In the Dutch health care system pharmacies or national suppliers provide incontinence products.  Long-term usage is reimbursed by the health insurance for patients with urinary incontinence, if prescribed by a physician. The patient’s incontinence profile is based on the amount of urine loss, and determines the level of reimbursement. 

The Dutch ministry of Health commissioned an improvement trajectory, because there were doubts about the quality of continence care. This resulted in a new framework in which the individual daily activities are taken into account when providing the products (1). It is unknown what the impact of this new framework will be when applied into daily practice of especially pharmacies. Therefore, we have explored the expectations of pharmacy employees of the new framework. Current continence care and its facilitators and barriers was used as a starting point to gather knowledge for implementation of the new framework.

We conducted a qualitative study using focus group discussions with pharmacy employees involved in the delivery of incontinence products, as part of a larger project on the impact of the new framework on the quality of continence care. For that study, participating pharmacies received a training in the new framework. Prior to this training, the focus group meetings were held, with the first seven participating pharmacies, that differed in size, region and urbanization. There were two focus groups. The first one consisted of 11 participants (3 pharmacists, 7 pharmacy assistants and 1 continence nurse) from 5 pharmacies. The second focus group consisted of 4 pharmacy assistants from 3 pharmacies. The focus groups were conducted by a moderator and an observer, according to a semi-structured interview guide, formulated by the research group, consisting of researchers,  a GP and epidemiologist, experienced in this field. The four main topics in the interview guide were based on literature findings, the new framework and guideline knowledge of continence care: 1) delivery of incontinence products, 2) law en regulations, 3) incontinence product problems, and 4) the new framework.  We used an individual post-it assignment and a flip-over subgroup assignment to initiate group discussion. 

At the start of the focus groups the participants were asked for informed consent. The focus groups lasted respectively 110 and 70 minutes, excluding a 20 minute break, and  were audio and video recorded, and transcribed verbatim. The data was analyzed using a thematic content analysis using ATLAS.ti. The coding process was done by two of the authors. The open coding was done independently, after which the codes were discussed and recoded until consensus. During the coding process themes and subthemes were identified and discussed with a third author until consensus was reached on all themes.

Figure 1 shows the main themes derived from the two focus groups. 

Providing incontinence products
The limited level of reimbursement of the current system was considered to be challenging, although  the profiles also gave the participants a directive for the incontinence products.  The participants also found it challenging to define the degree of incontinence for the profile. 
Participants were positive about providing incontinence products based on individual daily activities as defined in the new framework, and would value the opportunity to provide products which are not needed on daily basis. However, participants were not convinced of the applicability in daily practice, because they expected insurers to remain the current reimbursement system, even with the new framework: "But the reimbursement is not yet based on individual daily activities."

Practice versus policy
Participants discussed that despite continence care policies, daily practice is different. Problems that are encountered are patients visiting the pharmacy directly without a prescription of the GP; incorrect usage of products; patients who change their behavior (e.g. drinking less fluid than advised), because of the limited reimbursement of products. Patient characteristics, such as age, weight, minority groups and shame also influence the behavior of and possibilities for the patient. 

Actors in continence care
Participants discussed facilitators and barriers related to different actors in continence care.  Barriers were caused by insurers, because of complicated policies on continence care and the current reimbursement system (e.g. ordering of products only allowed through national supplier): "Sometimes you don’t pay close attention. Then you're already busy with a patient, before realizing we can’t provide products for this insurer". In the collaboration between pharmacies and national suppliers the processes and communication were important themes. GPs were mentioned because of their (lack of) knowledge regarding incontinence products and other related treatments, while their prescriptions are needed in order to be reimbursed. Advices by home care professionals led to confusion because they sometimes gave patients advices for products that could not be reimbursed. 

Communication
Knowledge of the continence organizational system was an important theme in the communication between pharmacy staff and patients, for the system is hard to understand for patients: "It’s a difficult subject to explain; all those steps are quite difficult." Insurers reimbursement conditions were not clear for patients: available information for patients and pharmacies deviated. When patients had questions about reimbursement, they rather visited the pharmacy than asking their insurer. Communication between patients and national suppliers is often facilitated by the pharmacy, causing extra work for pharmacies. Pharmacies that invested in the relationship with local home care professionals experienced improved cooperation. Other pharmacies experienced problems with product advices by home care that were not covered by the health care insurer.

This focus group study aimed to explore the expectations of the new framework for continence care and its implementation and to establish facilitators and barriers in the current continence care from a pharmacy perspective. The participants supported the fundamental idea of the new framework to provide incontinence products taking individual daily activities into account. However, they were not convinced of the applicability in daily practice, because they expected the insurance companies to remain the current reimbursement system, even with the new framework. Information outside this qualitative study confirmed this expectation.

One of the main barriers we established in the current continence care was the low reimbursement for the profiles, which caused the participants to experience a limited freedom to provide incontinence products tailored for their patients. This also resulted in barriers when daily practice did not comply with the policies. Wider margins for reimbursement of products will enable pharmacy employees to take individual daily activities more into account when providing products.

The (lack of) communication between various actors in continence care is another important barrier. This causes a lot of frustration and extra work for pharmacies. Clear communication will save time and frustrations and is important for implementation of the new framework as well.

It was notable that home care was brought up multiple times by the participants as an important actor, since it was not included in the interview guide.

This is the first qualitative study exploring continence care provided by Dutch pharmacies. It shows that pharmacy employees are positive about the idea of the new framework to provide incontinence products taking individual daily activities into account, but they do have some reservations about the feasibility of the implementation in daily practice. The limited reimbursement possibilities and lack of communication are barriers in the current continence care. Participants expect that the new framework won’t change this. Policy makers in continence care should take this into account.

Medical aids care standard of continence: Care Intitute the Netherlands; 2018 [cited 13-02-2020. Available from: https://www.zorginzicht.nl/