Reflecting on her own experiences practising as both a community and hospital pharmacist, Heena Bhakta (2010), notes that there are substantial differences between these practice sectors with the latter being more ‘interdisciplinary’ and specialised. As such, in accordance with the Audit Commission’s (2001) recommendations, hospital pharmacists are more integrated into the medical practice team in comparison to those practising in the community who tend to be more ‘isolated’ (Cooper et al., 2009). Moreover, hospital pharmacy is typified by disciplinary specialisation in which pharmacists opt for a particular area of medicine to specialise in, such as Oncology or Paediatrics. This specialisation in hospital pharmacy practice means that hospital pharmacists cultivate a set of expertise and skills based around one substantive area of medical practice and the medications associated with it. In doing so, hospital pharmacists play a significant role in assisting physicians with prescription and treatment decisions, in contrast to their community-based colleagues (Taylor et al., 2003: 22).
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This more collaborative model of practice in hospital settings can be analysed through the use of Bourret’s (2005) and, latterly, Rabeharisoa and Bourret’s (2009) notion of a ‘bioclinical collective’. This model of practice is centred on clinicians and researchers working collaboratively to decide on the best course of treatment for a patient given the increased complexity of disease in the post-genomic era. Although much of hospital pharmacy practice is not routinely engaging with genomic techniques or information, the collaborative principles underpinning bioclinical collective practice are central to hospital pharmacy practice, as Hospital Pharmacist 4 notes:
“I work pretty closely with them [consultants] and the other specialist nurses and the whole team really” (HP 4)
Given this, the division of labour in hospitals is not hierarchically based on occupational categories but based on particular specialist fields where numerous practitioners from one specialism share their diverse expertise with others in order to identify the best course of action for the patient. In this way, the bioclinical collective practices that characterise professional relationships in hospitals tend to ascribe equal value to the expertise and work of practitioners from across occupational areas. This bioclinical collective model is particularly typical of specialist fields which require careful medicines management due to the increased risk of toxicity of the medications used in that field. Oncology is a particularly notable example of such a practice model where multi-disciplinary teams are a routine feature of practice due to the complexity of disease in this area and the increased risk of medications, as Hospital Pharmacist 3 (an Oncology pharmacist) and Oncologist 1 highlight below. Ideas around this understanding and framing of toxicity are discussed further below.
“You’ll have the junior doctors and the nurses and pharmacy… so there is certainly collaboration” (HP 3- Oncology)
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“The multidisciplinary team is the surgeon…the pathologist…the oncologist…the specialist nurse…usually somebody from radiology…sometimes you’ll have somebody from palliative care” (O 1)
The relative lack of hierarchical divisions of labour between hospital pharmacists and other hospital practitioners means that hospital pharmacists are often perceived as higher in status or more ‘professional’ than those practising in the community (Elvey et al., 2011). Here the absence of professional role strain or commercial pressures is central to patient and practitioner perceptions of hospital pharmacists as clinical practitioners, rather than just dispensers (see Rapport et al., 2010). Moreover, this elevated professional status of hospital pharmacy through a central role in bioclinical collective working practices is mediated through the technological interventions which hospital pharmacists mobilise in their routine work. Through an analysis of EPS technologies, Petrakaki et al. (2012) argue that pharmacists’ engagement with innovative technologies can increase their professional status by expanding their professional jurisdictions; engaging them in clinical judgements through an increased information pool; strengthening inter- professional trust; and rendering them part of the ‘NHS family’ (Petrakaki et al., 2012). This analysis of EPS demonstrates the ways in which the professional status of pharmacy can be influenced by engagement with technology. As hospital pharmacy practice engages with various diagnostic, ICT and medical technologies at the centre of its practice, this may go someway to understanding the disparity between the status of hospital and community pharmacists. This can be particularly witnessed in the case of patient medical records, as is touched upon below and discussed more fully in Chapter Seven.
Although previous commentaries (Bassey, 2011) and research (Rapport et al., 2010) have focused on the practice and status differences between community and hospital pharmacy, this binaried representation of pharmacy practice ignores the diversity found within each sector. The empirical data upon which this chapter is based suggests that the diverse contexts in which pharmacy is practised mean that those practising within the same sector (i.e. hospital or community) do not
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necessarily share similar experiences. In the case of community pharmacy, for example, the experiences of owner-occupiers, large or small multiple employees and urban or rural practitioners can differ greatly because of this diversity of practice settings.
Nonetheless, the safe and effective dispensing and administration of medications is a central principle underpinning all forms of pharmacy practice. Hence, although their experiences of everyday practice routines may vary greatly, the philosophy of good pharmaceutical care and medicines management is a central foundation in all practice contexts. The remainder of this chapter offers a sociological analysis of the everyday practices of pharmacists through their engagement with pharmaceutical care and the medicines management processes. The chapter presents a dual approach to these processes by arguing that alongside pharmacists’ engagement with formalised, bureaucratic pharmaceutical care and medicines management we find a more negotiated form of care and management, which co-constructs both medications and patients. Here, this is conceptualised as the ‘pharmacy gaze’. To place this notion in context, the chapter first outlines the formalised processes of medicines management and pharmaceutical care.