INTRODUCTION:Pharmaceutical manufacture, delivery and use produces an estimated 10%-55% of national healthcare greenhouse gas emissions. Addressing pharmaceutical supply chain emissions is essential to mitigating healthcare's climate impact. Our research aimed to explore the constraints to pharmaceutical supply chain climate action and how planetary health leadership can overcome these challenges. METHODS:We conducted 21 narrative interviews with representatives from pharmaceutical companies and industry and health system stakeholders. Interviews explored perspectives on climate action across pharmaceutical supply chains. Analysis was informed by argumentative discourse analysis, enabling the identification of key storylines. RESULTS:Climate action across pharmaceutical supply chains is sporadic and insufficient to achieve health system climate goals. Critical constraints to climate action include (a) structural constraints, particularly complex, fragmented, global supply chains as well as limited renewable energy infrastructure in some countries where supply chains operate and (b) conceptual constraints, the 'patient-profit-planet dilemma', where climate action is perceived to conflict with patient well-being and financial considerations.Planetary health leadership can help overcome these constraints in three key ways. First, planetary health leadership can help reconceptualise healthcare delivery, and the role of pharmaceuticals, to align patient and planetary well-being while meeting financial pressures. Second, planetary health leadership can mobilise collective climate action across pharmaceutical supply chains, reframing climate change as a shared problem and challenging issues of transparency, competition and blame. Third, planetary health leadership can challenge wider systems that constrain climate action, leveraging the economic and political power of pharmaceutical supply chains to drive global decarbonisation efforts. CONCLUSION:Planetary health leadership must confront considerable constraints to embed planetary health considerations across pharmaceutical supply chains. Leaders in this space must be willing to go against the status quo and challenge entrenched norms and systems to enable wider spread and support for sustainable healthcare delivery.

Background: Pharmacy education is evolving to better serve the community, as seen in the 'Nine-star Pharmacist' model. This model promotes the development of skills needed for pharmacists in their managerial and healthcare roles. However, pharmacy degrees often omit enterprise and entrepreneurship education, which could equip newly qualified pharmacists with essential skills that benefit the community. This study aimed to elucidate the benefits of enterprise and entrepreneurship education for pharmacy students, to identify the potential importance of integrating entrepreneurship education into the pharmacy curriculum. Methods: Fifty-five students registered for the undergraduate pharmacy degree at the University of Bradford were asked to complete a questionnaire concerning their perception of integrating enterprise and entrepreneurship in pharmacy education. The questionnaire consisted of a Likert scale and open-ended questions. Descriptive statistics were conducted. Results: Fifty-five students completed the questionnaire. Eighty percent (n=43) of students agreed that developing enterprise and entrepreneurial skills would enhance their career prospects. Eighty-five percent (n=46) of students agreed that enterprise and entrepreneurship education should be offered within the pharmacy curriculum. Conclusion: The results of this study indicate that pharmacy students believe enterprise and entrepreneurship education (EEE) should be integrated into the pharmacy curriculum, as it would benefit their future careers.

The incorporation of deprescribing into structured medication reviews (SMR) is a patient-centred and cost-effective practice in primary care settings. Pharmacists have a key role in deprescribing among older people to improve quality of life and reduce adverse events, but patients and healthcare professionals may be resistant to reducing their medication, and evidence around how deprescribing happens in practice is currently lacking. This study explores the implementation of a co-designed intervention in a single English General Practice (UK). To explore key stakeholders’ perceptions of a co-designed primary care intervention to involve patients and their families in deprescribing and its broader intervention context, guided by the Consolidated Framework for Implementation Research (CIFR). Qualitative semi-structured interview study with a purposive sample of staff, and patients with frailty, to explore perceptions of the deprescribing initiative. Data were analysed using an a priori framework structured by the domains of the CIFR. Interviews (24 in total) were conducted with 13 staff involved in delivering the intervention and 5 patients living with frailty who completed a structured medication review with recommended medication changes. Key factors (mapped to CFIR domains) included: an imperative for formal training around the intervention delivery (Inner setting), engagement with SMR delivery linked to payment through national agendas (Outer setting); the importance of the fit of the intervention with existing processes around prescribing practice and infrastructure (Inner setting); increased understanding of the aims of deprescribing among patients and recognition of the extended pharmacist role in primary care deprescribing (Individuals); recognition that the successful delivery of the intervention was a team effort (Implementation process). Structured medication reviews are a suitable mechanism to discuss and make deprescribing decisions as part of a shared consultation. Resources which support the patient through the deprescribing process can engage patients and promote greater satisfaction with service delivery. Operationally, staff can also benefit from tools which facilitate greater understanding of the process and fit within their usual practice plus improving patient care and saving medication costs. Barriers and facilitators to implementation success should be noted and addressed for upscaling and process sustainability.

The significance of medicines lies not only in their medicinal value but also in their cost, emphasizing the importance of proper utilisation to reduce waste and optimise resource allocation. The transition to a circular economy, which entails shifting from the current ‘take-use-dispose’ model to a closed-loop system, emerges as a pragmatic approach to curbing waste generation. This study therefore aims to identify the enablers and barriers associated with adopting circular economy practices in the management of medicines waste within hospital pharmacies, examining practices in both the United Kingdom and Kuwait. Employing a mixed-methods approach, this research is validated using empirical data gathered through qualitative interviews (Phase one, n = 29) and quantitative questionnaires (Phase two, n = 86). Key themes were identified in the qualitative data and supported by quantitative results, these were: Barriers and Enablers (Cognitive, Structural and Cultural) and CE Practices (Circulation of products and Eliminating waste and pollution). 89

While the National Health Service of the United Kingdom recovers from COVID-19, it's crucial to assess the impact of the dynamic capabilities within its healthcare services to ensure future public health protection. This study adopts mixed methods of literature review and surveys. Survey findings reveal that agility, flexibility, and building redundancy proved instrumental in reconfiguring resource foundations swiftly and fostering new partnerships. These actions were essential for sustaining service quality and efficiency. The analysis recommends that patients and healthcare professionals should co-design a technology-driven primary care service provision that is person-centric and digitally inclusive. Furthermore, primary care service stakeholders should develop targeted collaborations, and workforce development should be a priority to increase medical reserve in the healthcare system. This research provides empirical evidence, enabling the National Health Service to persist in enhancing dynamic capabilities and reinforcing resilience for anticipated and unforeseen future challenges.

Introduction Burnout is a syndrome resulting from unsuccessful stress management in the workplace, and is characterized by three dimensions: energy depletion, reduced professional efficacy, and feelings of negativism. Background Studies have confirmed that burnout causes deterioration in teamwork and job satisfaction and negatively impacts and compromises services. Many studies have examined the impact of burnout on health. Aim This cross-sectional study aimed to assess the rate of burnout among hospital pharmacists working in Sheikh Khalifa Medical City. Method The Maslach Burnout Inventory-Human Services Survey for Medical Professionals was used to assess burnout. The survey measured three subscales: emotional exhaustion, depersonalization, and personal achievement. In addition, pharmacists were asked questions regarding their demographic years of practice and qualifications. The surveys were distributed to inpatients, discharge/emergency, outpatients, and clinical pharmacies. The data were collected over two weeks and analyzed. Results Sixty-eight of the 90 pharmacists participated in this study. The response rate was 75.5%. Seventeen pharmacists were considered to have high burnout as they had both high emotional exhaustion and high depersonalization scores. Two pharmacists were considered to have moderate burnout, as they had moderate emotional exhaustion, depersonalization, and personal achievement. Only 17 pharmacists reported a low level of burnout. Conclusion The study revealed that 25% of the pharmacists had high burnout rates. Although statistically insignificant (P > 0.05), all pharmacists with high burnout were female and working in different pharmacy settings. Moreover, an additional 25% experienced low burnout, and 3% had moderate burnout levels. The remaining items were difficult to classify because they did not fit the Maslach definition of high, moderate, or low burnout. Further investigation is needed to identify the levels and causes of burnout among Sheikh Khalifa Medical City pharmacists.

BackgroundThe efficacy of medicines depends on their accessibility and availability. Dedicated medicine shortage reporting systems (MSRS) have been set up in different countries, either mandatory or voluntary, following the recommendations of the World Health Organisation to ensure these.ObjectivesTo explore how the Medicine Shortages Reporting System (MSRS) can tackle medicine shortages through improved access and sustainability.MethodsPersonnel directly involved in the reporting mechanisms for medicine shortages in eight (8) countries participated in semi-structured interviews. An interview protocol based on the Dynamic Capabilities View and Organisational Information Processing Theory (OIPT) was developed. It contained questions related to participant's views on the process involved in MSRS and how it was used to tackle shortages. Data were thematically analysed.ResultsThree core elements were identified to influence MSRS's ability to tackle shortages and ensure sustainability; (1) the ability to identify what information requirements the reporting system needs, (2) identify information processing capabilities, and (3) the ability to match requirements and information processing capabilities through a dynamic capability decision-making process. The dynamic decision-making process involves reiteratively sensing shortages by understanding and validating information received.ConclusionBuilding MSRS to tackle shortages for accessibility and sustainability is a systemic process that entails understanding the various elements and processes of MSRS. It includes defining medicine shortages, reconfiguring resources, defining accessibility and ensuring the system's sustainability. Our study provides insights into MSRS developed for mitigating medicine shortages and provides a framework for a sustainable MSRS. The findings extend the literature on medicine shortage management by identifying the various elements required to set up an MSRS. It also provides practical implications for countries that seek to establish MSRS to mitigate medicine shortages. Further studies could extend the number of participating countries to provide a clearer picture of the MSRS and how it can reduce medicine shortages.

Purpose Medicine shortages have a detrimental impact on stakeholders in the pharmaceutical supply chain (PSC). Existing studies suggest that building resilience strategies can mitigate the effects of these shortages. As such, this research aims to examine whether resilience strategies can reduce the impact of medicine shortages in the United Kingdom's (UK) PSC. Design/methodology/approach A sequential mixed-methods approach that involved qualitative and quantitative research enquiry was employed in this study. The data were collected using semi-structured interviews with 23 key UK PSC actors at the qualitative stage. During the quantitative phase, 106 respondents completed the survey questionnaires. The data were analysed using partial least square-structural equation modelling (PLS-SEM). Findings The results revealed that reactive and proactive elements of resilience strategies helped tackle medicine shortages. Reactive strategies increased relational issues such as behavioural uncertainty, whilst proactive strategies mitigated them. Practical implications The findings suggest that PSC managers and decision-makers can benefit from adopting structural flexibility and proactive strategies, which are cost-effective measures to tackle medicine shortages. Also engaging in strategic alliances as a proactive strategy mitigates relational issues that may arise in a complex supply chain (SC). Originality/value This study is the first to provide empirical evidence of the impact of resilience strategies in mitigating medicine shortages in the UK's PSC.

BackgroundHeart failure is a major global health challenge incurring a high rate of mortality, morbidity and hospitalisation. Effective medicines management at the time of hospital discharge into the community could reduce poor outcomes for people with heart failure. Within the Improving the Safety and Continuity Of Medicines management at Transitions of care (ISCOMAT) programme, the Medicines at Transitions Intervention (MaTI) was co-designed to improve such transitions, with a cluster randomised controlled trial to test effectiveness. The MaTI includes a patient toolkit and transfer of discharge medicines information to community pharmacy. This paper aims to determine the degree to which the intervention was delivered, and identify barriers and facilitators experienced by staff for the successful implementation of the intervention.MethodsThe study was conducted in six purposively selected intervention sites. A mixed-methods design was employed using hospital staff interviews, structured and unstructured ward observations, and routine trial data about adherence to the MaTI. A parallel mixed analysis was applied. Qualitative data were analysed thematically using the Framework method. Data were synthesised, triangulated and mapped to the Consolidated Framework for Implementation Research (CFIR).ResultsWith limited routines of communication between ward staff and community pharmacy, hospital staff found implementing community pharmacy-related steps of the intervention challenging. Staff time was depleted by attempts to bridge system barriers, sometimes leading to steps not being delivered. Whilst the introduction of the patient toolkit was often completed and valued as important patient education and a helpful way to explain medicines, the medicines discharge log within it was not, as this was seen as a duplication of existing systems. Within the CFIR the most applicable constructs were identified as 'intervention complexity' and 'cosmopolitanism' based on how well hospitals were networked with community pharmacies, and the availability of hospital resources to facilitate this.ConclusionThe MaTI was generally successfully implemented, particularly the introduction of the toolkit. However, implementation involving community pharmacy was more challenging and more effective communication systems are needed to support wider implementation.Trial registration11/04/2018 ISRCTN66212970. https://www.isrctn.com/ISRCTN66212970.

Abstract Introduction Problematic polypharmacy in older people living with frailty can cause harm due to adverse drug events and deprescribing (withdrawing inappropriate medication to manage polypharmacy and improve outcomes (1)) is one solution to mitigate this. Structured Medication Reviews (SMRs) have been commissioned in England to be conducted by Primary Care Network (PCN) pharmacists for which older people living with frailty are a priority group. SMRs are an ideal opportunity to deprescribe for this high-risk population and a person-centred approach is required to ensure deprescribing is safe, effective and acceptable to patients. However, the optimal deprescribing process has not been developed and tested in this context. Aim To develop a person-centred process for deprescribing for older people living with frailty which could potentially be implemented within SMRs in primary care. Methods We conducted qualitative research with older people living with frailty, carers and primary healthcare professionals to identify barriers and facilitators to deprescribing in this context in the North of England (2). We then used these findings and a “trigger film” of patients’ experiences to conduct Experience-based Co-design (EBCD), a multi-event process where older people living with frailty, informal carers and primary healthcare professionals came together to determine the key features of an ideal deprescribing process and identify priorities for a complex intervention to support the process. Following this, we presented the process model for feedback at the training day of a large multi-site primary care practice based (involving pharmacists, GPs and administrative practice staff) in the North of England and subsequently refined the model to integrate within their evolving SMR programme. Results The co-designed deprescribing process consisted of 3 phases: 1. Prior to the SMR consultation which involved case-finding of high-risk patients, case-note review for deprescribing eligibility and clinician planning for the consultation, inviting and preparing the patient for the consultation with written information (including what to expect during the medication review, and questions for patients about their medicines to reflect upon); 2. The consultation which included shared decision-making, agreement of plans to stop medicines, recording of decisions in the electronic health record, providing written information for patients on how to safely stop their medicines, safety netting and signposting to post-deprescribing support; 3. Post-consultation which involved evaluating patient experiences and organising follow-up and further review as needed. Key elements of the optimal process to ensure it was person-centred, were effective written and verbal communication for patients (during the entire process), shared decision-making and tailored support post-consultation. Conclusion We have developed a person-centred process for deprescribing for older people living with frailty and adapted it for implementation within nationally commissioned SMRs in England. Although the model is grounded in the requirements of multiple stakeholders, the final version requires evaluation. The next steps are to design and develop tools which can support our deprescribing process and to undertake feasibility testing in primary care. References 1. Reeve E, Gnjidic D, Long J, Hilmer S. A systematic review of the emerging definition of 'deprescribing' with network analysis: implications for future research and clinical practice. Br J Clin Pharmacol. 2015;80(6):1254-1268. 2. Peat G, Fylan B, Marques I, Raynor DK, Breen L, Olaniyan J, Alldred DP. Barriers and enablers of successful deprescribing as described by older patients with frailty, supporting peers and clinicians: A qualitative interview study. BMJ Open 2022. 12:e054279.

Access to healthcare is a basic human right and therefore every effort should be made to ensure it is available. Providing services in densely populated urban areas improves coverage in health delivery but also provides greater traction with respect to population health agendas. However, locating healthcare services in urban areas is not without its challenges. This chapter will focus on developments in the health sector with specific consideration of the challenges urban location presents to health logistics and proposes possible solutions.

Objectives: In China there is a cultural expectation ( Xiao, 孝 ‐ filial piety) that offspring should provide care for their parents. However, the sustainability of this is threatened by the impact of the One ‐ Child Policy (OCP) (1979–2015), which has resulted in a diminution in numbers of children available to care, rapid urbanisation and increase in the number of women in employment. In this context, the objective was to explore the motivations, meaning, and preparedness for future caregiving of offspring affected by the OCP. Design and Methods: We adopted a constructivist position using a hermeneutic phenomenology approach and interviewed eight current and prospective caregivers aged 20–35 years about future caregiving responsibilities. Data were obtained through in ‐ depth interviews, analysed using reflective Thematic Analysis. Results and conclusion(s): Three prominent themes: (i) Caregiving beliefs, (ii) Caregiving conditions and (iii) Contextual factors were identified under an over-arching theme “Competing pressures ‐ meanings, motivation and preparedness”. Despite the inherent stress, participants envisaged providing or organising care in the future to fulfil Xiao, and most viewed long ‐ term care settings as unviable. Ul-timately, the findings suggested that the actual performance of caregiving would not always measure up to ideal expectations, resulting in ‘filial discrepancy’ that is, a gap between societal expectations for caregiving to older relatives and actual caregiving performance. This could adversely impact the caregivers and quality of care provided. The findings highlighted the urgent need to develop culturally attuned services, including education and training for family caregivers, health and social care professionals

Objectives (1) Present deprescribing experiences of patients living with frailty, their informal carers and healthcare professionals; (2) interpret whether their experiences are reflective of person-centred/collaborative care; (3) complement our findings with existing evidence to present a model for person-centred deprescribing for patients living with frailty, based on a previous collaborative care model. Methods Qualitative design in English primary care (general practice). Semi-structured interviews were undertaken immediately post-deprescribing and 5/6 weeks later with nine patients aged 65+ living with frailty and three informal carers of patients living with frailty. Fourteen primary care professionals with experience in deprescribing were also interviewed. In total, 38 interviews were conducted. A two-staged approach to data analysis was undertaken. Key findings Three themes were developed: attitudes, beliefs and understanding of medicines management and responsibility; attributes of a collaborative, person-centred deprescribing consultation; organisational factors to support person-centred deprescribing. Based on these findings and complementary to existing evidence, we offer a model for person-centred deprescribing for patients living with frailty. Conclusions Previous models of deprescribing for patients living with frailty while, of value, do not consider the contextual factors that govern the implementation and success of models in practice. In this paper, we propose a novel person-centred model for deprescribing for people living with frailty, based on our own empirical findings, and the wider evidence base.

PurposeThe 999 ambulance call handler is critical in responding to emergency patient treatment; however, the call handlers are often a hidden component of the healthcare workforce and an under-researched group. The objective of this study is to understand stress triggers experienced by 999 ambulance call handlers that could lead to burnout and examine personal and organisational mechanisms and strategies which reduced the risk of burnout.Design/methodology/approachA single interview case study approach applying qualitative methods was undertaken. Participants were identified through a purposive sample of 999 ambulance call handlers with the Yorkshire Ambulance Service National Health Service Trust (UK). Participants were interviewed via telephone between July 2019 and September 2019.FindingsIn total, 18 staff participated in this study. Societal factors including public incivility and media representation and organisational factors, such as a demanding environment, lack of appreciation and career progression, training issues and protocols were key stressors. Organisational well-being services were helpful for some, but for others lacked accessibility and appropriateness. Positive public feedback and speaking with peers bolstered well-being. 999 ambulance call handlers suggested that sufficient breaks, co-design or feeding back on training and protocols and creating more informal opportunities to discuss ongoing everyday stressors as methods to reduce stress and burnout.Originality/valueThis paper explores a previously under researched area on stressors and potential burnout in 999 call handlers. This paper highlights the need for improved organisational support services and appropriate public and sector peer recognition of the role of ambulance 999 ambulance call handlers.