Developing Integrated Extended Pharmacist Roles and Services for Equitable Access and Outcomes in Primary Healthcare: A Realist Evaluation

Background: Pharmacists’ roles have been moving from dispensing towards more patient-focused extended clinical care, signalling changes in health service policy and delivery. This paper evaluates the development of practice pharmacists’ roles and services in primary healthcare (PHC) settings in New Zealand (Aotearoa), how services were implemented, and how pharmacists, patients, and other PHC professionals responded to role and service developments. Methods: We applied a realist evaluation methodology, identifying context (C) into which initiatives are introduced, mechanism (M) triggered or attenuated by the context, and resulting outcome (O). CMO configurations were developed, tested and refined through rapid realist review, key informant interviews, six case studies, and a national survey. Although not every project stage is fully documented in this paper, each contributed to the final theories. The desired outcome was defined as: Practice pharmacists are integrated within PHC teams, and their services are accepted and utilised by patients. Practice pharmacist services are equitably accessible throughout Aotearoa and contribute to equitable health outcomes. Results: Four programme theories, based on 22 CMO configurations, showed how contexts and mechanisms at national, service, role, and patient levels could enable or attenuate reaching the desired outcome; for example, through a burning platform for change, supportive colleagues and infrastructure, well-fitting roles, and patient awareness, or conversely through, disjointed leadership, limited understanding and role uncertainty, and lack of access to practice pharmacists. Funding, regardless of source, operated across all levels as context and mechanism. Conclusion: Practice pharmacist services operate within multiple contexts and levels; their development and implementation requires a systems view. Opportunities exist to achieve the desired outcome by strengthening enabling contexts or reducing barriers within attenuating contexts. Policy-makers now need to focus on equitable service distribution, sustainable ways to fund and employ practice pharmacists, and the equity impact of patient copayments.