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Social Science & Medicine 71 (2010) 451e458

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Social Science & Medicine

journal homepage: www.elsevier .com/locate/socscimed

Professional status in a changing world: The case of medicines use reviews inEnglish community pharmacyq

Ruth McDonald a,*, Sudeh Cheraghi-Sohi b, Caroline Sanders b, Darren Ashcroft b

aUniversity of Nottingham, Business School and CLAHRC, Sir Colin Campbell Building, Triumph Road, Nottingham, United KingdombUniversity of Manchester, M13, United Kingdom

a r t i c l e i n f o

Article history:Available online 12 May 2010

Keywords:UKProfessionsPharmacistsCommunityFinancial incentivesPrimary care

q We are grateful to the pharmacists concernegenerously.* Corresponding author. Tel.: þ44 115 8230588.

E-mail address: ruth.mcdonald@nottingham.ac.uk

0277-9536/$ e see front matter � 2010 Elsevier Ltd.doi:10.1016/j.socscimed.2010.04.021

a b s t r a c t

The health professions are engaged in an ongoing and dynamic process involving reflection and adap-tation, with factors such as socio-economic and cultural developments and technological innovationscompelling professions to respond to changed circumstances. This paper concerns English communitypharmacy, where recent reforms provide financial incentives to deliver interventions, which have thepotential for pharmacists to promote their knowledge and skills, as part of a professionalising strategy.The paper, drawing on interviews with 49 pharmacists, describes how responses to reforms are notnecessarily in accordance with either national policy goals or enhancement of professional status.Debates about professional status and role extension have often focused on health professions’ subor-dination to medicine. This paper highlights the importance and interplay of other factors which helpexplain the inability to capitalise fully on the potential contribution to professional status, which reformsto extend professional roles afford.

� 2010 Elsevier Ltd. All rights reserved.

Introduction

Professional status is linked in part, to control over thesubstance of work (Freidson, 1970: xv), but such control is neverguaranteed in perpetuity. Instead, professions are engaged in anongoing and dynamic process involving appraisal and adaptation oforganisational, skills and knowledge bases (Nancarrow &Borthwick, 2005). Pressures for change may arise from beyondthe immediate professional field, with factors such as socio-economic and cultural developments and technological innova-tions compelling professions to reflect and adapt to changingcircumstances. This paper examines the interplay of such factors inthe context of state sponsored reforms, which offer the potential toenhance professional status.

We are concernedwith English community pharmacy, which, likemany other professions, has been undergoing ongoing change andtransformation in recent decades. In the context of increasingconsumerism in health care, the traditional characterisation of usersof pharmaceutical services as passive recipients of expert advice isbecoming increasingly outdated (Fox & Ward, 2005). That manyindividuals are knowledgeable actors,making choices in consultation

d for giving their time so

(R. McDonald).

All rights reserved.

with professionals is reinforced by government policy which char-acterises patients as experts and exhorts professionals to developa partnership with patients (Taylor & Bury, 2007). Furthermore,growing competition in the community pharmacy sector placespharmacists under pressure to adapt to consumer demands tomaintain market share. At the same time, pharmacy’s businessorientation, which creates tension between ‘the conflicting demandsof professional and retail practice’ (Harding & Taylor, 2001: 176) isseen as compromising claims to professional status (Kronus, 1975).

Technological advances have been important in compelling thecommunity pharmacy profession to engage in reflection andadaptation. These advances include developments such as theability to purchase pharmaceuticals through online or e-pharma-cies and less recently, the move to large scale manufacture ofmedicinal products, which dramatically reduced the requirementfor pharmacists routinely to compoundmedicines from constituentingredients. The concerns this raised about the substance of workin community pharmacy and its potential contribution to healthcare (Nuffield Committee 1986) are reflected in the characterisationof pharmacy as ‘incomplete profession’ due to ‘its failure to gaincontrol over the social object [the drug] which justified the exis-tence of its professional qualities in the first place.’ (Denzin &Mettlin 1968: 378).

For Dingwall and Wilson (1995) this lack of control over thesupply of drugs is seen as less problematic from the perspective of‘completeness’ (or otherwise) of pharmacy as a profession. They

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suggest that the social object of pharmacy is not the drug asa material object, but the drug as basis for social action. Pharma-cists’ use of knowledge about patients, their advice giving role andunderstanding of drug interactions and adverse effects all imbuethe drug with social significance, transforming a material objectinto a social one, thereby contributing to ‘the maintenance of orderor discipline in the social world’(Dingwall & Wilson, 1995: 125).

This description of the application of expert knowledge reso-nates to some extent with Freidson’s description of a profession asinvolving possession of an expertise ‘which is distinctly theirs andnot part of the normal competence of adults in general’ (Freidson,1994: 157). Professions are characterised by a high degree of clin-ical autonomy, enabling individuals ‘to exercise discretion in theirwork, to assert their own judgment and responsibility as the arbi-ters of their activities’ (Freidson, 1994: 164). The distinctionbetween doctors as ‘autonomous’ prescribers and pharmacists as‘mere’ dispensers has traditionally reinforced the status differentialbetween the two groups (Britten, 2001). Recent legislative changesallowing other health professionals, primarily pharmacists andnurses, to prescribe medicines (Avery & Pringle, 2005) do notappear to have loosened medicine’s control over the knowledgeunderpinning prescribing practice or to represent a serious threatto medicine’s professional dominance (Weiss & Sutton, 2009). Inthe context of overlapping jurisdictions (Abbott, 1988) and phar-macy’s subordinate status relative to medicine (Adamcik et al.,1986; Hughes & McCann, 2003) claims by pharmacists regardingtheir possession of a ‘singular expertise on medicines, superior toother health-care professionals’ (Weiss & Sutton, 2009: 415) appearto be overstated.

Policy makers apparently recognise that pharmacists possessa distinctive expertise and in various countries reforms have beenintroduced to extend roles and consolidate and reward existingpharmacy skills (Gilbert, 1998). In the UK, pharmacy’s representa-tional bodies have been involved in campaigns for reprofessional-isation, seeking to redefine the role as one which goes far beyondthe dispensing of medicines (Birenbaum,1982; Holloway, Jewson, &Mason, 1986; for a brief review see Edmunds & Calnan, 2001:944e945).

The number of pharmacists who are prescribers, as a percentageof the profession as awhole, is relatively small (Cooper et al., 2008).Furthermore, a focus on the differential power relationshipbetween doctors, as prescribers, and pharmacists as (mere)dispensers means that the pharmacist’s role in the dispensingprocess is likely to be undervalued, even by pharmacists, with theresult that the profession fails to capitalise on the potential this roleaffords (Harding & Taylor, 1997).

Although role extension has been pursued as a strategy forenhancing status, critics suggest that extended roles, involvingactivities other than dispensing, will have a deprofessionalisingeffect. The promotion of advisory and health care services asprovided by pharmacists, who are freely available withoutappointments, runs contrary to the requirement, as part of a pro-fessionalising strategy, to encourage the public to view the phar-macist’s time as more valuable than their own. In addition,delegating elements of the dispensing process to other staff maymean that ‘pharmacy becomes no more than an exchange ofprescription form and drug with no apparent input from a profes-sional, the opportunity for a symbolic transformation is missed..the centrality of pharmacy to the dispensing process is not recog-nised’ (Harding & Taylor, 1997: 557).

Recent reforms in community pharmacy in England and Walesencourage pharmacists to reduce their dependence on dispensingas a source of income (Department of Health, 2003). They also offerfinancial incentives to undertake activities (PharmaceuticalServices Negotiating Committee, 2004) which may be interpreted

as enabling pharmacists to exercise their skills in a way whichenhances their professional status. This paper is concerned withone of these activities, the ‘Medicines Use Review and PrescriptionIntervention Service’ (MUR). We elaborate on these recent reformsin the following section.

Recent changes in the nature and context of communitypharmacy

The changing organisational and contractual framework

In England community pharmacies are privately owned busi-nesses contracted by the National Health Service (NHS) to providepharmaceutical services. Various training and accreditationprocesses have developed for non-pharmacists in communitypharmacy, which are intended to allow pharmacists to make betteruse of their skills. With regard to dispensing, pharmacists arerequired to perform a ‘clinical check’ on prescriptions received, toassess the drug prescribed and dose, but can delegate other stages(dispensing the medicine and counselling) of the process to non-pharmacists (Accredited Checking Technicians or ‘ACTs’ anddispensing assistants).

Health services are funded from the public purse, in a contextwhere professional activities and expertise can be seen as renderingthe complexities of life amenable to governing. The struggle overoccupational jurisdictions is part of this process of rendering affairsgovernable (Johnson, 1995) and recent reforms position the phar-macy profession as a key resource in shaping the self-regulatingcapacity of citizens. Government policy documents highlight therole of pharmacy as an integral part of the NHS and stress itscontribution to the delivery of high quality NHS services(Department of Health, 2000, 2003, 2008), as part of the Govern-ment’s declared intention to create a more flexible, choice-orien-tated health care service (Department of Health, 2000). In April2005, a new contractual framework came into effect, which wasintended tomakegreateruse of pharmacists’ expertise, encouragingthem ‘not simply to dispense..but to offer an ever-expanding rangeof clinical services’ (Department of Health, 2008: 14).

Pharmacy contractors (as distinct from employees) were rela-tively united in their support for the new contract (Anon, 2004),which reimbursed contractors on the basis of the range of servicesprovided, with less emphasis placed than previously on the volumeof medicines dispensed. Government has identified the threemajorchallenges for pharmacy asmeeting the changing needs of patients,maintaining professional standards and responding to a changingenvironment (Department of Health, 2003). With regard to thelatter, community pharmacy is becoming increasingly competitiveand the number of shops owned by large multiple (chain) phar-macies is growing (NHS Information Centre, 2009).

Although social scientists have been preoccupied with phar-macy’s status relative to medicine (Eaton & Webb, 1979), Edmundsand Calnan (2001), in their study examining ‘reprofessionalisation’in community pharmacy, identified divisions between ‘retailpharmacists’ (owners) and employee pharmacists working in largechains as holding back attempts to raise the profession’s status. Theincreasing number of large multiples has also been identified asreducing the potential for pharmacists to exercise autonomy inthose settings. The suggestion is that these large bureaucraticorganisations require their employees to follow standardisedprocedures dictated by company policy. In addition, this routini-sation is seen as potentially reducing interactions between phar-macists to ‘no more than asking structured, formulaic questions’(Harding & Taylor, 1997: 556).

Under the revised contractual framework, pharmacies areexpected to provide ‘essential services’, which include dispensing

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prescriptions, repeat dispensing (enabling patients to obtainsupplies of their repeat medicines from a pharmacy of their choice,without the need to contact their GP) and meeting clinical gover-nance requirements. There are also ‘enhanced services’, commis-sioned by primary care organisations (PCOs) to meet local priorities(e.g. smoking cessation). Contractors also have the option toprovide ‘advanced services’, which currently includes only oneservice, the MUR.

Medicine use reviews (MURs)

The aim of the MUR service is to improve the patient’s knowl-edge, concordance and use of medicines by ascertaining their use,understanding and experience of taking their medicines. This mayalso involve the pharmacist in identifying, discussing and resolvingpoor or ineffective use of medicines. Additionally, the pharmacistwill identify any side effects and drug interactions that may influ-ence patient compliance and thereby improve the clinical and costeffectiveness of prescribed medicines. The Pharmaceutical ServicesNegotiating Committee (2008) website contains downloadableposters to advertise MURs to patients containing the message ‘Geta Free Medicines Check from your Local Pharmacist ...A fewminutes with a pharmacist could change your life.’

An MUR is a documented, face-to-face consultation betweena community pharmacist and a patient. Community pharmacistsare not required to provide MURs, but if they wish to do so, theyneed to have undertaken a programme of training and achievednational accreditation. The premises must also have a suitableprivate consultation area, which is assessed by the local PrimaryCare Organisation contracting with the pharmacy. The service isfree to patients and pharmacists claim reimbursement from theNHS (currently £28), subject to a maximum of 400 MURs perpharmacy per year. MURs are documented in a structured formatusing a national MUR form. Recorded information has to beprovided to the patient’s general medical practitioner (GP) on anapproved form giving feedback and highlighting any medicationrelated problems the patient may be experiencing. The patient alsoreceives one copy of the form.

Whereas Edmunds and Calnan (2001) suggested in their studyof extended roles for community pharmacists that such activitieswould benefit independents, rates of MUR provision by multiplepharmacies are much higher than that of independent pharmacies(Bradley, Wagner, Elvey, Noyce, & Ashcroft, 2008). A recent studyreports a widespread belief in the potential for MURs to ‘contributeto professional integration and patient care’ (Bradley et al., 2008:263). At the same time it suggests that organisational pressurewithin multiple pharmacies was responsible for relatively highlevels of MUR activity, with lack of time and staff capacitycontributing to low levels in independents. Blenkinsopp, Bond,Celino, Inch, and Gray's (2007) evaluation of the new contractualreforms during the early stages of implementation highlights thepotential for MURs to increase pressure on pharmacists’ time,making delegation of dispensing tasks to others increasinglyimportant.

The foregoing raises a number of questions which we seek toanswer in this paper. Firstly, in a context where delegation ofelements of the dispensing process has been seen as beneficial(Bond, 2003) and detrimental (Harding & Taylor, 1997) to thedevelopment of the profession, to what extent are pharmacistswilling and able to free up time from their dispensing activity tofocus on other areas of work such as MURs? Secondly, concerningcommunity pharmacy’s contribution to ‘the maintenance of orderor discipline in the social world’ (Dingwall & Wilson, 1995: 125),how does the introduction of MURs impact on this, particularly ina context where the characterisation of consumers of medicines as

passive recipients of expert advice, is becoming increasinglyoutdated? Thirdly, in the context of the increasingly corporatenature of community pharmacy, to what extent do differencesbetween independents and multiples influence the potentialcontribution to professional status which MURs offer?

Methods

The paper draws on interviews with 49 pharmacists, based intwo English regions (North West and Yorkshire and Humber)conducted between Nov 2007 and Oct 2008. The sample waslargely opportunistic, using ‘snowballing’ (a small number ofinformants put the researcher in touch with others, who thennominated colleagues, and other contacts, and so on) to recruitparticipants. A limitation of this approach, however, is that thesample may be more negatively predisposed to the new contractand MURs than the general community pharmacy population,since those with grievances to air may be more willing toconsent to participate. Most of the interviews were conductedon a face to face basis within the community pharmacy setting,but a small number (n ¼ 6) were conducted by telephone. 5 ofthese telephone interviews were with locum pharmacists withno fixed base and one was with a pharmacist working fora multiple, but with no regular base, who was interviewed in hishome.

The sample comprised 10 independent/owner pharmacists, 6salaried pharmacists working in independents and 20 salariedpharmacists working in multiples. In addition, 13 locum pharma-cists were interviewed, although amongst pharmacists employedon permanent contracts, several supplemented their income withoccasional locum sessions and many drew on their previousexperience of working as a locum in the interviews. Twenty sixpharmacists were female and the average number of years sincequalifying for the sample was 18 (range 1e41 years).

All of the interviews were digitally recorded and transcribedverbatim. Analysis initially involved coding transcripts using AtlasTi software and identifying themes. A constant comparativemethod was used to interpret the data (Strauss & Corbin, 1990). Keyconcepts were identified using an open coding method. Oncecoding was complete, the codes that had common elements weremerged to form categories. Disagreements were discussed untila consensus was achieved. The interview schedule was open endedand covered reasons for entering pharmacy, likes and dislikes aboutwork, attitudes towards and impact of the new contractualarrangements on practice.

The study was approved by Leeds East Research EthicsCommittee.

Findings

Dispensing and MURs

Most pharmacists welcomed the intention underpinning thenew contract to encourage a move away from dispensing. But allpharmacists also described their working environment as verybusy and driven to a large extent by the need to maintaindispensing volumes. With regard to willingness and ability to focuson MURs, the range of contexts in which pharmacists work andrelated incentive structures they facewas reflected in the responsesof participants. Locums generally reported little desire or pressureto conduct MURs, owners described struggling to conduct MURswhilst maintaining dispensing income and salaried pharmacistsexperienced varying degrees of motivation to conduct MURs.

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MURs ..I’m protected in a way because I’m just there for theday or there for the week (ID11, locum)There’s no incentive for the individual. The incentive is purelytowards the company. (ID 45, salaried, multiple)Squeezing them in is always a difficult one. it’s putting.workonto us. (ID34, owner)

Where technicians were in post, most pharmacists welcomedthese as valuable resources enabling them to delegate much of thedispensing process. Some pharmacists expressed reservationsabout delegation. This arose in part from fears about the compe-tence of these staff and pharmacists who chose to retain greaterinvolvement in the process were depicted as belonging to ‘oldschool’ pharmacy, avoiding interaction with patients.

During the research interviews, which were often held inconsultation rooms used for MURs, staff members interrupted toask pharmacists to perform clinical checks and the rest of thedispensing process was carried out by non-pharmacists. Thissuggests that when pharmacists are conducting MURs, opportu-nities for other activities such as patient counselling as the laststage in the dispensing process are reduced. Only a small number ofinterviewees suggested that pharmacists needed to maintain aninvolvement throughout the process to use their skills andknowledge to understand the patient.

I see a patient’s [pharmacy] record and I look at a patient asa whole, and I see what is getting prescribed, what they are for,and what is going to go with that . because I have theknowledge here. . I can see if something is missing somethingshould be different. I do the intervention at the time oflabelling. a lot of pharmacists .. All they are really doing isaccuracy checks (ID 26, salaried, multiple)More ACTs [Accredited Checking Technicians]. Checking...Maybe I’m old school, but I like to be there involved with thechecking and the supervision. (ID 8, salaried, multiple)

In addition to contract reforms, pharmacists described otherchanges which free up time to enable pharmacists to undertakeMURs. One of these, home delivery of medicines to customers,allow pharmacies to plan their workload, as opposed to having torespond immediately to prescriptions presented in person at thecounter and was welcomed by most pharmacists. Where reserva-tions were expressed about delivery, this was usually due to theadded costs of the service.

Because the multiples started doing it, now we have to startdoing it, which is obviously an expense for us because we don’tcharge the patient.. But that’s something you’re forced to do.(ID 38, salaried, independent)

However, since the delivery of medicines to patient homesreduces the contact between patients and the pharmacist (ashighlighted in the quote below), this may have implications for thepharmacist’s role in transforming drugs into social objects andraising the status of pharmacy.

I really don’t like deliveries. The commercial nature ofcommunity pharmacy has driven that, really. But I think weshould be delivering only, really, in extreme circumstances,because you obviously lack the professional contact with people.(ID 48, salaried, multiple)

MURs and order in the social world

Reservations have been expressed about pharmacists taking onroles which rely on technology (e.g. diagnostic testing) or the provi-sionof adviceonnon-medicine related issues (e.g.nutrition, lifestyles)

(Harding&Taylor,1997). YetMURs, since theyare linked to prescribedmedicines, can be interpreted as allowing pharmacists to use theirskills and knowledge in the regulation of the patient’s way of life, inthe way Dingwall and Wilson outline, at least to some extent. Phar-macists described providing advice on prescribed medication andusing their knowledge of drug interactions to intervene to preventadverse consequences. MURs enabled pharmacists to formalise thisadvice-giving role and receive payment for these services.

However, pharmacists only rarely mentioned drawing oncomputer records of medication dispensed to customers to enablethem to act as an independent source of advice. In the US contextDingwall and Wilson describe ‘staff memories are backed up bya computer registerof about 20,000patients and1900doctors’ (1995:119)with patient records being retrieved on the computerwhenevera prescription is received. This is used to assess whether patients arecomplying with drug regimes. Pharmacists act as mediators usingtheir knowledge of the ‘social geography of the community and themoral standing or technical skills of prescribers’ (1995: 119) tomobilise the data from the computer record. In contrast, pharmaciesin our study held limited data on patients and the computer wasviewed as a data entry (rather than information retrieval) tool whichdetracted from the application of clinical skills.

More ACTs doing checking. is releasing us really from thecomputer. (ID8, salaried, multiple)

A small number of pharmacists described technological develop-ments which would enable them to enhance their advice giving role.

Next year I will have a computer system . so if I’m talking toyou about yourmedication I’ve got this computer screen in frontof me and I can reel out everything you have been on. because Ihave to have my information first before I ask you becausechances are as a patient you will leave one medication at home,you will not know the name of that medication (ID 5, owner)

However, computer systems vary between pharmacies in termsof software and data collected. This may discourage locum phar-macists, who experience a range of systems, from using these totheir full potential. In addition, pharmacists who are keen to exploitthe promise of electronic technology may experience frustrations,working in what they perceive as outdated (technological)environments.

The computer was broken .The fax was broken. You know, it’sthat kind of thing. Therewere lots of out-of-dates on the shelves.(ID 36, salaried, multiple)

Whilst technological constraints limit the pharmacist’s role intransforming drugs into social objects, other aspects of the roleresonate with activities described by Dingwall and Wilson. Manypharmacists described MUR activities involving advice giving andusing their knowledge of drug interactions as ‘just doing what wehave always done’. This being the case, some respondentsexpressed unease about financial incentives generally and some feltuncomfortable asking patients to sign MUR forms which pharma-cies submit to be paid for this activity.

We shouldn’t have incentives to do this, that or the other. Weshould be doing for the patients benefit, right? Not .. because..we want the maximummoney out of the government. (ID 18,salaried, multiple)Every day I am doing a medication review on several patients,because they come inwith a query or we query something abouttheir medication .when you’re chatting about this, you’rethinking, "Well, yes, I could be doing an MUR", but you get themto sign a form.. It doesn’t look good...the customer knowingthat I’m going to get some payment for that (ID 39, owner)

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The visible link between the payment and the service maytransform patient perceptions of the service provided from some-thing motivated by having the patient’s interests at heart toa financially driven intervention. Traditionally the pharmacist’sadvice giving role involves responding to patient concerns andqueries. Pharmacists respond to disorder (Dingwall &Wilson,1995:122), but the introduction of MURs increases the requirement forpharmacists to be proactive in this role. This has the potential tochange the nature of the interaction between pharmacist andpatient, with the pharmacist intervening where disorder is not inevidence. As part of the process, which links financial rewards toMURs, the relationship between pharmacist and customer appearsto be changing with the former becoming more dependent on thelatter. Despite advertising and posters, pharmacists reportedhaving to approach customers to try to persuade them to takeadvantage of the MUR service. Whilst some pharmacists describedinitially adopting an appointment system, all who had trialled thisreported having abandoned it due to lack of patient uptake.

A lot of people, they don’t want one. . There’s no pull. Youneed a pull from the customers (ID 19, salaried, multiple)We booked people in an appointment system... But, peoplejust don’t turn up for their appointments. Nowwe’re doing this:just grab them. Have you got a few minutes? [laughs] (ID 18,salaried, multiple)

The pharmacist Dingwall and Wilson describe spends time inthe dispensary, clearly visible from the counter area, with twopharmacists on duty at any time. In contrast, almost all participantsin our study worked as the sole pharmacist, in a role which addedMURs to existing workload and pressures. In addition to pressuringpatients, the effect may also be to choose to conduct MURs whichare less resource intensive, of limited benefit and cursory in nature.A small number of pharmacists described engaging in suchactivities.

They were opportunistic, simple as that, actually. In fact, onewas a member of staff who was having trouble with her medi-cation so we said, “Right, you are a candidate.” (ID 6, salaried,multiple)The way I feel about being forced into doing MURs. you’re justrunning through the motions .. they [patients] don’t have anyreal issues, and you feel a bit of a plonker because you’ve notreally told them anything useful, and you both go away thinking,“Well, that was a bit of a waste of time.” And that underminesthe service, as far as I’m concerned. (ID 44, salaried, multiple)

The issue of ‘being forced into doing MURs’ is a subject to whichwe return in our discussion of differences between multiples andindependents below. However, there is a danger that rather thanbeing seen as a trusted and independent source of advice, attemptsby community pharmacist to ‘sell’ MURs to patients may leadpatients to question their motives, particularly if the MURs areperceived as a waste of time. Furthermore, since copies of MURreports are forwarded to thepatient’sGP, the effectmaybe to furtherundermine the standing of pharmacy within the GP community.

the GP's . are probably getting a lot of MURs but nothing wasneeded. 24 (owner)

MURs and organisation in community pharmacy

For pharmacists working in independents (owners and salariedstaff), multiples were depicted as large and impersonal and drivenby profit motives, with much less emphasis on patient wellbeing.Rather than reflecting a multiples/independents divide, however,

even amongst many salaried pharmacists working in multiples,there was sympathy for the plight of independents struggling tocompete with large chains.

It has been financially demanding for independents. So, maybethat’s the imbalance that actually occurs with the new contract. Ithink a lot more should have been done to. help the inde-pendents. (ID 2, salaried, multiple)

Many respondents from independents highlighted features suchas continuity and knowledge of the community as contributing tothe quality of MURs and service more generally.

An independent pharmacist who knows his patient can doa better medicines use review. multiples . they’ve gotcontinuous flow of staff. (ID 5, owner)

Often these sentiments were expressed by pharmacists workingin multiples too.

Staff feel happier in smaller pharmacies . easier access to thepeople above.more personalized... bigger companies.moretargets.morebusinessdriven.. I haveworked for [multiple] forfive years.people are replaceable, so it is not quite the same sortof attitude.. that shows inpeople’sworkaswell. If peoplearenotbeing treated well, people might think, why should I care? Someof it is being passed onto customers. (ID 42, salaried, multiple)

With regard to standardised processes and systems, which havebeen described as undermining the exercise of autonomy andprofessional status in multiples in particular, all pharmacies arerequired to adopt a systematic approach to record keeping and havestandard operating procedures (SOPs). This requirement was seenas impacting differently on independents comparedwithmultiples.

SOPs. . Writing all these things yet again. For the independentit’s a hell of a job. For amultiple, someone at the head office doesthem all and sends them out. (ID 31, owner)

Having a standard template for standard operating procedureswhich could be adapted by the pharmacist was seen as helpfulrather than constraining professional autonomy. Furthermore, thedegree of standardisation and routinisation, with regard tosystems and processes, was not necessarily different between thetwo settings. MUR documentation follows a standard format, butthe relatively vague guidance on MURs meant that pharmacistsdid not appear to be reduced to ‘asking structured, formulaicquestions’ (Harding & Taylor, 1997: 556)’. Indeed, the opportu-nistic nature of MURs meant that pharmacists did not reportdissatisfaction with the MUR documentation or guidance in termsof constraining their autonomy in either multiple or independentsettings.

A recurring theme, however, was that pharmacists felt underpressure, due to the requirement to hit target levels of MURs. Thesepressures were described as being particularly pressing by phar-macists working in multiples. In part, this may reflect the relativelysmall number of pharmacists working in independents in oursample. It may also reflect the fact that for owners, there is nobodyfurther up in the hierarchy to blame for applying pressure toincrease MUR volumes, although rates of MUR provision bymultiple pharmacies are higher than for independent pharmacies(Bradley et al., 2008).

I have to deliver 400 MURs. No doubt about it. If I’m short bya hundred, then I’ll be in trouble. (ID 23, salaried, multiple)No one knows who we are at the head office. they’re alwaysgoing on at me about how many MURs that you’ve done andthat. .. I haven’t got enough hours in the day to do it all. (ID 25,salaried, multiple)

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The fact that in multiples targets and scrutiny processes weredescribed as emanating from a remote ‘head office’, which had littleknowledge of individuals on the front line, nor the local context inwhich they worked added to frustrations. However, there wereindications that pressures to undertake MURs were not confined tomultiples, as the comments below from a pharmacist who hadrecently left the independent pharmacy setting illustrate.

I felt that pressure, particularly with the independent pharmacy.He was leaning on me very heavily. . he had the cheek to tellme that I wasn’t doing enough MURs. I felt like throttling him.(ID 36, salaried, multiple)

Discussion

Our findings suggest that reactions to the introduction of MURsamongst our participants were variable and complex. In terms ofthe first of the questions we raised earlier, concerning the extent towhich pharmacists are willing and able to relinquish aspects of thedispensing process to focus on MURs, apart from a small number of‘old school’ pharmacists, there was a high level of support forchanges which reduced the pharmacist’s involvement inwhat wereperceived as routine aspects of the dispensing process. However,despite a willingness to delegate tasks to junior members of staff,many pharmacists described workload pressures which reducedtheir ability to conduct MURs.

Prescription collection and delivery services were largely seenas enabling pharmacies to plan workload, freeing up time forother activities. In addition, such developments might be viewedas being in line with the Government’s intention that communitypharmacy should be responsive to the changing needs of patients.In common with the provision of MURs, delivery services reducethe opportunity for face to face contact between patients andpharmacists. In the case of MURs, being in the consultation roommeans less opportunistic contact between the pharmacist andother patients as part of the dispensing process, potentiallyreducing patients’ awareness of the pharmacist’s expertise.However, this may be outweighed by the potential contributionto professional status and job satisfaction if pharmacists spendtime conducting MURs that both they and their patients see asvaluable. With regard to the dispensing of medicines, homedeliveries reduce patient visits to the pharmacy, in a way that theprovision of MURs does not. Deliveries have the potential tochange the nature of the relationship between pharmacies andthe public they serve by severing the physical contact betweenthe two. In such circumstances the public’s perception of thepharmacy may be as a supplier of material (as opposed to social)objects, in much the same way that other suppliers offering homedelivery are seen, rather than a provider of professional expertiseand advice.

Whereas Harding and Taylor point to the need for pharmaciststo create dependence on their skills as part of a professionalisingstrategy, by promoting their ‘knowledge and skills as mystical’(1997: 555), the pressures associated with operating ina commercial environment appear to be increasing the depen-dency of pharmacies on the public they serve. Similarly, ina context where pharmacists describe having limited time toconduct MURs and patients are less than keen to participate, thismay also change the relationship between pharmacists andpatients, making the former more dependent on the latter. Thisfactor is linked to the second question we raised concerning therole played by pharmacists ‘in the maintenance of order ordiscipline in the social world’(Dingwall & Wilson, 1995: 125). Ourdata suggest that the formalisation and incentivisation of MURs isleading to a distortion in the provision of advice to patients, withpharmacists under pressure to offer MURs to patients, based on

the commercial needs of the pharmacy rather than the patient.Furthermore, the clear link between the MUR and financialrewards makes some pharmacists uncomfortable, and may detractfrom the potential of MURs to raise professional status, by high-lighting commercial, as opposed to patient, interests.

MURs offer the potential to capitalise on ‘the chasm betweenpharmacists’ skills and knowledge and that of the lay public’(Harding & Taylor, 1997: 555). The introduction of appointmentssystems described by some pharmacists, in addition to allowingpharmacists to plan workload, can also be seen as an attempt toreflect a more formal approach to access, encouraging theperception of pharmacists’ time as being more valuable than that ofpatients. This to some extent mirrors the GP consultation process interms of access by appointment. Yet the responses of our partici-pants suggest that members of the public are not necessarilyconvinced of the need for this advice (as part of an appointmentssystem or otherwise). In a context where consumers increasinglywant to make informed choices in consultation with professionals,resistance to advice which is offered as part of an artificial inter-action created by the MUR, rather than occurring spontaneously aspart of the everyday exchanges which patients are used to expe-riencing, is understandable.

Dingwall and Wilson describe pharmacists responding todisorder. Yet the descriptions of many MURs given by our respon-dents suggest that pharmacists are intervening where disorder isnot present. Rather than bringing order and stability in an ‘intrin-sically anarchic material world’ (Dingwall & Wilson, 1995: 122),respecting the wishes and responding to the concerns of the publicin a way which respects their independence, the introduction ofMURs puts pressure on pharmacists, which threatens to disruptexisting relations and regularities.

The comments about GPs’ reactions to MURs suggest that theyplace no value on receiving copies of MUR reports. The introductionof MURs, which formalise advice giving for patients on medicinesprescribed by GPs and pay pharmacists for doing this from thelimited health care budget, might be expected to produce resis-tance amongst GPs. Resistance from GPs is a recurring theme in theliterature on extended roles for pharmacists and, as Dingwall andWilson write, ‘[t]he points at which pharmacy comes closest to themedical profession are clearly points at which their control over thetransformative work on the drug becomes less secure’ (1995: 124).Yet ‘territorial skirmishes’ with medicine do not mean that phar-macists cannot engage in their transformative work. However,doubts about the value of MURs are likely to undermine attempts toextend and consolidate roles.

Following on from this to the third question we posed, con-cerning MURs and the increasingly corporate nature of communitypharmacy, the perception of multiples as impersonal and hierar-chical was shared by many respondents in multiples as well asindependents. The descriptions of multiples as characterised byMUR targets backed up with surveillance, suggested an environ-ment in which pharmacists’ ability to exercise discretion andcontrol over their work is under threat. This environment might beseen as reducing pharmacy’s claims to professional status. Withregard to patient perceptions it seems reasonable to assume thatpatients’ views will be influenced by their own experiences ofinteracting with pharmacists. Even where pharmacists are moti-vated by a requirement to meet targets, patients may be unaware ofthis, although it also seems reasonable to assume that being pres-sured into MURs, some of which may yield little benefit, maydamage pharmacy’s standing.

In the context of the increasingly corporate nature of pharmacyand its impact on professional autonomy in multiples and inde-pendents, the depiction of large multiples as characterised by‘standardised pharmaceutical services dictated by company

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policies’ (Harding & Taylor, 1997: 556) requires a little unpackingwith respect to our data. Standardisation, in terms of standardoperating procedures, has long been a feature of communitypharmacy organisation in both independent and multiple settings.Whilst routinisation and the ability to codify knowledge are seen asinversely related to professional status, there is no suggestion,based on our findings, that codification is more prevalent inmultiples compared with independents. Whilst the interactionbetween pharmacists and customers was changed as a result of theMUR as described above, pharmacists’ accounts did not conveya process in which interactions are reduced to formulaic exchangesin either multiple or independent settings.

Edmunds and Calnan (2001) identified ‘clear divisions betweenindependent proprietors and salaried pharmacists working in largechains or supermarkets’ (954). Initiatives to extend pharmacists’roles were seen as likely to benefit independent pharmacists whostruggled to compete with large chains due to the latter’s financialmuscle. Yet, because their counterparts in large chains ‘do notexperience the financial pressures of the independents’(954), thebenefits for chain pharmacists from taking on enhanced roles (interms of economic autonomy) were fewer, with the result that suchinitiatives were seen as likely to enhance their clinical, but not theireconomic, autonomy. In the competitive environment of commu-nity pharmacy, multiples appear to be just as keen as independentsto maximise profits. What Calnan and Edmunds’ analysis fails toanticipate is the fact that non-owner pharmacists may face targetsfor MUR delivery and these may threaten (as opposed to enhance)clinical autonomy. Whilst these targets do not mean that work isroutinised, they do appear, from the accounts of our participants, toresult in some pharmacists undertaking MURs which are ofdubious quality in order to meet targets. Descriptions of beingunder pressure to meet targets suggest constraints on the ability ofpharmacists ‘to exercise discretion in their work, to assert theirown judgment and responsibility as the arbiters of their activities’(Freidson, 1994: 164).

Whilst divisions between multiples and independents havebeen described as weakening pharmacy’s attempts at repro-fessionalisation (Edmunds & Calnan, 2001: 954), according to ourstudy data, divisions which were linked to hierarchy and controlover work gave rise to the greatest tensions. Such divisionsbetween front line and more distant ‘head office’ pharmacists andmanagers more generally, were evident within multiples. However,our study also identified such tensions between owners and sala-ried pharmacists in independent settings. These accounts, whichdescribe pharmacists as pressurised into meeting MUR targetscreate the impression of pharmacists as workers unable to resisttop-down control, rather than autonomous professionals. They alsohighlight the way in which claims to professional status arehampered by the pursuit of commercial, as opposed to patient,interests.

Conclusion

Our analysis suggests that pharmacists are unable to capitalisefully on the potential to enhance professional status, which recentstate sponsored reforms afford. Debates about professional statusand role extension have focused on pharmacy’s subordination tomedicine, divisions between multiples and independents and thethreat to professional status posed by advice- giving on a range ofnon-medicine related (Harding & Taylor, 1997: 556). However,MURs are medicine related and, if conducted in a manner whichenables those involved to see them as a valuable process, offer thepotential to enhance professional status. Government policyemphasises meeting the changing needs of patients andenhancing public confidence in the profession as two of three key

challenges for pharmacy (Department of Health, 2003). Withmany users of medicines being knowledgeable actors (Weiss &Fitzpatrick, 1997), a model of MUR delivery which treats indi-viduals as passive recipients of expert advice appears to be aninappropriate response to these challenges. However, professionalreflection and adaptation to this changing environment may alsobe hampered by the third challenge. This concerns respondingpositively to the ever-changing and increasingly competitive retailpharmacy environment. Where this creates pressure to prioritiseincome targets over responding to the needs of service users, thepotential of MURs to enhance professional status appears to belimited.

Acknowledgements

Funding was provided by the NHS Service Delivery and Orga-nisation Research and Development Programme, and the UKDepartment of Health. The views and opinions expressed herein arethose of the authors and do not necessarily reflect those of thefunders.

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