Superdrug's pamphlet "The way forward", inserted as advertising matter in The Pharmaceutical Journal of September 11 and advocating the abandonment of limitation of pharmacy entry into National Health Service contracts, prompts some fundamental questions. Are medicines ordinary articles of commerce? Is pharmacy a profession? Or is it a commercial enterprise?
To my mind, the pamphlet is a polemic in favour of commercialism. Yet it claims that increased competition (meaning more pharmacies in areas that do not need them) will improve the profession's advisory service to the public.
Superdrug quotes with unqualified satisfaction the Consumers Association's criticisms of the quality of advice offered by pharmacies to customers. While treating with caution the CA's penchant for fault finding (its raison d'être), we can dismiss Superdrug's claim that the answer to insufficient or inadequate advice from pharmacies is deregulation.
Does Superdrug believe that there has been since 1987 (when limitation was introduced) a decline in the quality or quantity of advice given in pharmacies? If there has been a decline, it dates from 1948 when the NHS started, not 40 years later. Before 1948, pharmacists were in the forefront of primary care because the pharmacist was generally "on the counter" and to a considerable extent the poor man's doctor.
At the start of the NHS there was an avalanche of prescriptions. To cope with the deluge, pharmacists had largely to transfer their main activity to the dispensary. The most satisfactory answer to the problem of advice at the counter is not more pharmacies, but fewer and better staffed pharmacies with two pharmacists in each or more technicians in the dispensary.
However, in relation to Superdrug's real aim, the question of advice is a sideshow. The company's stated aim is more pharmacies in the high street. Superdrug used to be, so far as I am aware, cut-price drugstores. It appears gradually to be turning its premises into pharmacies with dispensing contracts. So, there is a self-interest rather than a public interest involved. Because high street or shopping centre rents tend to be high, it seem likely that new pharmacies in such locations would indeed have to be "commercial".
Superdrug appears to be arguing that if pharmacists were allowed to proliferate in the marketplace the standard of service would automatically rise (because of competition). But how could improved service be provided from second-rate profits, assuming all the competing newcomers would indeed survive? There are very few specialist shops in shopping centres and a true professional pharmacy would seem to be a specialist establishment. I would add that it has been, in my experience, the privately owned pharmacies that have been the most innovative and that have advanced professional standards, not the chain pharmacies commonly seen in town centres.
I recall that, four years ago, Mr Gordon Houston (as retiring managing director of Boots the Chemists) expressed his "one regret", namely, that the profession had failed to establish itself in the mainstream of primary health care (PJ, July 15, 1995, p89). My view then, as it is now, was that it is large-scale company pharmacy that has institutionalised commercialism in pharmacy, and it is that that has bedevilled the elevation in the public eye of pharmacy as a profession (PJ, August 12, 1995, p196). Remarkably, Superdrug states that "pharmacists' role as health providers will never be fully recognised until the ‘shopkeeper' image is jettisoned". Will that be achieved by giving commercialism a further boost in the shape of enhanced competition between pharmacies?
Superdrug complains about the failure of the Government to exploit the positive role pharmacies could play in primary care and goes on to express the belief that pharmacists will fail to contribute fully to the delivery of primary care until the regulations that determine the number and location of pharmacies are "modernised". Superdrug was apparently drawing upon an analysis by McKinsey & Co, which reminds me of the experience of Kate Graham (as publisher of the Washington Post) with the same organisation "regurgitating what we had told them in a slightly different but not very helpful way". She had other criticisms.
What three representative bodies in pharmacy recommended two years ago (PJ, December 13, 1997, p947) was not the fashionable, but meaningless, word "modernised" but "modified" regulations, with retention of contract limitation. They also called for compensation for contact relinquishment and the amalgamation of pharmacies where appropriate (not greater competition).
So, it is well recognised in pharmacy that Superdrug is correct in pointing to the unsatisfactory nature of the current regulations. That they were unsatisfactory was apparent at the outset; none the less, they were accepted by the general body of contractors, warts and all. Certainly, the PJ pointed out the puzzling nature of the "necessary or desirable" criterion for the award of a contract, something that judges have questioned from time to time. The Journal (August 10, 1995, p166) described the criterion as "curious" because the two words "represented the difference between that which was worth having and that which cannot be done without. The latter must surely encompass the former."
Superdrug's pamphlet claims that pharmacy numbers in the United Kingdom have not kept pace with prescription volumes over the last six years of deregulation. But the reason for limitation in the first place was because pharmacy numbers were rising, and the new contract was designed to stabilise, if not reduce, the number of pharmacies. The increase in 1984 was 150. Unfortunately, because of the inept way in which the new contract was introduced (with an unconscionable delay), the exact opposite happened. The new contract was finally introduced in 1987, but by the autumn of 1985, there were already 700 applications for the registration of new pharmacies in the pipeline at the Society's Law Department. Indeed, by 1987, the number of pharmacies had risen by nearly a thousand compared with 1984 - from 11,107 to 11,974 - and in 1997 there were 12,300. No wonder if there is a shortage of pharmacists.
What Superdrug's demand for modernisation entails is, apparently, abolition of the regulation of pharmacy numbers and locations. We are told that this will encourage the profession to be more dynamic and progressive in contrast to its current reactionary stance.
In contrast, the view expressed by The Journal in 1985 (May 25, 1985, p633) in favour of limitation was the diametric opposite. It said: "It is in the public interest and in the interest of the profession to have fewer, better pharmacies rather than a multiplicity of pharmacies that often do no credit to themselves let alone the profession as a whole."
Besides increasing competition between pharmacies, Superdrug has other proposals, including "rationalising" remuneration, which on past experience woulf benefit the Treasury rather than the profession.
There is a strange incoherence between two further statements. On the one hand, Superdrug strongly believes that its package of "reforms" is needed to "revitalise" the industry (my italics). The second reads: "In terms of developing status, there are lessons ro be learned from other professions. Nurses, for example."
What is clear is that, in 1966, the Pharmaceutical Society's branch representatives approved in principle the planned distribution of pharmacies. Limitation is the nearest to that pharmacy is ever likely to reach.
The pursuit of profit produces benefits to both individuals and to people in general, but moderation (limitation!) is necessary.
One final point: Superdrug says there are no more pharmacies per caput in Germany than in the UK. Is like being compared, by any chance, with like?