In the latter half of the twentieth century, pre-packaged medications produced by large pharmaceutical companies removed the need for pharmacists to compound their own medicines. This led to concerns around de-skilling, particularly in community pharmacy where Eaton and Webb (1979: 73) argued that they became ‘over trained for what they do and under-utilised in what they know’. Davey (1983) argued that this could be financially problematic for the NHS with patients using up GP appointments where the expert knowledge of pharmacists’ would be sufficient or, in the case of questions about medications, more appropriate. These concerns were addressed in the National Pharmacy Association’s 1982 Ask Your Pharmacist campaign and by a 1986 report by the Nuffield Foundation which suggested an ‘extended’ role for community pharmacists. This extended role expanded the community pharmacy contract to provide extra clinical services through prescribed medicines management; chronic illness management; common ailments management and the promotion of healthy lifestyles (Harding and Taylor, 1997). Much of this was undertaken under the rubric of the Pharmacy in a New Age (PIANA) strategy, which was launched by the Department of Health in 1995. This strategy was, and continues to be, a gradual process of change in community pharmacy within which the boundaries of practice are shifted towards a more clinical focus (Longley, 2006; Parkin, 1999). This extended role, and the initiatives such as PIANA which existed around it, somewhat shifted the professional identity of pharmacists as they became reconfigured as healthcare practitioners (Anderson, 2001). As such, pharmacy shifted from product-based to more clinically focused (Benson et al., 2009; Petrakaki
et al., 2012). Moreover, their increased clinical work and one-to-one contact with
patients altered the spatiality of community pharmacy practice in relocating pharmacists outside of the dispensary. In doing so, pharmacists became discursively posited as ‘first port of call’ for patients (Anderson, 2001: 23).
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More recently, the government published a White Paper in 2008 outlining the ways in which pharmacy’s extended role will be shaped in the future. In terms of practice, Pharmacy in England: Building on Strengths- Delivering the Future (Department of Heath, 2008) advocates that pharmacies and pharmacists ought to concentrate on expanding access to clinical services, supporting healthy living and lifestyles and providing better care for patients managing long-term conditions. Within this, the report recommends that community pharmacies become ‘healthy living centres’ where the public are able to obtain information about preventative health strategies such as nutrition and exercise, as well as about medications for both acute and chronic conditions. What this suggests is that contemporary policy is instrumental in shifting the professional identity, and practice boundaries, of community pharmacists.
This extension of the role of pharmacists into more clinical practices also affected hospital pharmacists where a report by the RPSGB (1977) suggested that;
There is an important role for pharmacists to play in direct contact with patients on all matters concerning medication. On the patient's admission, pharmacists can take the previous medication history; because of their specialist knowledge they can make an invaluable contribution in the selection of the drug treatment for the patient; they can monitor the progress of the medication, particularly in relation to possible side effects or adverse reactions; and they can counsel a patient on the proper use of drugs and medicines both in the hospital and when they return home
As in community settings, this extension of pharmacy work reconfigures pharmacists as healthcare professionals whose pharmacology expertise and pharmaceutical gaze (Barber, 2005) are of benefit to both the hospital organisation and the patient. In the hospital setting, this extended role was implemented, arguably, more readily than in the community setting given the increasing standardisation in hospital pharmacy and the absence of retail pressures.
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In both settings, the expansion of pharmacy’s professional role shifted the boundaries of practice and the professional identities of practitioners. Historically, Eaton and Webb (1979) argue, medical professionals have been anxious about paramedical occupations (such as pharmacy) encroaching on their traditional roles and duties and eroding their professional hegemony. As such, the shifting boundaries of the extended role which expanded pharmacy’s jurisdictions to include more clinical activities created sociologically interesting questions about potential boundary encroachment by pharmacists. More recently, the shifting of pharmacy’s jurisdictions to include supplementary and independent prescribing has also raised these boundary encroachment issues (Avery and Pringle, 2005). These issues can be understood with regards to Gieryn’s (1983) boundary work framework.
Briefly, Gieryn (1983) draws on the examples of anatomy and phrenology in the nineteenth century to demonstrate the demarcation of ‘science’ (anatomy) from ‘non-science’ (phrenology). He argues that boundary work is the process of groups drawing on their cultural and professional repertoires to define themselves and their expertise for the lay public and its authorities (Freidsons’s elite segment of society). In doing so, groups which become defined as ‘science’ are able to maintain their professional status and autonomy and lay legitimate claim to resources. They then secure a privileged position within the ‘intellectual ecosystem’ which makes them largely immune from government regulation and enables them to enjoy the social status of experts and the advantages associated with it (such as being called upon as a reliable expert witness in a court of law).
The most common sociological analyses of boundary work within medical practices tend to centre of the negotiation of professional boundaries between doctors and nurses within the hospital setting (see Allen, 1997; Wicks, 1998). Much of the focus of these analyses tends to be the official boundaries which are drawn between high-status doctors and low-status nurses and the concurrent expectation that nurses will transcend this boundary for the benefit of both patients and doctors but not expect the official boundaries of their work to be moved into the professional territory of doctors. Additionally, Mizrachi et al. (2005) point to the boundary work which perpetually occurs between co-located biomedical and complementary and alternative practitioners. They argue that biomedical practitioners have been able to
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draw on their cultural repertoires to discursively construct alternative practitioners as unreliable and unscientific which serves to maintain the hegemony of the biomedical practitioners.
Contrary to concerns about the potential encroachment of pharmacists onto the jurisdiction of medical practitioners, Eaton and Webb’s (1979) empirical data suggested that doctors were willing to delegate or relinquish certain tasks to pharmacists as part of their clinical work. Eaton and Webb (1979: 85) argue that a ‘negotiated’ settlement between medical practitioners and clinical pharmacists was reached whereby pharmacists accept the responsibility of medics in return for permission to practice certain ‘medical activities’. In the hospital setting they found that pharmacists most often shifted their boundaries into areas which medics have previously neglected, such as patient counselling or ADR monitoring. In doing so, it is argued that pharmacists take on some of medicine’s ‘dirty work’.
More recent work by Edmunds and Calnan (2001) also found that these concerns about boundary encroachment as a result of increased clinical work in pharmacy were unfounded in everyday practice. In their empirical study of community pharmacists involved in extended role projects, they found that pharmacists drew relatively rigid boundaries between their role as dispensers and doctors’ role as prescribers within the patient care team. As such, pharmacists were keen not to encroach on the work of doctors, particularly in relation to the management of chronic conditions, and discursively configured themselves as a point of guidance for patients rather than a substitute for doctors’ advice. Eaton and Webb’s (1979) and Edmunds and Calnan’s (2001) papers suggest that the boundary work between medical and pharmacy practitioners in both community and hospital setting is somewhat less pressing than that of Gieryn’s nineteenth century anatomists and phrenologist.
2.4.1 The Extended Role as a (Re)Professionalisation Project
According to Edmunds and Calnan (2001), the development of an extended role in community (and hospital) pharmacy can be understood as an attempt to (re)professionalise the sector. In the US context, Birenbaum (1982) presents this
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(re)professionalising project as an attempt to maintain prominence for pharmacy in the context of increased routinisation and uncertain financing of healthcare and pharmaceuticals. Pharmacists’ participation in extended role projects (such as adherence services; ADR monitoring; and chronic illness management) is understood by Edmunds and Calnan as a way for pharmacists to redefine their status as professionals and take full advantage of their training and expertise. Hence, the pharmacists in Edmunds and Calnan’s (2001) study understood the extended role as a positive (re)professionalising strategy for community pharmacy. In contrast to this, Harding and Taylor (1997) argued that the extended role as recommended in the 1986 Nuffield Report had, after ten years, ultimately failed to make significant impacts on the professional status of community pharmacy for a number of key reasons outlined below. They argued, instead, that the extended role has actually had a de-professionalising effect on community pharmacy in focusing too heavily on non-medicines related activities.
Firstly, they argued, the extended role does not acknowledge that professional status is based on the exclusivity of expert knowledge and the creation of a chasm and power imbalance between experts on the one hand and the lay public on the other. Here, Johnson’s (1977) notion of ‘mystification’ again becomes central. Harding and Taylor argued that the extended role is flawed in that it does not capaitalise on this chasm and instead concentrates on promoting services which are centred around technological devices (i.e. testing devices) which routinise work and undermine pharmacists’ claims to expertise (see Ritzer and Walczak, 1988). Moreover, they argued, the extended role necessitates pharmacists offering advice on non-medicine related issues, such as smoking cessation, which undermines their rightful claims to expert status in the field of medicines.
Secondly, the extended role fails to take into account the relatively limited autonomy of community pharmacists employed in large multiples, which contrasts with Freidon’s (1970) understanding of professional identity. Moreover, part of the extended role involves the provision of medicines advice services for patients which is based around a set of protocols. This protocol standardisation, Harding and Taylor (1997: 556) argued, removes the ability for pharmacists to use their professional judgement, curtails the scope for pharmacy-patient relationships (see Worley et al.,
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2007) and reduces their interactions to ‘nothing more than asking structured, formulaic questions’.
Thirdly, the 1982 Ask Your Pharmacist campaign regarded community pharmacists as a first port of call for patients who did not want to ‘waste’ doctors’ time (Harding and Taylor, 1994). The necessity of pharmacists being available all of the time without appointments or gatekeepers undermines a fundamental principle of a professional identity, which is the organisation of time by the professional. Harding and Taylor (1997: 556) contended that patients’ ability to make immediate demands on pharmacists’ time serves to ‘demystify and devalue’ the skills and judgements of pharmacists.
Finally, as mentioned, a key social role of pharmacy is the symbolic transformation of inert chemicals into socially meaningful objects of medications. Harding and Taylor (1997) argued that the jurisdictional reconfiguration following the implementation of the extended role has meant the delegation of many dispensing activities to pharmacy counter assistants in order for pharmacists to undertake more clinical activities. There is potential, then, for the dispensing process to be undertaken without the input of a professional. This removes the opportunity for pharmacists to enact the process of imbuing medications with social and cultural meanings which sociological analyses have identified as being central to community pharmacy’s professional identity.
More recently, in a study of EPS in community pharmacy, Petrakaki et al. (2012) centralise technological innovation in the professionalisation question which fits into a wider sociological focus on the role of technologies in shaping professional work, identity and jurisdictions. Petrakaki et al. (2012) argue that the integration of EPS into community pharmacy changes pharmacists’ everyday activities in the areas of nature of work; professional values; professional roles; jurisdictions; boundaries; and power. For example, they demonstrate the ways in which increased automation as a result of EPS may reconfigure the nature of work by altering the materiality, temporality and manual aspects of pharmacy activities. As such, EPS may eliminate paper in community pharmacy work; allow pharmacists to pre-dispense prescriptions (also see Motulsky, 2008); and remove the need for pharmacists to manually
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population patients’ demographic information. The consequences of the changes in these areas of everyday practice are not linear or deterministic and instead, they argue, open up the possibility of simultaneous de- and re-professionalisation of community pharmacy. Inasmuch, they argue that de-professionalisation may occur in four key ways; (i) by shifting the temporal and spatial aspects of community pharmacy work; (ii) by eroding inter-professional trust through a depersonalisation of communication with other healthcare practitioners; (iii) by rendering community pharmacy more visible and opening up opportunities for governmental control; and (iv) by expanding pharmacy’s professional boundaries to other occupational groups with different professional values- in doing this professional identities become blurred and, they argue, being a professional ‘could mean anything and therefore nothing’. Running concurrently to this, they identify three key ways in which EPS may re-professionalise community pharmacy; (i) by freeing pharmacists from mundane tasks to allow them to undertake more challenging clinical activities; (ii) by expanding community pharmacy’s jurisdictions and allowing them to exercise more discretion and professional judgement; and (iii) by expanding professional boundaries and allowing pharmacists to become more integrated in the ‘NHS family’.
This final point is also echoed by Barrett et al. (2011) in their study of the integration of robots into hospital pharmacy settings. They note that pharmacy robots reorganise professional relationships and boundaries throughout the hospital structure. In doing so, pharmacy assistants’ everyday work became increasingly focused on the maintenance of the robots (i.e. fixing technical problems and restocking) whilst pharmacists were freed from mundane dispensing tasks and able to undertaken more clinical work away from the dispensary. This reconfiguration of pharmacists’ work and jurisdictions, Barrett et al. (2011), argue, allowed pharmacists to become further integrated into medical teams and increased their ‘institutional legitimacy’. This can be understood in line with Petrakaki et al.’s (2012) analysis as a re-professionalising consequence of technology in everyday work.
So far this chapter has examined the historical context of pharmacy in the UK from its association with grocers in the medieval guild system to the increase in clinical pharmacy during the latter half of the twentieth century. In order to
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contextualise the later sociological analyses in this thesis, the chapter now turns to an overview of contemporary pharmacy practice primarily drawing on the most recent (2008) RPS Pharmacy Workforce Census.