Multidisciplinary collaboration in primary care: through the eyes of patients

Delving into Uncontrolled or Severe Asthma: Perspectives from Patients and Healthcare Professionals in a Cross-Sectional Study

Background

Despite the effectiveness of inhalation therapy, uncontrolled or severe asthma remains prevalent challenges in respiratory care Narrative Medicine (NM) offers a linguistic approach to comprehending illness experiences, thereby providing a framework for advancing healthcare.

Aim

The primary aim of this study was to gather narratives from individuals grappling with severe or uncontrolled asthma and their Healthcare Professionals (HCPs), in order to explore the intricate interplay among quality of care, quality of life, psychological and social determinants, and adherence patterns.

Methods

A cross-sectional NM study was conducted in Italy from February to December 2023, encompassing 135 patients with uncontrolled or severe asthma (54.7% male; mean age: 56.7 years) and 47 HCPs (64.9% male; mean age: 54.3 years). A mixed-method approach was adopted to scrutinize themes, language nuances, emotional expressions, and narrative classifications.

Results

Patients with uncontrolled or severe asthma reported an average illness duration of 4.46 years, with exacerbations occurring over the past 20.9 months. Pulmonologists (83% of HCPs) played a predominant role in diagnosing and treating the disease in 96.1% of patients. Additionally, participants with severe asthma reported higher healthcare needs. The most reported emotions were fatigue (25.96%) and a sense of suffocation (11.53%). Upon commencing treatment, while experiencing physical improvement, patients predominantly expressed feelings of "submission/dependence" on medication (28%), followed by "fear" (21%) and "serenity/joy" (21%). HCPs, primarily pulmonologists (83%), emphasized the importance of raising awareness among specialists and General Practitioners (GPs), disseminating information, optimizing prescriptions, implementing phenotyping, tailoring therapy, and considering paediatric needs.

Conclusion

These findings contribute to a deeper understanding of patient perspectives, facilitate personalized interventions, and underscore the factors influencing therapeutic adherence in uncontrolled or severe asthma.

Primary care transformation in Scotland: a qualitative evaluation of the views of patients

BACKGROUND

The new Scottish GP contract introduced in April 2018 aims to improve quality of care through expansion of the multidisciplinary team (MDT) to enable GPs to spend more time as expert medical generalists with patients with complex needs.

AIM

To explore patients' views on the changes in general practice in Scotland since the inception of the new contract.

DESIGN AND SETTING

Qualitative study with 30 patients (10 living in urban deprived areas, 10 living in urban affluent/mixed urban areas, and 10 living in remote and rural areas).

METHOD

In-depth semi-structured interviews with thematic analysis.

RESULTS

Patients were generally unaware of the new GP contract, attributing recent changes in general practice to the COVID-19 pandemic. Ongoing concerns included access to GP consultations (especially face-to-face ones), short consultation length with GPs, and damage to continuity of care and the GP-patient relationship. Most patients spoke positively about consultations with MDT staff but still wanted to see a known GP for health concerns that they considered potentially serious. These issues were especially concerning for patients with multiple complex problems, particularly those from deprived areas.

CONCLUSION

Following the introduction of the new Scottish GP contract, patients in this study's sample were accepting of first contact care from the MDT but still wanted continuity of care and longer face-to-face consultations with GPs. These findings suggest that the expert generalist role of the GP is not being adequately supported by the new contract, especially in deprived areas, though further quantitative research is required to confirm this.

Primary care micro-teams: a protocol for an international systematic review to describe and examine the opportunities and challenges of implementation for patients and healthcare professionals

INTRODUCTION

There has been a recent trend towards creating larger primary care practices with the assumption that interdisciplinary teams can deliver improved and more cost-effective services to patients with better accessibility. Micro-teams have been proposed to mitigate some of the potential challenges with practice expansion, including continuity of care. We aim to review the available literature to improve understanding of how micro-teams are described and the opportunities which primary care micro-teams can provide for practice staff and patients and limitations to their introduction and implementation. Our review asks: how is micro-team implementation described? What are the experiences of healthcare professionals and patients concerning micro-teams in primary care? What are the reported implications of micro-teams for patient care?

METHODS AND ANALYSIS

CINAHL, Cochrane Library, Embase, MEDLINE and Scopus will be searched for studies in English. Grey literature will be sourced from Google Scholar, government websites, CCG websites, general practice directives and strategies with advice from stakeholders. Included studies will give evidence regarding the implementation of micro-teams. Data will be synthesised using framework analysis. We will use iterative stakeholder and public and patient participation to embed the perspectives of those whom micro-teams could impact. Included studies will be quality assessed using the Mixed Methods Appraisal Tool. The quality assessment will not be used to exclude any evidence but rather to develop a narrative discussion evaluating included literature.

ETHICS AND DISSEMINATION

Ethical approval will not be necessary for this systematic review as there will only be a secondary analysis of data already available in scientific databases and the grey literature. This protocol has been submitted for registration to be made available on a review database (PROSPERO). Findings will be disseminated widely through peer-reviewed publication and in various media, for example, conferences, congresses or symposia.

PROSPERO REGISTRATION NUMBER

CRD42021225367.

Strategies to Improve the Quality of Team-Based Care for Neonatal Abstinence Syndrome

BACKGROUND

Prioritizing nonpharmacologic care for neonatal abstinence syndrome (NAS) requires a team-based care (TBC) approach to facilitate staff and family engagement. We aimed to identify the important structures and processes of care for TBC of infants with NAS and quality of care outcomes that are meaningful to care team members (including parents).

METHODS

Using a Donabedian framework, we conducted semistructured interviews from May to October 2019 with care team members at 3 community hospitals, including parents, nurses, social workers, physicians, lactation nurses, child protective services, volunteers, and hospital administrators. We used thematic analysis to identify important structures, processes of care, and outcomes.

RESULTS

We interviewed 45 interprofessional care team members: 35 providers and 10 parents. Structures critical to providing TBC included (1) building a comprehensive network of interprofessional team members and (2) creating an NAS specialized unit. Necessary processes of care included (1) prioritizing early involvement of interprofessional team members, (2) emphasizing nonjudgmental incorporation of previous experience with addiction, (3) establishing clear roles and expectations, and (4) maintaining transparency with social services. Lastly, we identified 9 outcomes resulting from these identified structures and processes that are meaningful to care team members to assess the quality of care for infants with NAS.

CONCLUSIONS

In this study, we identify important structures, processes of care, and meaningful outcomes to enhance and evaluate TBC for infants with NAS. Hospitals that adopt and implement these structures and processes have the potential to improve the quality of care for infants, caregivers, and providers who care for these infants.

Collaborative care model for diabetes in primary care settings in Qatar: a qualitative exploration among healthcare professionals and patients who experienced the service

BACKGROUND

Diabetes mellitus is highly prevalent and associated with huge economic burden globally. The conventional care and management of diabetes mellitus is highly fragmented and complex, warranting the need for a comprehensive Collaborative Care Model (CCM). Little is known about the perception of patients with diabetes and their healthcare providers about CCM, its barriers and facilitators. This study aimed to explore the value of CCM in diabetes care at a primary healthcare (PHC) setting from the perspective of patients with diabetes and healthcare professionals (HCPs), in an effort to expand our current knowledge on collaborative care in diabetes at primary care level for the purpose of quality improvement and service expansion.

METHODS

Using an exploratory case study approach, semi-structured interviews were conducted among patients and HCPs who encountered CCM in Qatar during 2019 and 2020. The semi-structured interviews were transcribed verbatim and the data were analysed and interpreted using a deductive-inductive thematic analysis approach.

RESULTS

Twelve patients and 12 HCPs at a diabetes clinic participated in one-to-one interviews. The interviews resulted in five different themes: the process and components of collaborative care model (four subthemes), current organizational support and resources (three subthemes), impact of collaborative care model on diabetes outcomes (three subthemes), enablers of collaborative care model (three subthemes), and barriers to collaborative care model (three subthemes). The participants indicated easy access to and communication with competent and pleasant HCPs. The patients appreciated the extra time spent with HCPs, frequent follow-up visits, and health education, which empowered them to self-manage diabetes. HCPs believed that successful CCM provision relied on their interest and commitment to care for patients with diabetes. Generally, participants identified barriers and facilitators that are related to patients, HCPs, and healthcare system.

CONCLUSIONS

The providers and users of CCM had an overall positive perception and appreciation of this model in PHC settings. Barriers to CCM such as undesirable attributes of HCPs and patients, unsupportive hospital system, and high workload must be addressed before implementing the model in other PHC settings.

Educational Intervention to Improve Citizen's Healthcare Participation Perception in Rural Japanese Communities: A Pilot Study

In this mixed-methods study, we hypothesized that social cognitive theory (SCT)-based educational interventions for healthcare participation can improve the self-efficacy of older rural citizens in participating in their health management without any difficulties. Quasi-experimental study before and after SCT-based educational interventions and semi-structured interviews were conducted. Participants were Japanese elderly (>65 years) from rural communities. Propensity score matching was performed to estimate the effectiveness of educational interventions on participants' perception (intervention: n = 156; control: n = 121). Interview contents were transcribed verbatim and analyzed based on thematic analysis. The intervention group scored significantly higher than the control group for participation in planning and managing self-care. Interviews revealed three themes: ability to manage health conditions, relationship with medical professionals, and relationship among citizens. Participants reported difficulties in judging symptoms and communicating with medical professionals. Hierarchy and low motivation to participate in healthcare hindered collaboration. The findings suggest that SCT-based educational interventions can positively impact rural citizens' self-efficacy in healthcare participation.

Understanding the Influences Behind Parents' Asthma Decision-Making: A Qualitative Exploration of the Asthma Network of Parents with Children with Asthma

Introduction

Interventions aimed at optimizing parents’ ability to manage their children’s asthma could be strengthened by better understanding the networks that influence these parents’ choices when managing asthma. This study aimed to explore the asthma networks of parents of children with asthma—specifically to gain insights into whom parents select to be within their networks and why; how individuals within parents’ networks influence the way in which they manage their children’s asthma medications, and factors driving the development of these networks.

Methods

A qualitative research methodology utilizing semi-structured interviews with parents of children with asthma was employed to fulfil the objectives of this study.

Results

Twenty-six face-to-face interviews with parents of children with asthma were conducted, recorded, and transcribed. Transcriptions were independently coded for concepts and themes by the research team. Asthma medications was a dominant theme identified, and revealed that parents actively sought advice and support from a series of complex and multidimensional relationships with people and resources in their health network. These not only included health care professionals (HCPs) but also personal connections, lay individuals, and resources. The composition and development of these asthma networks occurred over time and were determined by several key factors: satisfaction with their HCP provider; need for information; convenience; trust and support; self-confidence in management; and parents’ perceptions of their children’s asthma severity.

Conclusions

By exploring parents’ asthma network, this study uncovers the complex relationship between HCPs, family and friends of parents of children with asthma, and provides new insight into the intimate and parallel influence they have on parent’s decision-making.

Collaboration between the family nurse and family doctor from the perspective of patients: a qualitative study

BACKGROUND

There is increasing focus on collaboration in primary health care, but there is insufficient patient perspective on collaboration between the family nurse and family doctor.

OBJECTIVE

To explore how patients perceive collaboration between the family nurse and family doctor in primary health care in Poland.

METHODS

A qualitative approach and an inductive, naturalistic inquiry strategy were used. Thirty-seven patients from eight general practice clinics in the north-eastern part of Poland participated in semi-structured, face-to-face interviews. The qualitative data were examined by means of thematic analysis. The study was reported according to the consolidated criteria for reporting qualitative research (COREQ) checklist.

RESULTS

Four subthemes emerged in the context of nurse-doctor collaboration, namely: (i) carrying out the doctor's orders; (ii) visit preparation; (iii) the family nurse as a source of information and (iv) participants' perceptions of the status of the family nurse. Nurses performing instrumental activities connected with a doctor's orders was understood by the participants to be collaboration and prevailed in their responses.

CONCLUSION

The perception of collaboration (or lack thereof) between the family nurse and family doctor results from patients' varied experiences and observations during their visits to a primary care clinic. The traditional model of nursing care and the hierarchical relationship, in which the doctor has the dominant role, are evident in the patients' remarks. The autonomy of nursing could be strengthened by expanding, and highlighting, the primary care activities that a nurse can perform on her own.

Integrating health care in Australia: a qualitative evaluation

BACKGROUND

With aging populations, a growing prevalence of chronic illnesses, higher expectations for quality care and rising costs within limited health budgets, integration of healthcare is seen as a solution to these challenges. Integrated healthcare aims to overcome barriers between primary and secondary care and other disconnected patient services to improve access, continuity and quality of care. Many people in Australia are admitted to hospital for chronic illnesses that could be prevented or managed in the community. Western Sydney has high rates of diabetes, heart and respiratory diseases and the NSW State Ministry of Health has implemented key strategies through the Western Sydney Integrated Care Program (WSICP) to enhance primary care and the outcomes and experiences of patients with these illnesses.

METHODS

We aimed to investigate the WSICP's effectiveness through a qualitative evaluation focused on the 10 WSICP strategies using a framework analysis. We administered 125 in-depth interviews in two rounds over 12 months with 83 participants including patients and their carers, care facilitators, hospital specialists and nurses, allied health professionals, general practitioners (GPs) and primary care nurses, and program managers. Most participants (71%) were interviewed twice. We analysed data within a framework describing how strategies were implemented and used, the experiences around these, their perceived value, facilitators and barriers, and participant-identified suggestions for improvement.

RESULTS

Care facilitators helped patients access services within the hospital and in primary care and connected general practices with hospital specialists and services. Rapid access and stabilisation clinics with their patient hotlines assisted patients and carers to self-manage chronic illness while connecting GPs to specialists through the GP support-line. Action plans from the hospital informed GPs and their shared care plans which could be accessed by other community health professionals and patients. HealthPathways provided GPs with local, evidence-based guidelines for managing patients. Difficulties persisted in effective widespread access to shared records and electronic communication across sectors.

CONCLUSIONS

The combined WSICP strategies improved patient and carer experience of healthcare and capacity of GPs to provide care in the community. Information sharing required longer-term investment and support, though benefits were evident by the end of our research.

Asthma patients' perception on their care pathway: a qualitative study

Because of insufficient asthma control in many patients, the collaboration between stakeholders is regarded as a promising strategy to improve asthma outcomes. This study explored the perceptions of French adult asthma patients on their care pathway. We conducted a qualitative study based on the interviews of 30 asthma patients aged 18–40 years, recruited in French primary care. We performed a thematic analysis of the data collected, using the NVivo software. According to the patients, the stakeholders involved in asthma management included those visible to healthcare professionals (patient, general practitioner, specialist(s), pharmacist, physiotherapist, family and friends) and those concealed by the patients (complementary and alternative practitioners); other stakeholders, such as nurses and occupational physicians, were not involved. Asthma management at diagnosis and follow-up phases proved to be unstructured, and were associated with poor patient education. This was supported by patients’ ambivalence (in relation to illness and treatments), poor communication between patients and healthcare professionals (lack of listening and use of inappropriate vocabulary by physicians, underreporting of alternative medicine use by patients) and weak cooperation between professionals (limited to interaction between the general practitioner and the specialist, either pulmonologist or allergist). Asthma management would probably benefit from a more coordinated care pathway at each phase of the disease that is consistent with the expectations and goals of the patients. It should be based on improved organization (involvement of other healthcare professionals and the patient as partners) and processes (regular follow-up, specific tools such as peak flow meter or action plan).

It takes a village - asthma networks utilized by parents when managing childhood asthma medications

Objective: We are yet to understand how widely parents seek asthma medication management information for their children, how they are used for health information, how parents engage with them and their influence on parent's decision-making. This study aimed to gauge the current level of asthma knowledge and skills of parents of children with asthma and gain insight into who and what influences their child's asthma medication management decisions. Method: Social network theory was used to map parents' asthma networks and identify the level of influence of each individual/resource nominated. Parents of children with asthma (aged 4-18 years) were interviewed, completed an asthma network map, questionnaires and an inhaler technique assessment. Results: Twenty-six parents participated and had significant gaps in asthma knowledge and inhaler technique skills. The asthma networks of participants ranged from two to ten individuals/resources, with an average number of five. The most commonly nominated individual/resource was general practitioners followed by family members and the internet. Professional connections represented 44% of individuals/resources in networks, personal connections 42% and impersonal connections 14%. When parents were asked about how influential individuals/resources were, professional connections represented 53% of parents influences, personal connections 36% and impersonal connections 11%. Conclusion: This study highlights the priority and co-influence of non-medical sources of information/support on parent's behaviors and decision-making with regards to their child's asthma medicine taking. In further understanding the complexities surrounding these connections and relationships, HCPs are better positioned to assist parents in addressing their needs and better supporting them in the management of their child's asthma.

"They Are Talking About Me, but Not with Me": A Focus Group Study to Explore the Patient Perspective on Interprofessional Team Meetings in Primary Care

Background

The number of people with multiple chronic conditions receiving primary care services is growing. To deal with their increasingly complex health care demands, professionals from different disciplines need to collaborate. Interprofessional team (IPT) meetings are becoming more popular. Several studies describe important factors related to conducting IPT meetings, mostly from a professional perspective. However, in the light of patient-centeredness, it is valuable to also explore the patients’ perspective.

Objective

The aim was to explore the patients’ perspectives regarding IPT meetings in primary care.

Methods

A qualitative study with a focus group design was conducted in the Netherlands. Two focus group meetings took place, for which the same patients were invited. The participants, chronically ill patients with experience on interprofessional collaboration, were recruited through the regional patient association. Participants discussed viewpoints, expectations, and concerns regarding IPT meetings in two rounds, using a focus group protocol and selected video-taped vignettes of team meetings. The first meeting focused on conceptualization and identification of themes related to IPT meetings that are important to patients. The second meeting aimed to gain more in-depth knowledge and understanding of the priorities. Discussions were audio-taped and transcribed verbatim, and analyzed by means of content analysis.

Results

The focus group meetings included seven patients. Findings were divided into six key categories, capturing the factors that patients found important regarding IPT meetings: (1) putting the patient at the center, (2) opportunities for patients to participate, (3) appropriate team composition, (4) structured approach, (5) respectful communication, and (6) informing the patient about meeting outcomes.

Conclusions

Patients identified different elements regarding IPT meetings that are important from their perspective. They emphasized the right of patients or their representatives to take part in IPT meetings. Results of this study can be used to develop tools and programs to improve interprofessional collaboration.

Electronic supplementary material

The online version of this article (doi:10.1007/s40271-017-0214-3) contains supplementary material, which is available to authorized users.

Multidisciplinary Collaboration in the Treatment of Patients With Type 2 Diabetes in Primary Care: Analysis Using Process Mining

Background

Public health in several countries is characterized by a shortage of professionals and a lack of economic resources. Monitoring and redesigning processes can foster the success of health care institutions, enabling them to provide a quality service while simultaneously reducing costs. Process mining, a discipline that extracts knowledge from information system data to analyze operational processes, affords an opportunity to understand health care processes.

Objective

Health care processes are highly flexible and multidisciplinary, and health care professionals are able to coordinate in a variety of different ways to treat a diagnosis. The aim of this work was to understand whether the ways in which professionals coordinate their work affect the clinical outcome of patients.

Methods

This paper proposes a method based on the use of process mining to identify patterns of collaboration between physician, nurse, and dietitian in the treatment of patients with type 2 diabetes mellitus and to compare these patterns with the clinical evolution of the patients within the context of primary care. Clustering is used as part of the preprocessing of data to manage the variability, and then process mining is used to identify patterns that may arise.

Results

The method is applied in three primary health care centers in Santiago, Chile. A total of seven collaboration patterns were identified, which differed primarily in terms of the number of disciplines present, the participation intensity of each discipline, and the referrals between disciplines. The pattern in which the three disciplines participated in the most equitable and comprehensive manner had a lower proportion of highly decompensated patients compared with those patterns in which the three disciplines participated in an unbalanced manner.

Conclusions

By discovering which collaboration patterns lead to improved outcomes, health care centers can promote the most successful patterns among their professionals so as to improve the treatment of patients. Process mining techniques are useful for discovering those collaborations patterns in flexible and unstructured health care processes.

Multidisciplinary collaboration in primary care: a systematic review

BACKGROUND

Several studies have discussed the benefits of multidisciplinary collaboration in primary care. However, what remains unclear is how collaboration is undertaken in a multidisciplinary manner in concrete terms.

OBJECTIVE

To identify how multidisciplinary teams in primary care collaborate, in regards to the professionals involved in the teams and the collaborative activities that take place, and determine whether these characteristics and practices are present across disciplines and whether collaboration affects clinical outcomes.

METHODS

A systematic literature review of past research, using the MEDLINE, ScienceDirect and Web of Science databases.

RESULTS

Four types of team composition were identified: specialized teams, highly multidisciplinary teams, doctor-nurse-pharmacist triad and physician-nurse centred teams. Four types of collaboration within teams were identified: co-located collaboration, non-hierarchical collaboration, collaboration through shared consultations and collaboration via referral and counter-referral. Two combinations were commonly repeated: non-hierarchical collaboration in highly multidisciplinary teams and co-located collaboration in specialist teams. Fifty-two per cent of articles reported positive results when comparing collaboration against the non-collaborative alternative, whereas 16% showed no difference and 32% did not present a comparison.

CONCLUSION

Overall, collaboration was found to be positive or neutral in every study that compared collaboration with a non-collaborative alternative. A collaboration typology based on objective measures was devised, in contrast to typologies that involve interviews, perception-based questionnaires and other subjective instruments.

Qualitative meta-synthesis of barriers and facilitators that influence the implementation of community pharmacy services: perspectives of patients, nurses and general medical practitioners

OBJECTIVES

The integration of community pharmacy services (CPSs) into primary care practice can be enhanced by assessing (and further addressing) the elements that enable (ie, facilitators) or hinder (ie, barriers) the implementation of such CPSs. These elements have been widely researched from the perspective of pharmacists but not from the perspectives of other stakeholders who can interact with and influence the implementation of CPSs. The aim of this study was to synthesise the literature on patients', general practitioners' (GPs) and nurses' perspectives of CPSs to identify barriers and facilitators to their implementation in Australia.

METHODS

A meta-synthesis of qualitative studies was performed. A systematic search in PubMed, Scopus and Informit was conducted to identify studies that explored patients', GPs' or nurses' views about CPSs in Australia. Thematic synthesis was performed to identify elements influencing CPS implementation, which were further classified using an ecological approach.

RESULTS

Twenty-nine articles were included in the review, addressing 63 elements influencing CPS implementation. Elements were identified as a barrier, facilitator or both and were related to four ecological levels: individual patient (n=14), interpersonal (n=24), organisational (n=16) and community and healthcare system (n=9). It was found that patients, nurses and GPs identified elements reported in previous pharmacist-informed studies, such as pharmacist's training/education or financial remuneration, but also new elements, such as patients' capability to follow service's procedures, the relationships between GP and pharmacy professional bodies or the availability of multidisciplinary training/education.

CONCLUSIONS

Patients, GPs and nurses can describe a large number of elements influencing CPS implementation. These elements can be combined with previous findings in pharmacists-informed studies to produce a comprehensive framework to assess barriers and facilitators to CPS implementation. This framework can be used by pharmacy service planners and policy makers to improve the analysis of the contexts in which CPSs are implemented.

Patient asthma networks: understanding who is important and why

BACKGROUND

Multidisciplinary care (MDC) has been proposed as an essential component to the delivery of effective and efficient health care. However, patients have shown to establish their own sources of health advice and support outside the professional domain. It remained unclear as to how patients' choices may impact on MDC.

OBJECTIVE

This study aimed to explore the role of patients in MDC, specifically (i) how and why patients select sources of health services, information and support, that is, their health connections and (ii) the key elements contributing to the nature and development of patients' health connections.

METHODS

In-depth semi-structured interviews were conducted with asthma participants from Sydney, Australia. Participants were recruited from a broad range of primary health-care access points. Face-to-face and telephone interviews were audio recorded, transcribed verbatim, independently reviewed by two authors and analysed using a qualitative approach.

RESULTS

A total of 47 interviews were conducted. Participants established health connections around their asthma needs and selected a combination of professional, personal and impersonal health connections for advice and support. Several key elements were reported to contribute towards the nature and development of patients' health networks. These included participants' perceptions of the role of HCPs, their level of trust in relationships, the convenience of accessing health advice and their perceptions of asthma.

CONCLUSION

By exploring patients' sources of health advice and support, this research provided new insight into how patients choose to manage asthma, particularly the way in which they selected health connections and their potential impact on MDC.

Pharmaceutical Policy Part 2 Pharmaceutical engagement and policy development: a framework for influence

The formulation of pharmaceutical policy is a critical component of healthcare planning, made more important given that medicines are the ubiquitous technology in the diagnosis, treatment and prevention of disease and constitute a significant proportion of health care expenditure. Pharmacists need to inform policy development that will, in its implementation, offer opportunity to deliver greater rationality, safety, effectiveness and economy to the medicines use process and where patients experience enhanced health outcomes. This is the second of two articles directed to this specific issue focusing on how policy and strategic change can be affected. This is discussed from three overlapping perspectives - from the point of view of skills, that is, the skills or tactics needed to be employed to effect change; secondly, from a structural standpoint in terms of what positional arrangements exist that could be positively exploited; and thirdly, the subject, particularly its relevance to the contemporary situation. These approaches are then exemplified through a worked example on medication safety and its application in practice.