Chinese General Practice Journal 1 (2024) 18–26

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Chinese General Practice Journal

journal homepage: https://www.keaipublishing.com/en/journals/chinese-general-practice-journal/

Current situation of pharmacy services in community health centers and

the functioning of pharmacists in family doctor teams in Shanghai☆
Rui LIU 1, Yu CAO 2, Aiqun CHU 1, Huanyun WU 3,∗
1
Shanghai Bay Area High-tech Industrial Development Zone Community Health Service Center, Shanghai, China
2
School of Public Health, Fudan University, Shanghai, China
3
Shanghai Jinshan District Health Management Center, Shanghai, China

a " t i % l e i ( ) o a b , t " a % t

Keywords: Background: Currently, polypharmacy is common among residents at high risk of unsafe medication practices,
Pharmacy services;Community health partly due to a lack of medication reconciliation and comprehensive medication management. Pharmacy ser-
center;Family doctor team;Quantitative vices, facilitated by community health centers with regional advantages, align with their functional orientation.
study;Qualitative study
However, a signi-cant gap persists between the supply of pharmacy services in community health centers and
public demand.
Objective: To assess the current state of pharmacy services and the integration of pharmacists into family
doctor teams in Shanghai, as well as to identify the challenges faced by community pharmacists, with the goal
of providing recommendations for their development.
Methods: A combination of qualitative and quantitative approach was adopted. In December 2020, a strati-ed
sampling method was employed to survey 307 on-duty pharmacists with licensed pharmacist quali-cations from
29 community health centers, including 6 in the central urban areas, 8 in the inner and outer suburban areas,
and 15 in the outer suburban areas. The contents of the questionnaire covered basic information about the
pharmacists, the development of pharmacy services, and the participation of community pharmacists in the family
doctor team. Concurrently, a convenience sampling method was used to invite 29 key stakeholders, including
11 head of pharmacies, 6 family doctors, 12 community health center directors or health commission managers
from central urban areas, inner and outer suburban areas, and outer suburban areas, for semi-structured focus
interviews on pharmacy service demands, resources allocation, and service processes.
Results: The quantitative results indicated that the most community pharmacists attended 1-2 times of training
programs [139 (45.3 %)], with continuing education as the main form of training [252 (82.1 %)]. The most com-
mon pharmacy service activities were prescription dispensing [284 (92.5 %)], prescription review [253 (82.4 %)],
and pharmacy window advice or outpatient consultation guidance [196 (63.8 %)]. The services consuming the
most pharmacist hours were prescription dispensing [280 (91.2 %)], prescription review [244 (79.5 %)], and pre-
scription feedback [145 (47.2 %)]. Only 78 (25.4 %) participants joined family doctor teams. Qualitative results
revealed a high demand for pharmacy services among older patients, alongside weak awareness of rational drug
use. Challenges included shortage of pharmacist workforce, need for enhanced professional quality, incomplete
community pharmacy drug lists, and need for more applying information technology. Furthermore, community
pharmacists are often undervalued, with services focusing narrowly on dispensing, insu.cient targeted training
on rational drug use, and limited functioning within family doctor teams.
Conclusion: Currently, the resources allocation and supply capacity of pharmacy services are inadequate to
meet resident demands, and the pharmacy service process requires improvement and optimization. The impact
of pharmacists who have joined family doctor teams is limited. Therefore, it is necessary to enhance incentive
mechanism, clarify service content and improve the service model.

☆
The Chinese version of this paper was published in Chinese General Practice on [2024-01-03] (DOI:10.12114/j.issn.1007-9572.2022.0863). The current English
paper is a compliant secondary publication by Chinese General Practice Journal after obtaining copyright permission from both the authors and Chinese General
Practice.
∗
Corresponding author.
E-mail address: 1105791129@qq.com (H. WU).

https://doi.org/10.1016/j.cgpj.2024.03.001
Received 3 January 2024; Received in revised form 29 January 2024; Accepted 3 March 2024
Available online 13 May 2024
2950-5593/© 2024 Chinese General Practice Publishing House Co., Ltd. Publishing services by Elsevier B.V. on behalf of KeAi Communications Co. Ltd. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)
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R. LIU, Y. CAO, A. CHU et al. Chinese General Practice Journal 1 (2024) 18–26

Introduction pharmacy services, and collaborative participation within family doc-

tor systems. The construct validity of the questionnaire was thoroughly
Primary care is pivotal to medical and public health infrastructure in evaluated and validated by a panel of postgraduate mentors and experts.
China, serving as the cornerstone of a three-tiered medical system and A preliminary assessment among a group of pharmacists yielded a Cron-
the -rst line in tiered medical treatment. Central to these e/orts, the bach’s alpha coe.cient of 0.850, indicating robust internal consistency.
“Healthy China 2030” initiative underscores the importance of strength- With the support of district health commission and the quality control
ening primary care, advocating for reforms and innovations that bolster supervised by postgraduate students, the survey was distributed using
primary care facilities as key provider of public health.1 In this con- “Wenjuanxing”. It received responses from 64 central urban, 108 inner
text, medication emerges as a critical approach of disease prevention and outer suburban, and 135 outer suburban pharmacists.
and treatment, particularly as shifting disease spectrum and an aging Building on an extensive review of relevant literature, consultations
population lead to increased demand and risk of medication.2 Unsafe with experts, and insights from preliminary survey results, the research
medication is common due to the lack of medication reconciliation and team developed interview guides.
comprehensive medication review by pharmacists. This gap highlights The interview guides include: (1) What is the current status of ratio-
the urgent need for innovative approaches to medication reconciliation nal drug use among the community people? (2) What are the contents
and standardized medication management, tailored to the realities of of pharmacy services in the community health center at present? Can
community health service. Shanghai’s pioneering family doctor system they meet the needs of the community people? (3) What systems or
o/ers a promising model, demonstrating how integrated pharmacy ser- standards are in place for pharmacy services in your setting? Are there
vices within contracted family doctor services can meet speci-c health any procedures and work standards for pharmacy services? Is there any
care needs e/ectively, signaling a step towards optimizing pharmacy assessment process and incentive approach for pharmacy services? (4)
services delivery. This study examines the integration of pharmacy ser- What is the situation of pharmacist working with the family doctor team
vices within Shanghai’s community health centers and their alignment members? Is there a clear path, authority and responsibility? (5) What
with the family doctor service. By evaluating the current landscape of are the challenges of pharmacy service, informatic process, service pro-
pharmacy services of community health centers and their potential for cess and system construction? (6) Your suggestions for improving the ca-
synergy with family doctor services, the current study aim to contribute pacity of pharmacy services. Employing a semi-structured focus group
to the evolution of pharmacy services in contexts of family doctor ini- approach, interviews were conducted by graduate students of the re-
tiative. search team, who adeptly adjusted the 0ow and depth of questioning
in response to emerging themes and speci-c situational dynamics, en-
Methods suring a comprehensive exploration of relevant issues.4 Consent was
obtained prior to recording these discussions, with strict anonymization
Study subjects procedures applied to all participant information. Y1-Y11 were used to
replace the head of pharmacy, J1-J6 were used to replace the family
A strati-ed sampling method was employed to explore the integra- doctors, and G1∼G12 were used to replace the community health cen-
tion of pharmacy services within Shanghai’s family doctor system, re- ter directors or health commission managers. Following transcription,
0ecting the city’s diverse economic levels and geographical distribution. the discussions were independently coded by dual researchers, using
In December 2020, Shanghai’s 16 districts were categorized into three NVivo 12 for data organization and thematic framework analysis for
groups — central urban, inner and outer suburban, and outer subur- interpretive depth. This analysis was further enriched by applying the
ban—based on their economic status and proximity to the city center.3 Macro Model of Health System framework, facilitating the theoretical
A total of 29 community health centers were selected for the study: six contextualization of -ndings.
from central urban districts (Xuhui, Jing’an, Yangpu), eight from in-
ner and outer suburban districts (Minhang, Baoshan, Jiading, Pudong), Statistical analysis
and -fteen from outer suburban districts (Jinshan, Songjiang, Qingpu).
A comprehensive survey was conducted involving 307 pharmacists, all For quantitative section, data were extracted from “Wenjuanxing,”
holding pharmacist quali-cations, across these centers to assess the cur- then cleaned and systematically organized using Microsoft Excel 2016.
rent state of pharmacy services. Additionally, focus group interviews Statistical analyses were performed employing SPSS 22.0. Categori-
were conducted with 29 key informants from the three groups of dis- cal variables were described using frequencies and percentages. Group
tricts. These informants included 11 head of pharmacy, 6 family doc- comparisons were conducted using chi-squared tests or Fisher’s ex-
tors, 12 community health center directors and health committee man- act test, with a P value of less than 0.05 considered statistically
agers, selected through convenience sampling. Participation in the study signi-cant.
provided informed consent. Individuals unwilling or unable to provide For qualitative section, the conducting the interviews, the record-
consent were excluded from the study, ensuring ethical compliance and ings were meticulously transcribed, and the resulting text was indepen-
the integrity of the research -ndings. dently coded by two researchers. Any discrepancies in coding were thor-
oughly discussed until consensus was reached. The qualitative data anal-
Study methods ysis software NVivo 12(NVivo 12, QSR International Pty Ltd.) was used
to facilitate the coding and thematic analysis processes, enabling the
This study employed a combination of qualitative and quantitative systematic organization of data into distinct themes and sub-themes.5-6
research methods. Quantitative research was primarily conducted to col- This approach was crucial in identifying signi-cant concepts, all framed
lect basic information of the pharmacists, the contents of pharmacy ser- within the Macro Model of Health System.7
vices, and the role of pharmacists within family doctor teams. This ap-
proach aimed to comprehensively understand the current state of phar- Results
macy services. On the other hand, qualitative research explored chal-
lenges faced by pharmacy services surrounding pharmacy services de- Basic information of pharmacists
mands, resources allocation, and the operational processes.
Following a comprehensive review of existing literature and -eld In the survey of 307 pharmacists, 238 (77.5 %) of them are female,
investigations, the “Pharmacist Survey Questionnaire” was developed. and 156 (50.8 %) of them in the age range of 30 to 39 years. The ma-
This tool covers a wide range of variables, including demographic and jority, 230 (74.9 %), held a bachelor’s degree, and 253 (82.4 %) were
socioeconomic pro-les, professional training, the implementation of specialized in the -eld of pharmacy. Among these, 139 (45.3 %) held

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R. LIU, Y. CAO, A. CHU et al. Chinese General Practice Journal 1 (2024) 18–26

Table 1
Comparison of the basic situation of 307 community pharmacists in di/erent urban areas

Inner and outer

Central urban suburban areas Outer suburban
Project areas (n=64) (n=108) areas (n=108) 𝜒 2 value P value

Gender 1.701 0.427

Male 17 (26.6) 20 (18.5) 32 (23.7)
Female 47 (73.4) 88 (81.5) 103 (76.3)
Age (Years) 14.344 0.026
20-29 3 (4.7) 21 (19.4) 28 (20.7)
30-39 41 (64.1) 58 (53.7) 57 (42.2)
40-49 14 (21.9) 23 (21.3) 35 (25.9)
50-59 6 (9.4) 6 (5.6) 15 (11.1)
Education level
Secondary school and below 0 2 (1.9) 5 (3.7)
College degree 13 (20.3) 25 (23.2) 30 (22.2)
Bachelor’s degree 51 (79.7) 80 (74.1) 99 (73.3)
Master’s degree and above 0 1 (0.9) 1 (0.7)
Specialty 14.707a 0.150
Pharmacy 57 (89.1) 88 (81.5) 108 (80.0)
Clinical Pharmacy 0 1 (0.9) 1 (0.7)
Traditional Chinese Medicine 4 (6.3) 12 (11.1) 14 (10.4)
Pharmacy administration 2 (3.1) 1 (0.9) 3 (2.2)
Pharmaceutical preparations 0 0 7 (5.2)
Pharmaceutical analysis 0 2 (1.9) 0
Other 1 (1.6) 4 (3.7) 2 (1.5)
Professional title 6.981a 0.527
Pharmacy Technician 5 (7.8) 16 (14.8) 22 (16.3)
Pharmacist 29 (45.3) 51 (47.2) 59 (43.7)
Supervisory Pharmacist 26 (40.6) 39 (36.1) 45 (33.3)
Deputy Chief Pharmacist 2 (3.1) 1 (0.9) 3 (2.2)
Other 2 (3.1) 1 (0.9) 6 (4.4)
Years of Experience in Pharmacy (years) 16.768 0.010
1-5 4 (6.3) 16 (14.8) 22 (16.3)
6-10 17 (26.6) 26 (24.1) 35 (25.9)
11-19 33 (51.6) 49 (45.4) 39 (28.9)
≥ 20 10 (15.6) 17 (15.7) 39 (28.9)
Number of Trainings (times)
0 10 (15.6) 22 (20.4) 43 (31.8)
1-2 28 (43.7) 50 (46.3) 61 (45.2)
3-4 16 (25.0) 20 (18.5) 21 (15.6)
5-6 2 (3.1) 6 (5.6) 5 (3.7)
>6 8 (12.5) 10 (9.3) 5 (3.7)
Training Format b
Continuing education courses 56 (87.5) 86 (79.6) 110 (81.5) 1.752 0.416
Pairing assistance with superior hospitals 28 (43.8) 48 (44.4) 84 (62.2) 9.867 0.007
Self-organized training 28 (43.8) 48 (44.4) 44 (32.6) 4.278 0.118
Further study 18 (28.1) 40 (37.0) 49 (36.3) 1.627 0.443
Other 0 3 (2.8) 1 (0.7) 3.003 0.223
Obtained quali-cation of Shanghai community clinical pharmacist 0.672 0.715
Yes 17 (26.6) 28 (25.9) 41 (30.4)
No 47 (73.4) 80 (74.1) 94 (69.6)

Note:
a
indicates the use of Fisher’s exact probability method;
b
indicates a multiple-choice question; due to rounding of -gures, the sum of some proportional compositions is not exactly 100.0 %.

the professional title of pharmacist. A segment of 121 (39.4 %) reported Process of pharmacy services
working in the pharmacy for a period of 11 to 19 years, with a sim-
ilar proportion (45.3 %) one to two training programs. The training The three most commonly provided services were prescription dis-
modalities included continuing education courses, with 252 individ- pensing, reported by 284 participants (92.5 %), prescription review by
uals (82.1 %) participating, mentorship programs facilitated by supe- 253 participants (82.4 %), and guidance through pharmacy window ad-
rior hospitals [160 participants (52.1 %)], self-directed training e/orts vice or outpatient consultation guidance by 196 participants (63.8 %).
[120 participants (39.1 %)], and advanced studies [107 participants Correspondingly, the activities that occupied the majority of pharma-
(34.9 %)]. Notably, 86 pharmacists (28.0 %) had obtained the quali- cists’ time were prescription dispensing, with 280 participants (91.2 %)
-cation of Shanghai community clinical pharmacist. Statistical analysis dedicating signi-cant time to this service, followed by prescription re-
revealed signi-cant di/erences (P<0.05) among pharmacists from dif- view at 244 participants (79.5 %), and providing prescription feedback
ferent urban areas in terms of age, years of pharmacy practice, and par- at 145 participants (47.2 %). It was observed that the engagement in
ticipation rates in the training form of mentorship programs facilitated other services did not exceed 25.0 %. The predominant method for
by superior hospitals, as detailed in Table 1. delivering pharmacy services was through consultation windows, as

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R. LIU, Y. CAO, A. CHU et al. Chinese General Practice Journal 1 (2024) 18–26

Table 2
Comparison of the implementation of pharmacy services in di/erent urban areas

Central Inner and outer

Total urban areas suburban areas Outer suburban 𝜒2
Project (n=307) (n=64) (n=108) areas (n=108) valueb P Value

Pharmacy services
Prescription dispensing 284 (92.5) 61 (95.3) 102 (94.4) 121 (89.6) 2.924 0.232
Prescription review 253 (82.4) 53 (82.8) 92 (85.2) 108 (80.0) 1.122 0..571
Prescription comment 163 (53.1) 38 (59.4) 52 (48.1) 73 (54.1) 2.127 0.345
Medication reconciliation 35 (11.4) 11 (17.2) 10 (9.3) 14 (10.4) 2.754 0.252
Adverse reaction reporting 133 (43.3) 30 (46.9) 47 (43.5) 56 (41.5) 0.517 0.772
Pharmacy ward rounds 41 (13.4) 4 (6.3) 15 (13.9) 22 (16.3) 3.828 0.147
Discharge medication guidance 34 (11.1) 12 (18.8) 11 (10.2) 11 (8.1) 5.089 0.079
Pharmacy window advice or outpatient consultation 196 (63.8) 46 (71.9) 70 (64.8) 80 (59.3) 3.062 0.216
guidance
Medication knowledge consultation or training 113 (36.8) 32 (50.0) 42 (38.9) 39 (28.9) 8.629 0.013
Education on rational drug use 146 (47.6) 4 (6.3) 7 (6.5) 4 (3.0) 1.922 0.382
Patient Medication follow-up 40 (13.0) 4 (6.3) 11 (10.2) 20 (14.8) 3.397 0.183
Other 2 (0.7) 0 3 (2.8) 7 (5.2) 3.491a 0.148
Top 3 services by duration 4 (6.3) 1 (0.9) 0 8.112a 0.003
Prescription dispensing 280 (91.2) 15 (23.4) 24 (22.2) 24 (17.8) 1.148 0.563
Prescription review 244 (79.5) 2 (3.1) 5 (4.6) 5 (3.7) 0.299a 0.931
Prescription comment 145 (47.2) 2 (3.1) 5 (4.6) 10 (7.4) 1.785 0.410
Medication reconciliation 15 (4.9) 0 1 (0.9) 2 (1.5) 0.755a 0.999
Adverse reaction reporting 35 (11.4) 1 (1.6) 1 (0.9) 0 2.218a 0.313
Pharmacy ward rounds 10 (3.3) 61 (95.3) 105 (97.2) 130 (96.3) 0.603a 0.732
Discharge medication guidance 5 (1.6) 31 (48.4) 53 (49.1) 71 (52.6) 0.444 0.832
Pharmacy window advice or outpatient consultation 63 (20.5) 14 (21.9) 30 (27.8) 41 (30.4) 1.566 0.457
guidance
Medication knowledge consultation or training 12 (3.9) 23 (35.9) 36 (33.3) 50 (37.0) 0.366 0.833
Education on rational drug use 17 (5.5) 13 (20.3) 18 (16.7) 28 (20.7) 0.704 0.703
Patient medication follow-up 3 (1.0) 30 (46.9) 51 (47.2) 59 (43.7) 0.352 0.839
Other 2 (0.7) 31 (48.4) 49 (45.4) 56 (41.5) 0.929 0.629
Service delivery method 29 (45.3) 50 (46.3) 55 (40.7) 0.844 0.656
Consultation counter 296 (96.4) 0 1 (0.9) 0 1.854a 0.560
Pharmacy clinic 155 (50.5) 4 (6.3) 7 (6.5) 4 (3.0) 1.922 0.382
Online platform(WeChat and other social platforms, 85 (27.7) 4 (6.3) 11 (10.2) 20 (14.8) 3.397 0.183
consultation website)
WeChat o.cial account 109 (35.5) 0 3 (2.8) 7 (5.2) 3.491a 0.148
Pharmacy APP 59 (19.2) 4 (6.3) 1 (0.9) 0 8.112a 0.003
Educational lectures 140 (45.6) 15 (23.4) 24 (22.2) 24 (17.8) 1.148 0.563
Medication information 136 (44.3) 2 (3.1) 5 (4.6) 5 (3.7) 0.299a 0.931
booklet
Telephone consultation 134 (43.6) 2 (3.1) 5 (4.6) 10 (7.4) 1.785 0.410
Other 1 (0.3) 0 1 (0.9) 2 (1.5) 0.755a 0.999

Note:
a
indicates the use of Fisher’s exact probability method;
b
represents the statistical analysis results comparing the provision of pharmacy services across di/erent urban areas; all options in the table are multiple-choice
questions.

indicated by 296 participants (96.4 %), with pharmacy outpatient ser- resident service demands, pharmacy resources allocation, and the oper-
vices being used by 155 participants (50.5 %). Statistical analysis re- ational processes of pharmacy services.
vealed signi-cant di/erences (P<0.05) across urban areas regarding the Theme 1: Demands of Community Residents for Pharmacy Services
provision of “medical sta/ medication knowledge consultation or train- Interviews revealed a signi-cant prevalence of multimorbidity
ing” and the top three time-consuming services, including “medication among the elderly, often leading to polypharmacy. One participant (Y4)
guidance upon discharge,” as detailed in Table 2. pointed out “Community hospital regulations limit prescriptions to a
maximum of -ve medications. This restriction does not align with the
reality faced by elderly patients with multiple chronic conditions, who
Participation of pharmacists in family doctor team works
must visit the clinic multiple times in a short period to secure all nec-
essary medications. Consequently, it’s not uncommon for some elderly
Among the participants, 78 (25.4 %) were members of family doc-
individuals to be taking more than ten di/erent medications simultane-
tor teams. The predominant activities within these roles included ratio-
ously.” The problem is exacerbated by the overuse of auxiliary medica-
nal medication education, engaged by 69 participants (88.5 %), patient
tions, redundancy in prescribed medications, and misconceptions about
medication guidance and consultation, by 68 participants (87.2 %), and
health supplements.
medication follow-up, with 36 participants (46.2 %) participating in this
Participant J1 noted “Many elderly individuals place excessive trust
activity, as detailed in Table 3.
in traditional Chinese medicine (TCM), resulting in the overconsump-
tion of various TCM preparations.” Another participant, G4, highlighted
Results of interview study that “When a patient goes to see a cardiologist, the doctor prescribes
him a medicine that invigorates blood circulation and removes blood
From the interviews, three principal themes, encompassing eleven stasis; when he has a cerebral infarction, the neurologist prescribes him
sub-themes, were discerned, revealing eleven critical issues confronting another medicine that invigorates blood circulation and removes blood
pharmacy services. These issues were categorized under the domains of stasis; when he goes to see an orthopaedic surgeon because of pain in

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R. LIU, Y. CAO, A. CHU et al. Chinese General Practice Journal 1 (2024) 18–26

Table 3
Comparison of the participation of community pharmacists in family doctor teams in di/erent urban areas

Central Inner and outer Outer suburban

Project Total urban areas suburban areas areas 𝜒 2 valuec P Value

Participation in family doctor team 3.786 0.151

Yes 78 (25.4) 16 (25.0) 21 (19.4) 41 (30.4)
No 229 (74.6) 48 (75.0) 87 (80.6) 94 (69.6)
Services provided in the family doctor teamb
Rational medication education 69 (88.5) 16 (100.0) 20 (95.2) 33 (80.5) 4.734a 0.081
Patient medication guidance and consultation 68 (87.2) 15 (93.8) 17 (81.0) 36 (87.8) 1.261a 0.491
Medication follow-up 36 (46.2) 4 (25.0) 10 (47.6) 22 (53.7) 3.828 0.147
Medication reconciliation 8 (10.3) 1 (6.3) 2 (9.5) 5 (12.2) 0.384a 0.891
Establishment of personal 14 (17.9) 1 (6.3) 6 (28.6) 7 (17.1) 2.901a 0.198
medication records
Providing medication consultation for medical sta/ 32 (41.0) 7 (43.8) 7 (33.3) 18 (43.9) 0.703 0.704
Provide medication knowledge training to medical 17 (21.8) 3 (18.8) 6 (28.6) 8 (19.5) 0.835a 0.759
sta/
Note:
a
indicates the use of Fisher’s exact probability method;
b
indicates a multiple-choice question, aimed at those participating in the family doctor team;
c
represents the statistical analysis results comparing the participation of community pharmacists in family doctor teams across di/erent urban areas.

the bones and so on, the orthopaedic surgeon prescribes him another establishment within the community is limited, forcing us to hire phar-
medicine that invigorates blood circulation and removes blood stasis, macists outside the traditional framework.” Y1 observed, “Our commu-
which results in the combined use of a number of medicines with simi- nity’s pharmaceutical team, consisting of just three to four pharmacists,
lar medicinal properties, and some of the ingredients are even the same.” falls well below the number needed for integration into the family doc-
Participant G7 added that “The widespread consumption of health sup- tor team. A minimum of ten professionals is considered necessary.” Y2
plements among the elderly, some of which contain active medicinal added, “Although our community has ten pharmacists, a number that
ingredients that can negatively impact conditions like diabetes by af- seems adequate, it only su.ces for outpatient medication dispensing.
fecting blood glucose control.” There is no spare capacity for dedicated clinical pharmacy roles, which
The interviews also revealed a noticeable de-ciency in the elderly’s are performed on an ad hoc basis. Furthermore, some suburban clinics,
understanding of the rational use of drug and a notable inadequacy despite a high volume of outpatient visits, lack specialized pharmacists.”
in adhering to medical advice, highlighting a disconnect in patient en- G3 mentioned, “The scarcity of pharmaceutical experts is particularly se-
gagement with pharmacy services. Participant G4 noted that “There is vere in village clinics, many of which depend entirely on rural doctors.”
a general lack of public awareness about the importance of pharmacy The pro-ciency and range of services provided by community phar-
services, with patients often relying on hearsay for medication informa- macists currently do not meet healthcare demands e/ectively. This de-
tion and neglecting doctors’ recommendations, either for selecting or -ciency is attributed to systemic de-ciencies in professional training
avoiding certain medications. This behavior indicates a broader issue and limited clinical exposure, impacting their ability to support diag-
of patients not actively seeking professional pharmacy services. Partic- nostic and therapeutic decision adequately. Participant Y3 noted that
ipant G5 highlighted that “In clinical practice, patients request speci-c “there is a absence of systematic training that compromises their ca-
medications based on recommendations from specialists in major hos- pability to evaluate the appropriateness of diagnoses and medication
pitals, without engaging in open discussions about their conditions or plans. This gap highlights the pressing need for improved professional
treatment alternatives“. This presents a challenge for general practition- development programs that equip pharmacists with the comprehensive
ers in managing patient expectations and promoting the rational use of knowledge necessary for e/ective participation in patient care teams.”
drugs. Additionally, Participant G3 added that “I often come across this Similarly, Participant Y4 discussed that “the limited roles of pharma-
situation, that is, whoever is taking this medicine is very good, I have cists, mainly restricted to documenting adverse drug reactions, without
to dispense this medicine, that is, to buy this medicine.” Issues with involvement in broader medication management or patient counseling.
medication adherence were also highlighted, with Participant J2 not- This constrained role not only limits pharmacists’ potential impact on
ing that “Although some contracted patients e/ectively manage their patient outcomes but also points to a wider issue of pharmacy profes-
medication regimes, certain elderly population either discontinues their sionals being underutilized in healthcare settings.”
medication prematurely or modi-es prescribed dosages independently, “The challenges are exacerbated by the limited clinical exposure ex-
lacking medical supervision. “There is a prevalent disregard among the perienced by pharmacists in primary care,” as noted by Participant Y7,
elderly for proper medication storage practices and attention to expi- “which restricts their opportunity to gain diverse clinical experience.
ration dates”, as Participant G7 mentioned. “this negligence can lead This limitation is particularly pronounced in comparison to their coun-
to deterioration and failure of some medications due to lack of proper terparts in larger hospitals, underscoring a disparity in learning oppor-
storage, and the elderly will take them out next time, creating a safety tunities across di/erent healthcare settings.” Participant G8 noted that
hazard”. “At present, I personally feel that it is still di.cult to meet the needs of
the residents according to the professional ability of the pharmacy team
Theme 2: Resources allocated to pharmacy services in our center.”
Participant G9 added that “The fundamental problem is that there
Directors from various community health centers and heads of phar- is a mismatch between the medication advice provided by pharmacists
macy have expressed concerns about insu.cient sta.ng levels and a and the medication advice needed by doctors.
notable shortage of pharmacist workforce. One participant, designated What the pharmacist provides is only his advice on medicines, not
as G7, emphasized, “Sta.ng within the community health center de- on the diagnostic plan for the disease, which cannot meet the needs of
pends on the composition of the family doctor team, with assistants not general practitioners and patients. What the GP needs is a medication
exceeding 30 % of the total team composition. This limit constrains op- plan based on a holistic view of the patient’s condition, not a single drug
portunities for pharmacist involvement.” G2 noted, “The capacity for e/ect.”

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R. LIU, Y. CAO, A. CHU et al. Chinese General Practice Journal 1 (2024) 18–26

The lack of a coherent incentive mechanism signi-cantly a/ects the pharmacists’ own misconceptions about their roles, leading to physi-
motivation and performance of medical and pharmaceutical sta/ in cians frequently providing medication guidance. This dynamic dimin-
community health centers. Despite the critical role of pharmacists in ishes the pharmacist’s role, with patients preferring to consult their
healthcare delivery, current reimbursement models fail to adequately family doctors for medication advice, thereby further eroding pharma-
re0ect their workload and contributions, lacking a direct correlation be- cists’ positions as medication management experts. Participant G6 high-
tween e/ort and remuneration. lighted that “Patients primarily view pharmacists as dispensers, rarely
Participant G12 described that “The challenges faced by pharmacists seeking their advice for medication reconciliation or guidance and typi-
in community health centers included low status, insu.cient pay, and cally inquiring about dosage and administration.” Participant Y11 added
unstandardized workloads, which are not considered in performance- that “Despite common occurrences of medication repetition among pa-
based salary structures. This situation has been exacerbated by the tients, e/orts by pharmacists to o/er guidance are often met with skep-
elimination of drug markups—a previous source of income for pharma- ticism, with patients showing a pronounced preference for doctors’ ad-
cists—without introducing alternative reimbursement models like phar- vice, indicating a higher level of trust and compliance with physicians.”
macy service fees.” Participant Y9 emphasized that “Although a portion Participant J5 noted that “Family doctors typically do not consult phar-
of the overall performance pool is allocated to pharmacists, the distri- macists, relegating them to tasks such as dispensing medications and
bution does not directly relate to their individual contributions, leaving reviewing prescriptions.”
reimbursement largely at the discretion of each community health cen- “We don’t have such a barrier in our current process necessarily to
ter.” be pharmacist validation. The doctor has prescribed the drug, and you
The selection of medications available in community pharmacy cat- have to go to the pharmacist and ask to go and look at it and scrutinize
alogs is notably limited, primarily to essential drugs. Participant G12 it, and if the patient doesn’t accept it, the doctor doesn’t accept it. So
elucidated that “Due to policy-driven constraints, such as health insur- the most critical thing is that the pharmacist has no authority, and the
ance bulk purchasing agreements, which limit the availability of certain clinical pharmacist says that this drug is not reasonable, how should
medications crucial for comprehensive disease management and adher- it be adjusted? Both the doctors and patients don’t accept it. This situa-
ence to rational medication using principles.” Participant G7 added that tion is very common.” as pointed out by Participant G4. Participant G11
“Regulatory standards require that basic medications constitute no less commented that “The routine nature of pharmacists’ reviews stricts on
than 90 % of total drug use within community settings, thereby nar- prescription standardization, often do not adequately address the ratio-
rowing the scope for non-essential drug provision. Although community nal use of drugs.”
health centers are authorized to expand their drug lists and o/er ex- The pharmacy sta/ in primary care settings primarily focus on dis-
tended prescription services through family doctors, these e/orts often pensing medications, which limits their capacity to actively engage in
do not meet the community’s healthcare needs adequately.” Participant promoting the rational use of drugs. Despite some initiatives aimed at
G9 shared that “Despite augmenting their drug catalog with over 120 ad- enhancing medication use, participating in pharmacy rounds, and of-
ditional medications beyond an initial list of 250, their center still faces fering medication guidance, these e/orts remain inadequate. Partic-
challenges in meeting patient demand.” Participant G11 noted that “The ipant G7 emphasized that “The proactive exploration of service de-
current drug procurement and distribution system further impedes med- livery modi-cations and the promotion of direct pharmacist-patient
ication accessibility, with cataloged drugs frequently unavailable or out interactions includes pharmacists conducting educational sessions on
of stock, leaving little to no alternatives for patient care.” Participant medication knowledge within the community and establishing phar-
G6 emphasized that “A consistent drug supply is essential to protect the macy clinics adjacent to family doctors’ o.ces.” However, Participant
continuity of medication for the elderly, because the elderly who recog- G5 noted that, “Despite ful-lling the mandates of the health commis-
nize a drug, if then change it, they will be .dissatis-ed.” sion, such as providing pharmacy services, conducting prescription re-
The application of information technology (IT) in healthcare, par- views, and operating pharmacy clinics, the outcomes have been sub-
ticularly through pre-prescription reviews, prescription feedback, and optimal. The e/orts toward rational medication use often fall short
monitoring for rational drug use, has increasingly supported physicians of addressing the practical needs, serving mainly to satisfy assessment
in prescribing medications judiciously. As Participant G3 explained, criteria.”
“This year, we introduced a system for the comprehensive pre-review Participant G9 highlighted that, “The disparity in commitment be-
of prescriptions for both traditional Chinese and Western medicines. tween full-time clinical physicians in large hospitals and part-time com-
This system has been e/ective in timely identifying and intervening munity clinical pharmacists, who also handle dispensing duties and clin-
against irrational prescriptions, thereby improving the overall quali- ical pharmacy service assessments. This split focus hinders their ability
-cation rates of prescriptions. Additionally, the use of a prescription to devote adequate attention to clinical pharmacy, limiting their activi-
feedback platform for monthly prescription reviews has signi-cantly im- ties to basic assessment compliance without realizing the full potential
proved the quality of these reviews, providing a solid foundation for the of pharmacy services. The predominant activities in the community in-
rational use of drug in our center. However, the e/ectiveness of these IT volve dispensing at the window and reviewing prescriptions, with min-
interventions is limited by their lack of compulsory enforcement capabil- imal additional involvement.” Participant Y10 expressed that “We also
ities and the relatively low level of intelligence in monitoring, indicating have a clinical pharmacist assigned to us, but we can’t do the actual
areas for further improvement.” work. We are all part-time clinical pharmacists, and our main job is still
Participant G10 provides a critical perspective, stating, “We have a medication dispensing in the pharmacy.”
pre-prescription review system in place, but it has not been as e/ec- The increase in medication variety within community settings,
tive as anticipated. Despite being con-gured with certain criteria, the alongside the introduction of new pharmaceuticals, has exposed a criti-
system’s absence of a mandatory interception feature means it merely cal gap in the knowledge base of community health center sta/, partic-
alerts the doctor to potential issues without enforcing any corrective ularly in clinical pharmacy. This gap, attributed to limitations in sta/
measures. This allows doctors to neglect these alerts, continuing with educational backgrounds, underscoring an urgent need for targeted,
their intended prescriptions, thus reducing the system’s intended im- scienti-c training to e/ectively establish and develop pharmacy ser-
pact.” vices. Participant Y11 expressed that, “The inadequacy of knowledge re-
stricts professional performance to a basic level. There is a strong desire
Theme 3: The process of pharmacy services among these professionals to improve their skills through more special-
ized training, especially as the applicability of their textbook knowledge
In community health centers, the traditional role of pharmacists is over time. Participant Y10 noted that, “The professional training oppor-
often eclipsed by physicians, due to residents’ care-seeking habits and tunities for pharmacists are lacking, especially regarding new medica-

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tions for chronic diseases.” To address these challenges, Participant G12 of services, thereby directly linking the remuneration of primary care
mentioned that “Initiatives within ‘medical consortiums’ include phar- physicians to metrics of service volume, quality, and patient satisfac-
macists from secondary and tertiary hospitals provide essential training tion. Such strategic measures are expected to signi-cantly elevate phar-
on rational drug use, prescription review, and general medical and phar- macists’ involvement and initiative in providing proactive healthcare
maceutical guidance to community health center sta/.” services.11-13
The integration of pharmacists into family doctor teams within com- The survey reveals a concerning scenario regarding pharmacist train-
munity health centers appears to be limited by a notable scarcity of ing, with 45.3 % of pharmacists reporting only one to two training
pharmacy professionals. This shortage restricts the amount of time phar- programs per year, and 24.4 % having never received any pharmacy-
macists can allocate to working within these teams, consequently ham- speci-c training. This de-ciency is corroborated by interview feedback,
pering the depth and breadth of pharmacy services that can be o/ered. highlighting the absence of systematic training frameworks and gaps in
Participant J1 highlighted that “Family doctors want pharmacists to join professional expertise. Consequently, expanding and diversifying train-
the team, and in fact pharmacists should come to family doctors to pro- ing for community pharmacists to meet these identi-ed needs is es-
vide medication guidance.” Participant J3 pointed out that, “Despite sential. A future-oriented training strategy should include well-de-ned
blueprints, there aren’t enough people, the workload is too much, we goals, content, and trajectories, segmented into short, medium, and
have a total of three or four pharmacists and a team of eight family long-term plans, to support scienti-cally robust and e/ective profes-
doctors, which can not complete that workload.” Participant G3 further sional growth.14 Moreover, the establishment of ‘medical consortiums’
elucidated that “While each pharmacist is a.liated with multiple fam- (regional medical group) could signi-cantly bolster pharmaceutical sup-
ily doctor teams—sometimes two to three teams per pharmacist—the port. Establishing regional ’Pharmacy Service Alliances’ and introducing
ratio signi-cantly limits their capacity to contribute e/ectively.” Partic- a chief pharmacist system are proposed to promote integrated pharma-
ipant G5 added that, “At present, all the pharmacists in our center have ceutical management, ensuring a uni-ed and comprehensive approach
joined the family doctor team, but it is still worth exploring the role they to improving the quality and e.cacy of pharmacy services.15-17
play in the actual implementation of the work. Patients with medication Interviews with pharmacists reveal a pronounced underestimation of
problems de-nitely consult their family doctors, not pharmacists. their professional roles, predominantly relegating themselves to passive
service providers focused on prescription dispensing. This view contrasts
Discussion sharply with the expansive roles outlined by the World Health Organi-
zation and the International Pharmaceutical Federation in 2009, which
Our quantitative analysis reveals a sporadic engagement of phar- consider pharmacists as essential healthcare providers, decision-makers,
macists of community health centers in professional development, with and educators, among other roles.18-19 Transitioning towards a patient-
the majority (45.3 %) attending only 1 to 2 training sessions, predom- centered model requires a fundamental shift in pharmacists’ perception
inantly in continuing education (82.1 %). The core activities of these of their roles, moving beyond traditional dispensing to adapt to a ser-
pharmacists include prescription dispensing (92.5 %), medication re- vice model that includes professional medication guidance and active
view (82.4 %), and pharmacy window advice or outpatient consulta- participation in clinical medication management.20 Pharmacists are en-
tion guidance(63.8 %), indicating the bulk of their service provision. couraged to re-ne their service paradigms proactively and enhance their
Notably, a quarter (25.4 %) are integrated within family doctor teams. expertise, thereby establishing their authority in medication manage-
Qualitative insights highlight a signi-cant demand for pharmacy ser- ment and aligning with global standards. This transformation is crucial
vices among the elderly in communities, juxtaposed against a notable for integrating pharmacists more fully into the healthcare delivery sys-
de-ciencies in medication literacy, limitations in pharmacist numbers tem, enhancing patient care quality, and ensuring optimal medication
and expertise, gaps in medication availability at the community level, use.
and the marginal impact of digital tools in service enhancement. Addi- The landscape of pharmacy services of community health centers in
tional challenges include diminished recognition of pharmacists’ roles Shanghai is largely uniform, with a predominant focus on prescription
by both professionals and patients, a narrow scope of services, inad- dispensing. This narrow scope makes the services mostly transactional,
equate specialized training, and suboptimal integration within family as pharmacists report their main activities center around basic dispens-
doctor team. Internationally, the separation between prescription and ing tasks. This approach contrasts sharply with international models of
dispensing roles, primarily carried out by retail pharmacies, represents pharmacy service provision, where the standardization of pharmacy ser-
a progressive trend. The International Pharmaceutical Federation’s 2012 vices is common practice.21 Examples include the UK’s universal health
report highlights that, on average, 55 % of pharmacists globally are em- coverage framework and the highly privatized healthcare system in the
ployed in community settings.8 In contrast, China shows a lower propen- US, both of which support standardized pharmacy services in primary
sity towards this professional distinction, with research by Yu Cuiting care.22-23 Although “Standards for Pharmacy Services in Medical Insti-
indicating a predominant dependence on public medical institutions for tutions”24 and “Expert Consensus on Standards and Pathways for Family
pharmacy services, thus marginalizing community pharmacies as the Pharmacist Services”25 exist, these guidelines are lacking in speci-city
principal service providers.9 This analysis advocates for a strategic en- and enforceability, especially within the context of community health
hancement of community pharmacists’ service delivery capacities and centers. This gap underscores the urgent need for the development of
their integration into family doctor teams as essential measures to meet uni-ed, enforceable standards tailored to Shanghai’s unique healthcare
the growing demand for pharmacy services, especially within the con- landscape. Such standards should cover a broad spectrum of pharmacy
text of China’s unique healthcare landscape. service projects, providing clear content and operational guidelines that
Qualitative -ndings highlight a pronounced de-cit in pharmacists match the real service needs and conditions of the community. The cre-
in Shanghai, limiting diversity of pharmacy services available. An in- ation of these standards is a critical step toward improving the qual-
crease in pharmacist sta.ng is essential, facilitating a shift towards ity and breadth of pharmacy services, enabling pharmacists to make
more comprehensive service o/erings beyond traditional dispensing a more signi-cant contribution to the healthcare system beyond tra-
roles. Currently, Shanghai lacks clear guidelines for the -nancial in- ditional dispensing roles. By aligning pharmacy services with interna-
centive of pharmacy service projects, a de-ciency that signi-cantly af- tional best practices through targeted regulatory reforms, Shanghai can
fects healthcare professionals’ motivation.10 Informed by the regulatory move towards a more integrated, patient-centered model of pharmacy
frameworks and incentive mechanisms used in Europe, America, and services.
Japan, it is advisable for Shanghai’s health authorities develop and im- Using the Pharmacy Service Alliance to establish regional pharmacy
plement standardized payment models for pharmacy services. These information platforms and develop medication history applications has
models should be based on transparent criteria that cover the scope the potential to transform pharmacy services dramatically. Such techno-

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R. LIU, Y. CAO, A. CHU et al. Chinese General Practice Journal 1 (2024) 18–26

logical advancements would facilitate remote consultations, online ed- Consent for publication
ucational sessions, personalized medication education, and access to an
extensive pharmacy knowledge base. Additionally, the adoption of elec- Not applicable.
tronic medication records for chronic conditions and the enhancement
of information sharing services mark signi-cant strides in personalized Availability of data and materials
healthcare.26 The implementation of community intelligent pharmacies,
complemented by the deployment of automated medication dispensing Data used in this study are available upon reasonable request from
machines, represents a strategic move towards optimizing pharmacy the corresponding author.
operations. By automating the routine task of medication dispensing,
pharmacists can shift their focus to providing comprehensive medication Funding
guidance to patients. This shift not only enhances the e.ciency of phar-
macy services but also signi-cantly reduces patient wait times for med- This research was supported by grants from the Science and Tech-
ication collection, enhancing the overall healthcare experience. These nology Commission of Shanghai Municipality (2020-3-60) and Shanghai
initiatives highlight the potential of technology to streamline pharmacy Municipal Health Commission (2022HP53).
operations, enhance patient education and engagement, and promote a
more e.cient, patient-centered approach to medication management.27 Competing interests
The integration of community pharmacists into family doctor teams
represents a pivotal step towards transforming pharmacy services. This The authors declare that they have no competing interests
collaboration provides comprehensive, professional, and specialized
pharmacy services to all contracted residents, addressing the issue of ir- Acknowledgements
rational drug use in primary care and aiding the implementation of the
family doctor contracting system. Currently, only a fraction (25.4 %) of Not applicable.
pharmacists have joined family doctor teams, and their impact remains
limited. Future strategies should focus on exploring models for pharma- Authors’ other information
cist integration, employing tiered and categorized management to tailor
pharmacy services for the general populations, high-risk patients, and Not applicable.
individuals with chronic diseases. This approach should include medi-
cation management, monitoring, consultation, and education.13 References
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