In this article, the author argues that if the community pharmacy is to achieve some its objectives, the Government must adopt a contract and remuneration system which encourages change
Although community pharmacy describes itself as a profession, some community pharmacists think that it is not always perceived as such by others.1 To enhance its own belief and to change the perception of others, a profession strives to take on or be given more characteristics of a profession, and to increase its rewards to a level which it equates with the status and rewards received by such traditional professions as law and medicine. It may be that the quantity of reward should be different but the style of payment should be similar. If that is the case, it will create difficulties within community pharmacy, since it is likely that large multiple pharmacies would prefer a style associated with other multiple retailers and small independents would prefer a style associated with the medical profession, in particular, that of general medical practitioners.
Pharmacy has regarded itself as a major health care profession for at least the past 50 years and probably much longer. However, established professions like law and medicine command a much superior status and better rewards than does pharmacy, teaching and social work. There are hierarchies within professions, for example, consultant medical practitioners have higher rewards than general practitioners. Thus even though the inputs may be similar between professions (education, devotion, specialisation, skill, knowledge) they are not rewarded equally. This range of variations in outcomes (pay, fringe benefits, social acceptability) has made it difficult to define the essential features of a profession. Goode,2 in 1957, described professions as "a community within a community", stressing the highly distinctive and integrated nature of their occupational cultures. He went on to suggest that a profession can be identified as an occupation with which its members have a common sense of identity and values, share a consensus as regards their social role, speak a common language, are life time members of their occupation, have a unique body of knowledge and a unique educational system.
What is more important than defining what constitutes a profession is determining the nature of professional work. Professions traditionally enjoy the high status and material rewards associated with positions of authority, yet they are also involved in concrete processes of work. Sometimes, this can be manual work (for example, a surgeon is frequently involved in quite hard manual work, albeit delicate and skilled) and, although there remains a belief that professions are white collar in nature and demand fees or salaries but not wages, there remains the belief that professionals should perform the work themselves and not merely delegate it to others. In an attempt to try to determine what constitutes professional work, the following aspects have been singled out by Fincham.3
The skills and knowledge of professionals, and their concern with services of exceptional importance, have conventionally been used to explain their superior status and rewards. It has been pointed out that to see professional status merely as a reflection of the intrinsic qualities of professional work is to paint a rather static and misleading picture. Johnson4 has argued that studies which focus on the supposed qualities of professions have never been able to agree a list of traits that are typical of all professions in all circumstances. Similarly, the suggestion that professions serve fundamental social needs (for example, health, law and education) is also rather doubtful.
So far as pharmacy is concerned, the suggestion that only a pharmacist can safely and efficiently dispense medicines is often called into question, since it is argued that modern dispensing involves only the labelling of packs prepared by industry. However, it is counter argued that dispensing also embraces all the elements of pharmaceutical care and that pharmaceutical care is an essential social and health need.5
It must, however, be accepted that the alleged and maintained altruism of professions has often been exaggerated and the professed ethical and progressive role of the professions has been called into question. Johnson4 indicated that such acceptance falls into the error of accepting professionals' own definition of themselves.
Fincham3 suggested that, instead of regarding professionalism as an inherent quality of a few select occupations, it is best regarded as an occupational strategy whereby groups attempt to gain recognition as professions in order to receive the rewards (including remuneration) received by the established professions. This accusation could be levied at pharmacy. Certainly, the sociologist Everett Hughes said that he passed from the false question, "Is this occupation a profession?", to the more fundamental one, "What are the circumstances in which people in an occupation attempt to turn it into a profession and themselves into professional people?" (quoted by Johnston4). The emphasis thus turns to a dynamic process of a group or groups attempting collectively to upgrade their occupational strategy.
The process of the pharmacy profession attempting to change from, fundamentally, a trade selling for profit products skilfully produced into providers of cognitive services to patients could be regarded as an occupational strategy. The desire by the profession to increase the quantum of remuneration and to change the system of allocating remuneration to a style more associated with the established professions could be used to confirm this proposition.
It is, therefore, worth going into more detail about the characteristics of an occupational strategy.
It is often taken for granted that the older established professions are used as a benchmark from which the status of all professional groups is measured. However, the nature of most professional work has undergone major changes in recent times. Professionalism as an occupational strategy reflects both the opportunities that have arisen for groups like pharmacy to move up in status and at the same time threaten the status of existing groups.
Mills6 pointed out two main aspects of this dynamic situation in 1951. The first was that comparable established professions change over time. It is true that pharmacy and the comparable profession of medicine have been transformed in recent times. The independent, self-employed medical practitioner beholden to no one but his client/patient was represented as the model professional. Nowadays, even medical practitioners, lawyers and accountants - who are, in general, regarded by the public as having a high status - are often employees rather than independent partners in an independent practice. This is also true of pharmacy.
The second aspect was that all professional/technical categories have grown very rapidly within the occupational structure, as can be seen from Table 1. The rapid development and expansion of the basic and applied sciences has demanded new skills and knowledge appearing and being utilised. Again, this is true of pharmacy.
Table 1: Occupational analysis of persons employed in Britain |
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| Occupation | 1984 (000s) |
1989 (000s) |
1990 (000s) |
1984-90 increase (%) |
| Managerial, administrative and related professional | 3,515 | 4,328 | 4,589 | 30.6 |
| Professional in education, welfare and health | 2,053 | 2,285 | 2,377 | 15.8 |
| Professional in science, engineering and technology | 1,047 | 1,144 | 1,173 | 12.1 |
| Clerical | 3,546 | 4,098 | 4,237 | 19.5 |
| Other non-manual | 1,779 | 2,011 | 1,949 | 9.5 |
| Skilled manual | 3,993 | 4,079 | 4,073 | 2.0 |
| Other manual | 6,584 | 6,997 | 6,797 | 3.2 |
| All non-manual occupations | 12,193 | 14,241 | 14,703 | 20.6 |
| All manual occupations | 10,879 | 11,241 | 11,018 | 1.3 |
| From Employment Gazette (London, 1991, p183) | ||||
Mills6 further pointed out that, perhaps more relevantly, the effect of the growth of State provision of services influences the development of a profession. The growth of State provision results in expanded groups being employed directly or indirectly by the State rather than operating as independent practitioners. The growth in number of such groups, and the growth in numbers within each group has posed problems for these groups in defining, expanding and, indeed, in protecting their boundaries. This is certainly the case with the pharmaceutical profession.
Theorists (such as Mills6) have enunciated important tactics for securing occupational control in such circumstances. Several tactics were singled out by Mills and those relevant and important to pharmacy include the following.
The membership of the group should be a uniting force, and the professional association is vitally important in representing and furthering the interest of the profession. This is certainly true of the intentions of the Royal Pharmaceutical Society. However, the Jenkin judgment of 19217 means that the furthering of the remuneration of the profession cannot be carried out by the Society. Thus there are several groups carrying out this function. Also such groups as the pharmaceutical scientists, hospital pharmacists, community pharmacists and industrial pharmacists, in spite of the best efforts of the Society, do not always see themselves as part of the whole profession with a common interest. Either they see themselves as the whole or only worthwhile part of the profession, or they see themselves as not part of it at all. The Society does, however, regulate undergraduate and preregistration education and training by statute. It has no legal powers to regulate post-qualification education and training, though it attempts to do so by other means. By various means, it attempts to ensure a high level of skill and knowledge and practical ability among all members of the profession, all of which are regarded by Mills6 as important tactics in the occupational strategy process. Clearly the availability of a progressive post-qualification education system is a factor which increases the pharmacist's motivation to provide an improved service.
This occupational strategy of the pharmacy profession has common elements with two other major occupational strategies of advancement, namely, the trade union strategy of workers and the career strategy of managers. Mindful of this, Parry and Parry8 have defined a professional strategy as a form of upward collective mobility. Thus, if a profession has to be successful in its occupational strategy, it has to be a firm coalition of interests and act collectively, not unlike a trade union. Professionals have been known to take industrial action but are anxious not to be identified by the public as trade unions. Thus, professional associations are closer to craft unions than to large general trade unions, which operate in such a way as to represent as many people as possible in a particular industry, whatever their specific occupation or skills.
With craft unions, the opposing principles of inclusion and exclusion favour the latter. The Society, for example, has resisted representing the interest of pharmacy technicians, dispensing assistants and counter assistants. Trade unions are condemned for using restrictive practices in defence of jobs, while the tactics of the professions, including the pharmacy profession, which are aimed at exclusivity, tend to be accepted by the public as being in its interest.
Against this, the type of rewards and remuneration being sought by the professions are clearly different from those aimed at by workers' trade associations. The professions aim to provide a setting for members to pursue individualistic career paths and achieve distinctively middle class rewards. Trade unions are more egalitarian than this in their aspirations.
Professions pay particular attention to the collective ethics of the group. Studies have shown that such ethics, as well as ostensibly protecting clients, crucially serve the interests of the professions.8 The accuracy of the ideological character of professional ethics, rather than the truth, or otherwise, of the claims of the profession, must be ascertained and accepted by society and the public if the profession is to be fully accepted and appropriately rewarded. It is, perhaps, true in the sociological sense that it is in the public interest to have secure professions looking after the interests of the individual members of the public. Nevertheless, the control of the action of members by the use of ethics enhances the vested interest of the professions concerned. The ethics of a profession can come to represent a sort of occupational ideology uniting the members of the profession, rather than representing the ethics of a society, which it is the duty and responsibility of a profession to protect.
For example, a professional threatened by legal action for alleged incompetence can normally expect his colleagues to close ranks behind him, as long as he has not broken the code of ethics. Internal discipline within professions tends to be overwhelmingly concerned with cases where the profession itself may be brought into disrepute - mostly involving illegal or immoral behaviour - rather than investigating cases of incompetence on behalf of the client or the public.
Pharmacy claims to be a profession and demands the privileges of a profession because of its superior knowledge of medicines and the usage of medicines. Hughes9 suggests that this type of action is the mark of an occupation struggling to gain exclusive rights to practise and self-regulation. The more established professions guard their monopoly of knowledge very closely. Thus pharmacy, in promoting its interests, finds itself in conflict with the medical profession, and more recently the nursing profession, since both these professions require some, however limited, knowledge of medicines.
The manner that professionals adopt in their practice is an important tactic in maintaining their possession of vital knowledge. The rise of the concept of pharmaceutical care as opposed to what is perceived by some as the more low level concept of dispensing is an example of this tactic.
As mentioned already, the power of a profession extends frequently beyond its own immediate occupation. Esland10 has stressed that the expertise which professions command confers upon them a mandate to produce and generate certain kinds of knowledge for society as a whole. Thus the pharmaceutical care which a patient requires and the provision of drug information are to an extent determined by the pharmaceutical profession and not by the patient or other recipient. In such circumstances the profession concerned feels that this gives it the right to determine the level of reward which its members receive for that service.
In a democratic, or indeed an autocratic society, it is axiomatic that there is no guarantee that any occupation will be successful in its demands for professional recognition and the status and rewards which would follow. Even if it is successful, there is no guarantee that it will retain its status and rewards over the longer term. This is particularly true when social or other circumstances radically alter over time and the profession and its members do not respond by altering their behaviour, practice and organisational structure. In these cases the profession ceases to be relevant.
As a strategy, professionalism is open-ended and many groups calling themselves a profession will enjoy only a limited form of autonomy, although the members of the group may not see it that way or refuse to accept that this is so.
The result of this is that a profession which the public do not perceive as having the status of a senior profession, nevertheless can be very jealous of the trappings of the professional autonomy that it has acquired. Such a profession may consciously adopt the tactic of drawing attention to its trappings rather than its substance.11
Community pharmacy is not a whole profession in itself. It is the branch with the most members and it is certainly the branch with which the public is most familiar. However, solutions to its current motivational and reward problems arrived at in isolation, would not necessarily enhance the status and rewards of the whole profession. Indeed they could further fragment the profession to such an extent that it could no longer claim to be a unique and comprehensive medicines related profession. This is the crux of the matter. Solutions to the perceived and/or alleged problems of community pharmacy must take into account the attempts at self-actualisation of all members of the profession and give motivation to them all. If not the profession as presently conceived will cease to exist.
How can the differences in the rate of progress along the path of professionalism of different groups, like pharmacists and nurses, be explained? Why are medical practitioners capable of sustaining their elite status in a changing world while pharmacists - it is claimed - are not? Is this an important issue? Certain professions may have managed to achieve prestige, while others have not. It may be simply serendipity and not be capable of explanation. It would appear, however, that the pharmacy profession demands a definitive answer to these questions. It may do this so that it has a theoretical basis on which to revise its strategy or change its tactics to achieve its objectives rather than to meet the real needs of society. Put another way, the objectives may be self generated, and may not reflect the needs of society.
If there are to be theoretical answers to these questions, historical and institutional factors must be taken into account. For example, Johnston4 and Parry and Parry8 pointed out that state intervention into an occupation seems to be a major factor in explaining why relevant occupational groups, like pharmacy, have become (or could become) marginally professional. The same could be said of medicine in the current state-controlled system of health care. In such circumstances, the ethics of the profession are shaped wholly or partly by government law and bureaucracy and reflect the rules of the employing or contracting agency of the state. At the same time control over the service provided resides with that agency - all of which detracts from true objective professional values, if indeed such exist.
To further progress this hypothesis at a more theoretical level, two related concepts help to explain variations in professional autonomy. Carchidihas12 has drawn attention to the contrasting forces operating on middle-class occupations, such as pharmacy, some of which degrade and constrain occupational control, while others serve to enhance an occupation's market position and the reward received from the market. He asserts that the extent to which the functions of capital are being served is an important criterion. If the profession concerned plays an important role in administrative and control functions crucial to the production of surplus value, it will command a market position that will bring power and exceptional rewards.
If on the other hand, the profession has tenuous links with these fundamental capitalist processes, occupational prestige will be more marginal.
Further, as well as the salience of the function performed, the rewards accruing to a profession and its members are also determined by the nature of the work involved. Jamous and Peloille13 have argued that, where a high degree of indeterminacy exists in the work of a professional (ie, the tasks are very variable and non-rationalised), then those who control this uncertainty are likely to command and enjoy high status.
Conversely, where such work has been systematised and subject to laid down procedures or legal rules and regulations or to guidelines or protocols, it becomes possible for forces outside the occupation to intervene and control the work process.
In a study that was carried out on remuneration systems for community pharmacy in Scotland14 it was demonstrated that with the organisational changes in the structure of the NHS and in the changes in pharmaceutical practice over the past 20 years or so there has been an increase in the formalisation of the rules and regulations governing the sale and supply of medicines, both by the state and the profession itself. The hypothesis of Carchidihas12 could indicate that the independent professional status of pharmacy and the consequent high rewards and status are in danger of decline rather than the reverse.
Further, this hypothesis or explanation of the way we distinguish between professions still seems to be circular. It is still possible to ask why the job of general medical practitioner (who is subject to similar increasing state intervention, rules and regulations as the community pharmacist) would appear to be both indeterminate and at the same time likely to enhance the capital base of the NHS (ie, salient for capital) but the community pharmacist's job is not. It may be that salience and indeterminacy are more subjective than objective features of the work process and that social and political factors also play a crucial role in creating, or failing to create, the correct conditions for high status and reward.
Close scrutiny of the development of elite professions will result in the observation that, at crucial points in their development, they have been able to take advantage of the objective conditions of their work situation. Modern medicines are potent agents for both good and ill and must be used carefully and skilfully in order to ensure that the former dominates the latter. It is generally accepted that considerable improvements in the safe, effective and efficient use of medicines could be made. Pharmaceutical care could be regarded as a legitimate attempt to take advantage of the objective conditions of the work situation of community pharmacists.15 In other cases, the less well renowned professions have a self-defeating aspect. This may manifest itself by internal quarrelling or marked jealousy between sections or branches of a profession. This may have been the case with pharmacy in the recent past.
As Jamous and Peloille13 have pointed out, pursuit of best practice may mean codifying and mechanising the work of a profession, thus shifting the control to outside managerial elements. It would appear that with, for example, the New Age proposal for pharmacy,16 frameworks and guidelines for clinical pharmacy practice,17 Royal Pharmaceutical Society guidelines for the sale and supply of medicines in community pharmacy practice and a host of similar and commendable initiatives, the pharmacy profession is currently engaged in such a process. Within the requirement of clinical governance it is accepted that all health care professions will be required to produce similar guidelines and frameworks. However, it would be wise not to lose sight of some of the consequences for pharmacy and the other health care professions which could arise from such initiatives. For example, the professions may pass control of their activities from the practitioners to the managers of the organisation to which they are contracted to provide a service.
Therefore, the concepts of salience and indeterminacy link strategic factors with structural constraints on strategy. They point to the crucial necessity of a profession such as pharmacy behaving as an all embracing occupational group in its struggle to exert control over its occupational domain, seizing on the objective conditions which its work setting of pharmacy within the NHS provides.
In this respect, the growth of corporate chain pharmacies and pharmacies in large supermarkets, and in their taking over of pharmacy practices in opposition to independent practitioners, is a crucial factor in determining a remunerative structure suitable and acceptable to the whole profession and not just community pharmacy or the corporate part thereof.
In the remuneration study of which this paper is but a small part 14 it was the view of the author that attempts should be made by the Government and the profession to ensure that a revised remuneration system meets specific and acceptable criteria which assist in retaining the viability of all pharmacy contractors and improves the outcomes in the care of those patients who require medication. The latter is the "pure" objective which could not be achieved without the former. There are, however, some constraints placed by the organisation of the NHS which make it difficult to achieve a remuneration system which achieves the "pure" objective. For example, the NHS has no direct interest in the remuneration contractors pay their employees or in their terms of service particularly since these are often in competition with similar retailers. Nor is the NHS directly concerned with the relative viability of individual contractors, as long as a service is available when and where needed by the public. Individual contractors may require incentives different from those required by their professional staff who are required to provide direct patient care when the latter is often secondary to the objective of the non-NHS part of the business of the contractor. In the case of large multiple retailers, one (if not the main) objective of the business is to maximise profit and sales in the interest of their shareholders. These objectives do not necessarily conflict but the circumstances do exist where they can.
Corporate retail organisations are in the market to sell and supply medicines and to profit from that activity. As they have to satisfy their shareholders, it could be argued that they will only embrace a wider spread of services which do not directly involve dispensing and supply and an increasing role of providing cognitive services to patients as long as this will give a competitive advantage and increase the return on capital invested in the business. Such an approach could, at some point, be at variance with the objectives of the composite NHS and other sections of the pharmacy profession. This is not a criticism of the large corporate retail organisations and large multiples: it is a simple statement of fact.
If a remuneration system precluded all profit from the sale and supply of medicinal products to the NHS and returned all discounts received by suppliers to the NHS drugs bill and not to the contractor, then it could be that the provision of cognitive services and the motivation to provide these would have to come from or be directed to a group other than the group currently and collectively known as community pharmacy (eg, the primary care pharmacist?). Community pharmacy and pharmacists will not be exempt from the principles and practices of clinical governance nor from performing evidence based practice. Thus pharmaceutical care in the primary care service will have to be evidence based. To accommodate these Government initiatives it is possible that the community pharmacy as we currently know it will have to change or adapt both organisationally and in the methods used to deliver such care.
The system used by the Government (ie, the NHS) to reward and give status to the profession must in some way reflect the aspirations and requirements of all three parties (ie, the profession, the patient and the NHS). If the profession is to change to achieve some of the current objectives of its members (ie, fairer rewards and high status) then the Government must adopt a contract and a remuneration system which encourages and even if necessary directs change. If the patient is to have a high regard for the profession, the profession and in particular its practitioners must clearly state what services it (they) should provide which are needed by the patient and make sure that both the patient and the Government are convinced that the services provided ensure value for money and achieve the required health outcomes compatible with the resources expended.
This paper is an extract from an MPhil thesis, "Remuneration of community pharmacy in Scotland" (Aberdeen: Robert Gordon University). Although the project was sponsored by the Scottish Pharmaceutical General Council, and its assistance is gratefully acknowledged, the views and opinions expressed in this extract and in the thesis are those of the author and do not in any way represent the policy, views or opinions of the council, its standing committee, or any of its members or officials.
Professor Calder is visitng professor at the University of Strathclyde and honorary professor at the Robert Gordon University, Aberdeen