Pharmaceutical Public Health: A Mixed Method Study Exploring Pharmacy Professionals’ Advanced Roles in Public Health, Including the Barriers and Enablers

1. Introduction

Pharmacy professionals (pharmacists and pharmacy technicians) have an increasing role in improving the health and wellbeing of populations and communities. Currently, pharmacy colleagues work across the three core domains of public health practice [1]: health improvement, health protection and healthcare public health (Box 1), informing population care beyond individual health outcomes (Figure 1). Pharmaceutical Public Health (PPH) was first defined in the literature in 2000 as “the application of pharmaceutical knowledge, skills and resources to the science and art of preventing disease, prolonging life, promoting, protecting, and improving health for all through organised efforts of society” [2]. At the time, Walker recognized that “Pharmaceutical Public Health is a real value-added role that the profession has, to date, chosen not to exploit” [2].

Walker’s observation is reflected in the relatively narrow focus of the literature on PPH. Mulvale and colleagues organized contextual factors as an interrelated set of policy (macro), organizational (meso), team (micro) and individual factors [3]. Over the years, the available literature on the pharmacy professions public health function has predominantly focused on the contribution of community pharmacy and pharmacists’ delivering public health interventions to individuals, through micro-level activities such as health promotion, secondary prevention measures through medicines management and prescribing advice, rather than on population health or broader public health interventions more broadly [4]. Community pharmacies are frequently located in some of the most deprived and challenging communities, providing daily contact for individuals seeking ad hoc and unplanned health advice alongside collection of prescribed medicines or purchasing over the counter health related products [5,6]. In England, there are over 1.2 million daily health-related visits to community pharmacies. This presents an important opportunity to support behavioural change at an individual micro level. However there are also opportunities for community pharmacy teams as well as pharmacy professionals across all sectors to address wider societal aspects of public health at meso and macro levels [3,5,6].

An evidence gap currently exists that describes the involvement of pharmacy professionals working at the meso and macro levels. The meso level involves partnership working and involvement in community support networks (group/institution level); the macro level, involves influencing and working within local, regional and national governments on complex agendas such as tackling health inequalities and implementing health policies (Figure 2). Involvement at these broader levels requires advanced public health skills in addition to pharmacy specialty skills.

In the UK, key population health policies include the following: in England the NHS Long term plan, including the development of integrated care systems (ICSs) and integrated care boards (ICBs) and primary care networks (PCNs); in Scotland the Public Health Priorities for (2018); in Northern Ireland ‘Making Life Better—a whole system framework for public health (2013-23) and in Wales A Healthier Wales: Long Term Plan for Health and Social Care [7,8,9,10]. These policies have the clear aim to improve the health and wellbeing of the UK population by bringing together multi professional groups, including pharmacy professionals, to coordinate care better.

Box 1. Definitions of public health, domains of public health and population health.

Public Health is defined as “the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society”

Health protection is the protection of individuals, groups and populations through the effective collaboration of experts in identifying, preventing and mitigating the impacts of infectious diseases and of environmental, chemical and radiological threats.

Healthcare public health is concerned with the application of population sciences to the design, organisation, and delivery of healthcare services, with the ultimate aim of improving population health.

Health improvement is concerned with assessment of population health needs, and commissioning and evaluating health programmes and initiatives to promote healthy behaviours. These include improving nutrition, physical activity, sexual health, substance use, disease prevention, and the importance of vaccinations.

Population health is an approach aimed at improving the health of an entire population. It is about improving the physical and mental health outcomes and wellbeing of people, whilst reducing health inequalities within and across a defined population. It includes action to reduce the occurrence of ill-health, including addressing wider determinants of health, and requires working with communities and partner agencies.

This evidence review (commissioned by the UK Chief Pharmaceutical Officers in 2020,) aimed to address the UK national policy direction publications [7,8,9,10] and pharmacy professionals’ specialist public health contributions. It aimed to assess the barriers and opportunities to contributions at meso and macro levels of public health, and to mak recommendations for future action. The overall aim was to provide evidence as part of the national policy directions on the PPs role in population and public health.

2. Methods

2.1. Survey of Pharmacy and Public Health Professionals—Overview and Data Analysis

Two independent cross-sectional electronic surveys were developed, piloted, and deployed to pharmacy and public health specialists via email and social media cascades. The surveys explored the extent to which pharmacy professionals are involved in public health roles, including barriers and opportunities encountered.

A combination of purposive and convenience sampling was employed to identify pharmacy and public health professionals in all of the four UK nations (England, Scotland, Wales and Northern Ireland).

The surveys (Supplementary Material 1 and 2) were developed by pharmacist researchers with experience and advanced skills in public health and a public health professional (authors—DAO, UO, EW, CN, RO, MB, AE, CP, CG), after an extensive literature review and regular meetings to assess the survey questions. The surveys were pilot-tested and reviewed by the study researchers and independent researchers. The surveys were revised following feedback from reviewers. Independent researchers outside the core project team researchers and convenience sampling of participants with similar demographics to intended participants (8 pharmacists and 14 public health professionals) were asked to pilot test the survey to ensure clarity; revisions were made based on feedback.

The links to the surveys were disseminated via social media platforms (including LinkedIn, Twitter (X), and WhatsApp), also via email to universities with public health courses and public health offices at acute trusts; in addition they were disseminated via telephone calls and directed contact to professional colleagues. The survey for public health professionals was also disseminated by the Faculty of Public Health and the Association of Directors of Public Health through email and newsletter cascade routes.

The questions comprised mainly closed-ended multiple choice questions, alongside questions that allowed for open-ended responses inviting additional insights. Respondents were asked to append links to previously published relevant work. Data responses were collected anonymously, although survey respondents could voluntarily provide their name and email address via a separate link at the end of the survey, with personal information disaggregated from their survey responses. This allowed these individuals the opportunity to join a network of pharmacists with interest and experience in public and population health.

Survey data was imported into Microsoft Excel for analysis. The response rate was not calculated since information was not available on the number of unique individuals who viewed or initiated the survey. Descriptive statistics were used to summarise the quantitative data collected. Missing data was excluded from analysis. Open-ended free text responses were analysed using inductive content analysis.

All data were stored securely in line with the General Data Protection Regulation 2016/679.

2.1.1. Survey of Pharmacy Professionals

The intended audience for the pharmacy survey were pharmacy professionals (pharmacists and pharmacy technicians) across all four UK nations. The survey included 32 questions and remained open for responses over a 4-week period (25th June 2021 till 27th July 2021).

The objectives of the pharmacy professionals survey were to:

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Explore the number of pharmacy professionals who have experience in leading public/population health projects or have completed/are undertaking additional public/population health training.

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Explore the context in which pharmacists are currently involved in public/population health related roles (excluding nationally commissioned public health services through community pharmacy),

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Understand the drivers and barriers associated with pharmacists undertaking public/population health roles.

The pharmacy professional survey elicited participant demographics, public/population health qualifications and public/population professional experience, including barriers and facilitators to undertaking advanced public/population health roles, and public health projects they had been involved in. In addition, participants were asked how the projects were disseminated. The survey included a comment box to provide further details about the projects and how to access the published information about the projects.

2.1.2. Survey of Public Health Professionals

The intended audience for the public health professionals survey were public health specialists, registrars and public health practitioners. The survey included 35 questions and remained open for responses over a 6-week period (15th September till 27th October 2021). All participation was voluntary.

The objectives were to seek the views of public health professionals on:

• The potential functions of public health that can benefit from pharmacists’ unique expertise including access to care, prevention services as well as pharmacotherapy, pharmacoepidemiology and economics,
• The contributions of pharmacy professionals to public/population health (in addition to traditionally/nationally commissioned community pharmacy services) that they were aware of in the four UK nations.

The public health professional survey elicited participant demographics, their experience of working with pharmacy professionals, examples of how correct and efficient use of medicines currently or previously had arisen as an area of challenge or consideration. The survey also requested their perceptions of the benefits, barriers and opportunities of pharmacists/pharmacy technicians specialising in public health and areas of public/population health they felt would benefit having individuals with pharmacy backgrounds working directly as part of the public health team.

The conduct and reporting of the study adhered to the Consensus-Based Checklist for Reporting of Survey Studies (CROSS). The completed CROSS checklist is available as supplementary information

2.2. Call for Evidence

A call for evidence questionnaire (Supplementary Material 3) was sent by the Project Lead (DAO) on 25 June 2021 via email to key stakeholders who held senior pharmacy related positions in the UK for further cascade. The questionnaire was designed to identify any published or unpublished reports, documents, or case histories related to PPH. In addition, they were asked to give examples of pharmacists in the UK who have received public health training or had experience working at a strategic level and influencing population health in UK. To optimise responses, additional reminders were sent and an extension until 16 July was sent out on 5th July 2021 (initial deadline).

The evidence received from published or unpublished reports, documents or case histories was collated via the questionnaire and was used to classify all findings under one of 8 topic headings:

• National Strategic Approach
• Expanding Service Delivery within Community Pharmacy
• Expanding Service Delivery beyond Community Pharmacy
• Embedding Optimisation of Medicines at a Population Health Level
• Emergency Preparedness, Resilience and Response
• Integration of Pharmacy to Better Support Public Health Protection & Improvement Goals
• Public Health Skills and Training
• Mitigating Health Inequalities

Findings were shared via two workshops, each with a selected group of stakeholders, to promote discussion and help clarify questionnaire responses.

2.3. Workshops

Two workshops were held with key stakeholders on 16 July 2021 and 02 September 2021. The first workshop included the participation of key stakeholders in a presentation and discussion regarding the mixed method review, a literature review, key findings and interim survey and call for evidence findings.

Ahead of the second workshop, a slide set summary of the literature review and interim results of the two surveys and call for evidence were sent to invitees, with a request via a Slido tool to recommend how to steer national changes to improve pharmacy professionals’ contribution to public health across the four UK nations, in addition to what already existed as commissioned community pharmacy services. These recommendations were further discussed at the workshop (Supplementary box 1 includes the workshop agenda) and each participant was asked to share which one recommendation they deemed most important regarding the involvement of pharmacy professionals in PPH.

2.4. Ethics Approval and Consent

Ethical approval was not required according to the NHS Health Research Authority tool, the surveys aimed to evaluate through exploration specialist contributions of pharmacy professionals to national policies/direction on public health. Consent was sought from all participants and anonymity of contributions provided.

3. Results

3.1. Survey of Pharmacy and Public Health Professionals

3.1.1. Survey of Pharmacy Professionals

3.1.1.1. Demographics

A total of 128 pharmacy professionals (85% pharmacists) responded from the four UK nations (n=96 (England), n=13 (Scotland), n=9 (Wales), n=9 (Northern Ireland) and n=1 (stated Great Britain)) (Table 1). Respondents were predominantly female (70%; 90/128); 27% (35/128) were male and 3% (3/128) preferred not to say. Most were of white British background (48%; 62/128), 14% (19/128) were Asian or Asian British, 12% (14/128) were Black or Black British. Within England, most respondents worked in the South East (20%; 20/96)), while 19% (18/96), 17% (17/96) and 11% (11/96) worked in Midlands, London and North East and Yorkshire respectively. Regions that were represented in lower proportions included the Southwest, North West and East of England.

Respondents worked in a range of sectors including primary care, secondary care, health boards, public health bodies, community pharmacies, local authority and health and justice settings (Figure 3). Many respondents (33%; 43/128) worked in the primary care setting and 25% (33/128) in the secondary care setting. Thirteen per cent (16/128) stated they worked across both the community setting and public health bodies. Eighty-five per cent (109/128) of survey respondents stated their role was a pharmacist, while 15% (19/128) stated pharmacy technician. No trainees (pharmacists or pharmacy technicians) responded to the survey.

3.1.1.2. Public Health Qualifications and Motivation

Most of the respondents (63%, 80/128) had no formal public health qualification, 27% (34/128) had formal public health qualification, and the remaining 10% (14/128) had a qualification in progress. For those who held a public health qualification, the year of qualification ranged from one to 49 years ago. One respondent was a Fellow of the Faculty of Public Health and another was a member of the Royal Society of Public Health. In response to the question “How long have you been using your public health qualification or skills within role(s)?”, over half (55.2%, 16/29) answered they had been using their public health qualifications or skills within their roles for five or more years, 20.7% (6/29) had not used their qualification nor skills, and 13.8% (4/29) and 10.3% (3/29) had used their qualifications or skills for three to four years and one to two years respectively.

The public health education modules most often completed by pharmacy professionals (most commonly as part of a Masters in Public Health course) were health improvement/promotion (12%, 15/128), epidemiology (12%, 15/128), health policy (11%, 14/128), infectious and tropical diseases (10%, 13/128), health services (10%, 13/128), global health/global health policy (110%, 3/128), health systems (10%, 13/128), health economics (0.1%, 2/128), climate change (0.1%, 1/128) and community pharmaceutical public health (0.1%, 1/128).

When respondents were asked what best described their motivation for undertaking an additional public/ population health qualification(s), 31% (17/55) selected an ambition to work in public health as a pharmacy professional, 29% (16/55) selected ambition to work in public health as an alternative career to pharmacy. About a third 27% (15/55) also selected that it was completed for general interest, seven per cent (4/55) and 4% (4/55) of the respondents stated that their motivation was based on recommendations received and qualification required for their roles, respectively, while 2% (1/55) of respondents did not identify a specific motivation.

3.1.1.3. Public Health Experience

Within public health, pharmacy professionals were involved in various non-COVID-19 related public health areas as shown by Figure 4. Over 70% of respondents were involved in antimicrobial stewardship activities to tackle antimicrobial resistance, managing long term conditions, health improvement and data analysis/statistics before and since the COVID-19 pandemic. The proportion of respondents that were engaged in the development of Pharmaceutical Need Assessments** was 31% (21/68) before, and 4% (3/68) since the pandemic and for health inequalities this was 16% (9/57) pre and 10% (6/57) since the pandemic.

Pharmacy professionals respondents had conducted diverse public health projects. Forty per cent (69/174) of pharmacy professionals had not shared project findings beyond their organisation;18% (32/174) had their project findings disseminated during conference presentations and abstracts, 16% (28/174) via guidance, protocols or Patient Group Directions (PGDs) and 11% (20/174) as peer review publications. Eight per cent (13/174) and 7% (12/174) of respondents had their findings published in non peer-reviewed publications or as blogs and online reports respectively.

3.1.1.4. Barriers and Opportunities

Most respondents to the question on barriers (71%; 89/126) believed there are barriers for pharmacy professionals to engage in public and population health, 23% (29/126) of the respondents believed there might be barriers for pharmacy professionals to public and population health engagement and only 6% (8/126) did not believe barriers exist for pharmacy professionals to get involved in public and population health.

Eight key themes were identified from the barriers provided by respondents (Table 2). The highest number of comments mentioned as a barrier to PPH related to limited career opportunities or no defined career pathway.

Most respondents (80%; 102/127) believed opportunities exist for pharmacy professionals to engage in public and population health. Six themes were identified as opportunities for pharmacy professionals to engage in public or population health (Table 3). The most popular theme was that pharmacy professionals are well placed to make a public health impact.

There were specific barriers and opportunities highlighted by pharmacy technician respondents (Supplementary Box 2 and 3). The main barrier reported by pharmacy technicians was an underuse of skills. Technicians also remarked on a lack of professional accreditation which resulted in a gap in service provision.

3.2. Survey of Public Health Professionals

A total of 54 public health professionals participated in the survey; 67% (36/54) were female, 30% (16/54) male and 3% (2/54) preferred not to say (Table 4). Most respondents (59%, 32/54) were practising in England, 28 (15/54) in Scotland and 13% (7/54) in Wales. Participants worked in a range of roles, 19% (10/54) were public health consultants, 9% (5/54) directors of public health, 11% (6/54) public health registrar ST4-5 and 13% (7/54) public health registrar ST1-3.

Almost half of the public health participants (44.4%, 24/54) reported they had pharmacy professionals as part of their current public health team. Fifty-two per cent (27/52) stated that they were aware of a pharmacy professional who was also a public health professional; example of roles included public health partnerships and improvement leads, chief pharmacist for Public Health Scotland, pharmacists guiding the analysis of national prescribing data and production of official statistics and ad hoc reports, lead antimicrobial resistance pharmacists.

Twenty-one per cent (10/54) of respondents agreed that their organisation would be willing to provide a placement to a funded pharmacy professional to undertake a secondment or fellowship in public health, whereas 12.8% (6/54) of respondents did not agree to provide a placement. A third (34%; 16/54) of respondents stated that their organization may possibly provide a placement.

Over half of respondents (54%; 27/54) stated the challenge of ensuring efficient medicine use in patient cohorts for the 12 months prior to the COVID-19 pandemic.

In England, more than half of the respondents (57%) stated that their public health teams had contributed to a pharmaceutical needs assessment (PNA) in the previous 5 years. Of which, 47% stated that a pharmacy professional was part of the public health team and 40% did not know. In Scotland, Wales and Northern Ireland, the survey captured the involvement of pharmacy professionals in the public health reports or delivery strategies, with a variable response across nations in the engagement of pharmacy professionals in reports.

Respondents were also asked what level of experience or qualification was required for a pharmacy professional who wants to focus on medicines or pharmacy-related public health activities. Almost half (43%; 13/29) specified a Masters in Public Health, two specified credentials at a consultant level by a public health or pharmacy professional body (Box 2).

Box 2. Examples of comments on level of experience or qualification required for a pharmacy professional who wants to focus on medicines or pharmacy-related public health activities.

“Bachelors degree standard public health qualification or masters modules in public health pertaining to determinants of health, inequalities, health economics (not necessarily the whole masters but perhaps a certain count of credits across key modules)”

“I think this would depend on what they were being asked to do however probably working towards masters in public health.”

“MPH and working toward UKPHR if not on formal training scheme.”

“MSc Pharmacy and MPH as minimum also at Royal Pharmaceutical Society consultant pharmacist ready status.”

Postgraduate qualification incorporating at least one module on public health or a public health related area. There are certain vocational aspects in healthcare where things can be learned on the job e.g., clinical practice, however in public health you need to know fundamentals and these are best taught in an academic context.

3.2.1. Benefits and Barriers to Specialist Roles for Pharmacists in Public Health

Eighty-seven per cent of public health professional respondents (45/52) agreed that having pharmacists or pharmacy technicians specialising in public health would be beneficial (37%) or very beneficial (50%), 13% agreed that it would be somewhat beneficial (Table 5 and Box 3). Respondents selected several areas of public health where they believed direct benefits would be realised and achieved by having direct involvement of pharmacy professionals. There were 15 areas that over a third of respondents selected as their top five areas (Figure 5), the top one being antimicrobial resistance/stewardship.

Example quotes from respondents are provided in Box 3.

Box 3. Examples of quotes from respondents on benefits of having pharmacy professionals as part of public health teams.

“Pharmacy professionals’ knowledge of medicines and medicines use is second to none. This knowledge could be utilized to analyse medicines use data and the development of public health strategies and campaigns. There are several areas within public health where the expertise of a pharmacy professional would be beneficial including vaccination, antimicrobial stewardship, smoking cessation, weight loss management and substance misuse. Within health institutions multi-disciplinary working is fully embedded and the role of the pharmacy professional is appreciated but the same system of working has not been established within public health.”

“They can bring knowledge of pharmacoeconomic, understanding of how pharmacy services are delivered in the community to the wider population, an independent prescriber would have the authority to help deliver health protection interventions e.g., managing outbreaks”

“Pharmacies are ideally placed to provide local people with information to support behaviour change and start them on their journey to improved H&WB. Health campaigns are promote via pharmacy a lot, this model could be used to support behaviour change through e.g., increased physical activity, signposting, raising the issue of PA or Healthy Weight, greenspace access etc”

Sixty per cent of respondents (30/50) believed there are barriers for pharmacy professionals to get involved in public or population health, while 26% (13/50) believed that there are no barriers for pharmacy professionals. Very few participants (4%;2/50) were unsure. (Table 6).

3.2.2. Call for Evidence

Forty-five stakeholders responded to the call for evidence. Sixty-nine per cent (n=31) were from England, 18% (n=80) from Northern Ireland, 9% (n=4) from Scotland and 4% (n=2) from Wales.

Most documents, reports and case histories identified were unpublished, and the case histories varied in detail. The number of papers identified by the respondents across each of the eight topic headings are illustrated in Figure 6. The majority of papers (n=21) related to expanding service beyond community pharmacy (CP), followed by expanding service delivery within CP (n=12). Fewer papers were identified for public health skills training (n=7), embedding optimisation of medicines at population level (n=8) and mitigating health inequalities (n=9).

3.3. Workshops to Generate Recommendations

The first workshop was attended by 12 people and the second workshop by 42 people. Seven attendees from the first workshop also attended the second workshop. From these two workshops, 94 recommendations were proposed and grouped under 8 themes (Table 7). For the full list of recommendations see Supplementary Material 4.

4. Discussion

The findings from this exploratory evidence review showcase the scope of existing PPH and further opportunities for pharmacy professionals to make substantial contributions in the public health landscape. In Griffiths et al., the importance of a varied skill mix within public health was highlighted, stating that “different levels of skill and a wide range of contributions are needed if public health programmes are to make the most impact” [11]. The WHO-ASPHER Competency Framework for the Public Health Workforce in the European Region stands as a cornerstone and valuable resource that offers comprehensive insights into skill mix for competent public health teams. Through their training, pharmacy professionals possess skills that align with all ten of the competency categories outlined by the WHO ASPHER framework [12]. Additionally, collaborative public health efforts between healthcare professionals are highlighted within the UK Faculty of Public Health Functions and Standards of a Public Health System [28] and the Royal Society of Public Health’s Unlocking the Potential of the Wider Public Health Workforce report [29].

The majority of pharmacy professionals surveyed do not hold a formal qualification in public health, and cited inadequate public health knowledge as a substantial barrier to further PPH involvement. Concurrently, the public health professionals surveyed stated that they would expect qualifications to be available for pharmacy professionals, such as public health Masters courses or postgraduate modules in public health related areas (e.g., health economics, health inequalities). As a result, the clear need for dedicated PPH training and system wide leadership is required to fully unlock the involvement of pharmacy professionals for population level benefits.

The barriers and opportunities identified in this study can be categorised as macro-, meso- or micro-level factors, as per an established socio-institutional framework previously used to examine how healthcare professionals expand scope of practice [13]. This framework helps recognise the opportunities that decision-makers have at each level to encourage more effective collaboration in interprofessional care teams [15]. Macro factors include professional regulation, education, funding, and provider payment schemes [17–23]. Meso factors include organisational structure, rewards, and information systems. Micro factors include processes based on mutual trust, and power-sharing that reflects knowledge and experience rather than titles [24,25,26]. and individual factors such as maturity in one’s profession and attitudes toward collaborative practices [27]. The delicate interactions between factors at all three levels shed light on the interconnectedness which is crucial for shaping and enabling collaborative practices within the ever-evolving public health landscape.

From our study, macro-level barriers as well as lack of pharmacy representation in public health domains coincide with the recent change in the UK healthcare landscape, policies such as the NHS Long Term Plan for England and the impact of the COVID-19 pandemic. In the wake of the pandemic, there are clear opportunities within the field of PPH.

Analysing the meso-level barriers and opportunities, the focus was on issues within local institutions and the wider community. Meso-level barriers identified by pharmacy professionals included organisational and structural barriers, a deficit in training and support, inadequate professional recognition and limited time and/or financial resources for pharmacy professionals to develop more advanced skills in public health. Meso-level opportunities were identified by at least half of the public health professional survey respondents, who had either previously or presently encountered pharmacy professionals working as members of public health teams or organisations. Additionally, over a third of respondents acknowledged 15 public health areas where pharmacy professionals could directly add value through the strategic position of pharmacy professionals in the community and good public health perception.

The micro-level barriers of day-to-day practice emphasised the limited career prospects and absence of defined career pathways for pharmacy professionals within the public health sector. This perceived lack of job opportunities also emphasizes the broader issue of scarce recognition of core knowledge, skills and qualifications pharmacy professionals bring to the public health sector.

The eight main themes identified from the proposed recommendations, outline the potential multifaceted nature of pharmacy professionals’ roles within the public health setting. Recently Todd and Ashiru-Oredope proposed that the definition of pharmaceutical public health is updated to include health inequalities. Suggesting the following definition: ‘the application of pharmaceutical knowledge, skills and resources to the science and art of preventing disease, prolonging life, promoting, protecting, improving health and reducing health inequalities for all through organized efforts of society’ [30]. A knowledge of the barriers and opportunities that pharmacy professionals face in public health can serve to advance and optimise their contributions in all themed areas.

Consensus from the emerging themes of both the surveys and rapid review findings highlighted the contribution pharmacy professionals can make to public health at all levels. There appears to be strong support from public health professionals regarding the impact and benefits of working in partnership with pharmacy professionals with advanced public health knowledge and skills, either directly or as part of a multidisciplinary public health team. As the health and care sector face intense challenges exacerbated by a declining labour pool, innovative and diverse roles within both the public health and pharmacy sectors can serve to unlock hidden potential [14].

Further grouping the eight themes, hidden potential can be focused on the macro-level of national strategic approach and commissioning, the meso-level pertaining to training and workforce development and the micro-level of individual development and involvement in research. Recent scoping reviews have proposed pharmaceutical public health competences for pharmacists [31,32]. There is currently a gap in the literature for pharmacy technicians. Recent qualitative study including pharmacists from Australia, United Kingdom, Canada and the United States of America, and Australia concluded that development strategies are required to be more effective in integrating public health approaches into pharmacy professional practice and for them to be recognised for their public health-related roles [33].

One of the main limitations of the study was the low response. However, the consensus from the themes emerging from both surveys’ findings highlighted the significant contribution pharmacy professionals make to the public health despite the barriers. Future qualitative studies should be considered to investigate and identify how to best resource advanced PPH resources.

4.1. Recommendations for Action

Using the findings of this mixed-methods exploratory study (surveys, call for evidence, workshops), overall recommendations for action to advance the public health skills of pharmacy professionals are grouped as follows:

National Strategic Approach and Commissioning

• Clearer regional and national leadership is required, defining standards and career pathways for pharmacy professionals in public health, with a robust competency framework and accreditation.
• Review of relevant regulations such as the Pharmaceutical Needs Assessment (PNA) regulations in UK would ensure that the emerging role of pharmacy professionals in public health is highlighted, and that data is formally collected as part of the PNA process.
• Setting priorities for public health contributions from pharmacy professionals in areas with limited pharmacy input, such as in emergency preparedness and planning, health protection, medicines surveillance and interventions, integration of primary, secondary and tertiary care, and health inequalities—the latter particularly in areas with a high population of underserved communities.

Workforce Development

• Defining a PPH career pathway will allow pharmacy professionals to remain within the profession whilst contributing or leading on public health matters, including at strategic levels. Within undergraduate and postgraduate programmes, public health competencies can be embedded within the curricula, such as undergraduate foundation modules or public health components in clinical and prescribing courses.
• Promoting specialism in PPH, for example in the UK through the Royal Pharmaceutical Society’s consultant credentialing and/or joint recognition or registration with the General Pharmaceutical Council and Faculty of Public Health (or UKPHR) would be a strong step to validating pharmacy professionals pursuing this avenue. For pharmacy technicians and pharmacy support staff, embedding PPH within their respective training courses would highlight the importance of pharmacy involvement in this area.
• Training programme for pharmacy professionals should include options to undertake public health activities, including health policy, wider determinants of health and financial drivers of population health. Constructing an effective professional development network will provide peer support and continual workforce development.

Evidence Development and Research

• Promoting the sharing of good PPH practice models and increasing the dissemination and adoption of research, audits and project findings by individuals will strengthen the PPH community. For high quality research, creating funding mechanisms for PPH with in turn promote involvement and collaboration in public health spheres.

5. Conclusions

This study highlights the multifaceted nature of pharmacy professionals’ roles within public health. The involvement of pharmacy professionals in public health aligns with global competency frameworks and public health standards. Barriers and opportunities to PPH involvement were analysed and categorised through a socio-institutional lens, spanning macro to micro-level factors. Recommendations to advance pharmacy professional involvement in PPH include their involvement with national strategic approach and commissioning, workforce development and further pharmaceutical public health evidence reviews and research.

Against the backdrop of an ever-changing healthcare landscape, shaping a transformative future for PPH must recognise, address, and leverage the interwoven factors at macro-, meso- and micro-level to identify innovative solutions that will unlock the full hidden potential of pharmacy professionals within public health and pharmacy sectors. Future qualitative studies should investigate and identify how to best utilise advanced PPH resources for the benefit of populations.