PONE-D-19-33807

A service evaluation and stakeholder perspectives of an innovative digital minor illness referral service from NHS 111 to community pharmacy

PLOS ONE

Dear Dr. Nazar,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

In addition to the comments raised by the reviewers and cited below, please also consider the following issues:

• The methods refer to the qualitative analysis as using both a modified grounded theory approach as well as thematic analysis.  This is confusing -since no theory was proposed, how is this grounded theory.  Referring to the study as thematic analysis seems suitable.
• Can the authors comment on a further aspect of pharmacists' opinions - namely that apparently pharmacists were providing referral services without recompense for their time and effort.  The pharmacy literature is replete with "wonderful" studies of pharmacists giving away their services for free.  Such pharmacy programs rarely seem to be scalable or replicable because not all pharmacists are so public minded as to work for free towards the public good.
• A major stakeholder not included in the analysis is that of physicians.  Can the authors address this oversight.

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John Rovers, PharmD, MIPH

Academic Editor

PLOS ONE

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2. Please address the following:

- Please ensure you have thoroughly discussed any potential limitations of this study within the Discussion section, including the potential bias introduced by the sampling method used and the nature of qualitative data.

- Please include additional information regarding the semi-structured interview guide used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a guide as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. In addition, please include any details of pre-testing of this guide, including the number of participants and where they were recruited from.

Thank you for your attention to these queries.

3. Thank you for stating the following in the Financial Disclosure section:

"HN received funds to undertake evaluative work for the Digital Minor Illness Referral Service from NHS England (Grant number: BH181784). Funders supported the study design, data collection, analysis and decision to publish the work."

We note that one or more of the authors are employed by a commercial company: Local Professional Network.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: N/A

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The paper focuses on an important issue, addressing a contemporary population health need. The authors used a large dataset to evaluate the effectiveness of a digital referral system towards shifting the burden of urgent and emergency care services by referring patients calling NHS 111 with low acuity conditions to community pharmacists. To improve the readability and application of the findings of this paper, the authors need to make some major revision of the current version.

The Authors need to identify who their target audience is and tailor the presentation of the results to meet their context and needs. The results of the qualitative strand while important is too long. This will be a challenge for easy assimilation by readers who have less time to read a long paper. The authors should consider alternative forms such as visual representing of the results in a figure to accommodate such readers.

There is a need for more discussion of the system to help readers understand its functionality. Authors need to consider unintended consequences of the system especially in their discussion of the findings. How is this accounted for in the development of the system? Does the system consider patient history such as comorbidities, for instance, in the decision on community pharmacist referral? What is the possible harm from the high proportion of referrals among patients aged 0-9 years considering the inability of this age group to extensively self-report their symptoms (themselves or through a third party such as caregivers) given the reliance of the system on symptoms described by patients?

The quantitative strand of the paper was too descriptive and do not present strong empirical evidence to inform policy decisions and the translation of this intervention in other settings. The dataset holds more potentials for an extensive evaluation of the system. The authors need to apply more robust statistical models in understanding the factors associated with the performance of the system. The data on patients’ demography, for instance, could be used to model the behaviour of rejecting referrals for community pharmacist consultations. As a process evaluation paper aiming to optimise the potentials of the DMIRS system, one will expect a detailed investigation to understand why 1/3 of those referred rejected.

With the current analysis, it is unclear whether the DMIRS is actually shifting the burden of low acuity conditions from urgent and emergency care. It is possible for those referred and completed to go back to their GP or A&E. The possibility of this happening was reiterated in the interview result (lines 270-272). The authors need to consider this in plans to improve the statistical analysis.

The Authors reported adopting a mixed-methods design in their paper. Although the results of analyses of qualitative and quantitative data were presented, there was a lack of integration of both methods expected in a mixed-methods design. It is unclear how the design of the interview relates to the analysis and results of the service activity data. Both strands do not seem to complement each other. For instance, the interview result in lines 258-264 on the negotiating abilities of the call handlers could inform statistical investigation towards the level of rejections. Rejection as an outcome of the referral process could be patterned alongside call handler characteristics such as negotiating ability and understanding this pattern is important in optimising acceptance of the referral system.

The qualitative interviews present important insights into the implementation of the intervention and can be a standalone study. I recommend the authors consider splitting the manuscript into two papers, focusing the current paper on the qualitative study exploring the experiences and perspectives of stakeholders in the implementation of the DMIRS system in North East of England. Alternatively, to maintain a mixed-methods design, the statistical analysis should be improved by conducting more robust investigations, and both strands should be well integrated.

Minor comments

Line 51: brief explanation (1 or 2 sentences) of what low acuity conditions mean. This will be useful to the non-clinical audience.

Line 94: is this an exploratory or explanatory mixed methods design? It is unclear how the design of the interview relates to the service activity data. Both strands do not seem to complement each other.

Line 105: add some examples of these specific minor illnesses. It is helpful to prepare your readers at this point on the conditions considered to be low acuity.

Lines 222-226: I was interested in seeing how this will be interpreted in the discussion section. Are those of lower IMD generally more likely to call NHS 111 for low acuity conditions compared to those of higher IMD? Are those of higher IMD more likely to call NHS 111 for more serious/high acuity conditions. Can these explain the high referral into the service seen in the most deprived areas of England?

Line 231: what informed the decision on the number of interviews to conduct and the proportion of each group (CH, TM, CP) contributing to the stakeholders' data? This needs to be explained.

Reviewer #2: Overall, I think this is an interesting evaluation of a unique (and needed) service. (Granted, I am a pharmacist, so I am a bit biased in that area.) The paper is well-written and makes a compelling argument in favor of these types of referrals to community pharmacists for the treatment of minor illnesses. My comments are mainly related to adding additional detail to help readers who are unfamiliar with the UK health care system better understand the referral service developed in this pilot program.

1. At several points in the paper, a list of low acuity conditions are mentioned, but these are never really defined until the Results. Were these conditioned defined prior to the implementation of this service (e.g., as part of the pilot program development)? Some discussion of what these conditions are and how they were selected might be helpful, especially for those who might be interested in implementing this outside the UK.

2. Related to the previous point, some Canadian provinces have implemented pharmacist prescribing for minor ailments. It might be helpful to provide some mention of these efforts outside the UK to provide additional context. This would probably be a discussion point.

3. In the introduction, some of the information struck me as potentially being better suited for the Discussion section. Mainly, the 2nd and 3rd full paragraphs on page 4. Those seem to discuss the status of the DMIRS program after what is being evaluated in the current paper. By presenting these up front, it felt a little out of order to me. You might consider moving these to the end of the paper as a sort of “where is it now” part of the discussion.

4. It would be helpful to explain who the call handlers were. Were these nurses or somebody else? If not nurses, did they have any health care training? That was a big question in my mind in terms of their ability to make appropriate referrals to the community pharmacist vs. to the GP or ED.

5. When referrals were made to a community pharmacy, the call handler selected the pharmacy closest to the patient’s home address. Was there any consideration of whether or not that was the patient’s “usual” pharmacy? Sometimes people use pharmacies that aren’t necessarily the closest geographically to their home.

6. For the participating pharmacies, were these all community pharmacies or only certain ones who were signed up to be part of this pilot service? (My apologies if I missed that in the paper.)

7. On page 6 under Service activity data, the first paragraph and the data extra description seemed a little redundant. You might consider reworking those to combine them without being repetitive. For example, the first paragraph mentions the what was recorded and then the second part notes the data extracted. These are basically the same elements in that prior paragraph.

8. Under Sampling (page 7, line 152), patients attending the community pharmacy referral were asked to provide consent for participation in research and evaluation. Strictly speaking, this project is not research, rather it is an evaluation. Is the “research and evaluation” terminology used because the consent was for the DMIRS pilot more generally (and potential follow-up projects)? You might clarify this and update the wording if needed.

9. In Table 2, the term “safety netting” is used, but it is not defined. This may be a common term for the UK context, but it may not be familiar to those elsewhere.

10. In the results referring to the level of completion (bottom of page 10, line 209; top of page 11, line 214), a percentage is listed in parentheses. It is unclear if these percentages are what were used for “good” vs. “not good” in terms of completion. Please clarify this.

11. The supplemental figure for the Michie wheel (page 12, line 243) was not available when I checked the supplemental information. I was only able to access the TIDieR table. I’m not sure if this was a technological issue on my end or if the file wasn’t attached.

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Reviewer #1: Yes: Dr Philip Anyanwu

Reviewer #2: Yes: Spencer E. Harpe

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A service evaluation and stakeholder perspectives of an innovative digital minor illness referral service from NHS 111 to community pharmacy

PONE-D-19-33807R1

Dear Dr. Nazar,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

Within one week, you will receive an e-mail containing information on the amendments required prior to publication. When all required modifications have been addressed, you will receive a formal acceptance letter and your manuscript will proceed to our production department and be scheduled for publication.

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With kind regards,

John Rovers, PharmD, MIPH

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: N/A

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Authors have responded to review comments and amended the manuscript accordingly.

A limitation section has been included by the authors to further demonstrate the scope of the investigations conducted.

Reviewer #2: Thank you for your responses to the comments from the editors and the reviewers. All of my concerns were addressed. I think the paper is stronger and tells a more clear story about this interesting service that was implemented.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

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Reviewer #1: Yes: Dr. Philip Anyanwu

Reviewer #2: Yes: Spencer E. Harpe