C M H ughes and S M cC ann

600 British Journal of General Practice August 2003

Perceived interprofessional barriersbetween community pharmacists andgeneral practitioners a qualitativeassessmentCarmel M Hughes and Siobhan McCann

Introduction

PHARMACISTS are being challenged to become keyplayers in the prescribing process as well as becoming

advocates for patients through optimising and monitoringdrug use1-3 Clearly this requires more formal integration ofpharmacists into health care and the development of part-nerships particularly with general practitioners (GPs)

This may be realised through the Crown report on pre-scribing supply and administration of medicines4 Thereport recommended extending prescribing rights to otherprofessional groups including pharmacists It is envisagedthat pharmacists will become dependent or supplemen-tary prescribers (as opposed to independent prescriberssuch as GPs and dentists and to some extent nurses)which will allow them to prescribe a wide range of drugsafter diagnosis by a doctor and within a clinical manage-ment plan They will be responsible for continuing care forpatients who have been assessed by an independent pre-scriber eg in the management of asthma or hypertensionAccess to medical notes would be granted to supplemen-tary prescribers4

Clearly such recommendations will have major legislativetraining clinical and professional implications notably in pri-mary care Hospital physicians are familiar with clinical phar-macists who are often part of ward rounds and are active inthe drug management of patients5 GPs have become famil-iar with the role of prescribing advisers or practice pharma-cists who provide advice on prescribing67 Links betweenGPs and community pharmacists however are less for-malised One issue raised by previous research in relation tothe development of the role of the pharmacist is the per-ceived professional barriers between GPs and communitypharmacists8 The Crown report recommendations implicitlydemand greater collaboration between the two professionsand if barriers exist these must be overcome before com-prehensive interprofessional working can be realised Thusthe aim of this study was through qualitative methodologyto identify and explore perceived (or otherwise) barriersbetween GPs and community pharmacists in relation tointerprofessional working and the extension of prescribingrights to pharmacists

MethodThe study population included GPs and community phar-macists from three locality areas (A B and C) of a healthand social services board in Northern Ireland This boardwas selected as there were a number of well-established

C M Hughes BSC PHD MRPHARMS senior lecturer School of PharmacyQueenrsquos University Belfast S McCann BA MPSYCHSC research associ-ate School of Nursing University of Ulster

Address for correspondenceDr Carmel M Hughes School of Pharmacy Queenrsquos UniversityBelfast 97 Lisburn Road Belfast BT9 7BL Northern IrelandE-mail chughesqubacuk

Submitted 9 December 2002 Editorrsquos response 18 February 2003final acceptance 26 March 2003

copyBritish Journal of General Practice 2003 53 600-606

SUMMARYBackground There have been calls for greater collaborationbetween general practitioners (GPs) and community pharmacistsin primary careAim To explore barriers between the two professions in relationto closer interprofessional working and the extension of prescrib-ing rights to pharmacistsDesign of study Qualitative studySetting Three locality areas of a health and social services boardin Northern IrelandMethod GPs and community pharmacists participated inuniprofessional focus groups data were analysed using interpre-tative phenomenologyResults Twenty-two GPs (distributed over five focus groups)and 31 pharmacists (distributed over six focus groups) partici-pated in the study The lsquoshopkeeperrsquo image of community phar-macy emerged as the superordinate theme with subthemes ofaccess hierarchy and awareness The shopkeeper image andconflict between business and health care permeated the GPsrsquodiscussions and accounted for their concerns regarding theextension of prescribing rights to community pharmacists andinvolvement in extended services Community pharmacists feltsuch views influenced their position in the hierarchy of health-care professionals Although GPs had little problem in accessingpharmacists they considered that patients experienced difficul-ties owing to the limited opening hours of pharmaciesConversely pharmacists reported great difficulty in accessingGPs largely owing to the gatekeeper role of receptionists GPsreported being unaware of the training and activities of commu-nity pharmacists and participating pharmacists also felt that GPshad no appreciation of their role in health careConclusion A number of important barriers between GPs andcommunity pharmacists have been identified which must beovercome if interprofessional liaison between the two professionsis to be fully realisedKeywords general practitioner community pharmacist pre-scribing barriers qualitative research

GPndashpharmacist collaborations already in place Six focusgroups (considered optimal to achieve data saturation) ofGPs and pharmacists respectively were planned (twouniprofessional groups per locality one group having hadexperience of interprofessional working and the other hav-ing had relatively little experience) The extent of this previ-ous experience was based on information obtained fromappropriate staff based at board headquarters Focusgroups were used in preference to individual interviews asthis was perceived to be a more cost-effective and efficientmeans of accessing the views of a large number of individu-als It was also believed that the group interaction wouldgenerate discussion and debate Letters were sent to all GPs(n = 140) and community pharmacies (n = 74 lettersaddressed to the proprietor or pharmacy manager) in thethree locality areas which outlined the nature and format ofthe study along with a reply slip and prepaid return enve-lope Payment was offered (pound110) to participants A follow-up telephone call was made to those who had not replied tothe original letter

The focus groups were held in convenient locations forparticipants (local hotels) between May and September2001 Each discussion lasted for approximately 70 to 90minutes was facilitated by the project leader (CMH) andanonymity was assured The discussion was based arounda topic guide which had been compiled following an exten-sive review of the literature (using MEDLINE Web of Scienceand International Pharmaceutical Abstracts) on GPndashpharma-cist relationships collaboration in primary care and theextension of prescribing rights to pharmacists (Box 1)During the discussion the facilitator clarified the Crownreport recommendations4 and ensured that participantsunderstood the terms lsquosupplementaryrsquo and lsquoindependentrsquoprescribing All discussions were audiotaped and tran-scribed

AnalysisAll transcripts were independently checked against the orig-inal recordings (CMH) A researcher from a non-pharmacybackground (SMcC health psychology) participated in theanalysis to minimise any investigator bias9 The transcripts

were analysed independently by the authors using interpre-tative phenomenology10 Interpretative phenomenologicalanalysis is concerned with the interpretation of an individ-ualrsquos personal perception or account of an object or event10

The transcripts were read repeatedly recurrent themes wereidentified and coded (along with supporting quotes) inde-pendently and consensus was reached by discussionbetween the two researchers A network of subordinate andsuperordinate themes was established The authors agreedon the major themes that arose from the analysis The prin-ciples of grounded theory were used to develop explanato-ry theories for the emerging themes to further understandthe interface between community pharmacy and generalpractice1112 This approach involved the use of lsquoconstantcomparisonrsquo whereby the aim of the research is the devel-opment of substantive theory and the emergent theory wastested in subsequent focus group interviews Analysis of thetranscripts yielded similar themes and therefore additionaltheoretical sampling was deemed to be unnecessary

ResultsTable 1 summarises demographic information pertaining tothe focus groups From the initial mailing to 140 GPs 22agreed to participate (distributed over five groups) and fromthe 70 community pharmacies that were contacted 31 phar-macists participated (distributed over six focus groups)Eleven practices from a total of 63 practices in the threelocalities had accredited training status of these six had GPrepresentatives in the focus groups Twelve non-trainingpractices were also represented

Owing to the low response rate it was not possible to holda second GP focus group in locality B The response ratehad an impact on the constitution of the focus groupsbecause GPs and pharmacists who had little experience ofworking with each other participated in focus groups withcolleagues who had more experience of interdisciplinarycollaboration Analysis of the transcripts from the focusgroups however revealed similar themes emerging from alldiscussions Furthermore Table 1 indicates that the groupswere diverse Although there were a greater number ofmales than females in the groups this had no impact on thethemes extracted from the data

Analysis of the data revealed the emergence of a super-ordinate theme mdash the lsquoshopkeeperrsquo image of communitypharmacy mdash which was a common thread throughout allthe transcripts and which permeated the three subthemesof access hierarchy and awareness (shown in Figure 1)All four themes represented barriers between the two pro-fessions

British Journal of General Practice August 2003 601

O riginal papers

HOW THIS FITS IN

What do we knowPharmacists have been challenged to become key players in the prescribing process and the extension of prescribing rights asrecommended by the Crown report may help realise this goalProfessional barriers between general practice and communitypharmacy may hinder this development

What does this paper addThe shopkeeper image of the community pharmacistemerged as the main barrier between the two professions andthis was further reflected in the barriers of access hierarchand awareness Acknowledgement of these barriers may gosome way to pre-empt difficulties which could emerge withthe extension of prescribing rights to pharmacists

Box 1 Topic areas for GP and community pharmacist focusgroups

Experience of professional contact with the other profession Views on the other profession Barriers to better professional relationships Attitudes to pharmacist prescribing as advocated by the

Crown report Role of community pharmacy in primary care

Shopkeeper image of community pharmacyMany of the GPs in the focus groups saw community phar-macists as businesspeople shopkeepers or specialist retail-ers and believed this represented a conflict of interest inhealth care Pharmacists felt the shopkeeper image influ-enced the attitude of GPs and had an impact on the devel-opment of the pharmacistrsquos role

lsquoI think that they are probably more businessmen than weare probably more motivated by the business side ofthings than we tend to bersquo [GP13]

lsquoThere is definitely a conflict between the NHS primaryhealthcare team effort that we all feel we are involved inand with pharmacists and their role as the shopkeeperand their role in looking for profits for themselvesrsquo[GP18]

lsquoThey [some GPs] donrsquot have any opinion at all aboutcommunity pharmacists They think we have no rolethey think we are shopkeepers that are useless and whoare grasping for greater things hellipThe GPs see us ascommercial and they have this idea that we make loadsof moneyrsquo [Pharmacist (P)8]

lsquoWell that is the perception we have always had even bythe medical profession We are shopkeepers asopposed to professionalsrsquo [P16]

The commercial aspect of community pharmacy also influ-enced GPsrsquo views on pharmacist prescribing GPs consid-ered that current systems created perverse incentives forcommunity pharmacists to sell more medication or if agreater role in prescribing was realised to prescribe morethis conflict was also recognised by the pharmacists

lsquoAnd many times you [the patient] donrsquot need anythingand while we are motivated to say that you donrsquot needanything the pharmacist if he is making money by sell-ing something his motivation is going to be different andI see that as not necessarily to the patientsrsquo best advan-tagersquo [GP2]

lsquoI wonder if you leave it that the person who is monitor-ing the condition and also putting in the claims that theyhave dispensed the drugs and supplied the drugs thereis a probity issue therersquo [GP9]

lsquoBut the difficulty I could see that they [GPs] would seeis that we would be prescribing for our benefitrsquo [P13]

Two GPs commented that in their view community pharma-cy of today resembles the organisation of general practice30 years ago and while there was a commercial element togeneral practice it was not as blatant as community pharmacy

lsquoThey [community pharmacists] may look upon eachother the way general practice did 20 or 30 years agowhen it was all one or two-man shows Everyone outthere was your competitor fighting for the same marketrsquo[GP9]

lsquoThey do remind you of general practice in the 1950swhen there were single-handed GPs working out of theirpremises reasonably tightly regulatedrsquo [GP18]

lsquoAs GPs we want to make a profit as well and we arehealthcare providers but I think it is all the commercial-ism around the chemistsrsquo shopsrsquo [GP20]

Many GPs saw a practice pharmacist (located within thepractice and working directly with GPs) as the preferredmodel in terms of interprofessional working and prescribingsupport owing to the absence of the shopkeeper image

lsquoThe pharmacist who is based within the practice doesnot have that commercial interest is there purely toserve the patient and be interested in the wellbeing ofthe patient They may well be salaried so they do nothave that commercial interest and it frees them up con-siderablyrsquo [GP16]

602 British Journal of General Practice August 2003

C M H ughes and S M cC ann

Table 1 Focus group demographics

Doctorsrsquo Pharmacistsrsquo groups groups

Number of groups 5 6Total number of participants 22 31Sex

Male 17 19Female 5 12

Average years of registration 164 137Location of practice

Urban 15 23Rural 7 8

Commercial statusFundholdingproprietor 17 14Non-fundholdingnon-proprietor 5 17

SHOPKEEPER IMAGE

AWARENESS

ACCESS

HIERARCHY

Figure 1 Overview of the main themes that emerged from the qual-itative analysis

AccessGenerally GPs did not report difficulties in contacting com-munity pharmacists However they expressed reservationsabout patient access to pharmacy services especially outsideworking hours This stemmed from GPs viewsrsquo of pharmacistspractising from a shop environment with set opening times

lsquoIf they want to be members of the primary healthcareteam I would welcome them on board but if itrsquos still ashopkeeper mentality making money open nine to fiveand not open on bank holidays and limited availabilitywhich is what we have got at the minute then I think thatdoes not cross the boundaries very wellrsquo [GP9]

lsquoThe GP has total 24-hour responsibility we just cannotswitch off at 600pmrsquo [GP21]

In contrast many pharmacists had encountered difficultiesin contacting GPs and this was often attributed to reception-ists Pharmacists recounted instances where they had beenkept on hold or asked to call back which they found unsat-isfactory while patients waited in their pharmacies for theirmedication

lsquoSometimes once you get the doctor they are very recep-tive but it is getting past whoever is in between you andthe doctor be it a receptionist or whoeverrsquo [P12]

lsquoIf you can get past the receptionist Some of them arelike biting dogs you just back off hellip There are timeswhen I have said that I have a patient here as well sodoes that mean that his patient is more important thanthe person who is waiting and who happens to be hispatient as wellrsquo [P27]

In contrast to GP perceptions pharmacists felt that theywere very accessible had a unique relationship withpatients had convenient opening hours and were a sourceof health information for the public

lsquoThe pharmacist is bombarded day in and day out withpeople coming in and out Itrsquos in your face Therersquos noappointments you are directly accessiblersquo [P24]

lsquoFrom feedback from customers you know that they sayldquoI come in to see what you say rather than them goingand bothering the GP as it takes up to three weeks to getan appointment Because I canrsquot get hold of the doctor Iam coming to yourdquorsquo [P28]

Recognising that prescribing rights for community pharma-cists would require access to medical notes a number ofGPs felt that patient confidentiality would be compromisedThis was also illustrated by GPsrsquo concerns over the designof many pharmacies and their suitability for giving advice

lsquoIf they are going to take on that role they are taking ona consulting role and most of the premises were notdesigned for that If you stand in pharmacies the confi-dentiality is zero mdash you can hear what is going onrsquo [GP9]

lsquoThe other issue is the issue of confidentiality When I amwriting in patient records the understanding has beenbetween myself and the patient that these are confiden-tial recordsrsquo [GP11]

Furthermore GPs felt that continuity of care would suffer withpharmacist prescribing because of the lack of patient registra-tion and the turnover of pharmacists in community practice

lsquoIt is an aspect definitely that should be considered asto whether the patient should register with a pharmacyrsquo[GP8]

lsquoYou do not know who you are dealing with and you can-not build up a relationship with them [employee phar-macists] because they are forever changingrsquo [GP20]

Again the practice pharmacist model was preferred in termsof regular contact and easy access

lsquoEase of communication is very important and they [prac-tice pharmacists] have access to the full patient notesWithin the practice we all work according to the samecode of confidentiality and I am quite happy to speak tothe practice pharmacist knowing that it stays within thepracticersquo [GP16]

HierarchyHierarchy in terms of professional standing and role inhealth care was apparent in all GP discussions GPsexpressed concerns about pharmacists assuming roles theyconsidered to be general practice activities and were notenthusiastic about their involvement in prescribing

lsquoA lot of repeat prescribing is not clinical You are notseeing the patient you are merely sorting out prescrip-tions Perhaps the pharmacist can do that It would freeup our time to do other thingsrsquo [GP2]

lsquoOh I think you can go too far and the pharmacist cangive too strong an opinion as to what we should pre-scribe I think they should leave the prescribing up tousrsquo [GP7]

Pharmacists also believed that any extension of their rolewould be seen as an encroachment on GP activity

lsquoWe have not got pharmacy prescribing yet hellip but thatwould be seen by some as an invasion of their territoryand the thin edge of the wedge and some would see itas brilliant A lot of GPs with some justice they feel thatwe are crossing on to their territory and taking away theirterritoryrsquo [P8]

lsquoGPs are very reluctant to relinquish any sort of control tous The pharmacist is an outsider and to a certain extentis a threat to the GPrsquo [P30]

Pharmacists expressed strong views about how they wereperceived by GPs in terms of hierarchy with many com-

British Journal of General Practice August 2003 603

O rig ina l papers

menting that GPs considered them to be subordinate in pro-fessional terms

lsquoThe other thing which was quite interesting was duringa dinner before a lecture was being given a GP said tome ldquoWell I suppose prescribing advisers are the accept-able face of pharmacyrdquo I said ldquoSo that makes commu-nity pharmacists the unacceptable face of pharmacyrdquoand her silence told me everythingrsquo [P10]

lsquoThe GP sits with his prescription pad and until he doessomething with it we sit with our degrees impotent untilwe get the piece of paper He is the instigator the pre-scriber is the instigator of the whole thing So no we arenot going to be equalrsquo [P18]

Community pharmacists were also considered on theperiphery of the primary healthcare team and once againthe shopkeeper image influenced GPsrsquo views

lsquoIf you could get them linked in to the practice then youcould put them under that umbrella but they are seenoutside that as they are at the moment That causes thedivisionrsquo [GP21]

lsquoIf pharmacists want to become more integrated into theprimary healthcare team I think they are going to have togive up their small shopkeeper empire if you like andbecome more integrated and more involved in healthcentresrsquo [GP18]

lsquoWe are not part of their team because we are outside thebuilding and although we might be considered by thegovernment to be part of the primary healthcare team weare not part of the ldquoin crowdrdquo that is round the surgeryall day every day so they see us as outsidersrsquo [P9]

lsquoI donrsquot think we are fully recognised as being part of itthe primary healthcare teamrsquo [P19]

However some GPs did feel that pharmacists were part of awider community team and this was also reflected in thepharmacistsrsquo views

lsquoI suppose they are helping to service the team mdash wouldthat be fair to say mdash without actually being part of itrsquo [GP16]

lsquoWe are secondary in that we are not involved in the pri-mary decision making perhaps they [pharmacists] aresweepers-up afterwardsrsquo [P23]

AwarenessGPs had some awareness of the community pharmacistrsquos rolein health care However many had little knowledge of phar-macistsrsquo training and their continuing professional develop-ment obligations and saw pharmacists working in a purelycommercial environment (returning to the shopkeeper image)

lsquoPharmacists treat an awful lot of things hellip a lot of con-sultation and prescription happens alreadyrsquo [GP2]

lsquoI think it should be publicly known that the pharmacistcan advise about minor ailmentsrsquo [GP12]

lsquoThey are not updated are they Or maybe they areMaybe theyrsquore not After their three years they are moreinto the business of dispensing and the rest of itrsquo [GP4]

lsquoI donrsquo t know what their training involves whether theyare made aware of what is involved in a shop a com-munity pharmacy as you say lipsticks cough mixturesetcrsquo [GP8]

Pharmacists also reported that there were some importantmisconceptions and lack of understanding about pharmacyon the part of GPs

lsquoThe GPs have a very poor understanding of what we dowith the public they think we dish out the medicinesrsquo [P8]

lsquoIn my profession I am never going to be a doctor butI think we have to be respected for what we do with med-icines and I think at the minute GPs do not fully under-stand what we do I think they think that we just put it intoa bag and throw it out I donrsquot think they see the rolersquo[P17]

Such views had led to a sense of frustration and pharma-cists felt undervalued in their work

lsquoI know I do a worthwhile job but I think only pharmacistsappreciate what a worthwhile job we do I donrsquot think weare held in particularly high esteem by the publicbecause they can go to any pharmacy They have gotone GP but they can go to any pharmacy I see their atti-tude at the health centre where they have to wait for fiveor ten minutes I see them queue patiently at the bankand at Tescorsquos and the post office and then they comeinto the pharmacy and want to know why their medica-tion is taking so longrsquo [P18]

Joint training at undergraduate and postgraduate level ofthe two professions was suggested by pharmacists as a wayto overcome barriers and increase awareness of profession-al skills and strengths

lsquoWe need to work together we have to start working asteams We really do have to break down those barrierswe really should start our training together The first yearof pharmacy and medicine should be the same thesame as medicine and dentistry So that you know thosepeople have the same training and same backgroundknowledgersquo [P9]

Discussion The overarching theme that emerged from this study wasthe shopkeeper image of community pharmacy that perme-ated the three major subthemes of access hierarchy andawareness Participants reported problems only from theirprofessional perspective despite being part of the samehealthcare system

604 British Journal of General Practice August 2003

C M H ughes and S M cC ann

British Journal of General Practice August 2003 605

O rig ina l papers

Limitations of the studyAlthough this study was conducted in a specific geographi-cal region with a defined sample it was broadly representa-tive and there was nothing to suggest that the groups wouldbe different from other practitioners in other parts of theUnited Kingdom Although it may be suggested that thosewho participated in the study were more likely to have a pre-established interest in this topic this did not appear to influ-ence their views as evidenced by their commentsConversely it may have been the case that these individualsheld very strong views and considered the focus group as away of voicing concerns Although the focus group facilita-tor was a pharmacist this also appeared to have little bear-ing on the GP discussions which were frank and wide-rang-ing The facilitator had been introduced as someone fromthe university setting and was perhaps perceived differentlyto pharmacists from community practice The discussionsmay also have been facilitated by having uniprofessionalfocus groups as each profession may have been less forth-coming if the groups had been mixed in terms of discipline

Interpretation of findingsIt had been thought that GPs who had had previous contactwith pharmacists through interdisciplinary projects wouldhave had a more positive view of community pharmacy Thecommercial imperative of community pharmacy howeverseemed to be an important barrier for GPs Indeed it couldbe argued that contact with pharmacists in prescribing sup-port may have only reinforced GPsrsquo views of the shopkeep-er image of community pharmacy Adamcik et al noted thatphysicians who had had contact with clinical pharmacistsmay have attributed those pharmacistsrsquo skills and expertiseas something unique to them and by acknowledging theexcellence of these so-called lsquodeviant clinical pharmacistsrsquothey confirmed the stereotype of the community pharma-cist13 This may be the case with the GPs in this sampleIndeed GPs preferred the practice pharmacist modelbecause of the absence of the commercial trappings TwoGPs commented on the similarities between present-daycommunity pharmacy and that of general practice decadesago Ironically present day general practice has also beenlikened to a small business14 although less overtly com-mercial than pharmacy and without the appearance of aretail environment Other characteristics of the GPs such asage sex or the training status of their practice had no influ-ence on the emergence of the main themes

Access was a barrier for both professions but from differ-ent perspectives with GPs expressing concern aboutrestricted hours of services in pharmacies confidentialityand turnover of staff and pharmacists stating that recep-tionists limited their access to GPs Arber and Sawyer report-ed that receptionists acted as gatekeepers between patientswanting access and doctors needing to manage the numberof contacts with patients and reported that lsquohellip since thereceptionist is a lay person this can cause resentment in theminds of patientsrsquo15 Pharmacists could be substituted forpatients in this comment

Hierarchy was implicit in the comments from GPs in thatthey questioned the role and skills of pharmacists in certain

activities and felt that greater involvement in prescribingwould not be particularly appropriate This has been inter-preted as boundary encroachment16-22 This also raises theissue of professional autonomy and professional dominancemdash how certain professions not only control the content oftheir own work but can also define the limits of work of otherprofessional groups23 This is clearly exemplified by the rela-tionship between pharmacists and GPs1624 Pharmacists inthis study were conscious of this hierarchical system as theyarticulated dependence on doctors to issue prescriptions25

Elston and Holloway reported that professional identitiesand traditional power structures created conflict betweenGPs nurses and practice managers and suggested that anew generation of professionals would be required to pro-mote an interprofessional culture in the NHS26 This mayalso be reflected in medicine and pharmacy

Lack of awareness emerged as a major barrier with GPsreporting that they had little idea of the training and skills ofpharmacists and pharmacists reporting that GPs and theirstaff were not aware of their role in health care and believingthat their contribution was undervalued Thompson et alhave stated that conflict between nurses and pharmacistsarises through lack of trust respect competition betweenpatient care roles and lack of appreciation for each other asprofessionals27 Greenfield et al found that practice nursesfelt that doctorsrsquo attitudes were the most important limitingfactor in the expansion of the nursersquos role28 SimilarlyBradshaw and Doucette considered that the reactions andattitudes of GPs could either hinder or facilitate an expan-sion of the community pharmacistrsquos role and the rarity ofregular face-to-face contact with doctors and other health-care professionals represented a considerable obstacle torole expansion29

ConclusionImplications of findings for primary careAwareness of barriers between the two professions may helpto pre-empt some of the practical difficulties that couldemerge during any pilot evaluation of pharmacist prescribingsuch as the retention of dispensing duties by pharmacists inconjunction with prescribing rights430 On a more generallevel the findings have implications for team-working withinprimary care Williams and Sibbald described how the move-ment of healthcare work from doctors to nurses contributedto a culture of uncertainty and could affect the care given topatients 31 This is also reflected in these findings and per-haps helps to explain why GPs struggled to see where com-munity pharmacists could fit into prescribing Continuingreorganisation of primary care may accelerate changes inroles and responsibilities through a new GP contract32 anda proposed new remuneration system for community phar-macy33 Multidisciplinary training at both undergraduate andpostgraduate level may go some way to improving mutualunderstanding trust and communication and the literaturesupports this view34-37

References1 Hepler CD Strand LM Opportunities and responsibilities in phar-

maceutical care Am J Hosp Pharm 1990 47 533-5422 Report of the joint working party on the future role of community

GPndashpharmacist collaborations already in place Six focusgroups (considered optimal to achieve data saturation) ofGPs and pharmacists respectively were planned (twouniprofessional groups per locality one group having hadexperience of interprofessional working and the other hav-ing had relatively little experience) The extent of this previ-ous experience was based on information obtained fromappropriate staff based at board headquarters Focusgroups were used in preference to individual interviews asthis was perceived to be a more cost-effective and efficientmeans of accessing the views of a large number of individu-als It was also believed that the group interaction wouldgenerate discussion and debate Letters were sent to all GPs(n = 140) and community pharmacies (n = 74 lettersaddressed to the proprietor or pharmacy manager) in thethree locality areas which outlined the nature and format ofthe study along with a reply slip and prepaid return enve-lope Payment was offered (pound110) to participants A follow-up telephone call was made to those who had not replied tothe original letter

The focus groups were held in convenient locations forparticipants (local hotels) between May and September2001 Each discussion lasted for approximately 70 to 90minutes was facilitated by the project leader (CMH) andanonymity was assured The discussion was based arounda topic guide which had been compiled following an exten-sive review of the literature (using MEDLINE Web of Scienceand International Pharmaceutical Abstracts) on GPndashpharma-cist relationships collaboration in primary care and theextension of prescribing rights to pharmacists (Box 1)During the discussion the facilitator clarified the Crownreport recommendations4 and ensured that participantsunderstood the terms lsquosupplementaryrsquo and lsquoindependentrsquoprescribing All discussions were audiotaped and tran-scribed

AnalysisAll transcripts were independently checked against the orig-inal recordings (CMH) A researcher from a non-pharmacybackground (SMcC health psychology) participated in theanalysis to minimise any investigator bias9 The transcripts

were analysed independently by the authors using interpre-tative phenomenology10 Interpretative phenomenologicalanalysis is concerned with the interpretation of an individ-ualrsquos personal perception or account of an object or event10

The transcripts were read repeatedly recurrent themes wereidentified and coded (along with supporting quotes) inde-pendently and consensus was reached by discussionbetween the two researchers A network of subordinate andsuperordinate themes was established The authors agreedon the major themes that arose from the analysis The prin-ciples of grounded theory were used to develop explanato-ry theories for the emerging themes to further understandthe interface between community pharmacy and generalpractice1112 This approach involved the use of lsquoconstantcomparisonrsquo whereby the aim of the research is the devel-opment of substantive theory and the emergent theory wastested in subsequent focus group interviews Analysis of thetranscripts yielded similar themes and therefore additionaltheoretical sampling was deemed to be unnecessary

ResultsTable 1 summarises demographic information pertaining tothe focus groups From the initial mailing to 140 GPs 22agreed to participate (distributed over five groups) and fromthe 70 community pharmacies that were contacted 31 phar-macists participated (distributed over six focus groups)Eleven practices from a total of 63 practices in the threelocalities had accredited training status of these six had GPrepresentatives in the focus groups Twelve non-trainingpractices were also represented

Owing to the low response rate it was not possible to holda second GP focus group in locality B The response ratehad an impact on the constitution of the focus groupsbecause GPs and pharmacists who had little experience ofworking with each other participated in focus groups withcolleagues who had more experience of interdisciplinarycollaboration Analysis of the transcripts from the focusgroups however revealed similar themes emerging from alldiscussions Furthermore Table 1 indicates that the groupswere diverse Although there were a greater number ofmales than females in the groups this had no impact on thethemes extracted from the data

Analysis of the data revealed the emergence of a super-ordinate theme mdash the lsquoshopkeeperrsquo image of communitypharmacy mdash which was a common thread throughout allthe transcripts and which permeated the three subthemesof access hierarchy and awareness (shown in Figure 1)All four themes represented barriers between the two pro-fessions

British Journal of General Practice August 2003 601

O riginal papers

HOW THIS FITS IN

What do we knowPharmacists have been challenged to become key players in the prescribing process and the extension of prescribing rights asrecommended by the Crown report may help realise this goalProfessional barriers between general practice and communitypharmacy may hinder this development

What does this paper addThe shopkeeper image of the community pharmacistemerged as the main barrier between the two professions andthis was further reflected in the barriers of access hierarchand awareness Acknowledgement of these barriers may gosome way to pre-empt difficulties which could emerge withthe extension of prescribing rights to pharmacists

Box 1 Topic areas for GP and community pharmacist focusgroups

Experience of professional contact with the other profession Views on the other profession Barriers to better professional relationships Attitudes to pharmacist prescribing as advocated by the

Crown report Role of community pharmacy in primary care

Shopkeeper image of community pharmacyMany of the GPs in the focus groups saw community phar-macists as businesspeople shopkeepers or specialist retail-ers and believed this represented a conflict of interest inhealth care Pharmacists felt the shopkeeper image influ-enced the attitude of GPs and had an impact on the devel-opment of the pharmacistrsquos role

lsquoI think that they are probably more businessmen than weare probably more motivated by the business side ofthings than we tend to bersquo [GP13]

lsquoThere is definitely a conflict between the NHS primaryhealthcare team effort that we all feel we are involved inand with pharmacists and their role as the shopkeeperand their role in looking for profits for themselvesrsquo[GP18]

lsquoThey [some GPs] donrsquot have any opinion at all aboutcommunity pharmacists They think we have no rolethey think we are shopkeepers that are useless and whoare grasping for greater things hellipThe GPs see us ascommercial and they have this idea that we make loadsof moneyrsquo [Pharmacist (P)8]

lsquoWell that is the perception we have always had even bythe medical profession We are shopkeepers asopposed to professionalsrsquo [P16]

The commercial aspect of community pharmacy also influ-enced GPsrsquo views on pharmacist prescribing GPs consid-ered that current systems created perverse incentives forcommunity pharmacists to sell more medication or if agreater role in prescribing was realised to prescribe morethis conflict was also recognised by the pharmacists

lsquoAnd many times you [the patient] donrsquot need anythingand while we are motivated to say that you donrsquot needanything the pharmacist if he is making money by sell-ing something his motivation is going to be different andI see that as not necessarily to the patientsrsquo best advan-tagersquo [GP2]

lsquoI wonder if you leave it that the person who is monitor-ing the condition and also putting in the claims that theyhave dispensed the drugs and supplied the drugs thereis a probity issue therersquo [GP9]

lsquoBut the difficulty I could see that they [GPs] would seeis that we would be prescribing for our benefitrsquo [P13]

Two GPs commented that in their view community pharma-cy of today resembles the organisation of general practice30 years ago and while there was a commercial element togeneral practice it was not as blatant as community pharmacy

lsquoThey [community pharmacists] may look upon eachother the way general practice did 20 or 30 years agowhen it was all one or two-man shows Everyone outthere was your competitor fighting for the same marketrsquo[GP9]

lsquoThey do remind you of general practice in the 1950swhen there were single-handed GPs working out of theirpremises reasonably tightly regulatedrsquo [GP18]

lsquoAs GPs we want to make a profit as well and we arehealthcare providers but I think it is all the commercial-ism around the chemistsrsquo shopsrsquo [GP20]

Many GPs saw a practice pharmacist (located within thepractice and working directly with GPs) as the preferredmodel in terms of interprofessional working and prescribingsupport owing to the absence of the shopkeeper image

lsquoThe pharmacist who is based within the practice doesnot have that commercial interest is there purely toserve the patient and be interested in the wellbeing ofthe patient They may well be salaried so they do nothave that commercial interest and it frees them up con-siderablyrsquo [GP16]

602 British Journal of General Practice August 2003

C M H ughes and S M cC ann

Table 1 Focus group demographics

Doctorsrsquo Pharmacistsrsquo groups groups

Number of groups 5 6Total number of participants 22 31Sex

Male 17 19Female 5 12

Average years of registration 164 137Location of practice

Urban 15 23Rural 7 8

Commercial statusFundholdingproprietor 17 14Non-fundholdingnon-proprietor 5 17

SHOPKEEPER IMAGE

AWARENESS

ACCESS

HIERARCHY

Figure 1 Overview of the main themes that emerged from the qual-itative analysis

AccessGenerally GPs did not report difficulties in contacting com-munity pharmacists However they expressed reservationsabout patient access to pharmacy services especially outsideworking hours This stemmed from GPs viewsrsquo of pharmacistspractising from a shop environment with set opening times

lsquoIf they want to be members of the primary healthcareteam I would welcome them on board but if itrsquos still ashopkeeper mentality making money open nine to fiveand not open on bank holidays and limited availabilitywhich is what we have got at the minute then I think thatdoes not cross the boundaries very wellrsquo [GP9]

lsquoThe GP has total 24-hour responsibility we just cannotswitch off at 600pmrsquo [GP21]

In contrast many pharmacists had encountered difficultiesin contacting GPs and this was often attributed to reception-ists Pharmacists recounted instances where they had beenkept on hold or asked to call back which they found unsat-isfactory while patients waited in their pharmacies for theirmedication

lsquoSometimes once you get the doctor they are very recep-tive but it is getting past whoever is in between you andthe doctor be it a receptionist or whoeverrsquo [P12]

lsquoIf you can get past the receptionist Some of them arelike biting dogs you just back off hellip There are timeswhen I have said that I have a patient here as well sodoes that mean that his patient is more important thanthe person who is waiting and who happens to be hispatient as wellrsquo [P27]

In contrast to GP perceptions pharmacists felt that theywere very accessible had a unique relationship withpatients had convenient opening hours and were a sourceof health information for the public

lsquoThe pharmacist is bombarded day in and day out withpeople coming in and out Itrsquos in your face Therersquos noappointments you are directly accessiblersquo [P24]

lsquoFrom feedback from customers you know that they sayldquoI come in to see what you say rather than them goingand bothering the GP as it takes up to three weeks to getan appointment Because I canrsquot get hold of the doctor Iam coming to yourdquorsquo [P28]

Recognising that prescribing rights for community pharma-cists would require access to medical notes a number ofGPs felt that patient confidentiality would be compromisedThis was also illustrated by GPsrsquo concerns over the designof many pharmacies and their suitability for giving advice

lsquoIf they are going to take on that role they are taking ona consulting role and most of the premises were notdesigned for that If you stand in pharmacies the confi-dentiality is zero mdash you can hear what is going onrsquo [GP9]

lsquoThe other issue is the issue of confidentiality When I amwriting in patient records the understanding has beenbetween myself and the patient that these are confiden-tial recordsrsquo [GP11]

Furthermore GPs felt that continuity of care would suffer withpharmacist prescribing because of the lack of patient registra-tion and the turnover of pharmacists in community practice

lsquoIt is an aspect definitely that should be considered asto whether the patient should register with a pharmacyrsquo[GP8]

lsquoYou do not know who you are dealing with and you can-not build up a relationship with them [employee phar-macists] because they are forever changingrsquo [GP20]

Again the practice pharmacist model was preferred in termsof regular contact and easy access

lsquoEase of communication is very important and they [prac-tice pharmacists] have access to the full patient notesWithin the practice we all work according to the samecode of confidentiality and I am quite happy to speak tothe practice pharmacist knowing that it stays within thepracticersquo [GP16]

HierarchyHierarchy in terms of professional standing and role inhealth care was apparent in all GP discussions GPsexpressed concerns about pharmacists assuming roles theyconsidered to be general practice activities and were notenthusiastic about their involvement in prescribing

lsquoA lot of repeat prescribing is not clinical You are notseeing the patient you are merely sorting out prescrip-tions Perhaps the pharmacist can do that It would freeup our time to do other thingsrsquo [GP2]

lsquoOh I think you can go too far and the pharmacist cangive too strong an opinion as to what we should pre-scribe I think they should leave the prescribing up tousrsquo [GP7]

Pharmacists also believed that any extension of their rolewould be seen as an encroachment on GP activity

lsquoWe have not got pharmacy prescribing yet hellip but thatwould be seen by some as an invasion of their territoryand the thin edge of the wedge and some would see itas brilliant A lot of GPs with some justice they feel thatwe are crossing on to their territory and taking away theirterritoryrsquo [P8]

lsquoGPs are very reluctant to relinquish any sort of control tous The pharmacist is an outsider and to a certain extentis a threat to the GPrsquo [P30]

Pharmacists expressed strong views about how they wereperceived by GPs in terms of hierarchy with many com-

British Journal of General Practice August 2003 603

O rig ina l papers

menting that GPs considered them to be subordinate in pro-fessional terms

lsquoThe other thing which was quite interesting was duringa dinner before a lecture was being given a GP said tome ldquoWell I suppose prescribing advisers are the accept-able face of pharmacyrdquo I said ldquoSo that makes commu-nity pharmacists the unacceptable face of pharmacyrdquoand her silence told me everythingrsquo [P10]

lsquoThe GP sits with his prescription pad and until he doessomething with it we sit with our degrees impotent untilwe get the piece of paper He is the instigator the pre-scriber is the instigator of the whole thing So no we arenot going to be equalrsquo [P18]

Community pharmacists were also considered on theperiphery of the primary healthcare team and once againthe shopkeeper image influenced GPsrsquo views

lsquoIf you could get them linked in to the practice then youcould put them under that umbrella but they are seenoutside that as they are at the moment That causes thedivisionrsquo [GP21]

lsquoIf pharmacists want to become more integrated into theprimary healthcare team I think they are going to have togive up their small shopkeeper empire if you like andbecome more integrated and more involved in healthcentresrsquo [GP18]

lsquoWe are not part of their team because we are outside thebuilding and although we might be considered by thegovernment to be part of the primary healthcare team weare not part of the ldquoin crowdrdquo that is round the surgeryall day every day so they see us as outsidersrsquo [P9]

lsquoI donrsquot think we are fully recognised as being part of itthe primary healthcare teamrsquo [P19]

However some GPs did feel that pharmacists were part of awider community team and this was also reflected in thepharmacistsrsquo views

lsquoI suppose they are helping to service the team mdash wouldthat be fair to say mdash without actually being part of itrsquo [GP16]

lsquoWe are secondary in that we are not involved in the pri-mary decision making perhaps they [pharmacists] aresweepers-up afterwardsrsquo [P23]

AwarenessGPs had some awareness of the community pharmacistrsquos rolein health care However many had little knowledge of phar-macistsrsquo training and their continuing professional develop-ment obligations and saw pharmacists working in a purelycommercial environment (returning to the shopkeeper image)

lsquoPharmacists treat an awful lot of things hellip a lot of con-sultation and prescription happens alreadyrsquo [GP2]

lsquoI think it should be publicly known that the pharmacistcan advise about minor ailmentsrsquo [GP12]

lsquoThey are not updated are they Or maybe they areMaybe theyrsquore not After their three years they are moreinto the business of dispensing and the rest of itrsquo [GP4]

lsquoI donrsquo t know what their training involves whether theyare made aware of what is involved in a shop a com-munity pharmacy as you say lipsticks cough mixturesetcrsquo [GP8]

Pharmacists also reported that there were some importantmisconceptions and lack of understanding about pharmacyon the part of GPs

lsquoThe GPs have a very poor understanding of what we dowith the public they think we dish out the medicinesrsquo [P8]

lsquoIn my profession I am never going to be a doctor butI think we have to be respected for what we do with med-icines and I think at the minute GPs do not fully under-stand what we do I think they think that we just put it intoa bag and throw it out I donrsquot think they see the rolersquo[P17]

Such views had led to a sense of frustration and pharma-cists felt undervalued in their work

lsquoI know I do a worthwhile job but I think only pharmacistsappreciate what a worthwhile job we do I donrsquot think weare held in particularly high esteem by the publicbecause they can go to any pharmacy They have gotone GP but they can go to any pharmacy I see their atti-tude at the health centre where they have to wait for fiveor ten minutes I see them queue patiently at the bankand at Tescorsquos and the post office and then they comeinto the pharmacy and want to know why their medica-tion is taking so longrsquo [P18]

Joint training at undergraduate and postgraduate level ofthe two professions was suggested by pharmacists as a wayto overcome barriers and increase awareness of profession-al skills and strengths

lsquoWe need to work together we have to start working asteams We really do have to break down those barrierswe really should start our training together The first yearof pharmacy and medicine should be the same thesame as medicine and dentistry So that you know thosepeople have the same training and same backgroundknowledgersquo [P9]

Discussion The overarching theme that emerged from this study wasthe shopkeeper image of community pharmacy that perme-ated the three major subthemes of access hierarchy andawareness Participants reported problems only from theirprofessional perspective despite being part of the samehealthcare system

604 British Journal of General Practice August 2003

C M H ughes and S M cC ann

British Journal of General Practice August 2003 605

O rig ina l papers

Limitations of the studyAlthough this study was conducted in a specific geographi-cal region with a defined sample it was broadly representa-tive and there was nothing to suggest that the groups wouldbe different from other practitioners in other parts of theUnited Kingdom Although it may be suggested that thosewho participated in the study were more likely to have a pre-established interest in this topic this did not appear to influ-ence their views as evidenced by their commentsConversely it may have been the case that these individualsheld very strong views and considered the focus group as away of voicing concerns Although the focus group facilita-tor was a pharmacist this also appeared to have little bear-ing on the GP discussions which were frank and wide-rang-ing The facilitator had been introduced as someone fromthe university setting and was perhaps perceived differentlyto pharmacists from community practice The discussionsmay also have been facilitated by having uniprofessionalfocus groups as each profession may have been less forth-coming if the groups had been mixed in terms of discipline

Interpretation of findingsIt had been thought that GPs who had had previous contactwith pharmacists through interdisciplinary projects wouldhave had a more positive view of community pharmacy Thecommercial imperative of community pharmacy howeverseemed to be an important barrier for GPs Indeed it couldbe argued that contact with pharmacists in prescribing sup-port may have only reinforced GPsrsquo views of the shopkeep-er image of community pharmacy Adamcik et al noted thatphysicians who had had contact with clinical pharmacistsmay have attributed those pharmacistsrsquo skills and expertiseas something unique to them and by acknowledging theexcellence of these so-called lsquodeviant clinical pharmacistsrsquothey confirmed the stereotype of the community pharma-cist13 This may be the case with the GPs in this sampleIndeed GPs preferred the practice pharmacist modelbecause of the absence of the commercial trappings TwoGPs commented on the similarities between present-daycommunity pharmacy and that of general practice decadesago Ironically present day general practice has also beenlikened to a small business14 although less overtly com-mercial than pharmacy and without the appearance of aretail environment Other characteristics of the GPs such asage sex or the training status of their practice had no influ-ence on the emergence of the main themes

Access was a barrier for both professions but from differ-ent perspectives with GPs expressing concern aboutrestricted hours of services in pharmacies confidentialityand turnover of staff and pharmacists stating that recep-tionists limited their access to GPs Arber and Sawyer report-ed that receptionists acted as gatekeepers between patientswanting access and doctors needing to manage the numberof contacts with patients and reported that lsquohellip since thereceptionist is a lay person this can cause resentment in theminds of patientsrsquo15 Pharmacists could be substituted forpatients in this comment

Hierarchy was implicit in the comments from GPs in thatthey questioned the role and skills of pharmacists in certain

activities and felt that greater involvement in prescribingwould not be particularly appropriate This has been inter-preted as boundary encroachment16-22 This also raises theissue of professional autonomy and professional dominancemdash how certain professions not only control the content oftheir own work but can also define the limits of work of otherprofessional groups23 This is clearly exemplified by the rela-tionship between pharmacists and GPs1624 Pharmacists inthis study were conscious of this hierarchical system as theyarticulated dependence on doctors to issue prescriptions25

Elston and Holloway reported that professional identitiesand traditional power structures created conflict betweenGPs nurses and practice managers and suggested that anew generation of professionals would be required to pro-mote an interprofessional culture in the NHS26 This mayalso be reflected in medicine and pharmacy

Lack of awareness emerged as a major barrier with GPsreporting that they had little idea of the training and skills ofpharmacists and pharmacists reporting that GPs and theirstaff were not aware of their role in health care and believingthat their contribution was undervalued Thompson et alhave stated that conflict between nurses and pharmacistsarises through lack of trust respect competition betweenpatient care roles and lack of appreciation for each other asprofessionals27 Greenfield et al found that practice nursesfelt that doctorsrsquo attitudes were the most important limitingfactor in the expansion of the nursersquos role28 SimilarlyBradshaw and Doucette considered that the reactions andattitudes of GPs could either hinder or facilitate an expan-sion of the community pharmacistrsquos role and the rarity ofregular face-to-face contact with doctors and other health-care professionals represented a considerable obstacle torole expansion29

ConclusionImplications of findings for primary careAwareness of barriers between the two professions may helpto pre-empt some of the practical difficulties that couldemerge during any pilot evaluation of pharmacist prescribingsuch as the retention of dispensing duties by pharmacists inconjunction with prescribing rights430 On a more generallevel the findings have implications for team-working withinprimary care Williams and Sibbald described how the move-ment of healthcare work from doctors to nurses contributedto a culture of uncertainty and could affect the care given topatients 31 This is also reflected in these findings and per-haps helps to explain why GPs struggled to see where com-munity pharmacists could fit into prescribing Continuingreorganisation of primary care may accelerate changes inroles and responsibilities through a new GP contract32 anda proposed new remuneration system for community phar-macy33 Multidisciplinary training at both undergraduate andpostgraduate level may go some way to improving mutualunderstanding trust and communication and the literaturesupports this view34-37

References1 Hepler CD Strand LM Opportunities and responsibilities in phar-

maceutical care Am J Hosp Pharm 1990 47 533-5422 Report of the joint working party on the future role of community

Shopkeeper image of community pharmacyMany of the GPs in the focus groups saw community phar-macists as businesspeople shopkeepers or specialist retail-ers and believed this represented a conflict of interest inhealth care Pharmacists felt the shopkeeper image influ-enced the attitude of GPs and had an impact on the devel-opment of the pharmacistrsquos role

lsquoI think that they are probably more businessmen than weare probably more motivated by the business side ofthings than we tend to bersquo [GP13]

lsquoThere is definitely a conflict between the NHS primaryhealthcare team effort that we all feel we are involved inand with pharmacists and their role as the shopkeeperand their role in looking for profits for themselvesrsquo[GP18]

lsquoThey [some GPs] donrsquot have any opinion at all aboutcommunity pharmacists They think we have no rolethey think we are shopkeepers that are useless and whoare grasping for greater things hellipThe GPs see us ascommercial and they have this idea that we make loadsof moneyrsquo [Pharmacist (P)8]

lsquoWell that is the perception we have always had even bythe medical profession We are shopkeepers asopposed to professionalsrsquo [P16]

The commercial aspect of community pharmacy also influ-enced GPsrsquo views on pharmacist prescribing GPs consid-ered that current systems created perverse incentives forcommunity pharmacists to sell more medication or if agreater role in prescribing was realised to prescribe morethis conflict was also recognised by the pharmacists

lsquoAnd many times you [the patient] donrsquot need anythingand while we are motivated to say that you donrsquot needanything the pharmacist if he is making money by sell-ing something his motivation is going to be different andI see that as not necessarily to the patientsrsquo best advan-tagersquo [GP2]

lsquoI wonder if you leave it that the person who is monitor-ing the condition and also putting in the claims that theyhave dispensed the drugs and supplied the drugs thereis a probity issue therersquo [GP9]

lsquoBut the difficulty I could see that they [GPs] would seeis that we would be prescribing for our benefitrsquo [P13]

Two GPs commented that in their view community pharma-cy of today resembles the organisation of general practice30 years ago and while there was a commercial element togeneral practice it was not as blatant as community pharmacy

lsquoThey [community pharmacists] may look upon eachother the way general practice did 20 or 30 years agowhen it was all one or two-man shows Everyone outthere was your competitor fighting for the same marketrsquo[GP9]

lsquoThey do remind you of general practice in the 1950swhen there were single-handed GPs working out of theirpremises reasonably tightly regulatedrsquo [GP18]

lsquoAs GPs we want to make a profit as well and we arehealthcare providers but I think it is all the commercial-ism around the chemistsrsquo shopsrsquo [GP20]

Many GPs saw a practice pharmacist (located within thepractice and working directly with GPs) as the preferredmodel in terms of interprofessional working and prescribingsupport owing to the absence of the shopkeeper image

lsquoThe pharmacist who is based within the practice doesnot have that commercial interest is there purely toserve the patient and be interested in the wellbeing ofthe patient They may well be salaried so they do nothave that commercial interest and it frees them up con-siderablyrsquo [GP16]

602 British Journal of General Practice August 2003

C M H ughes and S M cC ann

Table 1 Focus group demographics

Doctorsrsquo Pharmacistsrsquo groups groups

Number of groups 5 6Total number of participants 22 31Sex

Male 17 19Female 5 12

Average years of registration 164 137Location of practice

Urban 15 23Rural 7 8

Commercial statusFundholdingproprietor 17 14Non-fundholdingnon-proprietor 5 17

SHOPKEEPER IMAGE

AWARENESS

ACCESS

HIERARCHY

Figure 1 Overview of the main themes that emerged from the qual-itative analysis

AccessGenerally GPs did not report difficulties in contacting com-munity pharmacists However they expressed reservationsabout patient access to pharmacy services especially outsideworking hours This stemmed from GPs viewsrsquo of pharmacistspractising from a shop environment with set opening times

lsquoIf they want to be members of the primary healthcareteam I would welcome them on board but if itrsquos still ashopkeeper mentality making money open nine to fiveand not open on bank holidays and limited availabilitywhich is what we have got at the minute then I think thatdoes not cross the boundaries very wellrsquo [GP9]

lsquoThe GP has total 24-hour responsibility we just cannotswitch off at 600pmrsquo [GP21]

In contrast many pharmacists had encountered difficultiesin contacting GPs and this was often attributed to reception-ists Pharmacists recounted instances where they had beenkept on hold or asked to call back which they found unsat-isfactory while patients waited in their pharmacies for theirmedication

lsquoSometimes once you get the doctor they are very recep-tive but it is getting past whoever is in between you andthe doctor be it a receptionist or whoeverrsquo [P12]

lsquoIf you can get past the receptionist Some of them arelike biting dogs you just back off hellip There are timeswhen I have said that I have a patient here as well sodoes that mean that his patient is more important thanthe person who is waiting and who happens to be hispatient as wellrsquo [P27]

In contrast to GP perceptions pharmacists felt that theywere very accessible had a unique relationship withpatients had convenient opening hours and were a sourceof health information for the public

lsquoThe pharmacist is bombarded day in and day out withpeople coming in and out Itrsquos in your face Therersquos noappointments you are directly accessiblersquo [P24]

lsquoFrom feedback from customers you know that they sayldquoI come in to see what you say rather than them goingand bothering the GP as it takes up to three weeks to getan appointment Because I canrsquot get hold of the doctor Iam coming to yourdquorsquo [P28]

Recognising that prescribing rights for community pharma-cists would require access to medical notes a number ofGPs felt that patient confidentiality would be compromisedThis was also illustrated by GPsrsquo concerns over the designof many pharmacies and their suitability for giving advice

lsquoIf they are going to take on that role they are taking ona consulting role and most of the premises were notdesigned for that If you stand in pharmacies the confi-dentiality is zero mdash you can hear what is going onrsquo [GP9]

lsquoThe other issue is the issue of confidentiality When I amwriting in patient records the understanding has beenbetween myself and the patient that these are confiden-tial recordsrsquo [GP11]

Furthermore GPs felt that continuity of care would suffer withpharmacist prescribing because of the lack of patient registra-tion and the turnover of pharmacists in community practice

lsquoIt is an aspect definitely that should be considered asto whether the patient should register with a pharmacyrsquo[GP8]

lsquoYou do not know who you are dealing with and you can-not build up a relationship with them [employee phar-macists] because they are forever changingrsquo [GP20]

Again the practice pharmacist model was preferred in termsof regular contact and easy access

lsquoEase of communication is very important and they [prac-tice pharmacists] have access to the full patient notesWithin the practice we all work according to the samecode of confidentiality and I am quite happy to speak tothe practice pharmacist knowing that it stays within thepracticersquo [GP16]

HierarchyHierarchy in terms of professional standing and role inhealth care was apparent in all GP discussions GPsexpressed concerns about pharmacists assuming roles theyconsidered to be general practice activities and were notenthusiastic about their involvement in prescribing

lsquoA lot of repeat prescribing is not clinical You are notseeing the patient you are merely sorting out prescrip-tions Perhaps the pharmacist can do that It would freeup our time to do other thingsrsquo [GP2]

lsquoOh I think you can go too far and the pharmacist cangive too strong an opinion as to what we should pre-scribe I think they should leave the prescribing up tousrsquo [GP7]

Pharmacists also believed that any extension of their rolewould be seen as an encroachment on GP activity

lsquoWe have not got pharmacy prescribing yet hellip but thatwould be seen by some as an invasion of their territoryand the thin edge of the wedge and some would see itas brilliant A lot of GPs with some justice they feel thatwe are crossing on to their territory and taking away theirterritoryrsquo [P8]

lsquoGPs are very reluctant to relinquish any sort of control tous The pharmacist is an outsider and to a certain extentis a threat to the GPrsquo [P30]

Pharmacists expressed strong views about how they wereperceived by GPs in terms of hierarchy with many com-

British Journal of General Practice August 2003 603

O rig ina l papers

menting that GPs considered them to be subordinate in pro-fessional terms

lsquoThe other thing which was quite interesting was duringa dinner before a lecture was being given a GP said tome ldquoWell I suppose prescribing advisers are the accept-able face of pharmacyrdquo I said ldquoSo that makes commu-nity pharmacists the unacceptable face of pharmacyrdquoand her silence told me everythingrsquo [P10]

lsquoThe GP sits with his prescription pad and until he doessomething with it we sit with our degrees impotent untilwe get the piece of paper He is the instigator the pre-scriber is the instigator of the whole thing So no we arenot going to be equalrsquo [P18]

Community pharmacists were also considered on theperiphery of the primary healthcare team and once againthe shopkeeper image influenced GPsrsquo views

lsquoIf you could get them linked in to the practice then youcould put them under that umbrella but they are seenoutside that as they are at the moment That causes thedivisionrsquo [GP21]

lsquoIf pharmacists want to become more integrated into theprimary healthcare team I think they are going to have togive up their small shopkeeper empire if you like andbecome more integrated and more involved in healthcentresrsquo [GP18]

lsquoWe are not part of their team because we are outside thebuilding and although we might be considered by thegovernment to be part of the primary healthcare team weare not part of the ldquoin crowdrdquo that is round the surgeryall day every day so they see us as outsidersrsquo [P9]

lsquoI donrsquot think we are fully recognised as being part of itthe primary healthcare teamrsquo [P19]

However some GPs did feel that pharmacists were part of awider community team and this was also reflected in thepharmacistsrsquo views

lsquoI suppose they are helping to service the team mdash wouldthat be fair to say mdash without actually being part of itrsquo [GP16]

lsquoWe are secondary in that we are not involved in the pri-mary decision making perhaps they [pharmacists] aresweepers-up afterwardsrsquo [P23]

AwarenessGPs had some awareness of the community pharmacistrsquos rolein health care However many had little knowledge of phar-macistsrsquo training and their continuing professional develop-ment obligations and saw pharmacists working in a purelycommercial environment (returning to the shopkeeper image)

lsquoPharmacists treat an awful lot of things hellip a lot of con-sultation and prescription happens alreadyrsquo [GP2]

lsquoI think it should be publicly known that the pharmacistcan advise about minor ailmentsrsquo [GP12]

lsquoThey are not updated are they Or maybe they areMaybe theyrsquore not After their three years they are moreinto the business of dispensing and the rest of itrsquo [GP4]

lsquoI donrsquo t know what their training involves whether theyare made aware of what is involved in a shop a com-munity pharmacy as you say lipsticks cough mixturesetcrsquo [GP8]

Pharmacists also reported that there were some importantmisconceptions and lack of understanding about pharmacyon the part of GPs

lsquoThe GPs have a very poor understanding of what we dowith the public they think we dish out the medicinesrsquo [P8]

lsquoIn my profession I am never going to be a doctor butI think we have to be respected for what we do with med-icines and I think at the minute GPs do not fully under-stand what we do I think they think that we just put it intoa bag and throw it out I donrsquot think they see the rolersquo[P17]

Such views had led to a sense of frustration and pharma-cists felt undervalued in their work

lsquoI know I do a worthwhile job but I think only pharmacistsappreciate what a worthwhile job we do I donrsquot think weare held in particularly high esteem by the publicbecause they can go to any pharmacy They have gotone GP but they can go to any pharmacy I see their atti-tude at the health centre where they have to wait for fiveor ten minutes I see them queue patiently at the bankand at Tescorsquos and the post office and then they comeinto the pharmacy and want to know why their medica-tion is taking so longrsquo [P18]

Joint training at undergraduate and postgraduate level ofthe two professions was suggested by pharmacists as a wayto overcome barriers and increase awareness of profession-al skills and strengths

lsquoWe need to work together we have to start working asteams We really do have to break down those barrierswe really should start our training together The first yearof pharmacy and medicine should be the same thesame as medicine and dentistry So that you know thosepeople have the same training and same backgroundknowledgersquo [P9]

Discussion The overarching theme that emerged from this study wasthe shopkeeper image of community pharmacy that perme-ated the three major subthemes of access hierarchy andawareness Participants reported problems only from theirprofessional perspective despite being part of the samehealthcare system

604 British Journal of General Practice August 2003

C M H ughes and S M cC ann

British Journal of General Practice August 2003 605

O rig ina l papers

Limitations of the studyAlthough this study was conducted in a specific geographi-cal region with a defined sample it was broadly representa-tive and there was nothing to suggest that the groups wouldbe different from other practitioners in other parts of theUnited Kingdom Although it may be suggested that thosewho participated in the study were more likely to have a pre-established interest in this topic this did not appear to influ-ence their views as evidenced by their commentsConversely it may have been the case that these individualsheld very strong views and considered the focus group as away of voicing concerns Although the focus group facilita-tor was a pharmacist this also appeared to have little bear-ing on the GP discussions which were frank and wide-rang-ing The facilitator had been introduced as someone fromthe university setting and was perhaps perceived differentlyto pharmacists from community practice The discussionsmay also have been facilitated by having uniprofessionalfocus groups as each profession may have been less forth-coming if the groups had been mixed in terms of discipline

Interpretation of findingsIt had been thought that GPs who had had previous contactwith pharmacists through interdisciplinary projects wouldhave had a more positive view of community pharmacy Thecommercial imperative of community pharmacy howeverseemed to be an important barrier for GPs Indeed it couldbe argued that contact with pharmacists in prescribing sup-port may have only reinforced GPsrsquo views of the shopkeep-er image of community pharmacy Adamcik et al noted thatphysicians who had had contact with clinical pharmacistsmay have attributed those pharmacistsrsquo skills and expertiseas something unique to them and by acknowledging theexcellence of these so-called lsquodeviant clinical pharmacistsrsquothey confirmed the stereotype of the community pharma-cist13 This may be the case with the GPs in this sampleIndeed GPs preferred the practice pharmacist modelbecause of the absence of the commercial trappings TwoGPs commented on the similarities between present-daycommunity pharmacy and that of general practice decadesago Ironically present day general practice has also beenlikened to a small business14 although less overtly com-mercial than pharmacy and without the appearance of aretail environment Other characteristics of the GPs such asage sex or the training status of their practice had no influ-ence on the emergence of the main themes

Access was a barrier for both professions but from differ-ent perspectives with GPs expressing concern aboutrestricted hours of services in pharmacies confidentialityand turnover of staff and pharmacists stating that recep-tionists limited their access to GPs Arber and Sawyer report-ed that receptionists acted as gatekeepers between patientswanting access and doctors needing to manage the numberof contacts with patients and reported that lsquohellip since thereceptionist is a lay person this can cause resentment in theminds of patientsrsquo15 Pharmacists could be substituted forpatients in this comment

Hierarchy was implicit in the comments from GPs in thatthey questioned the role and skills of pharmacists in certain

activities and felt that greater involvement in prescribingwould not be particularly appropriate This has been inter-preted as boundary encroachment16-22 This also raises theissue of professional autonomy and professional dominancemdash how certain professions not only control the content oftheir own work but can also define the limits of work of otherprofessional groups23 This is clearly exemplified by the rela-tionship between pharmacists and GPs1624 Pharmacists inthis study were conscious of this hierarchical system as theyarticulated dependence on doctors to issue prescriptions25

Elston and Holloway reported that professional identitiesand traditional power structures created conflict betweenGPs nurses and practice managers and suggested that anew generation of professionals would be required to pro-mote an interprofessional culture in the NHS26 This mayalso be reflected in medicine and pharmacy

Lack of awareness emerged as a major barrier with GPsreporting that they had little idea of the training and skills ofpharmacists and pharmacists reporting that GPs and theirstaff were not aware of their role in health care and believingthat their contribution was undervalued Thompson et alhave stated that conflict between nurses and pharmacistsarises through lack of trust respect competition betweenpatient care roles and lack of appreciation for each other asprofessionals27 Greenfield et al found that practice nursesfelt that doctorsrsquo attitudes were the most important limitingfactor in the expansion of the nursersquos role28 SimilarlyBradshaw and Doucette considered that the reactions andattitudes of GPs could either hinder or facilitate an expan-sion of the community pharmacistrsquos role and the rarity ofregular face-to-face contact with doctors and other health-care professionals represented a considerable obstacle torole expansion29

ConclusionImplications of findings for primary careAwareness of barriers between the two professions may helpto pre-empt some of the practical difficulties that couldemerge during any pilot evaluation of pharmacist prescribingsuch as the retention of dispensing duties by pharmacists inconjunction with prescribing rights430 On a more generallevel the findings have implications for team-working withinprimary care Williams and Sibbald described how the move-ment of healthcare work from doctors to nurses contributedto a culture of uncertainty and could affect the care given topatients 31 This is also reflected in these findings and per-haps helps to explain why GPs struggled to see where com-munity pharmacists could fit into prescribing Continuingreorganisation of primary care may accelerate changes inroles and responsibilities through a new GP contract32 anda proposed new remuneration system for community phar-macy33 Multidisciplinary training at both undergraduate andpostgraduate level may go some way to improving mutualunderstanding trust and communication and the literaturesupports this view34-37

References1 Hepler CD Strand LM Opportunities and responsibilities in phar-

maceutical care Am J Hosp Pharm 1990 47 533-5422 Report of the joint working party on the future role of community

AccessGenerally GPs did not report difficulties in contacting com-munity pharmacists However they expressed reservationsabout patient access to pharmacy services especially outsideworking hours This stemmed from GPs viewsrsquo of pharmacistspractising from a shop environment with set opening times

lsquoIf they want to be members of the primary healthcareteam I would welcome them on board but if itrsquos still ashopkeeper mentality making money open nine to fiveand not open on bank holidays and limited availabilitywhich is what we have got at the minute then I think thatdoes not cross the boundaries very wellrsquo [GP9]

lsquoThe GP has total 24-hour responsibility we just cannotswitch off at 600pmrsquo [GP21]

In contrast many pharmacists had encountered difficultiesin contacting GPs and this was often attributed to reception-ists Pharmacists recounted instances where they had beenkept on hold or asked to call back which they found unsat-isfactory while patients waited in their pharmacies for theirmedication

lsquoSometimes once you get the doctor they are very recep-tive but it is getting past whoever is in between you andthe doctor be it a receptionist or whoeverrsquo [P12]

lsquoIf you can get past the receptionist Some of them arelike biting dogs you just back off hellip There are timeswhen I have said that I have a patient here as well sodoes that mean that his patient is more important thanthe person who is waiting and who happens to be hispatient as wellrsquo [P27]

In contrast to GP perceptions pharmacists felt that theywere very accessible had a unique relationship withpatients had convenient opening hours and were a sourceof health information for the public

lsquoThe pharmacist is bombarded day in and day out withpeople coming in and out Itrsquos in your face Therersquos noappointments you are directly accessiblersquo [P24]

lsquoFrom feedback from customers you know that they sayldquoI come in to see what you say rather than them goingand bothering the GP as it takes up to three weeks to getan appointment Because I canrsquot get hold of the doctor Iam coming to yourdquorsquo [P28]

Recognising that prescribing rights for community pharma-cists would require access to medical notes a number ofGPs felt that patient confidentiality would be compromisedThis was also illustrated by GPsrsquo concerns over the designof many pharmacies and their suitability for giving advice

lsquoIf they are going to take on that role they are taking ona consulting role and most of the premises were notdesigned for that If you stand in pharmacies the confi-dentiality is zero mdash you can hear what is going onrsquo [GP9]

lsquoThe other issue is the issue of confidentiality When I amwriting in patient records the understanding has beenbetween myself and the patient that these are confiden-tial recordsrsquo [GP11]

Furthermore GPs felt that continuity of care would suffer withpharmacist prescribing because of the lack of patient registra-tion and the turnover of pharmacists in community practice

lsquoIt is an aspect definitely that should be considered asto whether the patient should register with a pharmacyrsquo[GP8]

lsquoYou do not know who you are dealing with and you can-not build up a relationship with them [employee phar-macists] because they are forever changingrsquo [GP20]

Again the practice pharmacist model was preferred in termsof regular contact and easy access

lsquoEase of communication is very important and they [prac-tice pharmacists] have access to the full patient notesWithin the practice we all work according to the samecode of confidentiality and I am quite happy to speak tothe practice pharmacist knowing that it stays within thepracticersquo [GP16]

HierarchyHierarchy in terms of professional standing and role inhealth care was apparent in all GP discussions GPsexpressed concerns about pharmacists assuming roles theyconsidered to be general practice activities and were notenthusiastic about their involvement in prescribing

lsquoA lot of repeat prescribing is not clinical You are notseeing the patient you are merely sorting out prescrip-tions Perhaps the pharmacist can do that It would freeup our time to do other thingsrsquo [GP2]

lsquoOh I think you can go too far and the pharmacist cangive too strong an opinion as to what we should pre-scribe I think they should leave the prescribing up tousrsquo [GP7]

Pharmacists also believed that any extension of their rolewould be seen as an encroachment on GP activity

lsquoWe have not got pharmacy prescribing yet hellip but thatwould be seen by some as an invasion of their territoryand the thin edge of the wedge and some would see itas brilliant A lot of GPs with some justice they feel thatwe are crossing on to their territory and taking away theirterritoryrsquo [P8]

lsquoGPs are very reluctant to relinquish any sort of control tous The pharmacist is an outsider and to a certain extentis a threat to the GPrsquo [P30]

Pharmacists expressed strong views about how they wereperceived by GPs in terms of hierarchy with many com-

British Journal of General Practice August 2003 603

O rig ina l papers

menting that GPs considered them to be subordinate in pro-fessional terms

lsquoThe other thing which was quite interesting was duringa dinner before a lecture was being given a GP said tome ldquoWell I suppose prescribing advisers are the accept-able face of pharmacyrdquo I said ldquoSo that makes commu-nity pharmacists the unacceptable face of pharmacyrdquoand her silence told me everythingrsquo [P10]

lsquoThe GP sits with his prescription pad and until he doessomething with it we sit with our degrees impotent untilwe get the piece of paper He is the instigator the pre-scriber is the instigator of the whole thing So no we arenot going to be equalrsquo [P18]

Community pharmacists were also considered on theperiphery of the primary healthcare team and once againthe shopkeeper image influenced GPsrsquo views

lsquoIf you could get them linked in to the practice then youcould put them under that umbrella but they are seenoutside that as they are at the moment That causes thedivisionrsquo [GP21]

lsquoIf pharmacists want to become more integrated into theprimary healthcare team I think they are going to have togive up their small shopkeeper empire if you like andbecome more integrated and more involved in healthcentresrsquo [GP18]

lsquoWe are not part of their team because we are outside thebuilding and although we might be considered by thegovernment to be part of the primary healthcare team weare not part of the ldquoin crowdrdquo that is round the surgeryall day every day so they see us as outsidersrsquo [P9]

lsquoI donrsquot think we are fully recognised as being part of itthe primary healthcare teamrsquo [P19]

However some GPs did feel that pharmacists were part of awider community team and this was also reflected in thepharmacistsrsquo views

lsquoI suppose they are helping to service the team mdash wouldthat be fair to say mdash without actually being part of itrsquo [GP16]

lsquoWe are secondary in that we are not involved in the pri-mary decision making perhaps they [pharmacists] aresweepers-up afterwardsrsquo [P23]

AwarenessGPs had some awareness of the community pharmacistrsquos rolein health care However many had little knowledge of phar-macistsrsquo training and their continuing professional develop-ment obligations and saw pharmacists working in a purelycommercial environment (returning to the shopkeeper image)

lsquoPharmacists treat an awful lot of things hellip a lot of con-sultation and prescription happens alreadyrsquo [GP2]

lsquoI think it should be publicly known that the pharmacistcan advise about minor ailmentsrsquo [GP12]

lsquoThey are not updated are they Or maybe they areMaybe theyrsquore not After their three years they are moreinto the business of dispensing and the rest of itrsquo [GP4]

lsquoI donrsquo t know what their training involves whether theyare made aware of what is involved in a shop a com-munity pharmacy as you say lipsticks cough mixturesetcrsquo [GP8]

Pharmacists also reported that there were some importantmisconceptions and lack of understanding about pharmacyon the part of GPs

lsquoThe GPs have a very poor understanding of what we dowith the public they think we dish out the medicinesrsquo [P8]

lsquoIn my profession I am never going to be a doctor butI think we have to be respected for what we do with med-icines and I think at the minute GPs do not fully under-stand what we do I think they think that we just put it intoa bag and throw it out I donrsquot think they see the rolersquo[P17]

Such views had led to a sense of frustration and pharma-cists felt undervalued in their work

lsquoI know I do a worthwhile job but I think only pharmacistsappreciate what a worthwhile job we do I donrsquot think weare held in particularly high esteem by the publicbecause they can go to any pharmacy They have gotone GP but they can go to any pharmacy I see their atti-tude at the health centre where they have to wait for fiveor ten minutes I see them queue patiently at the bankand at Tescorsquos and the post office and then they comeinto the pharmacy and want to know why their medica-tion is taking so longrsquo [P18]

Joint training at undergraduate and postgraduate level ofthe two professions was suggested by pharmacists as a wayto overcome barriers and increase awareness of profession-al skills and strengths

lsquoWe need to work together we have to start working asteams We really do have to break down those barrierswe really should start our training together The first yearof pharmacy and medicine should be the same thesame as medicine and dentistry So that you know thosepeople have the same training and same backgroundknowledgersquo [P9]

Discussion The overarching theme that emerged from this study wasthe shopkeeper image of community pharmacy that perme-ated the three major subthemes of access hierarchy andawareness Participants reported problems only from theirprofessional perspective despite being part of the samehealthcare system

604 British Journal of General Practice August 2003

C M H ughes and S M cC ann

British Journal of General Practice August 2003 605

O rig ina l papers

Limitations of the studyAlthough this study was conducted in a specific geographi-cal region with a defined sample it was broadly representa-tive and there was nothing to suggest that the groups wouldbe different from other practitioners in other parts of theUnited Kingdom Although it may be suggested that thosewho participated in the study were more likely to have a pre-established interest in this topic this did not appear to influ-ence their views as evidenced by their commentsConversely it may have been the case that these individualsheld very strong views and considered the focus group as away of voicing concerns Although the focus group facilita-tor was a pharmacist this also appeared to have little bear-ing on the GP discussions which were frank and wide-rang-ing The facilitator had been introduced as someone fromthe university setting and was perhaps perceived differentlyto pharmacists from community practice The discussionsmay also have been facilitated by having uniprofessionalfocus groups as each profession may have been less forth-coming if the groups had been mixed in terms of discipline

Interpretation of findingsIt had been thought that GPs who had had previous contactwith pharmacists through interdisciplinary projects wouldhave had a more positive view of community pharmacy Thecommercial imperative of community pharmacy howeverseemed to be an important barrier for GPs Indeed it couldbe argued that contact with pharmacists in prescribing sup-port may have only reinforced GPsrsquo views of the shopkeep-er image of community pharmacy Adamcik et al noted thatphysicians who had had contact with clinical pharmacistsmay have attributed those pharmacistsrsquo skills and expertiseas something unique to them and by acknowledging theexcellence of these so-called lsquodeviant clinical pharmacistsrsquothey confirmed the stereotype of the community pharma-cist13 This may be the case with the GPs in this sampleIndeed GPs preferred the practice pharmacist modelbecause of the absence of the commercial trappings TwoGPs commented on the similarities between present-daycommunity pharmacy and that of general practice decadesago Ironically present day general practice has also beenlikened to a small business14 although less overtly com-mercial than pharmacy and without the appearance of aretail environment Other characteristics of the GPs such asage sex or the training status of their practice had no influ-ence on the emergence of the main themes

Access was a barrier for both professions but from differ-ent perspectives with GPs expressing concern aboutrestricted hours of services in pharmacies confidentialityand turnover of staff and pharmacists stating that recep-tionists limited their access to GPs Arber and Sawyer report-ed that receptionists acted as gatekeepers between patientswanting access and doctors needing to manage the numberof contacts with patients and reported that lsquohellip since thereceptionist is a lay person this can cause resentment in theminds of patientsrsquo15 Pharmacists could be substituted forpatients in this comment

Hierarchy was implicit in the comments from GPs in thatthey questioned the role and skills of pharmacists in certain

activities and felt that greater involvement in prescribingwould not be particularly appropriate This has been inter-preted as boundary encroachment16-22 This also raises theissue of professional autonomy and professional dominancemdash how certain professions not only control the content oftheir own work but can also define the limits of work of otherprofessional groups23 This is clearly exemplified by the rela-tionship between pharmacists and GPs1624 Pharmacists inthis study were conscious of this hierarchical system as theyarticulated dependence on doctors to issue prescriptions25

Elston and Holloway reported that professional identitiesand traditional power structures created conflict betweenGPs nurses and practice managers and suggested that anew generation of professionals would be required to pro-mote an interprofessional culture in the NHS26 This mayalso be reflected in medicine and pharmacy

Lack of awareness emerged as a major barrier with GPsreporting that they had little idea of the training and skills ofpharmacists and pharmacists reporting that GPs and theirstaff were not aware of their role in health care and believingthat their contribution was undervalued Thompson et alhave stated that conflict between nurses and pharmacistsarises through lack of trust respect competition betweenpatient care roles and lack of appreciation for each other asprofessionals27 Greenfield et al found that practice nursesfelt that doctorsrsquo attitudes were the most important limitingfactor in the expansion of the nursersquos role28 SimilarlyBradshaw and Doucette considered that the reactions andattitudes of GPs could either hinder or facilitate an expan-sion of the community pharmacistrsquos role and the rarity ofregular face-to-face contact with doctors and other health-care professionals represented a considerable obstacle torole expansion29

ConclusionImplications of findings for primary careAwareness of barriers between the two professions may helpto pre-empt some of the practical difficulties that couldemerge during any pilot evaluation of pharmacist prescribingsuch as the retention of dispensing duties by pharmacists inconjunction with prescribing rights430 On a more generallevel the findings have implications for team-working withinprimary care Williams and Sibbald described how the move-ment of healthcare work from doctors to nurses contributedto a culture of uncertainty and could affect the care given topatients 31 This is also reflected in these findings and per-haps helps to explain why GPs struggled to see where com-munity pharmacists could fit into prescribing Continuingreorganisation of primary care may accelerate changes inroles and responsibilities through a new GP contract32 anda proposed new remuneration system for community phar-macy33 Multidisciplinary training at both undergraduate andpostgraduate level may go some way to improving mutualunderstanding trust and communication and the literaturesupports this view34-37

References1 Hepler CD Strand LM Opportunities and responsibilities in phar-

maceutical care Am J Hosp Pharm 1990 47 533-5422 Report of the joint working party on the future role of community

menting that GPs considered them to be subordinate in pro-fessional terms

lsquoThe other thing which was quite interesting was duringa dinner before a lecture was being given a GP said tome ldquoWell I suppose prescribing advisers are the accept-able face of pharmacyrdquo I said ldquoSo that makes commu-nity pharmacists the unacceptable face of pharmacyrdquoand her silence told me everythingrsquo [P10]

lsquoThe GP sits with his prescription pad and until he doessomething with it we sit with our degrees impotent untilwe get the piece of paper He is the instigator the pre-scriber is the instigator of the whole thing So no we arenot going to be equalrsquo [P18]

Community pharmacists were also considered on theperiphery of the primary healthcare team and once againthe shopkeeper image influenced GPsrsquo views

lsquoIf you could get them linked in to the practice then youcould put them under that umbrella but they are seenoutside that as they are at the moment That causes thedivisionrsquo [GP21]

lsquoIf pharmacists want to become more integrated into theprimary healthcare team I think they are going to have togive up their small shopkeeper empire if you like andbecome more integrated and more involved in healthcentresrsquo [GP18]

lsquoWe are not part of their team because we are outside thebuilding and although we might be considered by thegovernment to be part of the primary healthcare team weare not part of the ldquoin crowdrdquo that is round the surgeryall day every day so they see us as outsidersrsquo [P9]

lsquoI donrsquot think we are fully recognised as being part of itthe primary healthcare teamrsquo [P19]

However some GPs did feel that pharmacists were part of awider community team and this was also reflected in thepharmacistsrsquo views

lsquoI suppose they are helping to service the team mdash wouldthat be fair to say mdash without actually being part of itrsquo [GP16]

lsquoWe are secondary in that we are not involved in the pri-mary decision making perhaps they [pharmacists] aresweepers-up afterwardsrsquo [P23]

AwarenessGPs had some awareness of the community pharmacistrsquos rolein health care However many had little knowledge of phar-macistsrsquo training and their continuing professional develop-ment obligations and saw pharmacists working in a purelycommercial environment (returning to the shopkeeper image)

lsquoPharmacists treat an awful lot of things hellip a lot of con-sultation and prescription happens alreadyrsquo [GP2]

lsquoI think it should be publicly known that the pharmacistcan advise about minor ailmentsrsquo [GP12]

lsquoThey are not updated are they Or maybe they areMaybe theyrsquore not After their three years they are moreinto the business of dispensing and the rest of itrsquo [GP4]

lsquoI donrsquo t know what their training involves whether theyare made aware of what is involved in a shop a com-munity pharmacy as you say lipsticks cough mixturesetcrsquo [GP8]

Pharmacists also reported that there were some importantmisconceptions and lack of understanding about pharmacyon the part of GPs

lsquoThe GPs have a very poor understanding of what we dowith the public they think we dish out the medicinesrsquo [P8]

lsquoIn my profession I am never going to be a doctor butI think we have to be respected for what we do with med-icines and I think at the minute GPs do not fully under-stand what we do I think they think that we just put it intoa bag and throw it out I donrsquot think they see the rolersquo[P17]

Such views had led to a sense of frustration and pharma-cists felt undervalued in their work

lsquoI know I do a worthwhile job but I think only pharmacistsappreciate what a worthwhile job we do I donrsquot think weare held in particularly high esteem by the publicbecause they can go to any pharmacy They have gotone GP but they can go to any pharmacy I see their atti-tude at the health centre where they have to wait for fiveor ten minutes I see them queue patiently at the bankand at Tescorsquos and the post office and then they comeinto the pharmacy and want to know why their medica-tion is taking so longrsquo [P18]

Joint training at undergraduate and postgraduate level ofthe two professions was suggested by pharmacists as a wayto overcome barriers and increase awareness of profession-al skills and strengths

lsquoWe need to work together we have to start working asteams We really do have to break down those barrierswe really should start our training together The first yearof pharmacy and medicine should be the same thesame as medicine and dentistry So that you know thosepeople have the same training and same backgroundknowledgersquo [P9]

Discussion The overarching theme that emerged from this study wasthe shopkeeper image of community pharmacy that perme-ated the three major subthemes of access hierarchy andawareness Participants reported problems only from theirprofessional perspective despite being part of the samehealthcare system

604 British Journal of General Practice August 2003

C M H ughes and S M cC ann

British Journal of General Practice August 2003 605

O rig ina l papers

Limitations of the studyAlthough this study was conducted in a specific geographi-cal region with a defined sample it was broadly representa-tive and there was nothing to suggest that the groups wouldbe different from other practitioners in other parts of theUnited Kingdom Although it may be suggested that thosewho participated in the study were more likely to have a pre-established interest in this topic this did not appear to influ-ence their views as evidenced by their commentsConversely it may have been the case that these individualsheld very strong views and considered the focus group as away of voicing concerns Although the focus group facilita-tor was a pharmacist this also appeared to have little bear-ing on the GP discussions which were frank and wide-rang-ing The facilitator had been introduced as someone fromthe university setting and was perhaps perceived differentlyto pharmacists from community practice The discussionsmay also have been facilitated by having uniprofessionalfocus groups as each profession may have been less forth-coming if the groups had been mixed in terms of discipline

Interpretation of findingsIt had been thought that GPs who had had previous contactwith pharmacists through interdisciplinary projects wouldhave had a more positive view of community pharmacy Thecommercial imperative of community pharmacy howeverseemed to be an important barrier for GPs Indeed it couldbe argued that contact with pharmacists in prescribing sup-port may have only reinforced GPsrsquo views of the shopkeep-er image of community pharmacy Adamcik et al noted thatphysicians who had had contact with clinical pharmacistsmay have attributed those pharmacistsrsquo skills and expertiseas something unique to them and by acknowledging theexcellence of these so-called lsquodeviant clinical pharmacistsrsquothey confirmed the stereotype of the community pharma-cist13 This may be the case with the GPs in this sampleIndeed GPs preferred the practice pharmacist modelbecause of the absence of the commercial trappings TwoGPs commented on the similarities between present-daycommunity pharmacy and that of general practice decadesago Ironically present day general practice has also beenlikened to a small business14 although less overtly com-mercial than pharmacy and without the appearance of aretail environment Other characteristics of the GPs such asage sex or the training status of their practice had no influ-ence on the emergence of the main themes

Access was a barrier for both professions but from differ-ent perspectives with GPs expressing concern aboutrestricted hours of services in pharmacies confidentialityand turnover of staff and pharmacists stating that recep-tionists limited their access to GPs Arber and Sawyer report-ed that receptionists acted as gatekeepers between patientswanting access and doctors needing to manage the numberof contacts with patients and reported that lsquohellip since thereceptionist is a lay person this can cause resentment in theminds of patientsrsquo15 Pharmacists could be substituted forpatients in this comment

Hierarchy was implicit in the comments from GPs in thatthey questioned the role and skills of pharmacists in certain

activities and felt that greater involvement in prescribingwould not be particularly appropriate This has been inter-preted as boundary encroachment16-22 This also raises theissue of professional autonomy and professional dominancemdash how certain professions not only control the content oftheir own work but can also define the limits of work of otherprofessional groups23 This is clearly exemplified by the rela-tionship between pharmacists and GPs1624 Pharmacists inthis study were conscious of this hierarchical system as theyarticulated dependence on doctors to issue prescriptions25

Elston and Holloway reported that professional identitiesand traditional power structures created conflict betweenGPs nurses and practice managers and suggested that anew generation of professionals would be required to pro-mote an interprofessional culture in the NHS26 This mayalso be reflected in medicine and pharmacy

Lack of awareness emerged as a major barrier with GPsreporting that they had little idea of the training and skills ofpharmacists and pharmacists reporting that GPs and theirstaff were not aware of their role in health care and believingthat their contribution was undervalued Thompson et alhave stated that conflict between nurses and pharmacistsarises through lack of trust respect competition betweenpatient care roles and lack of appreciation for each other asprofessionals27 Greenfield et al found that practice nursesfelt that doctorsrsquo attitudes were the most important limitingfactor in the expansion of the nursersquos role28 SimilarlyBradshaw and Doucette considered that the reactions andattitudes of GPs could either hinder or facilitate an expan-sion of the community pharmacistrsquos role and the rarity ofregular face-to-face contact with doctors and other health-care professionals represented a considerable obstacle torole expansion29

ConclusionImplications of findings for primary careAwareness of barriers between the two professions may helpto pre-empt some of the practical difficulties that couldemerge during any pilot evaluation of pharmacist prescribingsuch as the retention of dispensing duties by pharmacists inconjunction with prescribing rights430 On a more generallevel the findings have implications for team-working withinprimary care Williams and Sibbald described how the move-ment of healthcare work from doctors to nurses contributedto a culture of uncertainty and could affect the care given topatients 31 This is also reflected in these findings and per-haps helps to explain why GPs struggled to see where com-munity pharmacists could fit into prescribing Continuingreorganisation of primary care may accelerate changes inroles and responsibilities through a new GP contract32 anda proposed new remuneration system for community phar-macy33 Multidisciplinary training at both undergraduate andpostgraduate level may go some way to improving mutualunderstanding trust and communication and the literaturesupports this view34-37

References1 Hepler CD Strand LM Opportunities and responsibilities in phar-

maceutical care Am J Hosp Pharm 1990 47 533-5422 Report of the joint working party on the future role of community

British Journal of General Practice August 2003 605

O rig ina l papers

Limitations of the studyAlthough this study was conducted in a specific geographi-cal region with a defined sample it was broadly representa-tive and there was nothing to suggest that the groups wouldbe different from other practitioners in other parts of theUnited Kingdom Although it may be suggested that thosewho participated in the study were more likely to have a pre-established interest in this topic this did not appear to influ-ence their views as evidenced by their commentsConversely it may have been the case that these individualsheld very strong views and considered the focus group as away of voicing concerns Although the focus group facilita-tor was a pharmacist this also appeared to have little bear-ing on the GP discussions which were frank and wide-rang-ing The facilitator had been introduced as someone fromthe university setting and was perhaps perceived differentlyto pharmacists from community practice The discussionsmay also have been facilitated by having uniprofessionalfocus groups as each profession may have been less forth-coming if the groups had been mixed in terms of discipline

Interpretation of findingsIt had been thought that GPs who had had previous contactwith pharmacists through interdisciplinary projects wouldhave had a more positive view of community pharmacy Thecommercial imperative of community pharmacy howeverseemed to be an important barrier for GPs Indeed it couldbe argued that contact with pharmacists in prescribing sup-port may have only reinforced GPsrsquo views of the shopkeep-er image of community pharmacy Adamcik et al noted thatphysicians who had had contact with clinical pharmacistsmay have attributed those pharmacistsrsquo skills and expertiseas something unique to them and by acknowledging theexcellence of these so-called lsquodeviant clinical pharmacistsrsquothey confirmed the stereotype of the community pharma-cist13 This may be the case with the GPs in this sampleIndeed GPs preferred the practice pharmacist modelbecause of the absence of the commercial trappings TwoGPs commented on the similarities between present-daycommunity pharmacy and that of general practice decadesago Ironically present day general practice has also beenlikened to a small business14 although less overtly com-mercial than pharmacy and without the appearance of aretail environment Other characteristics of the GPs such asage sex or the training status of their practice had no influ-ence on the emergence of the main themes

Access was a barrier for both professions but from differ-ent perspectives with GPs expressing concern aboutrestricted hours of services in pharmacies confidentialityand turnover of staff and pharmacists stating that recep-tionists limited their access to GPs Arber and Sawyer report-ed that receptionists acted as gatekeepers between patientswanting access and doctors needing to manage the numberof contacts with patients and reported that lsquohellip since thereceptionist is a lay person this can cause resentment in theminds of patientsrsquo15 Pharmacists could be substituted forpatients in this comment

Hierarchy was implicit in the comments from GPs in thatthey questioned the role and skills of pharmacists in certain

activities and felt that greater involvement in prescribingwould not be particularly appropriate This has been inter-preted as boundary encroachment16-22 This also raises theissue of professional autonomy and professional dominancemdash how certain professions not only control the content oftheir own work but can also define the limits of work of otherprofessional groups23 This is clearly exemplified by the rela-tionship between pharmacists and GPs1624 Pharmacists inthis study were conscious of this hierarchical system as theyarticulated dependence on doctors to issue prescriptions25

Elston and Holloway reported that professional identitiesand traditional power structures created conflict betweenGPs nurses and practice managers and suggested that anew generation of professionals would be required to pro-mote an interprofessional culture in the NHS26 This mayalso be reflected in medicine and pharmacy

Lack of awareness emerged as a major barrier with GPsreporting that they had little idea of the training and skills ofpharmacists and pharmacists reporting that GPs and theirstaff were not aware of their role in health care and believingthat their contribution was undervalued Thompson et alhave stated that conflict between nurses and pharmacistsarises through lack of trust respect competition betweenpatient care roles and lack of appreciation for each other asprofessionals27 Greenfield et al found that practice nursesfelt that doctorsrsquo attitudes were the most important limitingfactor in the expansion of the nursersquos role28 SimilarlyBradshaw and Doucette considered that the reactions andattitudes of GPs could either hinder or facilitate an expan-sion of the community pharmacistrsquos role and the rarity ofregular face-to-face contact with doctors and other health-care professionals represented a considerable obstacle torole expansion29

ConclusionImplications of findings for primary careAwareness of barriers between the two professions may helpto pre-empt some of the practical difficulties that couldemerge during any pilot evaluation of pharmacist prescribingsuch as the retention of dispensing duties by pharmacists inconjunction with prescribing rights430 On a more generallevel the findings have implications for team-working withinprimary care Williams and Sibbald described how the move-ment of healthcare work from doctors to nurses contributedto a culture of uncertainty and could affect the care given topatients 31 This is also reflected in these findings and per-haps helps to explain why GPs struggled to see where com-munity pharmacists could fit into prescribing Continuingreorganisation of primary care may accelerate changes inroles and responsibilities through a new GP contract32 anda proposed new remuneration system for community phar-macy33 Multidisciplinary training at both undergraduate andpostgraduate level may go some way to improving mutualunderstanding trust and communication and the literaturesupports this view34-37

References1 Hepler CD Strand LM Opportunities and responsibilities in phar-

maceutical care Am J Hosp Pharm 1990 47 533-5422 Report of the joint working party on the future role of community

606 British Journal of General Practice August 2003

C M H ughes and S M cC ann

pharmacy services Pharmaceutical care the future for communitypharmacy London Royal Pharmaceutical Society of Great Britain1992

3 Posey LM Pharmaceutical care will pharmacy incorporate its phi-losophy of practice J Am Pharm Assoc 1997 NS37 145-148

4 Crown report Review of prescribing supply and administration ofmedicines Final report London Department of Health 1999

5 Barber ND Batty R Ridout DA Predicting the rate of physician-accepted interventions by hospital pharmacists in the UnitedKingdom Am J Health Syst Pharm 1997 54 397-405

6 Mason P A pharmacist in the surgery what better prescription forthe new age Pharm J 1996 256 192-197

7 Bradley CP Taylor RJ Blenkinsopp A Developing prescribing inprimary care BMJ 1997 314 744-747

8 Bell HM McElnay JC Hughes CM Woods A A qualitative investi-gation of the attitudes and opinions of community pharmacists topharmaceutical care J Soc Admin Pharm 1998 15 284-295

9 Mays N Pope C Qualitative research rigour and qualitativeresearch BMJ 1995 311 109-112

10 Smith JA Jarman M Osborn M Doing interpretative phenome-nonological analysis In Murray M Chamberlain K (eds)Qualitative Health Psychology Theories and Methods LondonSage Publications 1999 218-241

11 Glaser B Strauss A The discovery of grounded theory strategiesfor qualitative research Chicago Aldine Publications 1967

12 Pope C Mays N Qualitative methods in health and health ser-vices research In Mays N Pope C (eds) Qualitative research inhealth care London BMJ Publishing Group 1996 1-9

13 Adamcik BA Ransford HE Oppenheimer PR et al New clinicalroles for pharmacists a study of role expansion Soc Sci Med1986 23 1187-1200

14 Foy R Parry J McAvoy B Clinical trials in primary care BMJ1998 317 1168-1169

15 Arber S Sawyer L The role of the receptionist in general practicea lsquodragon behind the deskrsquo Soc Sci Med 1985 20 911-921

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AcknowledgementsThe authors gratefully acknowledge the assistance of the prescribingadvisers in the health board where the focus groups took place Theauthors also wish to thank the GPs and pharmacists who participated inthe focus groups Carmel Hughes is supported by a National PrimaryCare Career Scientist Award from the Research and Development OfficeNorthern Ireland