked to
discuss any situations when they had chosen to visit the
pharmacy for anything relating to their LTCs and the use of
their medicines, instead of going to their GPs. Most
participants struggled to think of a situation like that and
went on to indicate that they always sought the help of their
GP if they had any concerns about their medicines or their
LTCs. They suggested that they would not readily consider
seeking help from community pharmacy unless they had
run out of all other options. When asked for the reason for
this, most participants could not come up with a clear
reason but indicated that it could be because they viewed
community pharmacy as a medicines supplier.
I: And then with the diabetes what sort of situation
would want you to go to the pharmacy and ask to see
R: I suppose I would go there if, say, there was a big
waiting list at my doctor’s, I couldn’t easily get to my
diabetic doctor; they [community pharmacy] would
probably be like my third or fourth choice of
someone to ask….. Yeah. I honestly, I don’t know why,
but I never really thought of using them, I’d just seen
them as the people who give me my medication.
EP4 (26 year old male with diabetes)
Some participants further admitted that, while they were
aware that community pharmacists were suitably qualified
to help them, they felt community pharmacists did not
appear visible enough for them to be approached for help.
They again confirmed their perspective of community
pharmacy being that of a medicines supplier, which
dissuaded them from viewing and utilising community
pharmacy for other purposes.
I know they are qualified; it’s just that it’s not your
immediate thought …But for some reason, I don’t
know, the pharmacist um, you just forget that the
pharmacist is actually there [laughs]. You know,
because you go into the pharmacy and there are lots
and lots of, mainly women, um, who are making up
medications and so on, according to prescriptions,
and you tend to forget that the pharmacy and not a
dispenser, you know, yea.
EP3 (57 year old female with diabetes,
hypocholesteraemia and psoriasis)
While previous research has explored patients’ lived
experiences of their LTCs, [20, 57] their perspectives of
self-care  and support needs , this study extends
this knowledge in the pharmacy literature. Earlier work by
the authors that explored community pharmacy’s
contributions to self-care support of LTCs found that pharmacists
conceptualised and operationalised self-care support from a
medicines-focussed and opportunistic perspective,
although there was the recognition of the potential to
contribute to a more holistic approach [32, 59]. This study
complements this earlier work and provides a more
complete understanding by drawing on patients’ perspectives of
community pharmacy’s contributions to self-care support
of LTCs. The key findings from all studies highlight the
gaps of low public/patient awareness, and use of,
community pharmacy as a resource for self-care support of
LTCs, as well as a need for a more comprehensive self-care
support and LTCs strategy in community pharmacy if its
potential are to be realised.
There are some limitations in this study which should be
acknowledged. None of the participants had recently used a
community pharmacy LTC-specific service (MUR, NMS
or CMS), possibly resulting in an unbalanced perspective
as people who use these services may have a different view
of community pharmacy’s self-care support roles.
Furthermore, participants’ interest in taking part in this study
and their high levels of education may mean that they were
already knowledgeable and more involved in their
healthcare, and this may have skewed their perceptions of
community pharmacy’s potential role in self-care support. The
short duration of the interviews may also be considered a
potential limitation. However, this study did not aim to
duplicate previous research that has explored patients’
perspectives of illness and self-care, but focussed on views
and use of community pharmacy as a self-care support
Patients with LTCs encounter and interact with a wide
range of healthcare and non-healthcare networks that shape
how they engage in self-care . Patients in this study
suggested that while healthcare professionals provided
selfcare information and advice relating to their LTCs, use of
prescribed medicines and lifestyle management, these were
often provided didactically and passively. This meant that
patients had to rely on and combine other resources for
active support to engage in self-care, mainly
non-healthcare resources that included personal communities,
nonhealth professionals and voluntary and community groups
. Among healthcare professionals, community
pharmacists did not feature as a potential resource for
selfcare, even with regards to the use of prescribed medicines
that were dispensed by community pharmacies.
Participants suggested that the supply of prescribed medicines
was the primary reason for interacting with community
pharmacy and despite the LTC support services and
interventions available in community pharmacy they were
either not aware or did not readily take advantage of
Patients in this study looked to their GPs to take the lead
in the care of their LTCs and viewed them as the first point
of call for support with their medicines and general
management of their health. There is however increasing
recognition that community pharmacists are well-suited to
lead the care of patients with stable, uncomplicated LTCs
(those on stable medications) [62, 63]. This case has been
made stronger with government recognition that the current
structure and organisation of the primary care workforce
and pressures on general practices may not be able to cope
with current and future healthcare demands .
Collaborative partnership between the multidisciplinary teams and
patients is a necessity to improve the effectiveness and
cost-effectiveness of healthcare . Community pharmacy
in the UK has, in recent times, consistently made a case for
an extended clinical role in the ongoing management of
LTCs [62–64]. Better integration between GPs and
pharmacists is thus likely to be fundamental to the success of
community pharmacy’s contribution to self-care support.
Indeed, self-care support of LTCs interventions that have
been shown to be effective commonly involve
GP-community pharmacy collaboration [64, 65].
This integration however, has not yet been successfully
achieved, with the main barriers identified as professional
isolation and ‘shopkeeper’ image of community pharmacy,
lack of information sharing and limited cooperation and
support between community pharmacy and GPs [66–70].
There is a plethora of studies that have examined and
recommended major reforms to the working relationships
and interactions between community pharmacy and GPs
[71–74]. Some of these recommendations include
interprofessional education at both undergraduate and
practitioner levels [75, 76]; regular communication to improve
the flow of information;  incentivising to work
collaboratively through joint contracts;  and establishing
and expanding the roles and contributions of GP practice
pharmacists . Recently, pivotal steps have been taken
towards integration of medical and pharmaceutical service
delivery in primary care , and there is a proposal to
further improve GP-community pharmacy integration by
recommending the development and incentivisation of
joint contractual frameworks .
Finally, the ‘patient voice’, the perspectives of patients,
is an area that needs to be given further consideration if
community pharmacy is to improve its contributions to
self-care support of LTCs. NHS England recognises this as
a key policy area and stated that it ‘‘will ensure that public,
patient and carer voices are at the centre of our healthcare
services, from planning to delivery’’ . This will require
a better understanding of the factors and determinants of
patient self-care behaviours and the resources they access,
and recognising and incorporating patients’ perspectives of
how they want to be supported to enhance their abilities to
engage in self-care . While patients in this study
suggested that community pharmacy currently plays a limited
role in self-care support of LTCs, this finding may be more
closely linked to patients’ low awareness and lack of
recognition of community pharmacists’ potential as a
clinical healthcare professionals that could manage and
support LTCs . Furthermore, studies have shown that
community pharmacists view themselves primarily as
‘‘dispensers of medicines’’ as their main professional role
, which may reflect the lens that patients also use to
view them. Indeed, the perspectives of patients in this study
was that the primary role of community pharmacy was that
of medicine supplier. Hence community pharmacy could
do more to promote its professional image and what it
Community pharmacy remains an untapped resource for
self-care support of LTCs. This can be attributed to low
awareness and uptake of community pharmacy as a
resource by LTC patients. Community pharmacy may need
to demonstrate evidence of its value in the management
and self-care support of LTCs, alongside effectively
‘marketing’ this value to patients, healthcare professionals
and the public.
Acknowledgements We would like to thank the general practice and
community pharmacy staff who helped with the recruitment of study
participants; we would particularly like to thank that patients who
gave up their time to openly share their views and experiences,
without which this study would not have been possible.
Funding This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest There are no conflicts of interest to declare.
Open Access This article is distributed under the terms of the
Creative Commons Attribution 4.0 International License (http://crea
tivecommons.org/licenses/by/4.0/), which permits unrestricted use,
distribution, and reproduction in any medium, provided you give
appropriate credit to the original author(s) and the source, provide a
link to the Creative Commons license, and indicate if changes were
1. World Health Organization (WHO). Global status report on noncommunicable diseases . Geneva ; 2014 .
2. Department of Health. The expert patient: a new approach to chronic disease management for the 21st century . London: Crown Copyright ; 2001 .
3. Department of Health. Improving chronic disease management . London: Department of Health ; 2004 .
4. Department of Health. Self care-a real choice: self care support-a practical option . London: Crown Copyright ; 2005 .
5. NHS England. Five Year Forward View. London. http://www. england.nhs.uk/wp-content/uploads/2014/10/5yfv-web.pdf ( 2014 ). Accessed 02 Feb 2015 .
6. De Silver D. Evidence: helping people help themselves. A review of the evidence considering whether it is worthwhile to support self-management . London: The Health Foundation ; 2011 .
7. Corben S , Rosen R. Self-management for long-term conditions: patients' perspectives on the way ahead . London: King's Fund ; 2005 .
8. Department of Health. Supporting people with long term conditions: an NHS and social care model to support local innovation and integration . London: Department of Health ; 2005 .
9. British Columbia Ministry of Health. Self-management support: a health care intervention . Victoria: BC Ministry of Health ; 2011 .
10. Galdas P , Fell J , Bower P , Kidd L , Blickem C , McPherson K , et al. The effectiveness of self-management support interventions for men with long-term conditions: a systematic review and metaanalysis . Br Med J Open . 2015 ; 5 ( 3 ) :e006620 . doi:10.1136/bmjo pen- 2014 - 006620 .
11. Taylor S , Pinnock H , Epiphanou E , Pearce G , Parke H , Schwappach A , et al. A rapid synthesis of the evidence on interventions supporting self-management for people with long-term conditions: PRISMS-Practical systematic Review of SelfManagement Support for long-term conditions . Health Serv Deliv Res . 2014 ; 2 ( 53 ): 1 - 622 . doi:10.3310/hsdr02530.
12. Bodenheimer T , Wagner EH , Grumbach K. Improving primary care for patients with chronic illness . J Am Med Assoc . 2002 ; 288 ( 15 ):1909. doi:10.1001/jama.288.15. 1909 .
13. Glasgow RE , Funnell MM , Bonomi AE , Davis C , Beckham V , Wagner EH . Self-management aspects of the improving chronic illness care breakthrough series: implementation with diabetes and heart failure teams . Ann Behav Med . 2002 ; 24 ( 2 ): 80 - 7 .
14. Bodenheimer T. Improving primary care for patients with chronic illness . J Am Med Assoc . 2002 ; 288 ( 14 ): 1775 . doi:10.1001/jama. 288.14.1775.
15. Barlow JH , Sturt J , Hearnshaw H. Self-management interventions for people with chronic conditions in primary care: examples from arthritis, asthma and diabetes . Health Educ J . 2002 ; 61 ( 4 ): 365 - 78 .
16. Kennedy A , Rogers A , Bower P. Support for self care for patients with chronic disease . Br Med J . 2007 ; 335 ( 7627 ): 968 - 70 . doi:10. 1136/bmj.39372.540903.94.
17. Coulter A , Roberts S , Dixon A. Delivering better services for people with long-term conditions: building the house of care . London: The King's Fund ; 2013 .
18. Wellard S. Constructions of chronic illness . Int J Nurs Stud . 1998 ; 35 ( 1-2 ): 49 - 55 .
19. Zolnierek CD . Exploring lived experiences of persons with severe mental illness: a review of the literature . Issues Ment Health Nurs . 2011 ; 32 ( 1 ): 46 - 72 . doi:10.3109/01612840.2010.522755.
20. Jeon Y , Jowsey T , Yen L , Glasgow NJ , Essue B , Kljakovic M , et al. Achieving a balanced life in the face of chronic illness . Aust J Prim Health . 2010 ; 16 ( 1 ): 66 - 74 . doi:10.1071/PY09039.
21. Schulman-Green D , Jaser SS , Park C , Whittemore R. A metasynthesis of factors affecting self-management of chronic illness . J Adv Nurs . 2016 . doi:10.1111/jan.12902.
22. Dwarswaard J , Bakker EJM , van Staa A , Boeije HR . Self-management support from the perspective of patients with a chronic condition: a thematic synthesis of qualitative studies . Health Expect Int J Public Particip Health Care Health Policy . 2015 . doi:10.1111/hex.12346.
23. Cheong LH , Armour CL , Bosnic-Anticevich SZ . Primary health care teams and the patient perspective: a social network analysis . Res Soc Adm Pharm . 2013 ; 9 ( 6 ): 741 - 57 . doi:10.1016/j.sapharm. 2012 .12.003.
24. Jesson J , Bissell P. Public health and pharmacy: a critical review . Crit Public Health . 2006 ; 16 ( 2 ): 159 - 69 .
25. Department of Health. Pharmacy in England: building on strenghts-delivering the future . Norwich: Crown Copyright ; 2008 .
26. Department of Health. Choosing health through pharmacy: a programme for pharmaceutical public health 2005-2015 . London: Department of Health ; 2005 .
27. Department of Health. Pharmacy in the future-implementing the NHS plan . London: Crown Copyright ; 2000 .
28. International Pharmaceutical Federation (FIP). Sustainability of Pharmacy Services: Advancing Global Health-International overview of remuneration models for community and hospital pharmacy . The Hague: FIP; 2015 .
29. Noyce PR . Providing patient care through community pharmacies in the UK: policy, practice, and research . Ann Pharmacother . 2007 ; 41 ( 5 ): 861 - 8 . doi:10.1345/aph.1K015.
30. Latif A , Pollock K , Boardman HF . The contribution of the Medicines Use Review (MUR) consultation to counseling practice in community pharmacies . Patient Educ Couns . 2011 ; 83 ( 3 ): 336 - 44 . doi:10.1016/j.pec. 2011 .05.007.
31. Latif A , Boardman H. Community pharmacists' attitudes towards medicines use reviews and factors affecting the numbers performed . Pharm World Sci . 2008 ; 30 ( 5 ): 536 - 43 . doi:10.1007/ s11096- 008 - 9203 -x.
32. Ogunbayo OJ , Schafheutle EI , Cutts C , Noyce PR . A qualitative study exploring community pharmacists' awareness of, and contribution to, self-care support in the management of long-term conditions in the United Kingdom . Res Soc Adm Pharm . 2015 ; 11 ( 6 ): 859 - 79 . doi:10.1016/j.sapharm. 2014 .12.010.
33. Mossialos E , Naci H , Courtin E. Expanding the role of community pharmacists: policymaking in the absence of policy-relevant evidence? Health Policy . 2013 ; 111 ( 2 ): 135 - 48 . doi:10.1016/j. healthpol. 2013 .04.003.
34. Armour CL , Smith L , Krass I. Community pharmacy, disease state management, and adherence to medication-a review . Dis Manag Health Out . 2008 ; 16 ( 4 ): 245 - 54 . doi:10.2165/ 00115677 - 200816040 - 00005 .
35. Cheema E , Sutcliffe P , Singer DR . The impact of interventions by pharmacists in community pharmacies on control of hypertension: a systematic review and meta-analysis of randomized controlled trials . Br J Clin Pharmacol . 2014 ; 78 ( 6 ): 1238 - 47 . doi:10. 1111/bcp.12452.
36. Saramunee K , Krska J , Mackridge A , Richards J , Suttajit S , Phillips-Howard P. How to enhance public health service utilization in community pharmacy?: general public and health providers' perspectives . Res Soc Adm Pharm . 2014 ; 10 ( 2 ): 272 - 84 . doi:10.1016/j.sapharm. 2012 .05.006.
37. Bradley F , Wagner AC , Elvey R , Noyce PR , Ashcroft DM . Determinants of the uptake of medicines use reviews (MURs) by community pharmacies in England: a multi-method study . Health Policy . 2008 ; 88 ( 2-3 ): 258 - 68 . doi:10.1016/j.healthpol. 2008 .03. 013.
38. Latif A , Boardman HF , Pollock K. Understanding the patient perspective of the English community pharmacy Medicines Use Review (MUR) . Res Soc Adm Pharm . 2013 ; 9 ( 6 ): 949 - 57 . doi:10. 1016/j.sapharm. 2013 .01.005.
39. Twigg MJ , Poland F , Bhattacharya D , Desborough JA , Wright DJ . The current and future roles of community pharmacists: views and experiences of patients with type 2 diabetes . Res Soc Adm Pharm . 2013 ; 9 ( 6 ): 777 - 89 . doi:10.1016/j.sapharm. 2012 .10.004.
40. Lowrie R , Johansson L , Forsyth P , Bryce S , McKellar S , Fitzgerald N. Experiences of a community pharmacy service to support adherence and self-management in chronic heart failure . Int J Clin Pharm Net . 2014 ; 36 ( 1 ): 154 - 62 . doi:10.1007/s11096- 013 - 9889 -2.
41. Tinelli M , Bond C , Blenkinsopp A , Jaffray M , Watson M , Hannaford P , et al. Patient evaluation of a community pharmacy medications management service . Ann Pharmacother . 2007 ; 41 ( 12 ): 1962 - 70 . doi:10.1345/aph.1K242.
42. Bissell P , Blenkinsopp A , Short D , Mason L. Patients' experiences of a community pharmacy-led medicines management service . Health Soc Care Community . 2008 ; 16 ( 4 ): 363 - 9 . doi:10. 1111/j.1365- 2524 . 2007 .00749.x.
43. Lindenmeyer A , Hearnshaw H , Vermeire E , Van Royen P , Wens J , Biot Y. Interventions to improve adherence to medication in people with type 2 diabetes mellitus: a review of the literature on the role of pharmacists . J Clin Pharm Ther . 2006 ; 31 ( 5 ): 409 - 19 . doi:10.1111/j.1365- 2710 . 2006 .00759.x.
44. Eades CE , Ferguson JS , O'Carroll RE . Public health in community pharmacy: a systematic review of pharmacist and consumer views . BMC Public Health . 2011 ; 11 ( 1 ): 582 . doi:10.1186/ 1471 - 2458 - 11 - 582 .
45. Anderson C , Blenkinsopp A , Armstrong M. Feedback from community pharmacy users on the contribution of community pharmacy to improving the public's health: a systematic review of the peer reviewed and non-peer reviewed literature 1990-2002 . Health Expect Int J Public Particip Health Care Health Policy . 2004 ; 7 ( 3 ): 191 - 202 . doi:10.1111/j.1369- 7625 . 2004 .00274.x.
46. Yen L , Gillespie J , Rn YH , Kljakovic M , Anne Brien J , Jan S , et al. Health professionals, patients and chronic illness policy: a qualitative study . Health Expect Int J Public Particip Health Care Health Policy . 2011 ; 14 ( 1 ): 10 - 20 . doi:10.1111/j.1369- 7625 . 2010 . 00604.x.
47. Abma TA . Patient participation in health research: research with and for people with spinal cord injuries . Qual Health Res . 2005 ; 15 ( 10 ): 1310 - 28 . doi:10.1177/1049732305282382.
48. Serrano-Aguilar P , Trujillo-Martin MM , Ramos-Goni JM , Mahtani-Chugani V , Perestelo-Perez L , Posada-de la Paz M. Patient involvement in health research: a contribution to a systematic review on the effectiveness of treatments for degenerative ataxias . Soc Sci Med . 2009 ; 69 ( 6 ): 920 - 5 . doi:10.1016/j.socscimed. 2009 .07.005.
49. Schipper K , Abma TA . Coping, family and mastery: top priorities for social science research by patients with chronic kidney disease . Nephrol Dial Transpl . 2011 ; 26 ( 10 ): 3189 - 95 . doi:10.1093/ndt/ gfq833.
50. Elwyn G , Crowe S , Fenton M , Firkins L , Versnel J , Walker S , et al. Identifying and prioritizing uncertainties: patient and clinician engagement in the identification of research questions . J Eval Clin Pract . 2010 ; 16 ( 3 ): 627 - 31 . doi:10.1111/j.1365- 2753 . 2009 .01262.x.
51. Abma TA , Nierse CJ , Widdershoven GA . Patients as partners in responsive research: methodological notions for collaborations in mixed research teams . Qual Health Res . 2009 ; 19 ( 3 ): 401 - 15 . doi:10.1177/1049732309331869.
52. Trappenburg J , Jonkman N , Jaarsma T , van Os-Medendorp H , Kort H, de Wit N , et al. Self-management: one size does not fit all . Patient Educ Couns . 2013 ; 92 ( 1 ): 134 - 7 . doi:10.1016/j.pec. 2013 .02.009.
53. Todres L. Clarifying the life-world: descriptive phenomenology . In: Holloway I, editor. Qualitative research in health care . Maidenhead: Open University Press ; 2005 . p. 104 - 24 .
54. Wojnar DM , Swanson KM . Phenomenology: an exploration . J Holist Nurs Official J Am Holist Nurses' Assoc . 2007 ; 25 ( 3 ): 172 - 80 . doi:10.1177/0898010106295172 discussion 81-2; quiz 83-5 .
55. Creswell JW . Qualitative inquiry and research design: choosing among five approaches . Thousand Oaks: SAGE Publications , Inc.; 2006 .
56. Braun V , Clarke V. Using thematic analysis in psychology . Qual Res Psychol . 2006 ; 3 ( 2 ): 77 - 101 .
57. Thorne SE , Paterson BL . Two decades of insider research: what we know and don't know about chronic illness experience . Ann Rev Nurs Res . 2000 ; 18 : 3 - 25 .
58. Spenceley SM , Williams BA . Self-care from the perspective of people living with diabetes . Can J Nurs Res . 2006 ; 38 ( 3 ): 124 - 45 .
59. Ogunbayo OJ , Schafheutle EI , Cutts C , Noyce PR . How do community pharmacists conceptualise and operationalise selfcare support of long-term conditions (LTCs)? An English crosssectional survey . Int J Pharm Pract . 2016 . doi:10.1111/ijpp. 12283.
60. Cheong LH , Armour CL , Bosnic-Anticevich SZ . Patient asthma networks: understanding who is important and why . Health Expect Int J Public Particip Health Care Health Policy . 2014 . doi:10.1111/hex.12231.
61. Vassilev I , Rogers A , Sanders C , Kennedy A , Blickem C , Protheroe J , et al. Social networks, social capital and chronic illness self-management: a realist review . Chronic Illness . 2011 ; 7 ( 1 ): 60 - 86 . doi:10.1177/1742395310383338.
62. The Scottish Government. Prescription for Excellence: A Vision and Action Plan for the right pharmaceutical care through integrated partnerships and innovation . Edinburgh: The Scottish Government ; 2013 .
63. Wilson H , Barber N. Review of NHS Pharmaceutical Care of Patients in the Community in Scotland . Edinburgh: Scottish Government; 2013 .
64. Smith J , Picton C , Dayan M. Now or never: shaping pharmacy for the future . The Report of the Commission on future models of care delivered through pharmacy . London: RPS ; 2013 .
65. Twigg MJ , Wright D , Barton GR , Thornley T , Kerr C. The four or more medicines (FOMM) support service: results from an evaluation of a new community pharmacy service aimed at over65s . Int J Pharm Pract . 2015 . doi:10.1111/ijpp.12196.
66. Jesson JK , Wilson KA . One-stop health centres: what co-location means for pharmacy . Health Place . 2003 ; 9 ( 3 ): 253 - 61 . doi:10. 1016/S1353-8292(02)00057- 6 .
67. Hughes CM , McCann S. Perceived interprofessional barriers between community pharmacists and general practitioners: a qualitative assessment . Br J Gen Pract . 2003 ; 53 ( 493 ): 600 - 6 .
68. Bradley F , Elvey R , Ashcroft DM , Hassell K , Kendall J , Sibbald B , et al. The challenge of integrating community pharmacists into the primary health care team: a case study of local pharmaceutical services (LPS) pilots and interprofessional collaboration . J Interprof Care . 2008 ; 22 ( 4 ): 387 - 98 . doi:10.1080/13561820802 137005.
69. Dobson RT , Taylor JG , Henry CJ , Lachaine J , Zello GA , Keegan DL , et al. Taking the lead: community pharmacists' perception of their role potential within the primary care team . Res Soc Adm Pharm . 2009 ; 5 ( 4 ): 327 - 36 . doi:10.1016/j.sapharm. 2008 .11.002.
70. Bradley F , Ashcroft DM , Noyce PR . Integration and differentiation: a conceptual model of general practitioner and community pharmacist collaboration . Res Soc Adm Pharm . 2012 ; 8 ( 1 ): 36 - 46 . doi:10.1016/j.sapharm. 2010 .12.005.
71. Wells KM , Thornley T , Boyd MJ , Boardman HF . Views and experiences of community pharmacists and superintendent pharmacists regarding the New Medicine Service in England prior to implementation . Res Soc Adm Pharm . 2014 ; 10 ( 1 ): 58 - 71 . doi:10.1016/j.sapharm. 2013 .03.003.
72. Van C , Mitchell B , Krass I. General practitioner-pharmacist interactions in professional pharmacy services . J Interprof Care . 2011 ; 25 ( 5 ): 366 - 72 . doi:10.3109/13561820.2011.585725.
73. Brock KA , Doucette WR . Collaborative working relationships between pharmacists and physicians: an exploratory study . J Am Pharm Assoc . 2004 ; 44 ( 3 ): 358 - 65 . doi:10.1331/1544345043230 63995.
74. Edmunds J , Calnan MW . The reprofessionalisation of community pharmacy? An exploration of attitudes to extended roles for community pharmacists amongst pharmacists and general practioners in the United Kingdom . Soc Sci Med . 2001 ; 53 ( 7 ): 943 - 55 . doi:10.1016/S0277-9536%2800% 2900393 - 2 .
75. Cooper H , Carlisle C , Gibbs T , Watkins C. Developing an evidence base for interdisciplinary learning: a systematic review . J Adv Nurs . 2001 ; 35 ( 2 ): 228 - 37 .
76. Hammick M , Freeth D , Koppel I , Reeves S , Barr H. A best evidence systematic review of interprofessional education : BEME Guide no . 9. Med Teach . 2007 ; 29 ( 8 ): 735 - 51 . doi:10. 1080/01421590701682576.
77. Mundasad S. Pharmacists 'should help ease GP pressure' . BBC News . 2015 .
78. NHS England. New £15 m scheme to give patients pharmacist support in GP surgeries . 2015 . http://www.england.nhs.uk/ 2015 / 07/07/pharm-supp-gp-surgeries/. Accessed 18 July 2015 .
79. Royal Pharmaceutical Society (RPS) and National Association of Primary Care (NAPC) . Improving patient care through general practice and community pharmacy integration; a consultation document . England: RPS and NAPC ; 2015 .
80. England NHS . Transforming participation in health and care: 'The NHS belongs to us all' . London: Patients and Information Directorate, NHS England ; 2013 .
81. Rosenthal MM , Breault RR , Austin Z , Tsuyuki RT . Pharmacists' self-perception of their professional role: insights into community pharmacy culture . J Am Pharm Assoc . 2010 ; 51 ( 3 ): 363 - 7 .