Professions & Professions & prescribing: insights from prescribing: insights from

nursing & pharmacynursing & pharmacyPaul BissellPaul Bissell

Public HealthPublic HealthScHARRScHARR

University of SheffieldUniversity of Sheffield

BackgroundBackground

Medical sociologist / worked in pharmacy for over 10 yearsMedical sociologist / worked in pharmacy for over 10 yearsNumerous evaluations community pharmacy practice:Numerous evaluations community pharmacy practice:

Advice-giving in pharmacyAdvice-giving in pharmacy Lay and professional perspectives on risk of non-prescription Lay and professional perspectives on risk of non-prescription

medicinesmedicines Pharmacy supply of emergency hormonal contraception (EHC)Pharmacy supply of emergency hormonal contraception (EHC) Public health and pharmacyPublic health and pharmacy Social capital, inequalities and pharmacySocial capital, inequalities and pharmacy Ethical dilemmas in community pharmacyEthical dilemmas in community pharmacy Medicines management in community pharmacyMedicines management in community pharmacy Evaluation of supplementary prescribing in nursing and Evaluation of supplementary prescribing in nursing and

pharmacypharmacy

Overview Overview

Nursing & pharmacy professions both Nursing & pharmacy professions both make claim to be rightful heirs to non make claim to be rightful heirs to non medical prescribing.medical prescribing.

Provide contrasting & overlapping insights Provide contrasting & overlapping insights into sociology of professions / continuing into sociology of professions / continuing dominance of medical profession around dominance of medical profession around medicines usage.medicines usage.

Context for non-medical prescribing: Context for non-medical prescribing:

power of medical professionpower of medical profession““Doctors have held a unique position of Doctors have held a unique position of power over prescribed medications for power over prescribed medications for some years, a role that has brought with it some years, a role that has brought with it the control of the scope of practice of other the control of the scope of practice of other health professionals. It is likely that some health professionals. It is likely that some will be reluctant to abandon it.” (Baird will be reluctant to abandon it.” (Baird 2000: 454)2000: 454)

Context for non-medical prescribing: Context for non-medical prescribing:

power of medical professionpower of medical profession““The medical profession has an almost The medical profession has an almost exclusive right to prescribe medicines but exclusive right to prescribe medicines but this right is being challenged by…other this right is being challenged by…other health professions. It is argued that in health professions. It is argued that in British General Practice, prescribing is a British General Practice, prescribing is a battle ground on which the cause of battle ground on which the cause of clinical autonomy is defended.” (Britten clinical autonomy is defended.” (Britten 2001:478)2001:478)

Role of professionsRole of professions

Classic theme in medical sociology.Classic theme in medical sociology.

Friedson’s ‘Profession of Medicine’:Friedson’s ‘Profession of Medicine’: medical power rests on medical power rests on autonomyautonomy over its over its

own work activities andown work activities and dominance / controldominance / control over the work of others in over the work of others in

the health care division of labour.the health care division of labour.

Medical DominanceMedical Dominance

““organised autonomy is not merely freedom from organised autonomy is not merely freedom from the competition or regulation of other workers, the competition or regulation of other workers, but in the case of such a profession as but in the case of such a profession as medicine…it is also a freedom to regulate other medicine…it is also a freedom to regulate other occupations. Where we find one occupation with occupations. Where we find one occupation with organised autonomy in a division of labour, it organised autonomy in a division of labour, it dominates the others. Immune from legitimate dominates the others. Immune from legitimate regulation or evaluation from other occupations, regulation or evaluation from other occupations, it can legitimately evaluate the work of others. it can legitimately evaluate the work of others. By its position in the division of labour we can By its position in the division of labour we can designate it as a designate it as a dominant professiondominant profession” ” (Friedson 1988:369).(Friedson 1988:369).

Medical DominanceMedical Dominance

Last 30 years various arguments about Last 30 years various arguments about decline of medical power: decline of medical power: Proleterianization: clinical freedom under Proleterianization: clinical freedom under

threat from state / HMOs threat from state / HMOs Deprofessionalisation: rise of assertive Deprofessionalisation: rise of assertive

patients / narrowing of knowledge gappatients / narrowing of knowledge gap

Nancarrow & Borthwick (2005) discuss the Nancarrow & Borthwick (2005) discuss the fluid nature of professional boundaries in fluid nature of professional boundaries in health carehealth care

Medical DominanceMedical Dominance

A consensus that medical power is being challenged, but A consensus that medical power is being challenged, but not necessarily eroded:not necessarily eroded: Internal stratification within medical professionInternal stratification within medical profession Cost awareness & containment: managerialism/ audit / Cost awareness & containment: managerialism/ audit /

clinical governance clinical governance Greater scrutiny & regulation as a result of medical errors / Greater scrutiny & regulation as a result of medical errors /

abuse abuse Consumerism / lay knowledge /greater assertiveness by Consumerism / lay knowledge /greater assertiveness by

patientspatients Professionalisation and availability of CAMProfessionalisation and availability of CAM Lay scepticism towards expert systems more generallyLay scepticism towards expert systems more generally Boundary encroachment from other health professionals Boundary encroachment from other health professionals

(eg. prescribing and medicines management nursing and (eg. prescribing and medicines management nursing and pharmacy…)pharmacy…)

Prescribing & medicines management in Prescribing & medicines management in nursing and pharmacynursing and pharmacy

General consensus about a challenge to, if not an General consensus about a challenge to, if not an erosion of medical power.erosion of medical power.How has the medical profession reacted to nurse and How has the medical profession reacted to nurse and pharmacist prescribing / medicines management roles?pharmacist prescribing / medicines management roles?Has this translated into enhanced status for nursing and Has this translated into enhanced status for nursing and pharmacy as a result of involvement in prescribing / pharmacy as a result of involvement in prescribing / medicines management tasks?medicines management tasks?What are the implications for nursing and pharmacy What are the implications for nursing and pharmacy professions?professions?

Nurse Prescribing - overview Nurse Prescribing - overview

Development & reaction to nurse Development & reaction to nurse prescribing in the UK and US.prescribing in the UK and US.

Different experiences and responses by Different experiences and responses by medical profession in UK and US.medical profession in UK and US.

Evidence of considerable concern from the Evidence of considerable concern from the medical profession.medical profession.

Nurse Prescribing Nurse Prescribing

UK - able to carry out both Independent and UK - able to carry out both Independent and Supplementary prescribing.Supplementary prescribing.Independent prescribing began in 1994 almost Independent prescribing began in 1994 almost opportunistically.opportunistically.Roots in DN – diagnosis requiring ‘rubber stamp’ / Roots in DN – diagnosis requiring ‘rubber stamp’ / geographical distance from doctors require to sign geographical distance from doctors require to sign / improvements in access./ improvements in access.Strong political support for prescribing role from Strong political support for prescribing role from RCN – alliances with BMA & RPSGB / stressed RCN – alliances with BMA & RPSGB / stressed partnership model.partnership model.Push for private members bill (1992 Medicinal Push for private members bill (1992 Medicinal Products: Prescription by Nurses etc Act).Products: Prescription by Nurses etc Act).

Nurse Prescribing Nurse Prescribing

Conservative government concerned about cost.Conservative government concerned about cost.June Crown appointed to carry out review of non June Crown appointed to carry out review of non medical prescribing.medical prescribing.Series of pilot sites set up – rise of independent Series of pilot sites set up – rise of independent prescribing (from limited formulary)prescribing (from limited formulary)Pace of change speeded up post Labour victoryPace of change speeded up post Labour victoryExtended Independent Nurse Prescribing from Extended Independent Nurse Prescribing from 2001. 2001. Dependent, renamed supplementary prescribing Dependent, renamed supplementary prescribing (via Clinical Management Plan) implemented. (via Clinical Management Plan) implemented.

Nurse Prescribing - responsesNurse Prescribing - responses

Numerous (HSR) studies, claiming nurse Numerous (HSR) studies, claiming nurse prescribing viewed positively by patients, is cost prescribing viewed positively by patients, is cost effective, is (viewed as) safe, improves access effective, is (viewed as) safe, improves access and does not waste doctors time.and does not waste doctors time.Jones - ‘irrefutable proof’ that nurse prescribing Jones - ‘irrefutable proof’ that nurse prescribing was working on every criteria of safety, costs was working on every criteria of safety, costs and effectiveness.and effectiveness.By 2005 – prescribing from whole formulary was By 2005 – prescribing from whole formulary was announced (for both nurses and pharmacists) by announced (for both nurses and pharmacists) by Sec of State.Sec of State.

Nurse prescribing – concerns from Nurse prescribing – concerns from within professionwithin profession

Lack / absence of formal supervision for nurse prescribers.Lack / absence of formal supervision for nurse prescribers.Lack of incentives to assist with mentoring.Lack of incentives to assist with mentoring.Concern that it is driven by medical shortages / to reduce junior Concern that it is driven by medical shortages / to reduce junior doctors hours / size of medical budget.doctors hours / size of medical budget.Many nurses not prescribing despite completing training. Many nurses not prescribing despite completing training. Concern that nursing becomes medicalized / looses identity as a Concern that nursing becomes medicalized / looses identity as a ‘caring profession’.‘caring profession’.Aidroos (2002) – ‘offer and drug and depart’ service.Aidroos (2002) – ‘offer and drug and depart’ service.Will nurses be held to the same standards of care as other health Will nurses be held to the same standards of care as other health professionals?professionals?Do nurses have choice about whether to prescribe – evidence Do nurses have choice about whether to prescribe – evidence that employers alter job descriptions to include prescribing.that employers alter job descriptions to include prescribing.Considerable scope to develop a sociological research agenda in Considerable scope to develop a sociological research agenda in these areas.these areas.

Nurse prescribing – concerns from Nurse prescribing – concerns from medical professionmedical profession

BMA (2002) – ‘training nurses get is nothing like sufficient and will BMA (2002) – ‘training nurses get is nothing like sufficient and will not give them the clinical knowledge they need to prescribe these not give them the clinical knowledge they need to prescribe these drugs’.drugs’.Nurse prescribing - ‘a dangerous uncontrolled experiment’ (Horton Nurse prescribing - ‘a dangerous uncontrolled experiment’ (Horton 2002) - also refers to prescribing entailing a loss of nurses identity.2002) - also refers to prescribing entailing a loss of nurses identity.Criticism of nursing – seen through lens of professional attributes. Criticism of nursing – seen through lens of professional attributes. Others more cautiously optimistic about nurse prescribing (Avery Others more cautiously optimistic about nurse prescribing (Avery and Pringle 2005).and Pringle 2005).Concern about speed of change / availability of mentoring from GP / Concern about speed of change / availability of mentoring from GP / doctor / availability of role.doctor / availability of role.Medical press (eg Pulse) maintaining pressure & surveillance over Medical press (eg Pulse) maintaining pressure & surveillance over nurse prescribing.nurse prescribing.Numerous concerns about pharmacology & therapeutics training for Numerous concerns about pharmacology & therapeutics training for nurses.nurses.

Safety & nurse prescribingSafety & nurse prescribing

Systematic review of safety of nurse (supplementary) Systematic review of safety of nurse (supplementary) prescribing.prescribing.Most published papers not based on empirical research / Most published papers not based on empirical research / focus on adequacy of nurses training, knowledge & focus on adequacy of nurses training, knowledge & skills.skills.Review shows that doctors believe that Clinical Review shows that doctors believe that Clinical Management Plan allows them to retain power / provides Management Plan allows them to retain power / provides a framework for guiding decisions.a framework for guiding decisions.Little empirical evidence that nurse prescribing is Little empirical evidence that nurse prescribing is ‘unsafe’.‘unsafe’.Concerns tempered by awareness of scope / scale of Concerns tempered by awareness of scope / scale of nurse prescribing in England.nurse prescribing in England.

Overview of PACT dataOverview of PACT data

NursesNurses

YearYear Item volumeItem volume Net ingredient costNet ingredient cost

20042004 3.5 million3.5 million £52.2 million£52.2 million

20052005 4 million4 million £58.9 million£58.9 million

20062006 6.3 million6.3 million £79.3 million£79.3 million

2007 (to end of September)2007 (to end of September) 6.8 million6.8 million £79.5 million£79.5 million

PharmacistsPharmacists

YearYear Item volumeItem volume Net ingredient costNet ingredient cost

20042004 27062706 £25,348£25,348

20052005 11,45811,458 £96,846£96,846

20062006 31,05231,052 £278,634£278,634

2007 (to end of September)2007 (to end of September) 44,31844,318 £332,320£332,320

Nurse PACT DataNurse PACT Data

Nurse Prescribing 2004-2006

0

1

2

3

4

5

6

7

Item volume(millions)

200420052006

Nurse Prescribing 2006

Infections 10%

Respiratory 6%

Appliances 7%

Obs, Gynae and UTI 4%

Other 15%

Cardio-vascular 5%

Dressings 32%

CNS 9%

Skin 12%

Nurse prescribingNurse prescribingUK - establishing prescribing rights for nurses has UK - establishing prescribing rights for nurses has involved some conflict with the medical profession.involved some conflict with the medical profession.Not clear that supp rx based around CMP enhances Not clear that supp rx based around CMP enhances status.status.CMP provides reassurance for doctors.CMP provides reassurance for doctors.Maintains status divisions between supp & independent Maintains status divisions between supp & independent prescriber.prescriber.Indeterminacy / technicality ratio – supp rx based around Indeterminacy / technicality ratio – supp rx based around CMP / maintains status hierarchies. CMP / maintains status hierarchies. Diagnosis / independent prescribing may result in rather Diagnosis / independent prescribing may result in rather more conflict.more conflict.Different to situation in the US.Different to situation in the US.

Nurse prescribing in USNurse prescribing in US

Development of nurse prescribing resulted Development of nurse prescribing resulted in much more opposition in the US.in much more opposition in the US.

Nurse prescribing grew out of nurse Nurse prescribing grew out of nurse practitioner role in paediatrics / response practitioner role in paediatrics / response to ‘thin provision of care’ in rural areas.to ‘thin provision of care’ in rural areas.

Creation of ‘negative formularies’ for Creation of ‘negative formularies’ for nurses / negotiation of independent nurses / negotiation of independent prescribing in most states for NPs.prescribing in most states for NPs.

Nurse prescribing in US Nurse prescribing in US Mundinger et al (2000) ‘combination of authority Mundinger et al (2000) ‘combination of authority to prescribe drugs, direct reimbursement from to prescribe drugs, direct reimbursement from most payers and hospital admitting privileges most payers and hospital admitting privileges creates a situation in which NPs and primary creates a situation in which NPs and primary care physicians can have equivalent care physicians can have equivalent responsibilities’. responsibilities’. NPs reimbursed at same rate as physicians in NPs reimbursed at same rate as physicians in some states.some states.Fennell argues ‘inherent in the physician and Fennell argues ‘inherent in the physician and pharmacist opposition to nurse midwives pharmacist opposition to nurse midwives prescribing is…an interest in their own economic prescribing is…an interest in their own economic survival.’survival.’

Nurse prescribing in USNurse prescribing in US

Byrne & Helman (2002) – anti-competitive Byrne & Helman (2002) – anti-competitive practices of health plans where consumers practices of health plans where consumers are instructed to use mail order/internet are instructed to use mail order/internet pharmacy services, many of which refuse pharmacy services, many of which refuse to accept NPs prescription.to accept NPs prescription.

Chen-Scarabelli (2002) – ‘various state Chen-Scarabelli (2002) – ‘various state medical associations lobby against nurse medical associations lobby against nurse practitioners in a an attempt to maintain practitioners in a an attempt to maintain monopoly over health care management’.monopoly over health care management’.

Nurse prescribing in USNurse prescribing in US

Edgley et al – “federal state’s reactive Edgley et al – “federal state’s reactive stance has opened the way for overt stance has opened the way for overt conflict between the professions as they conflict between the professions as they fight it out over territory, rights and fight it out over territory, rights and responsibilities.”responsibilities.”

Professions’ responses to threats & Professions’ responses to threats & opportunities depends on organisational opportunities depends on organisational context.context.

SummarySummary

Nurses successfully developed prescribing role.Nurses successfully developed prescribing role.Concerns from within nursing and from medical Concerns from within nursing and from medical profession.profession.Appears to be significantly more conflict in the Appears to be significantly more conflict in the US than UK. US than UK. Medical profession able to mobilise arguments Medical profession able to mobilise arguments about appropriateness of nurse training, despite about appropriateness of nurse training, despite lack of evidence about risks / dangers / lack of evidence about risks / dangers / inappropriate prescribing / consideration of type inappropriate prescribing / consideration of type of prescribing being undertaken.of prescribing being undertaken.Likely that IP will evoke more conflict than SP.Likely that IP will evoke more conflict than SP.

Pharmacists’ roles in medicines Pharmacists’ roles in medicines management & prescribingmanagement & prescribing

Pharmacy - very different history & response to Pharmacy - very different history & response to challenges of non medical prescribing.challenges of non medical prescribing.Much slower engagement with prescribing agenda.Much slower engagement with prescribing agenda.IP only just getting started / several years of SP. IP only just getting started / several years of SP. Professional development shaped by commercial & Professional development shaped by commercial & organisational environment (community) pharmacy organisational environment (community) pharmacy operates in.operates in.Significant barriers to (community) pharmacists Significant barriers to (community) pharmacists developing role in this area.developing role in this area.Must overcome these barriers AND deal with potential Must overcome these barriers AND deal with potential opposition from medical profession vis a vis IP and SP.opposition from medical profession vis a vis IP and SP.

Pharmacist prescribing?Pharmacist prescribing?Eaton and Webb (1979) – interviewing Eaton and Webb (1979) – interviewing educators and policy makers:educators and policy makers:“…“…I would draw the line at prescribing – the I would draw the line at prescribing – the pharmacist isn’t trained to prescribe pharmacist isn’t trained to prescribe treatment.”treatment.”““Well really I think lines may be drawn in Well really I think lines may be drawn in terms of the medical degree…But they terms of the medical degree…But they (pharmacists) will never be involved in (pharmacists) will never be involved in prescribing, at least in Britain, unless they prescribing, at least in Britain, unless they have a medical degree. You can’t sign a have a medical degree. You can’t sign a prescription which somebody will honourprescription which somebody will honour.”.”

Community Pharmacy – recent historyCommunity Pharmacy – recent history

Up to mid C20Up to mid C20thth legitimacy based on expertise in legitimacy based on expertise in compounding / producing proprietary medicines.compounding / producing proprietary medicines. Original pack dispensing from 1960s onwards forced Original pack dispensing from 1960s onwards forced

loss of roleloss of role Pharmacy has long history of links with commerce / Pharmacy has long history of links with commerce /

‘petit bourgeoisie’.‘petit bourgeoisie’. Ambiguous relationship with the NHS – private provider Ambiguous relationship with the NHS – private provider

in socialised system.in socialised system.Community pharmacies seen as ‘dispensing’ factories – Community pharmacies seen as ‘dispensing’ factories – considerable professional dissatisfaction. considerable professional dissatisfaction. Pharmacists ‘over qualified & under utilised’ (Eaton & Pharmacists ‘over qualified & under utilised’ (Eaton & Webb 1979) – de-skilled.Webb 1979) – de-skilled.New roles for pharmacists – essentially a quest for survival New roles for pharmacists – essentially a quest for survival (Edmunds & Calnan 2001).(Edmunds & Calnan 2001).

Pharmacy & sociology of the Pharmacy & sociology of the professionsprofessions

Denzin and Mettlin (1968) – pharmacy Denzin and Mettlin (1968) – pharmacy viewed as a case of ‘Incomplete viewed as a case of ‘Incomplete professionalization’. professionalization’. Pharmacy lacked control over the ‘social Pharmacy lacked control over the ‘social

object’ of practice - the medicine.object’ of practice - the medicine. Pharmacists guided by Pharmacists guided by commercialcommercial interests interests

at odds with the altruistic, service orientation at odds with the altruistic, service orientation of a profession.of a profession.

Essentially, a highly damaging critique / Essentially, a highly damaging critique / retains potency.retains potency.

Pharmacy & sociology of the Pharmacy & sociology of the professionsprofessions

Dingwall & Wilson (1995) Dingwall & Wilson (1995) Critique of Denzin & Mettlin (1968) positionCritique of Denzin & Mettlin (1968) position Other professions (e.g lawyers) associated with Other professions (e.g lawyers) associated with

commerce, does not undermine professional status. commerce, does not undermine professional status. Pharmacists transform objects (drugs – medicines) and Pharmacists transform objects (drugs – medicines) and

have a (Foucauldian inspired) role in surveillance have a (Foucauldian inspired) role in surveillance around medicines usage.around medicines usage.

Hibbert et al (2002) – weak role over medicines Hibbert et al (2002) – weak role over medicines surveillance; protocol driven; role undermined by ‘lay surveillance; protocol driven; role undermined by ‘lay expertise’ / consumerism.expertise’ / consumerism.

Turner (1995) refers to pharmacy as tainted by ‘petite Turner (1995) refers to pharmacy as tainted by ‘petite bourgeoisie’ image.bourgeoisie’ image.

Pharmacy & sociology of the Pharmacy & sociology of the professionsprofessions

Pharmacists increasingly ‘corporatised’ – increasingly Pharmacists increasingly ‘corporatised’ – increasingly employees rather than independent practitioners.employees rather than independent practitioners.Key decisions not taken by pharmacists (tensions Key decisions not taken by pharmacists (tensions between superintendents & marketing departments) / between superintendents & marketing departments) / ‘de-pharmacisation’ of chains / multiples.‘de-pharmacisation’ of chains / multiples.Lack autonomy over work practises / boundary Lack autonomy over work practises / boundary encroachment from others.encroachment from others.Small profession (45 000 registered pharmacists – split Small profession (45 000 registered pharmacists – split between hospital and community.between hospital and community.Considerable dissatisfaction with working practises in Considerable dissatisfaction with working practises in community pharmacy.community pharmacy.

Re-professionalization project.Re-professionalization project.

Plethora of policy documents – PIANA, Choosing Health Plethora of policy documents – PIANA, Choosing Health Through Pharmacy, Pharmacy in the New NHS…Through Pharmacy, Pharmacy in the New NHS…Some new roles identified:Some new roles identified: smoking cessation, smoking cessation, PBNXPBNX supervised methadonesupervised methadone minor ailments schemesminor ailments schemes Supplying emergency contraceptionSupplying emergency contraception Chlamydia screeningChlamydia screening

NHS contractual framework for pharmacy – essential, NHS contractual framework for pharmacy – essential, advanced and enhanced.advanced and enhanced.Prescribing and medicines management…Prescribing and medicines management…

Re-professionalization project.Re-professionalization project.

Continuing issues in community pharmacy’s re-Continuing issues in community pharmacy’s re-professionalisation project:professionalisation project: Commercial environment in which pharmacy is Commercial environment in which pharmacy is

practisedpractised Limited autonomy as employeesLimited autonomy as employees Patient doubts about appropriateness of community Patient doubts about appropriateness of community

pharmacy as a site for advice / medicines pharmacy as a site for advice / medicines management / prescribing?management / prescribing?

Isolation from other professions / policy arenaIsolation from other professions / policy arena SubordinationSubordination

Community Pharmacy Medicines Community Pharmacy Medicines Management Project (CPMMP)Management Project (CPMMP)

Project developed / implemented by the Pharmaceutical Project developed / implemented by the Pharmaceutical Services Negotiating Committee (PSNC)Services Negotiating Committee (PSNC)Funded by DoH (2001-2004)Funded by DoH (2001-2004)

Aim: to evaluate the introduction of a community Aim: to evaluate the introduction of a community pharmacy led medicines management service for pharmacy led medicines management service for patients with coronary heart disease (CHD)patients with coronary heart disease (CHD)Evaluated by independent research team using RCT & Evaluated by independent research team using RCT & qualitative research:qualitative research:

University of AberdeenUniversity of Aberdeen University of NottinghamUniversity of Nottingham Keele UniversityKeele University

The CPMMPThe CPMMPS tu d y P ro toco l

R eview p h arm ac is t 'srecom m en d ation s

& ac tion if ap p rop ria te

G P in each a reain vited to p artic ip a te

R E A D cod e search toid en tify C H D p a tien ts

M ed ica tion + /o r lifes tylerecom m en d ation s m ad e

D iscu ssed w ith p a tien t an d G P

In te rven tion G rou pR ece ive m ed ica tion review

from p h arm ac is t & fo llow -u pd u rin g 1 2 m on th s

P h arm ac is t rece ivessu m m ary o f c lin ica l in fo rm ation

from au d it c le rk fo rin te rven tion p a tien ts

P h arm ac is ts in each a reain vited to p artic ip a te

H ave to com p le teC H D tra in in g

C on tro l G rou prece ive m ed ica tion

in u su a l w ay

P atien ts in vited top articp a te from G P su rg eryR an d om ised to in te rven tionor con tro l g rou p (2 :1 ) ra tio

9 loca lit ies p icked to p articp a te :N an tw ich , L ich fie ld , W alsa ll

P oo le , P ortsm ou th , S ou th wark ,S h ip ley, N . Tyn es id e , S a lfo rd

Results-% appropriatenessResults-% appropriateness

InterventionIntervention

Baseline Baseline

InterventionIntervention

Follow upFollow up

Control Control

BaselinBaselinee

ControlControl

Follow-upFollow-up

P-valueP-value

AspirinAspirin8282 8080 7676 7878 **

Aspirin-relatedAspirin-related 9595 9494 9191 9393 0.240.24

Target Target cholesterolcholesterol

5959 5858 5757 5555 1.001.00

StatinStatin 7373 7979 6868 7777 **

BP BP 4747 4949 4343 4747 0.490.49

Explanations…Explanations…

Qualitative interviews and focus groups with Qualitative interviews and focus groups with doctors, pharmacists and patients sheds doctors, pharmacists and patients sheds considerable light on ways in which the doctors considerable light on ways in which the doctors and pharmacists are working together?and pharmacists are working together?

Informs a sociology of pharmacy. Informs a sociology of pharmacy.

Very positive about service:Very positive about service:

““It’s wonderful to be able to talk to people” It’s wonderful to be able to talk to people” Better patient care:Better patient care:

““We’re getting closer to some of the patients because We’re getting closer to some of the patients because they think…feel that you’re taking more of an interest in they think…feel that you’re taking more of an interest in them rather than oh, another customer!”them rather than oh, another customer!” (P11/FG3) (P11/FG3)

Using clinical skills:Using clinical skills: ““It certainly is an extension of our role and a very It certainly is an extension of our role and a very

worthwhile one, actually using our clinical skills for a worthwhile one, actually using our clinical skills for a change.”change.” (P16/FG4) (P16/FG4)

Pharmacists views about Pharmacists views about medicines managementmedicines management

Pharmacists’ concerns: GPs’ perceptions Pharmacists’ concerns: GPs’ perceptions of their subordinate statusof their subordinate status

““We work as a team but they (GP) think they’re the We work as a team but they (GP) think they’re the upper class; we are the lower class you know”upper class; we are the lower class you know” (P13/FG8)(P13/FG8)

““They sort of think of…they still think that a They sort of think of…they still think that a pharmacist is a class down, like you know you pharmacist is a class down, like you know you think of a shopkeeper.”think of a shopkeeper.” (P14/FG7) (P14/FG7)

““Because they’re not used to having their judgement Because they’re not used to having their judgement questioned…Not by someone that they perceive questioned…Not by someone that they perceive as being a shopkeeper.”as being a shopkeeper.” (P12/FG4) (P12/FG4)

Pharmacists’ concerns: GPs feeling Pharmacists’ concerns: GPs feeling threatenedthreatened

““I think it’s because they feel threatened; it’s human I think it’s because they feel threatened; it’s human nature isn’t it? You are impinging on their territory.”nature isn’t it? You are impinging on their territory.” (P34/TI1)(P34/TI1)

““They might feel their opinion is being challenged, that They might feel their opinion is being challenged, that they are being checked upon, or whatever because I they are being checked upon, or whatever because I suppose they are not used to it. It is a new thing for suppose they are not used to it. It is a new thing for them really to have someone who is looking at the them really to have someone who is looking at the notes they have done themselves.”notes they have done themselves.” (P09/FG2) (P09/FG2)

Commerce & Pharmacy Commerce & Pharmacy

GPs concerned that community pharmacists GPs concerned that community pharmacists advice influenced by commercial factorsadvice influenced by commercial factors

““The difficulty I have really is trying to be certain The difficulty I have really is trying to be certain that their advice is not commercially related” that their advice is not commercially related” (GP19)(GP19)

Resulted in GPs being suspicious of the Resulted in GPs being suspicious of the clinical advice they received from community clinical advice they received from community pharmacists.pharmacists.

Access to Medical Records Access to Medical Records

“ “ I think the whole area then that opens up is all I think the whole area then that opens up is all the areas of confidentiality and people who the areas of confidentiality and people who are not actually part of the GP primary care are not actually part of the GP primary care team, who have access to confidential team, who have access to confidential medical records, which may include so and medical records, which may include so and so is having an affair with so and so, who so is having an affair with so and so, who might happen to be the pharmacists might happen to be the pharmacists neighbour you know. It may not, it’s a most neighbour you know. It may not, it’s a most unlikely scenario but our duty first and unlikely scenario but our duty first and foremost is to all our patients is foremost is to all our patients is confidentiality.” (GP15)confidentiality.” (GP15)

Pharmacists Changing Patients Pharmacists Changing Patients MedicationMedication

Concerns about whether it was appropriate for Concerns about whether it was appropriate for community pharmacists to change patient’s community pharmacists to change patient’s medication.medication. Do community pharmacists know patients well Do community pharmacists know patients well

enough to undertake this service?enough to undertake this service? Pharmacists involvement could cause fragmentation Pharmacists involvement could cause fragmentation

over patient care & responsibilityover patient care & responsibility Patients could become confused if more than one Patients could become confused if more than one

person had responsibility for medicationperson had responsibility for medication Pharmacists lack access to medical records when Pharmacists lack access to medical records when

undertaking medicines management roleundertaking medicines management role

Pharmacists Changing Patients Pharmacists Changing Patients MedicationMedication

“ “ I mean I think getting medication right is I mean I think getting medication right is quite complicated and it depends on quite complicated and it depends on quite a lot of medical historical quite a lot of medical historical information and unless they have got information and unless they have got the whole set of notes and they are the whole set of notes and they are sitting down with the patient and got to sitting down with the patient and got to know them over a period of time they know them over a period of time they can’t do that” (GP15)can’t do that” (GP15)

Likely to be highly relevant to prescribing.Likely to be highly relevant to prescribing.

Reasons for GPs’ ConcernsReasons for GPs’ Concerns

““Professional boundaries”Professional boundaries”

““Threatening…challenging management Threatening…challenging management and criticism”and criticism”

““The whole area opens up areas of The whole area opens up areas of confidentiality and people who are not confidentiality and people who are not actually part of the primary care team”actually part of the primary care team”

SummarySummary

Strong support for CPMMP in some areas, Strong support for CPMMP in some areas, GPs highlighted many concerns:GPs highlighted many concerns: Community pharmacist’s links with commerceCommunity pharmacist’s links with commerce Some resistance to pharmacists undertaking new Some resistance to pharmacists undertaking new

roles & boundary encroachmentroles & boundary encroachment Some resistance to community pharmacists Some resistance to community pharmacists

having access to patient’s medical recordshaving access to patient’s medical records Distance from patients - concerns that Distance from patients - concerns that

pharmacists do not possess a detailed knowledge pharmacists do not possess a detailed knowledge of the patient & clinical historiesof the patient & clinical histories

Isolation from medical / nursing professions and Isolation from medical / nursing professions and primary care more generally.primary care more generally.

Medicines Management: A challenge Medicines Management: A challenge to medical dominance?to medical dominance?

Issues identified by Denzin & Mettlin (1968) still relevant – Issues identified by Denzin & Mettlin (1968) still relevant – commerce / altruism / motivation.commerce / altruism / motivation.Strong discourse around community pharmacy’s subordinate Strong discourse around community pharmacy’s subordinate position in health care division of labour.position in health care division of labour.Distance from patients ‘everyday’ care.Distance from patients ‘everyday’ care.GPs able to mobilise powerful arguments against pharmacists GPs able to mobilise powerful arguments against pharmacists involvement. Eg commerce, access to records, confidentiality, involvement. Eg commerce, access to records, confidentiality, knowledge of patient.knowledge of patient.Able to name / identify roles for pharmacists eg. compliance / Able to name / identify roles for pharmacists eg. compliance / repeat dispensing but NOT changing medication.repeat dispensing but NOT changing medication.Pharmacists collude to re-produce and sustain their own Pharmacists collude to re-produce and sustain their own subordinate status. Eg. reference to ‘shops’; deference to GPs.subordinate status. Eg. reference to ‘shops’; deference to GPs.

Medicines Management: patients viewsMedicines Management: patients views

Patients’ views similar to GPs assessments of Patients’ views similar to GPs assessments of pharmacists involved.pharmacists involved.Cautiously welcoming ‘talking to pharmacists’Cautiously welcoming ‘talking to pharmacists’But anxious about them making recommendations But anxious about them making recommendations about treatment / changing medication.about treatment / changing medication.Concerns about the commercial environment / strong Concerns about the commercial environment / strong awareness of subordinate position of pharmacy.awareness of subordinate position of pharmacy.

Medicines Management: patients viewsMedicines Management: patients views

Commercial influences: Commercial influences:

““I’m just not sure I’m happy about it at all. I enjoyed I’m just not sure I’m happy about it at all. I enjoyed talking to him, that wasn’t the problem. It’s just at the talking to him, that wasn’t the problem. It’s just at the back of your mind, is it me, or is it a bit daft, you back of your mind, is it me, or is it a bit daft, you wonder about, well, you wonder about the drugs wonder about, well, you wonder about the drugs companies and all that, and all those promotions in companies and all that, and all those promotions in the shop…I came home from it, and we were talking, the shop…I came home from it, and we were talking, I said, is it the kind of place they should be doing this I said, is it the kind of place they should be doing this kind of thing?”kind of thing?” (R5) (R5)

Medicines Management: patients viewsMedicines Management: patients views

Subordinate position: Subordinate position:

““The pharmacists don’t diagnose, don’t they? The The pharmacists don’t diagnose, don’t they? The doctors do that. They put you on the treatment and doctors do that. They put you on the treatment and the pharmacist just gives you it.”the pharmacist just gives you it.”

‘‘Because you look at most prescriptions…It says if Because you look at most prescriptions…It says if you develop any of the following consult your GP. you develop any of the following consult your GP. And this is from the chemical company. They don’t And this is from the chemical company. They don’t say go to the pharmacist. They say go to the doctor.’say go to the pharmacist. They say go to the doctor.’

Subordination & isolationSubordination & isolation

Cooper’s research around ethical loneliness of Cooper’s research around ethical loneliness of pharmacists.pharmacists.Draws on qualitative research with pharmacists:Draws on qualitative research with pharmacists:

Subordinate position:Subordinate position:““I tend to feel that when I get a prescription, coming I tend to feel that when I get a prescription, coming back to your point, that it’s the doctors responsibility back to your point, that it’s the doctors responsibility ultimately and that I’m just a tool of the doctor really. ultimately and that I’m just a tool of the doctor really. I’m not happy with it, I’m passing the buck and not I’m not happy with it, I’m passing the buck and not accepting the responsibility that I should be taking.” accepting the responsibility that I should be taking.”

Subordination & isolationSubordination & isolation

Isolation: Isolation: ““In a way we are isolated as pharmacists and we In a way we are isolated as pharmacists and we haven’t got anyone to chat to, to ask about things, to haven’t got anyone to chat to, to ask about things, to find out what other pharmacists think”.find out what other pharmacists think”.

““We’re all islands and we’re all competing against each We’re all islands and we’re all competing against each other […] The only time when you come into contact other […] The only time when you come into contact with another pharmacist is when there’s a conflict with with another pharmacist is when there’s a conflict with something or when you want to borrow something.” something or when you want to borrow something.”

Habermas / Mead (discourse ethics) – loneliness / Habermas / Mead (discourse ethics) – loneliness / isolation may be ethically problematic for pharmacists. isolation may be ethically problematic for pharmacists.

A sociologically informed research A sociologically informed research agenda for pharmacyagenda for pharmacy

Commerce, altruism, isolation, subordination Commerce, altruism, isolation, subordination retain some force.retain some force.Nancarrow & Borthwick (2005) – not clear that Nancarrow & Borthwick (2005) – not clear that taking on new roles results in enhanced status.taking on new roles results in enhanced status.Moreover – ‘no examples of role changes that Moreover – ‘no examples of role changes that have removed the attributes that are associated have removed the attributes that are associated with the professional labels.’ with the professional labels.’ Community pharmacy remains a site tainted by Community pharmacy remains a site tainted by commerce, isolation, subordination. commerce, isolation, subordination. To develop, pharmacists leave the commercial To develop, pharmacists leave the commercial environment / undertake professional journeys / environment / undertake professional journeys / narratives of change. narratives of change.

Prescribing & medical dominance?Prescribing & medical dominance?

Britten (2001:478): Prescribing and the defence of Britten (2001:478): Prescribing and the defence of clinical autonomy:clinical autonomy:““The medical profession has an almost exclusive The medical profession has an almost exclusive right to prescribe medicines, but this right is being right to prescribe medicines, but this right is being challenged by the State, patients and other health challenged by the State, patients and other health care professionals…These changes do not yet care professionals…These changes do not yet support the thesis of proletarianization [or support the thesis of proletarianization [or deprofessionalization] as the medical profession deprofessionalization] as the medical profession continues to dominate the clinical agenda and continues to dominate the clinical agenda and responsibilities of other health care workers.”responsibilities of other health care workers.”