By Geoffrey Harding and Kevin Taylor
In a bygone era, the mystical activity of compounding mixtures and elixirs
embodied the pharmacist’s craft, reflecting a spirit of the age in which
individualised service and a product tailored to specific requirements was expected.
However, today, increasing rationalisation has resulted in a prepackaged world.
Bespoke products are increasingly considered quixotic, even exotic.
Cohesive social relations are founded on rational action. However, with the
onset of industrial capitalism, a new form of rationality, formal rationality,
emerged, exemplified by Henry Ford’s pioneering vision for manufacturing
cars using assembly lines. The impact of formal rationality applied to pharmacy
is most evident in the usurping of pharmacists’ compounding activities
by the pharmaceutical manufacturing industry, which might legitimately claim
to do it more efficiently and cost-effectively than individual pharmacists.
The public’s acceptance of prepackaged medicines may, in part, be explained
by the fact that standardisation becomes the price of speed of service, Indeed,
“speed of service” has become a mantra in service delivery, including
health care delivery.
Four dimensions of rationality
George Ritzer, an American sociologist, has coined the term “McDonaldisation”,1
wherein the policies and practices for optimal, efficient, routinised production
and delivery of fast food are evident in other organisations, including the
health care sector. Ritzer has identified four dimensions of the rationality
inherent to McDonaldisation: efficiency (employing optimal methods for completing
a task), predictability (organising the production process to guarantee uniformity
of products and standardised outcomes), calculability (outcomes are assessed
quantitatively, ie, there is an emphasis on quantity rather than quality), and
control (achieving control through automation or deskilling of the workforce,
because people are inherently unpredictable and inefficient).
These factors, accounting for the phenomenal success of McDonald’s, when
applied to community pharmacies pursuing efficient, rationalised and, above
all, profitable service delivery, spawn the “McPharmacy”. Ritzer’s
four dimensions will be clearly evident in the McPharmacy:
Efficiency There is standardisation and rationalisation of products and services. Choice within the McPharmacy is promoted, but is corporate rather than consumer-defined. Medicines are available as prepackaged units for rapid processing. Limited stock is held, with a “just-in-time” system in place for stock reordering. There is speedy service and rapid throughput of customers, “conditioned” to expect “fast-pharmacy”. With remuneration linked to prescription numbers, more customers served per unit time increases profit. Products are self-selected wherever possible, requiring customers “to do the work”, allowing minimal staffing. There is a production line approach to prescription filling, with a number of technicians each completing one small part of the overall process. The advent of electronic prescribing is set to overcome the inefficiencies inherent in conventional prescribing.2 The McPharmacy’s undifferentiated front and back of shop minimise unnecessary staff movement. The various chains of McPharmacies have bureaucratic structures, with clearly defined hierarchies.
Predictability McPharmacies standardise services, product and pack sizes,
so that all outlets offer identical “experiences”;
McParacetamol is available in all outlets. Outlets and fittings are of a uniform
design and are clean, hygienic, sanitary and sanitised. These, together with
standardised dress, name badges and staff behaviour, promote a distinct brand
identity. Staff have a corporate ethos instilled into them (corporate socialisation)
and, as a result of in-house training, the McPharmacy managers, as indeed are
other staff, are virtually indistinguishable one from another and are interchangeable.
Efficiency dictates that interactions between customers and employees are time-limited;
consequently, they can be regulated or even scripted using protocols and mnemonics.
Advertising is undertaken to promote corporate identity and the corporation’s
depiction of health and health care. The McPharmacy “product” (be
it a medicine or a service) cannot be the best available given the constraints
of efficiency, but it is of an acceptable standard. On entering a McPharmacy,
customers know what to expect from the “McPharmacy experience” and
their expections are always efficiently met.
Calculability The McPharmacy trades in commodities of which medicines are but one among a wide range of other, often lifestlye-related, products. Marketing focusses on “low-cost” and “value” products rather than on quality and efficacy.
Control Skilled activities are minimised. Workers undertake simple, clearly defined tasks in accordance with written procedures. Customers enter a controlled “conveyor” system, with rationalised queueing. Their expectations are conditioned through exposure to corporate advertising and familiarity with McPharmacy branding. Computer technology is used wherever possible, for example, to generate labels and information leaflets, order replacement stock and for drug information.
The future
“Pharmacy in the future”2 states that “pharmacies
which provide the best services should gain at the expense of those which are
prepared only to provide the minimum”. This suggests an attempt to standardise
services and, since discussions on this issue will, we are told, include “speed
and efficiency” and “premises standards”,3
it seems that the McPharmacy would thrive in the “new” NHS. However,
our version of the McPharmacy is but one. Others may be incorporated in the
one-stop primary care centres outlined in “Pharmacy in the future”.
Such centres are the very apotheosis of McDonaldised primary care, with “McDoctors”
or “Docs-in-a-Box”1 working alongside McPharmacists
and other health professionals for maximum efficiency. Perhaps the efficient,
rationalised McPharmacy might encompass e-pharmacies with online prescribing
and mail-order dispensing.
The McPharmacy possesses the features of a rational organisation that could
characterise future community pharmacies. However, it is pertinent to reflect
on the element noticeably absent from our exposition of the McPharmacy: namely,
the pharmacist. Where in such an organisation are pharmacists’ unique skills
and knowledge to be utilised? McPharmacists may become deskilled and perform
solely routinised activities. However, McPharmacies would ultimately function
more rationally and predictably without pharmacists at all, by employing workers
instilled with the corporate ethos and trained in the techniques of the McPharmacy,
at its equivalent of the hamburger universities run by McDonald’s. The
inevitability of the McPharmacy or its ilk and how closely the McPharmacy approximates
contemporary practice are open to debate.
Geoffrey Harding is senior lecturer at the department of general practice and primary care, St Bartholomew’s and the Royal London school of medicine and dentistry. Kevin Taylor is senior lecturer at the School of Pharmacy, University of London