By Stuart Anderson
When the headlines in The Pharmaceutical Journal read “pharmacy leaves
the crossroads” and “a watershed for the profession” it is clear
that something of considerable significance is in the air. Indeed, the event
which triggered these responses, the launch by the Parliamentary Under-Secretary
of State for Health of the paper “Pharmacy in the future: implementing
the NHS Plan”1 at the British Pharmaceutical Conference this year has been
both long awaited and eagerly anticipated.
But what are the prospects of another government report finally allowing pharmacy
to leave the crossroads? The significance of the analogy might well be lost
to the casual observer of the pharmaceutical scene. I suspect, however, that
those joining the Register of Pharmaceutical Chemists for the first time this
year will soon become accustomed to one of pharmacy’s more enduring characteristics:
an enthusiasm for describing itself as “at the crossroads”.
It is a phrase that has appeared consistently in pharmaceutical publications
over many years. Although the frequency of its appearance has perhaps been greater
over the past decade or two, many older pharmacists remember that it was very
much in vogue when they too first entered the Register. Pharmacy seems to have
been forever “at the crossroads”. It is a great relief therefore to
find that it is about to leave them behind.
The attraction of pharmaceutical politicians and commentators to such a metaphor
encourages a belief that, somehow, pharmacy either stands frozen to the spot
or else stumbles from one crisis to another. Yet examination of these so-called
crossroads indicates that each has generally been very different from the last.
Pharmacy has, it seems, managed to move on from one crossroads to the next after
all.
In fact, the metaphor of “being at the crossroads” is by no means
peculiar to pharmacy. It seems to be found in all occupational groups and most
walks of life. Far from indicating that the subject has come to a standstill
and does not know which way to turn, it generally indicates the need to make
difficult choices at all too frequent intervals. The metaphor of the crossroads
is also less than helpful in suggesting that progress can only be made by choosing
a single “right” route and rejecting the others.
Pharmacy has fallen into this trap before. The transition from apprenticeship
to degree course training was fundamental to all subsequent progress. Yet the
single-minded pursuit of this objective during the 1950s and 1960s greatly contributed
to the very circumstances that led to a need for an inquiry into pharmacy in
the early 1980s. In retrospect, it was perhaps unreasonable to suppose that
status, public respect and prosperity would automatically follow from increased
educational achievement, by making the profession degree entry only. But while
this objective was being pursued the pharmacist’s public profile was largely
neglected. What were pharmacists in the community actually doing, and how did
this contribute to the public good?
It is worth reflecting on the comments of Dr Gerard Vaughan, the then Minister
of Health, made at the British Pharmaceutical Conference in 1981. He famously
said: “One knew there was a future for hospital pharmacists, one knew there
was a future for industrial pharmacists, but one is not sure that one knows
the future for the general practice pharmacist.” He paid tribute to the
high skill of pharmacists, yet they were still unable to make full use of the
potential of their skills. Nearly 20 years later some of these same sentiments
are reflected in the comments of Lord Hunt. This time, however, Government uncertainty
about the future of community pharmacy has been replaced by a clear vision.
Will history judge the Government’s apparent willingness to support this
vision to be a “watershed”, as the Royal Pharmaceutical Society’s
President suggests? For historians, watersheds are those key events that come
to divide periods of human existence into manageable time frames. For pharmacy
in Britain, key watersheds have been the formation of the Pharmaceutical Society
in 1841, the National Health Insurance Act of 1911, and the National Health
Service Act of 1946.
But pharmacy in Britain has also been full of “false dawns”, those
potential watersheds which somehow did not fulfil the hopes and aspirations
initially attached to them. Examples from hospital pharmacy include the Linstead
reports of 1955 and 1958, which made all the right recommendations, but which
nevertheless failed to result in lasting change. Such changes were only finally
introduced following the Noel Hall report of 1970. This report was most certainly
a watershed for hospital pharmacy, but it would not be so without what came
after it, and it is all too easy to forget the opposition with which the Noel
Hall report was greeted at the time.
Analysis of successful policy initiatives in the past tells us that lasting
change in pharmacy has only come about when it is made compulsory, universal
and mandatory; where there has been strong support within the appropriate Government
department; where policy intentions have been followed by a series of directives
enforcing them; and of course, most importantly, where there money to make it
all happen.
Community pharmacy too has had more than its fair share of false dawns. Earlier
inquiries and reports have generally produced only limited change in practice.
It was the Nuffield report in 1986 that promised a real hope of permanent change
for the better. Yet it was the profession itself, by rejecting key recommendations
and pinning its hopes on others, which undermined the potential of the Nuffield
report to be the watershed that it should have been.
In short, it is as yet too early to judge whether “Pharmacy in the future”
will be the watershed it promises to be, and to say that, yes indeed, pharmacy
has moved away from the crossroads. For pharmacy the watersheds that defined
the 20th century were largely external events: acts of parliament concerning
the welfare state, the therapeutic revolution, and more recently the computer
revolution. The crossroads have been more like traffic lights stuck at red.
To date, few initiatives by pharmacists themselves have provided the key watersheds,
but could this be one? Initial responses to the strategy are not encouraging.
In a clear echo of the initial responses to Nuffield they indicate a selective
approach, accepting parts agreed with while rejecting others. The challenge
for the profession is clear enough: to take advantage of the opportunities now
offered, while avoiding the in-fighting, backsliding and intransigence which
have turned previous watersheds into false dawns. The consequences of failure
for pharmacy are too great to contemplate.
Dr Anderson is senior lecturer in the department of public health and policy at the London school of hygiene and tropical medicine, and vice-president of the British Society for the History of Pharmacy