Table 3. COM-B analysis of barriers and facilitators to delivering community pharmacy-based diabetes prevention services.

COM-B components with definitions	Mapped codes		Illustrative quotes
	Barriers	Facilitators
Physical capability (Physical skill, strength or stamina)		• Practical training	“I think if the CCG is commissioning a service then they should be able to provide us with the practical training” [Pharmacist]
Psychological capability (Knowledge or psychological skills, strength or stamina to engage in the necessary mental processes)	• Inadequate training to deliver services	• Knowledge of support staff • Consultation skills • Coaching and behaviour change skills	“I think we need to be very mindful that when we’re training our staff it’s not just about how you use the equipment. We have to up-skill them on consultation skills as well, because if people are to be utilising us more, they also need to feel that they’re getting quality service” [Pharmacist]
	• Maintenance of knowledge/skills is important		“You need the skills to be concentrated because if like say for example in the past we [GP practice] used to provide smoking cessation services, but we felt that we were not dealing with enough number of services so that our skills would remain at a high level” [GP]
Physical opportunity–(Opportunity afforded by the environment involving time, resources, locations, cues, physical affordance)		• Accessibility	“It’s about access as well. I think access is very important because I’ve had customers, they would have gone to the GP otherwise if we weren’t closer… one of them had to go in a wheelchair on the bus to go all the way to the surgery whereas they could just leave the house go in the wheelchair to the pharmacy and have it [Flu vaccination] done and then go home, so for them it’s easy access” [Pharmacist]
		• CP setting well placed to deliver pre-diabetes services	“How easy would it be to actually do things like mass screening in community pharmacy and the answer is really really easy…community pharmacy could be picking up pre-diabetics and you know giving the intensive lifestyle advice, weight management etc. you know that’s such a piece of cake” [Commissioner]
		• CP screening for NHS DPP could deliver faster referrals than surgeries	“I think it could only be a good thing for everybody because the delay in patients getting appointments in a busy practice means that if they are able to go via the pharmacist then they would get the referral quicker than perhaps waiting for an appointment to see somebody here to then be referred into the system” [Nurse]
		• Appointment systems with shorter waiting times than general practice • Walk in services	“Actually, booking appointments, I think, works for a lot of people even if they have to wait ten minutes. I think that’s better than what they have to wait at the doctors surgery’s” [Pharmacy technician]
		• A time-flexible alternative	“I think it’s again going back to individualisation…some patients would chose not to engage in the prevention programme, they may feel I don’t want to go to my GP surgery, I can’t ever get an appointment or I don’t have time to go there because their lifestyle and choices and things. So if they are willing to engage with their local pharmacy I would say its surely better that they engage with somebody and receive that advice and education that they need than getting signposted to somewhere that they are not going to follow-up with and not get any education at all” [Nurse]
	• Time pressure barrier to delivering diabetes prevention services • Pharmacist time constraints hindering delivery of services		“I can see this eruption this volcano erupting and suddenly not only will general practice be overwhelmed but so will the pharmacist delivering one to one because its very time consuming” [Nurse]
	• Time pressures leading to low quality service delivery	• Delivery of public health services need adequate time	“With diabetes our main problem is that we don’t have time of such for these kind of things we do them of course but there are a lot of time restraints that limit of us to the sort of quality that we may be able to give our patients with the services” [Pre-registration pharmacist]
	• Space challenges		“In terms of other barriers some pharmacies it would be their consultation rooms aren’t necessarily ideal” [Commissioner]
	• Lack of access to medical records		“The only thing I would say is that I don’t see how a pharmacy can help with medication reviews and tell patients they shouldn’t be taking certain drugs when they don’t have access to their blood results for some cases [laughter]” [Nurse]
	• Funding cuts a barrier to CP delivering more services	• Future CP services would need to be well funded	“You know what 6% shaved off! I mean that 6 seems like a small number but that’s big money you know because it’s paying for your staff to be able to deliver these services so that’s what it comes down to…we’re in this difficult situation right now… we want to be doing more we want to be involved more and like we’re tied, really we’re tied to the dispensary, we’re tied to these prescriptions” [Pharmacist]
	• Lack of resources to deliver beneficial services		“To give those services out and be beneficial to the patients a second pharmacist is always good . . .I mean we’ve got a second pharmacist in in our pharmacy for at least 4 days a week haven’t we but they said you know they are trying to that is getting harder and harder to fund” [Pharmacy technician]
	• Current CP services not Integrated in primary care • Pharmacists cannot deliver DPS without general practice • Perceives CP diabetes prevention services as fragmentation of primary care services	• Integration in primary care • Commissioning model and integration fundamental • CP and GP need to work together more • General practice should refer patients into new CP services	“The issue with all community pharmacy services at the moment is that they are not integrated at the end of the day they are an afterthought a bolt on…work separately” [Commissioner]
	• Current follow-up systems not efficient • Lack of feedback from CP services hindering referrals • Poor feedback from GP practice following CP referrals • IT systems not merged with GPs hindering GP referrals, follow-up and leading to duplication of work	Effective communication, feedback and referral systems to general practice are needed for the delivery of services IT connectivity fundamental for CP-GP integrated services	“You need the IT solutions etc. to be able to pass that information back to the GP practice, because at the moment it’s not an integrated system. So IT connectivity and read write abilities etc. are kind of fundamental I think to the integration of community pharmacy service going forward” [Commissioner]
Social opportunity (Opportunity afforded by interpersonal influences, social cues and cultural norms that influence the way that we think about things e.g. the words and concepts that make up our language)	• Challenges in funding services traditionally provided by general practice • No dedicated budget pot for commissioning CP services		“One of the problems at the moment with the way that commissioning happens in the NHS in primary care is if we are commissioned to do something that is a job that traditionally might have been done by the GP practice, how do you release that money?. You are not going to de-commission the GP practices, you’re not going to take money away from them etc. so how do you then fund that work that is being transferred to community pharmacy?” [Commissioner]
	• Commissioners do not prioritise CP • Pharmacy underrepresented in CCGs • Commissioners envision primary care as primary medical care (which doesn't include CP)		“I think the biggest barrier to developing community pharmacy services is the fact that commissioners at a local level do not see it as priority” [Commissioner]
		• Increased awareness • Targeted awareness • CP services awareness—responsibility of all HCP including CP	“I think the diabetes prevention program would be another good service we provide though provided we create the awareness so that people would know we are doing that, we’ve got the training to do that” [Pharmacist]
	• Patient barriers—only wanting to engage with prescription services	• Need positive promotion of CP i.e. not as cheaper alternative but accessing right level of care • Patient need to move in with the times and start using other HCP more rather than expecting to see GP	“I think also the raising of awareness of pharmacy need to be in a positive way, because you know the stuff that I’ve seen around pharmacy has been you know doctors too busy so go and see your pharmacist, or medicines are costing too much money go buy them cheaper in the pharmacy, and so I’m not 100% sure that that message is wholly positive” [Pharmacist]
	• Ethical challenges with promoting CP services		“Then again there’s another point with private companies like [pharmacy multiples] trying to advertise for services. It’s like this is a health thing do I really advertise it like I’m advertising for maybe perfume or milk? There’s that ethical aspect” [Pharmacist]
	• Lack of awareness of CP services (GP) • GP only aware of pharmacist role in medication • Lack of knowledge of CP role and skills		“I think that GP’s don’t understand, have no idea what pharmacists know and what pharmacists could do in community pharmacy… it’s just a lack of knowledge about that” [GP practice pharmacist]
	• Sceptical if prevention service is feasible in CP setting Sceptical if CP is the best setting for delivery of diabetes prevention advice		“I mean if they’ve got the appropriate resources then I can’t see any major disadvantages, but whether it’s feasible to provide all these services in a pharmacy setting I am not so sure, and whether one person can do all these things am not so sure” [GP]
	• Sceptical about follow-up following screening in CP • CP public health screening services with no follow-on programmes wasting primary care resources		“In terms of screening I can’t see any reason why it can’t be done outside of the surgery setting but I am a bit sceptical about how that would be dealt with in by the pharmacist. Meaning is it going to be a case of them just doing a blood test and then if they’ve got an HbA1c of 42 say oh go and see your GP or whether they can then give any focused advice about that or whether they would be empowered to do the necessary referrals to the say for example the diabetes prevention programme” [GP]
	• Commissioning CP services difficult due to multiple contractors	• Commissioning for outcomes better model of demonstrating impact of service	“They need to know what we they are commissioning and commissioning for outcomes… unless you can say what you are going to deliver and performance manage it then you know it’s always going to be questionable as to the impact that you’re providing” [Commissioner]
	• Commissioning CP services difficult due to multiple contractors		“Obviously we’ve got yes some big providers like [name of pharmacy multiples]… but we’ve also got individuals and if you were an evolving care organisation…an accountable care organisation and you wanted to commission something like that from community pharmacy….how do you manage it…in an area might be 30, 40, 50, 60 different contractors… so you need a vehicle really to actually deliver that” [Commissioner]
	• Competing interest in delivering services Competing interest with GP practices for services		“With regards to services moving out of primary care, if GPs provide the screening services then we get . . .as I said to you earlier we get kind of paid for it and it’s a source of income. So even though it might not be a huge source of income but because of the precarious state a lot of GP are around the country even smaller reduction in their income will have a destabilising effect” [GP]
	• Competing interest affecting CP-GP relationships		“There is some competition between services especially the flu vaccination… there’s been quite a lot of inappropriate advertising from both sides in the past few years to try to get patients so that’s something that kind of ruins the relationship a little bit” [Pharmacy technician]
	• GP perceiving that CP has an ulterior motive for providing services • Perceives CP delivering pre-diabetes advice as stepping on GPs toes	• DPP would need to be positively promoted to practices to ensure they don't see it as challenge upon their services	“Our satisfaction rates are have always been high in spite of whatever the newspaper say… and that's because we feel that the patients feel that we are doing what we are doing for them rather than for any other ulterior motive. I guess when they going to see a pharmacist even if they are very altruistic, even if they want to be just doing good for the patients, there always the suspicion if is it really just for me or is it because they are after their bottom line yeah so I don’t know” [GP]
		• Pre-diabetes education not efficient use of GP time	“We were referring patients to the health trainer…anyone who was diagnosed with [pre-] diabetes was sent her way because it’s not actually it’s not efficient use of our time to really educate somebody with pre-diabetes” [GP]
	• GP practices not referring patients to CP public health services		“There is an awful lot of surgeries that can't engage because they are busy as well and can't and don’t want to engage but they are not necessarily referring patients to community pharmacy” [Commissioner]
	• Potential patient resistance because historically they would see a nurse or a GP for diabetes services	• GP endorsement of CP services would positively influence uptake • GP endorsement of CP DPP would be important for instilling confidence in patients	“If the GP’s were to promote pharmacy then I think a lot more people will be more willing to uptake services” [Pharmacist]
		• CP could help reduce GP workload	“I think that’s good because from our point of view as primary care and GP practice were trying to reduce our footfall as much as possible in terms of patients coming into the surgery for things that can be dealt with by pharmacies” [Nurse]
	• CP time pressure leading to unwarranted referrals to general practice • CP public health screening services creating more referrals and workload for general practice		“If they are doing those things we need to see it…referring back if we need to something the only problem with that is that its more workload for us but it’s only the same as someone getting a private medical and then we have to deal with that so” [GP]
	• Fear of overwhelming working environment that CP DPS could create in primary care		“I can see this eruption this volcano erupting and suddenly not only will general practice be overwhelmed, but so will the pharmacist delivering one to one” [Nurse]
	• Poor relationships with pharmacy multiples	• Positive working relationships with general practice-owned pharmacies • Good referral systems depending on relationships	“I suppose because we have got our own pharmacy we just work through …yes so we know them all so they are employed by the practice so we’ve got pharmacy patients and dispensary patients so it’s all done within the practice” [GP]
		• GPs need to have confidence in pharmacy team ability to deliver DPP	“It’s you know trying to build the confidence of the doctors in us as well and our teams because at the end of the day if we do something like this it’s unlikely it’s going to be use that’s delivering the service it’s going to be our healthcare team so they have to build up confidence in what we’re doing” [Pharmacist]
		CP need to build trust with GPs	“Yeah I mean I guess there ought to be a bit more kind of trust in between, I think it’s mostly a trust issue. If GPs are to trust that what they are doing they are doing it properly and then the GPs don’t have to take up the extra burden but not be paid for it, then I think it would work well” [GP]
	• Potential resistance from general practice because historically patients go to a GP setting for diabetes services		“I would imagine that there could potentially be some resistance from obviously places like us as a GP setting, because historically it would always be that you came to your GP and you know if the GP or the practice nurse or whoever would see you and diagnose you and give you advice and so on” [Nurse]
	• GPs perceiving to be better than pharmacists at giving pre-diabetes due to extensive knowledge of diabetes and associated co-morbidities • GPs perceiving to be better placed to give pre-diabetes opportunistic advice due to links with co-morbidities in patients the consult		“I think the background knowledge is very important but what is also important is the experience behind it. I mean it will be very difficult for a pharmacist to replicate the experience which a GP will have because diabetes is not just diabetes, its kidney disease, its heart disease, its peripheral vascular disease and we see it day in and day out. I think a pharmacist will be adjunct to this but I don't think pharmacists will be able to do this all on their own.” [GP]
Reflective motivation (Reflective processes involving plans (self-conscious intentions) and evaluations (beliefs about what is good and bad))		Use pharmacy skill mix to deliver diabetes prevention services CP public health interventions don’t have to delivered by pharmacists	“We are supposed to be utilising and making best use of the skills mix … because as much as we get frustrated with the monotony of our role as do our dispensers and our healthcare assistants so introducing these things can make them feel challenged and provide opportunities for growth” [Pharmacist]
	• Dispensary role of pharmacist hindering scope to deliver more services • Pharmacy workload hindering delivery of services	Appropriate allocation of resources	“Our employers have to be on-board properly. We need the support unless this can be done by a designated member of staff, but if it’s on the pharmacists again then that would be a problem because as it is there is so much that I need to do” [Pharmacist]
	• Inadequate training leading to lack of confidence	Self-efficacy of staff in delivering services enhanced by training and experience Confidence of patient and GPs on CP delivering services enhanced by training and experience	“I think it’s imperative that you know the services are standardised across the board that will instil confidence ok for us and also for the patients you know you don’t want your patient to come in and you don’t know what you’re doing” [Pharmacist]
	• Lack of structure to deliver particular services leading to pressure on pharmacist resources • Overwhelming experience created by unstructured delivery of CP services		“If you get people come marching through your door to speak to your pharmacist, and as you were saying you’ve got your methadone addicts, and you’ve got your morning after, and you’ve got your MUR’s, it sometimes as a pharmacist you don’t know where your backside is really because you're everywhere” [Pharmacist]
		Implementation of service with GP to alleviate tensions caused by competing interests	“The worry is if the GP’s think oh you’re just taking their job away…so it’s trying to make sure that we get a good conversation going with the GP’s and actually come up with a good way to actually implement the service with them” [Pharmacist]
		Delivering pre-diabetes lifestyle advice does not require one to have a medical degree	“As a GP I mean I do do an awful lot of it [lifestyle advice] opportunistically within the consultation because it relates to so many things… blood pressure and anything but you don’t need a medical degree to give lifestyle advice” [GP]
Automatic motivation (Automatic processes involving emotional reactions, desired (wants and needs), impulses, inhibitions, drive states and reflex responses)	• GPs will only endorse services if there something in it for them		“If obviously the doctors have got QOF targets and they will be paid for a similar thing then they’re not going to be sending people to me if they can get that money isn’t it” [Pharmacist]
		CP diabetes prevention services would bring in financial benefits	“So cost wise in providing the service I think it would be cheaper for the NHS for us to do it [deliver DPS] than to get the GP surgery’s to do that…also hopefully they will channel a little bit of money you know from there into the community pharmacy so that they can provide us with extra hands that we need” [Pharmacist]
	• Pharmacists intimidated by GPs—affecting relationships		“I think as pharmacists we can find it you know really difficult to talk to GP’s sometimes… I think of what I used to be like with consultants, they seemed you know they were up here…that’s a personality thing sometimes and I think it would be the same” [GP practice pharmacist]