The Pharmaceutical Journal Vol 263 No 7074 p909-913
December 4, 1999 Original Papers

A pharmacy workforce survey in the West Midlands: (1) Current work profiles and patterns

By Alison Blenkinsopp, PhD, MRPharmS, Helen Boardman, BSc, MRPharmS, Jill Jesson, PhD, and Keith Wilson, PhD, MRPharmS

Part 2

Aim To identify and measure the current working patterns of pharmacists in one geographical region.
Design Piloted questionnaire containing open and closed questions.
Subjects and setting All registered pharmacists aged up to 65 years, together with those aged over 65 years and still working, in the West Midlands region.
Results The response rate was 67.7%. 90% of respondents were working as pharmacists. Of those who were not (10%), about one third were aged over 60 years. A further third were working in non-pharmacy jobs and had no plans to return. 40 were on maternity leave or taking a career break and planning to return. Royal Pharmaceutical Society records showed that fewer than 40 pharmacists had left the register in the past 5 years. Pharmacists from non-white ethnic groups were over-represented in community pharmacy and under-represented in hospital pharmacy for reasons unknown. A quarter of pharmacists, mostly women, worked part-time, mostly in community pharmacy.
Conclusion Pharmacy has a high retention of its workforce within the profession. Few pharmacists leave the register or work in non-pharmacy jobs. A substantial proportion of pharmacists work part-time and their choices about when and where to work have significant implications.

For all health professional groups the labour market is shaped by methods of health care delivery, the expectations and demands of society, and the distribution of tasks and activities according to professional boundaries. The balance between the output of education and training providers and the needs of the National Health Service and private health care sectors is an issue for all professional groups. Over-production brings with it the opportunity for employers to become more selective and perhaps to raise threshold requirements. At the same time, it brings the threat of reduced remuneration where supply is greater than demand. Under-production, on the other hand, means that employers may have more difficulty in filling posts and are likely to have to pay premium rates to attract applicants.

A shortage in one professional group may mean reductions in available services and ultimately a threat to patient care. Despite the consistent annual increases in the number of pharmacists on the Register of Pharmaceutical Chemists, there have been repeated reports of difficulties in recruiting pharmacists to the two major sectors of the profession, namely, community and hospital practice.1–6 Thus there have been apparent increases in both supply and demand, with the latter appearing to outstrip the former. Unlike medicine, pharmacy has no centralised workforce planning mechanism, nor is there a formal system to control the numbers of pharmacists produced by the schools of pharmacy. However, the Royal Pharmaceutical Society has monitored workforce numbers for many years, and, as part of its role in accrediting undergraduate pharmacy programmes, has advised schools of pharmacy on intake numbers. The annual number of pharmacy graduates for the United Kingdom has been around 1,100 for the past decade (personal communication, Royal Pharmaceutical Society). In recent years, claims have increasingly been made of a shortage of pharmacists, and the Society stated in 1997 that "significant numbers of employment opportunities for pharmacists are going unmet".7 Some factors which potentially lead to increased demand for and reduced supply of pharmacists are summarised in the Panel and described more fully below:

Factors potentially increasing demand for and reducing the pool of available pharmacists Factors potentially increasing demand Longer opening hours in both traditional and newer community pharmacy settings (supermarkets) "Wider roles" outside the community pharmacy, eg, sessional prescribing advice to general practitioner practices or primary care groups Non-contract pharmacies Health authority posts (pharmaceutical advisers, pharmaceutical facilitators) Establishment of primary care group pharmacist posts Factors potentially reducing the overall pharmacist pool or pharmacists' willingness to work in specific sectors Dissatisfaction and stress leading to reduction in hours worked Work patterns of women pharmacists Diverging levels of pay (lower in hospital compared with community) Fewer opportunities to become a community pharmacy proprietor or owner because of market changes

Women pharmacists There is an increasing number of women on the register. They accounted for 47 per cent nationally in 1994⁸ and currently account for 48.3 per cent of pharmacists in the West Midlands (Royal Pharmaceutical Society, data on file). The work patterns of women pharmacists, including part-time working (especially while bringing up young children), might reduce the pool of available pharmacists. In 1986, it was estimated that a woman pharmacist might be expected, over her career, to work 60 per cent of the amount of time worked by a man.⁹
General retailing trends Seven-day opening, extended opening hours, and no lunchtime closing have all contributed to an increase in the requirements for pharmacist coverage. These changes are driven by consumer demands and expectations and have affected pharmacy along with other retail sectors.
Corporate ownership The move towards corporate ownership and supermarket pharmacies has resulted in an increase in demand for pharmacists. Such increases may occur through policies of having more than one pharmacist per premises as well as from longer opening hours.
New roles The introduction of new roles, such as working with GP practices and domiciliary visiting, take pharmacists out of the shop or hospital environment. Such developments result in increased demand for pharmacists to provide cover to maintain core pharmaceutical services.
Health authority posts The development of pharmaceutical adviser and pharmaceutical facilitator posts in health authorities has increased demand for pharmacists.
Dissatisfaction Dissatisfaction among pharmacists may reduce the workforce pool as pharmacists leave the profession to pursue alternative careers, reduce their hours worked in pharmacy, or go into retirement or semi-retirement early. Stress and long hours have also been suggested as contributing to dissatisfaction within the profession.^10,11 Consumer expectations (for example, that pharmacies should remain open throughout the day, with a pharmacist on duty at all times) have probably played an important role here.
It was against this background that the Department of Health set up a working group in 1996 to explore pharmacy workforce issues. The group reported in 1997 and, although the report was primarily concerned with hospital pharmacy, it addressed the wider workforce picture.¹² One of the report's recommendations was that data should be collected which could be used in planning initiatives to enhance recruitment and retention. As a result the NHS Executive (West Midlands) commissioned a major regional survey of the pharmacy workforce.

Method

The survey employed both quantitative and qualitative approaches to produce primary data and used two methods of data collection: a structured postal questionnaire and semi-structured telephone interviews. In addition, secondary data supplied by the Royal Pharmaceutical Society revealed the numbers of pharmacists leaving the register in the West Midlands over each of the previous five years (Royal Pharmaceutical Society, data on file).
The findings reported here are from the questionnaire survey.
The questionnaire was designed by experienced researchers with pharmacy practice and social sciences backgrounds with input from a "user group" comprising representatives from community and hospital pharmacy, health authority pharmaceutical advisers and a provider of locum pharmacists. The questionnaire comprised closed and open questions on a series of themes:

• Current work profile (pharmacy and non-pharmacy)
• Changes in work patterns in the past three years and reasons
• Intended future employment changes and reasons
• For pharmacists not currently practising, the reasons why and likelihood of return
• Attitudes to returning to pharmacy or to increasing hours worked
• Postgraduate qualifications and future intentions and interest in these
• Morale and motivation

Demographic information collected included length of time registered as a pharmacist, age, gender, number of children aged under 19, other dependants, planned retirement age, and ethnic group (using Committee for Racial Equality categories). At various points in the questionnaire, pharmacists were asked to give their reasons for particular answers. Finally, respondents were asked if they had any other comments they wished to add.
The questionnaire was piloted with 20 pharmacists from community, hospital, industrial and academic settings and minor revisions were made as a result.
Pharmacy organisations and community pharmacy multiple groups were sent a copy of the final version of the questionnaire. They were asked to endorse it and to use their communication networks to encourage pharmacists to complete it.
Sample The questionnaire was mailed to all registered pharmacists in the Royal Pharmaceutical Society's West Midlands region up to age 65 together with those pharmacists aged over 65 whose registration category indicated that they were still working. The Society's branches which comprise the West Midlands region are: Birmingham, Coventry and Warwickshire, Dudley and Stourbridge, Hereford, North Staffordshire, Shropshire, South Staffordshire, Walsall, Wolverhampton, and Worcester. In total there were 2,568 pharmacists in the sample.
Mailing addresses were obtained from the Society in October, 1997. The first mailing was distributed to pharmacists in early November, with one follow-up to non-responders in January, 1998.
Data coding and entry Questionnaires were checked on receipt by the researcher and coded. A codebook was constructed for responses to open questions. A Microsoft Access database¹³ was constructed into which data were entered and from which they could be exported to the Statistical Package for the Social Sciences (SPSS)¹⁴ for further analysis.
Data analysis Frequency counts were performed for all questions. Cross-tabulations were conducted to explore the relationships and possible associations between variables by age, gender, ethnic origin and practice sector. Chi-squared tests were carried out to determine the strength of apparent associations and a p value of <0.05 was considered significant. Key variables in this respect were age, gender, ethnic group, work sector and intended work changes.

Results

The response rate after the first mailing was 53.2 per cent (1,365) and it increased to 68.8 per cent (1,767) after one follow-up.

Validation of the respondents Royal Pharmaceutical Society statistics for the total sample were used to test for the representativeness of the respondents. The age profile of our respondents was very close to that of the total sample (Table 1). Women were slightly over-represented (53.1 per cent v 48.3 per cent in the total sample) and men slightly under-represented (46.3 per cent v 51.7 per cent) among our respondents.

Table 1: Comparison of ages of West Midlands pharmacist population and survey repondents Age Percentage   West Midlands Respondents 21–30 24 24 31–40 31 28 41–50 22 21 51–60 14 15 61–70 8 9 Over 70 2 1

A comparison was made of our respondents' reported main occupation against Society data for the total sample. The Society figures have to be treated with some caution because divulgence of employment type is not compulsory for renewal of registration. Also an increasing number of pharmacists now pay their registration fee by direct debit and may not return the paper form to state their current employment category. Having recognised these potential limitations, the Society data are, however, the only data source on employment type. Table 2 shows the employment types for our respondents and the Society figures for the total West Midlands sample.

Table 2: Employment type of West Midlands pharmacists and survey respondents Employment Percentage   West Midlands (n=2,568) Respondents (n=1,767) Community 69.5 70.6 Hospital 14.5 15.6 Industry 1.0 0.8 Wholesale 0.2   Teaching 0.8   Academia   0.9 GP practice pharmacist   0.3 Other pharmaceutical 1.3 1.6 Non-pharmaceutical 1.5 3.7 No paid employment 1.2 6.3

The percentages for the two groups are very close, particularly for the two main employment sectors, community and hospital pharmacy. Although much smaller in numerical terms, the percentages of industrial and academic (classed as "teaching" by the Society), and "other pharmaceutical employment" are similar.
The percentages of pharmacists recording "non-pharmaceutical" and "no paid employment" were higher among our respondents (3.7 and 6.3 per cent, respectively, compared with 1.5 and 1.2 per cent in the Society data). However, for 10.0 per cent of pharmacists in the Society's database the employment type is "unknown" and may account for these differences.
Based on the comparison with Society data, our respondents appear to be representative of the total sample.

Finally we considered the Society's figures on extent of employment (Table 3). The Society's figures reflect its payment categories for registration purposes and are difficult to translate into actual time worked by pharmacists. However, the figures for pharmacists recording full-time employment should be directly comparable. For the total sample, 63.6 per cent paid the registration fee for full-time working. Among our respondents, 60.5 per cent of community and 64.1 per cent of hospital pharmacists said they were working full-time. The percentage of West Midlands pharmacists whose extent of employment is recorded as "unknown" in the Society's data is 11.8 per cent. This makes it difficult to draw definitive conclusions but, based on the data, community pharmacists working full-time may be slightly under-represented among our respondents. As yet the Society has no data on ethnic origin of pharmacists, so we were not able to assess whether our respondents were representative of the total sample in this respect.

Table 3: Extent of employment of West Midlands pharmacists (Royal Pharmaceutical Society categories) Employment Number Percentage Full-time 1,645 63.6 Part-time < 13 weeks 295 11.4 Part-time > 13 weeks 288 11.1 No paid employment 54 2.1 Not known 306 11.8

Pharmacists who had left the register The Society's data showed that 37 pharmacists with registered addresses in the West Midlands region had left the register in the five-year period up to the study (Royal Pharmaceutical Society, data on file).
Demographic profile Just over half the respondents (53.1 per cent) were female. The age breakdown of male and female pharmacists is shown in Table 4.
Four in five of our respondents were white and one in five non-white. Table 5 shows the ethnicity of responding pharmacists. Within the non-white respondents, most (68 per cent; 220) defined themselves as Indian.
Pharmacists from non-white ethnic groups were younger (Table 6); 67 per cent had been registered for less than 10 years compared with 31.5 per cent of the total sample. The proportion of pharmacists from non-white ethnic groups is thus higher in younger age groups - 40 per cent of 21-30 year-olds are from these groups. They were also more likely to be working in community pharmacy - only 5 per cent of non-white pharmacists worked in hospital pharmacy, compared with 18 per cent of white pharmacists.

Table 4: Profile of respondents by age and gender Age Number of respondents   Male Female 21–30 145 278 31–40 212 288 41–50 151 198 51–60 152 119 61–70 111 51 Over 70 18 5

Table 5: Ethnicity of survey respondents Ethnic group Number of respondents White 1,408 Black — Carribean 3 Black — African 8 Black — Other 1 Indian 220 Pakistani 41 Bangladeshi 7 Chinese 15 Other ethnic group 28

Table 6: Profile of respondents by age and ethnicity Age Number of respondents   White Non-white 21–30 251 170 31–40 101 41–50 319 48 51–60 263 2 61–70 154 1 Over 70 22 0

Pharmacists' current work Ninety per cent of respondents reported that they were currently working as a pharmacist. Of the 10 per cent (177) who said they were not working as a pharmacist, almost a third were aged over 60. Non-pharmaceutical employment was the main type of work for 66 respondents (3.7 per cent). When asked to state what sort of work they were currently doing, their answers demonstrated a wide range, including company directors, teachers and general practitioners. One hundred and eleven pharmacists reported not being in paid employment and their reasons are shown in Table 7. Almost half of these pharmacists (49 per cent; 54) said they had retired permanently and 9 per cent (10) were not working for health reasons. A further 20 per cent (22) were taking a career break and 16 per cent (18) were on maternity leave.

Table 7: Reasons for not being in paid employment (n=111) Reason Percentage of respondents Retired permanently 49 Career break 20 Maternity leave 16 Health reasons 9 Education or research 4 Looking for work 5 Other 6

Sector of practice Pharmacists' primary sector of work are shown in Table 8. Over three-quarters of the 1,587 pharmacists who were currently working (78.6 per cent) reported that their primary place of work was community pharmacy, while 17.3 per cent were working in hospital pharmacy. Pharmacists reporting "other" as their primary employment category included health authority pharmaceutical advisers and those working in more than one sector, such as teacher-practitioners.
Employment status The type of pharmacy ownership in which community pharmacist respondents (excluding locums) worked is shown in Table 9. Overall, 234 respondents (27.2 per cent) were owners or employers; the remainder were employees. This figure compares with a figure of 32 per cent for independent contractors calculated from national contractual data in 1995.¹⁵ Nearly half of our community pharmacist respondents worked for large multiples.
Age profile The age profiles of pharmacists working in the two main sectors of the profession are shown in Table 10. Over 60 per cent of hospital pharmacists were aged 40 or under (63.3 per cent compared with 52.3 per cent of community pharmacists). The age profiles probably reflect NHS retirement ages, inasmuch as only 1.5 per cent of hospital but 10.0 per cent of community pharmacists were aged over 60.

Table 8: Primary work sector of respondents (n=1,587) Sector Percentage of respondents Community 78.7 Hospital 17.3 Industry 0.9 Academia 1.0 GP practice 0.3 Other 1.8

Table 9: Pharmacy type of community pharmacy respondents (n=858) Pharmacy type Percentage of respondents Owner/employer 27.2 Independent 5.2 Small/medium multiple 19.7 Large multiple 47.8

Table 10: Age profile of community and hospital respondents Age Percentage of respondents   Community Hospital 21–30 24 32 31–40 28 31 41–50 22 24 51–60 16 11 61–70 9 2 Over 70 1 0

Profile of hours worked Pharmacists were asked to specify their current hours worked per week, by employment sector, for 1997. Of the 1,558 pharmacists who provided data, 1,093 (70.1 per cent) were working for 35 hours or more. The definition of "full-time" working is not straightforward in pharmacy, since in community pharmacy opening hours are increasingly likely to be 9am to 6pm at a minimum. Many pharmacists are contracted to work throughout the day; few pharmacies close for lunch. Typical "full-time" work in other sectors of pharmacy work would be 35–40 hours. About a quarter (466) of the working pharmacists said they worked part-time. Most of these (80.3 per cent) worked in community pharmacy, with 14.4 per cent working in hospital pharmacy. More than one in three pharmacists (36.1 per cent) were working more than 40 hours per week and 8.4 per cent more than 50 hours (Table 11).

Table 11: Profile of weekly hours worked by all respondents (n=1,558) Hours worked Percentage of respondents Up to 10 6.4 11–20 10.1 21–30 11.0 31–40 36.5 41–50 27.7 51–60 6.8 Over 60 1.6

Analysis of the figures for community and hospital pharmacists produces the profiles shown in Table 12. Just over 40 per cent of community pharmacists and 14.9 per cent of hospital pharmacists reported working for more than 40 hours a week. It is interesting to note these figures in relation to the maximum working week of 48 hours now specified by the recent EC directive.16 Analysis of hours worked by employment status showed that 67.8 per cent of the 233 employer/owner pharmacists reported working more than 40 hours, compared with 53.3 per cent of the 268 pharmacists in charge in large multiple branches. These figures contrast with the 6.4 per cent of the 141 second pharmacists in large multiples who reported working more than 40 hours per week.

Table 12: Weekly hours worked by community and hospital respondents Age Percentage of respondents   Community Hospital Up to 10 7.0 3.3 11–20 9.9 10.5 21–30 11.9 7.3 31–40 28.9 63.6 41–50 30.2 14.5 51–60 8.0 0.4 Over 70 1.9 0

Locum pharmacists More than one in five working pharmacists described themselves as "locums". In the past, it has been assumed that most such pharmacists worked on a part-time basis. However there have been anecdotal reports to suggest that in recent years more pharmacists have been opting to work as "career locums". Such pharmacists might work as many, or more, hours as a full-time equivalent pharmacy manager. However the extent of locums' working hours has been unavailable. The profile of weekly hours worked by our locum respondents is shown in Table 13. Our findings show that one-third (33.6 per cent) of locum pharmacists were working more than 30 hours a week, 18.1 per cent over 40 hours and almost 6 per cent more than 50 hours. We suggest that these are equivalent to three, four and five days a week in community pharmacy.

Table 13: Profile of weekly hours worked by locum respondents (n=354) Hours worked Percentage of respondents Up to 10 19.2 11–20 22.6 21–30 20.1 31–40 15.5 41–50 12.4 51–60 3.7 Over 60 2.0

Analysis of hours worked by age for locum pharmacists showed that younger pharmacists were working for considerably longer. Of the 64 locums working more than 40 hours a week, 52 were aged 40 or under, and of the 20 working more than 50 hours a week, 17 were aged 40 or under (Table 14).

Table 14: Profile of locum pharmacist respondents by age and weekly hours worked (n=354)
Age	Weekly hours worked
	0–10	11–20	21–30	31–40	41–50	51–60	Over 60
21–30	4	4	6	15	22	5	5
31–40	16	21	10	9	13	6	1
41–50	8	13	19	15	3	1	1
51–60	9	18	22	1	5	1
61–70	23	21	13	5	1
Over 70	8	3	1

Part-time pharmacists About a quarter (466, 26.4 per cent) of our respondents reported that they worked part-time. Over three-quarters (76.4 per cent) were female. Most part-time pharmacists (80.3 per cent; 374) work in community with 14.4 per cent (67) working in hospital pharmacy. The age profile of pharmacists working part-time is shown in Table 15.
As might be expected, most part-time pharmacists were in the age groups where family commitments might be expected to be highest, and where semi-retirement is likely.
Almost one third of pharmacists working part-time were aged 31–40 (Table 15), likely to be the time when pharmacists have major domestic commitments and young children. This is illustrated by the percentage of pharmacists working part-time who were women rising to 95 per cent and 93 per cent in the 31–40 and 41–50 age groups, respectively. Also 87 per cent of part-time pharmacists in these age groups had one or more children aged under 19.
Half of the pharmacists who classified themselves as working part-time (49.9 per cent) were working more than 20 hours per week (Table 16). In community pharmacy this suggests that such pharmacists were working two days a week or more, since the working day for many community pharmacies is likely to be from 9am to 6pm or 7pm.

Discussion

Our survey achieved a good response rate (68.8 per cent) and analysis of respondents indicates that they were representative of the sample as a whole. Our findings show that, in the West Midlands, pharmacy has a high retention level of its members (90 per cent). A small percentage have pursued other careers (4 per cent), and the remainder are either retired permanently (3 per cent) or are taking a break from work for family or health reasons. Given that very few (37) pharmacists in the West Midlands left the register in the five years prior to our survey, we surmise that there is not a significant pool of pharmacists who have left the profession.
Around a quarter of pharmacists work on a part-time basis. This study has determined their hours of work, and one way to increase the pool of available pharmacists is to explore the scope for encouraging part-time pharmacists to increase their hours of work.
The survey has confirmed anecdotal reports of significant numbers of locum pharmacists working the equivalent of full-time hours. This is particularly the case for younger pharmacists and the working week of some was outside the EU guidelines of a maximum of 48 hours.¹⁶ The reasons why pharmacists are choosing this career path were explored in the telephone interview section of our study and so are not reported here.
The shift in community pharmacy from a largely owner-proprietor structure to a predominantly employee one is illustrated by our results. In comparison with Magirr and Ottewill's study,¹⁵ we found 27.2 per cent were owners or employers (compared with their 32 per cent) but this definition could include a company director rather than independent contractor so direct comparison is difficult.
It is difficult to know whether the proportion of large multiple pharmacies is higher in the West Midlands than elsewhere. Nevertheless, our findings indicate that almost two-thirds of pharmacists are employees, and it is known that the decline of the independent sector and corresponding growth in multiples is accelerating. The potential implications for the attraction of new students to the profession as well as for the working patterns and job satisfaction of qualified pharmacists are considerable. The expansion in employee pharmacist posts with their opportunities for flexible working may be more attractive to women.
Ours is the first study to describe the working hours of pharmacists and the findings suggest that a substantial percentage of pharmacists in the community sector were working beyond the limit of the new EU directive. These long working hours, together with the changed pattern of retail working, with few pharmacies closing for lunch and the requirement for the pharmacist to remain on the premises, are also likely to have implications for job satisfaction and morale. Perhaps unsurprisingly, the highest working hours were reported by employer/owner pharmacists, although many managers of multiples are clearly also working long hours. Opting for work as a second pharmacist or locum is likely to offer more control over hours worked and this may be part of the explanation for reported difficulties in filling "traditional" community pharmacy posts.
Other researchers have explored the aspirations and experiences of pharmacists from minority ethnic groups.^17–19 Our study sheds further light on this issue by providing, for the first time, regional data on employment status by ethnic origin. The finding that 5 per cent of pharmacists from minority ethnic groups work in hospital pharmacy compared with 18 per cent of the sample overall is interesting and currently unexplained, although Platts and Tann reported that "in hospital pharmacy there were indications of underachievement and career anxiety among pharmacists from ethnic minorities, the proportion of hospital pharmacy managers from ethnic minorities being disproportionately low".¹⁹ Perhaps pharmacists from minority ethnic groups have a strong preference for working in community pharmacy. Alternatively there is the possibility that processes in recruitment or retention in hospital pharmacy may be having an effect, although at this stage it is impossible to prove or disprove either hypothesis. Further research is needed in this area.
Finally, although our response rate was good and our respondent profile was similar to that of the total pharmacist population of the West Midlands, it is not possible to gauge the extent to which our findings are generalisable outside this region.

Conclusions

Empirical evidence of a shortage of pharmacists is lacking and because of the competitive commercial nature of community pharmacy there are major difficulties in assessing the current situation or future demand levels. Nevertheless, our study has shed some light on the supply side of the workforce and on current patterns of working. Our findings confirm that most registered pharmacists are working as such and the rate of migration out of the profession is low. Thus if there is a shortage, it has not been caused by pharmacists leaving pharmacy.
The number of pharmacists who are not currently working and who are planning to return to practice is also low. There may be capacity to increase the pool of available pharmacists by encouraging part-time pharmacists to extend their hours.
There are unexplained differences in the work categories of white and non-white pharmacists. Substantial numbers of community pharmacists are working more than 40 hours per week, and some up to 60 hours.
While some locum pharmacists have opted to work long hours, the majority have shorter working hours and this may be a reason for pharmacists to opt out of "traditional" community pharmacy posts.

ACKNOWLEDGMENT This study was funded by the NHS Executive (West Midlands).

Professor Blenkinsopp is professor of the practice of pharmacy and Ms Boardman is research assistant in the department of medicines management at Keele University. Dr Jesson is research fellow and Dr Wilson is head of the pharmacy practice group in the department of pharmaceutical sciences at Aston university, Birmingham. Correspondence to Professor Blenkinsopp at the Department of Medicines Management, Keele University, Staffordshire ST5 5BG

References