Elsevier

Social Science & Medicine

Volume 53, Issue 7, October 2001, Pages 943-955
Social Science & Medicine

The reprofessionalisation of community pharmacy? An exploration of attitudes to extended roles for community pharmacists amongst pharmacists and General Practioners in the United Kingdom

https://doi.org/10.1016/S0277-9536(00)00393-2Get rights and content

Abstract

In the light of recent developments within the British National Health Service some sociologists have suggested that the medical profession's status is under threat. They have specified a range of factors contributing to this state of affairs, such as the new consumerism; however, it is thought that attempts by other, related occupations at reprofessionalisation are particularly significant in this trend. It may be possible to understand recent initiatives at extending community pharmacists’ role within this framework. This paper suggests that while community pharmacy is developing strategies to enhance its professional status, it is not so much an attempt at usurping general practitioners’(GPs) (primary care doctors’) role as a bid for survival, especially on the part of the rank and file. However, GPs do not necessarily see the initiatives in this light. Although many GPs are accommodating some changes in community pharmacy, they also perceive some of the initiatives as a threat to their autonomy and control, this was especially evident in representative bodies such as the Local Medical Committee. Doctors’ accommodating attitudes were qualified with traditional attitudes of dominance such as ‘limitation’ and ‘exclusion’. Such attitudes could prevent community pharmacy from achieving professional status. However, there is also evidence that pharmacists themselves contribute to this situation because many of them also attribute ultimate authority to doctors. Moreover, they are held back by internal occupational divisions particularly between retail pharmacists and employee pharmacists, with the former being the most insecure.

Introduction

The social position of the ‘traditional’ professions such as medicine is thought to depend on a number of factors one of which is having access to and control of a unique body of specialist knowledge. Pharmacists were no exception to this as their original role of compounders of medicines had involved an understanding of and control of an exclusive field of knowledge that led pharmacy to enjoy a status comparable with occupations such as medicine. While it has been argued that recent changes have threatened the position of medicine (Calnan & Williams, 1995) and its dominance and authority are waning, the professional status of pharmacists is said to have suffered a more dramatic decline in that the current pervasive view of pharmacy is that it is ‘marginal’, ‘incomplete’ or ‘limited’ in terms of its occupational status. This ‘quasi’-status stems from the shift during the 20th century to the mass production of medicines by the pharmaceutical industry that made pharmacy's role in production redundant. It also reflects internal divisions, especially that between the retail, profit-orientated sector and medical service and the division between hospital and community pharmacy. However, in recent years pharmacy's quasi-status may also be linked to its relationship with medicine, which is a typical case of occupational limitation involving constraints on a specific therapeutic method. There is a view that pharmacy's professional development has been hindered largely because of medicine's control over its clinical autonomy, which in turn has had implications for economic autonomy (Turner, 1996, pp. 138–142). Whereas in the past pharmacists enjoyed a high status because of their understanding of an exclusive field of knowledge, it is now thought that they have become overqualified for their roles and ‘over-educated’ distributors of medicines (Mesler, 1991, p. 312).

One understanding of professionalism portrays it as a political struggle to attain and maintain control and autonomy in a specific field and to protect territory in the labour market in order to secure higher income and more control over working conditions. According to this perspective the occupation aspires to control a monopoly in the market for that particular service. Professional autonomy is thought to exist when an occupation has control over its remuneration (economic autonomy); when it is in a position to influence policy decisions (political autonomy) and when it is able to make its own clinical judgements (clinical autonomy) (Elston, 1991, pp. 61–62). There are other ways of looking at professionalism (see Harrison & Ahmed, 2000) but we are using it in this way here.

In the United Kingdom (UK) pharmacy's autonomy remains quite limited in economic, political and clinical respects. Taking economic autonomy first, there is evidence of some independence. Community pharmacy has its own remuneration negotiating body, the Pharmaceutical Services Negotiating Committee (PSNC), for determining remuneration. Retail pharmacists also have opportunities to generate independent income from non-pharmaceutical products. However, it has long been recognised that the current method of remuneration, based on number of items dispensed, under the NHS ‘acts counter to the exercise of [pharmacists’] professional role and needs to be changed’. The PSNC itself spoke about the restraining influence of remuneration in its evidence to the Nuffield Committee of Inquiry (1986).1 Moreover, there is little evidence of pharmacists having the same kind of political autonomy enjoyed by the medical profession. Unlike pharmacy, its representative body, the British Medical Association (BMA), has become a powerful pressure group and has a much higher profile in public policy debates. With respect to the question of clinical autonomy, pharmacists’ control is also limited. While pharmacists have some autonomy when making decisions about ‘over-the-counter’ (OTC) sales, it currently has no autonomy over prescribing. Although pharmacists have a license that allows them to supply prescribed drugs, they have no legal right to prescribe ‘potent medications’. Rather, they have to supply according to the prescribers’ instructions ( Harding & Taylor, 1997, p. 553).

In response to the deskilling of pharmacy, pharmacy's representative institutions in the UK have led the campaign for reprofessionalisation through seeking to redefine community pharmacy's role in the Primary Health Care Team (PHCT). The Royal Pharmaceutical Society of Great Britain (RPSGB) and the National Pharmaceutical Association (NPA) are united in their aim for pharmacists to become more closely involved in the PHCT and to receive suitable professional recognition. The RPSGB initiated the Pharmacy in a New Age Project (PIANA) which outlined four main areas considered critical to the future of pharmacy. These were: the management of prescribed medicines; the management of long-term conditions; the management of common ailments and the promotion and support of healthy lifestyles. The project aimed at ‘realising the potential of pharmacy’ on the grounds that pharmacists were a ‘massively underused resource’ in healthcare. The RPSGB and the NPA are a major source of pressure for change. In the 1980s, for example, the NPA instituted a campaign aimed at encouraging the public to consult pharmacists on health matters. Its advertising campaign centred around the slogan ‘Ask Your Pharmacist’ and at the same time the RPSGB took measures to redefine its image (Holloway, Jenson, & Mason, 1986, pp. 325–329). Given that pharmacists’ clinical, economic and political autonomy is restricted, the campaign at the macro level might be portrayed as an attempt to lay claim to a new area — not necessarily expansionist but consolidating their field of work because of their lack of clinical autonomy and deskilling.

These professional organisations are the main actors in the reprofessionalisation project, though the government has also supported a shift in pharmacist roles through a series of proposals designed to develop wider functions for community pharmacists. The 1986 Nuffield Report and the 1996 White Paper,2 Choice and Opportunity: Primary Care in the Future, emphasised the need for community pharmacists to become more involved in the PHCT. Present changes in the NHS, in particular, the development away from a health service based on secondary care to one based more on primary care (Hassell et al., 1998 p. 5) have sharpened these debates about pharmacy's future. The new 1997 White Paper, The New NHS, Modern and Dependable, signals further changes in primary care by giving professionals who make prescribing and referral decisions more financial and clinical responsibility. This development could offer community pharmacists a further opportunity to integrate into the PHCT (Ruston et al., 1998, p. 2). The New NHS said that pharmacists would ‘need to be drawn in [to the Primary Care Groups (PCGs)] to contribute as appropriate to the planning and provision of services’.3 Although the Department of Health did not include pharmacists as members of the PCG boards in England, some health authorities are approaching pharmacists to do specific tasks and, in some cases, have included them on the boards (Livingstone, 1998, pp. 161–2). Frank Dobson (former Minister of Health) spoke at meetings of the RPSGB and at Local Pharmaceutical Committees (LPCs)4 about the government's support for this aim. In the past, he mentioned extending pharmacists’ role into diagnosis and prescribing for minor ailments.5 More recently the government has put forward proposals for one-stop health centres to include community pharmacists; the implementation of repeat dispensing by greater pharmacist involvement in medicines’ management; and a change in the remuneration system that rewards services provided and not just the volume of prescriptions dispensed.6

Initiatives to extend community pharmacy's role raise the issue of the occupation's lower status in relation to medicine (Hamilton, 1998, p. 42). Pharmacy's representative institutions are seeking to equalise relations between pharmacy and medicine and are unhappy about community pharmacy's apparent subordinate role. This has been highlighted in recent debates about the new PCGs. The Labour government introduced PCGs as part of its aim of dismantling the internal market created by general practitioner (GP) fundholding. The PCGs, incorporating all GPs (as well as community nurses) are responsible for commissioning health services and hold budgets for hospital and community health services within a given locality. Both the NPA and the RPSGB are conscious of the inequality between medicine and pharmacy and want to eradicate the differential. There is currently some disquiet about pharmacists not being included in the emergent PCGs and GPs’ numerical dominance in the boards (Livingstone, 1998, pp. 161–162). Individual PCG boards could co-opt pharmacists on to them, but even when pharmacists are on the boards they would not have voting rights.7 As members of PCG boards, pharmacists are able to offer advice on prescribing. In the debates that took place over this situation, the Director of the NPA told the former health minister, Alan Milburn, that the government's NHS White Paper had emphasised a need to draw pharmacists into the service planning and provision process through a “coming together of equals”’ and that the exclusion of pharmacists from the groups contradicted this.8

Medical sociology has not paid much attention to community pharmacy. This might be because of the discipline's own tendency to reproduce the existing hierarchies in health care and the disproportionate allocation of research resources to the study of issues relating to doctors (Dingwall & Wilson, 1995, p. 112). This study, however, attempts to fill this gap. Through an analysis of community pharmacists’ and GPs’ perceptions of projects involving extending community pharmacy's role, this study seeks to consider the explanatory power of the neo-Weberian position on professionalism and reprofessionalisation. It looks at whether pharmacists are expanding their role for professional (job satisfaction), business, political (survival or expansionist) or altruistic reasons. It also considers whether doctors are encouraging these initiatives or resisting them and for what reasons (altruistic, self interested or political). That is, do the doctors see extending pharmacy's role as an encroachment on their territory or as a way of expanding their empire through further subordination of pharmacy? Or do they see the extension of community pharmacy's role in ‘altruistic’ terms as a way of improving patient care? Our approach relies on the evidence from informants and on the basis of this evidence we can assess the ‘motives’ of the doctors and pharmacists and evaluate the sociological arguments. Evidence in support of the reprofessionalisation thesis would include statements supporting the development of community pharmacy in such a way as to make better use of pharmacist skills and training, taking on more patient oriented service roles, closer involvement in the PHCT and support for a service-based remuneration system.

Section snippets

Research and methods

In 1997, the Department of Health sponsored a series of pilot projects aimed at testing some form of extended role for community pharmacists in the UK. Each of these projects had their own local project managers and evaluators. However, our role was to provide an overall evaluation of all of the projects, looking specifically at questions of acceptability and feasibility. While they differed in some respects, all of the projects involved a departure from a remit that centred on dispensing to

Pharmacists’ strategies for reprofessionalisation

The pharmacists who took part in the projects clearly saw themselves as playing a part in redefining community pharmacy and enhancing their professional status. There was a general feeling that their skills were being under-used and that they could play a closer role in the PHCT. In particular, they believed that they could provide more help with medicines management, promotion of healthy life-styles and giving advice to other health care professionals. Moreover, it was thought that pharmacy

Discussion

Elite groups within a given occupation tend to be the key advocates of new roles in any reprofessionalisation project (Birenbaum, 1982). In Britain, the NPA, the RPSGB and the LPCs have been at the forefront of the movement to extend community pharmacy's role. This study shows that rank and file members of the occupation seem to be behind the drives to enhance pharmacy's status and to move away from an exclusively dispensing role to more patient oriented ones. This observation needs to be

Acknowledgements

We should like to acknowledge the Department of Health for providing the grant for this study; Dianne Kennard, Principal Pharmacist, Department of Health for her support and the pilots’ project managers for their co-operation. We should also like to thank Dr. Annmarie Ruston, Sonia Colwill, Dr. John Woodward and Alan Stewart for their advice.

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