The Pharmaceutical Journal
Vol 270 No 7231 p48
11 January 2003

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How should the profession respond to pharmacy's declining public image?

By Pauline Norris

Dr Lloyd Matowe (PJ, 9 November 2002, p674) suggested that the public image of pharmacy is declining and argued that individual pharmacists should bear the main responsibility for arresting this decline. Is pharmacy's public image declining? I would suggest that any decline in the public status of pharmacy may be the result of general changes in the status of professions and professionals in the late 20th century and early 21st century.

Since the 1970s some sociologists have argued that the medical profession is being "deprofessionalised" or "proletarianised". Others have suggested that the relationship between experts and the public is changing. Professionals and other experts no longer automatically occupy the priveleged status they once enjoyed. Publicity about medical scandals (such as the Bristol Royal Infirmary in the United Kingdom and the treatment of cervical cancer in New Zealand) and about crimes committed by individual practitioners (such as Harold Shipman in the UK, Morgan Fahey in NZ) suggest that the work of experts in under increasing public scrutiny. These scandals have also led to increases in that scrutiny. The rise of alternative medicine suggests that advice from experts is now seen as contestable, that is, many people see it as only one view of the world to be weighed up alongside others.

So, how should pharmacy improve its public image? Pharmacy's response to any image crisis needs to be more than public relations. The best strategy would be to concentrate on improving and extending pharmacy's contribution to patient well-being, and then communicating this effectively to the public. The worst option would be to tell the public that pharmacists perform these patient-oriented roles, in the absence of genuine attempts to ensure that they do.

Many professions are finding that professional authority can no longer act as protection against scrutiny by outsiders. Researchers (including sociologists like me), consumers' organisations and others will attempt to assess the real performance of professionals. Pharmacists, like other professionals, need to think genuinely about patient needs and how to address them, rather than simply attempt to convince the public that they are doing so.

There is a wide range of performance within the pharmacy profession. My recent study of how New Zealand pharmacists responded to requests for pharmacist-only medicines found a great difference between the best and the worst pharmacists.^1,2 Pharmacist-only products are legally required to be sold by pharmacists, and counselling is mandated by the Pharmaceutical Society of New Zealand. In some pharmacies these products were sold by non-pharmacist staff, and in some no counselling was given. In others a great deal of excellent counselling was provided. Graphing the level of counselling produced a more or less bell-shaped curve. It seems reasonable to suggest that there is a similar distribution in other areas of professional performance. It is likely that pharmacists, like those in other professions, vary greatly in their skills, attitudes and inclinations. Some pharmacists, for example, may have been attracted to the profession more by the opportunity to run a successful business than to provide health care.

Dr Matowe's suggestion that individual pharmacists should take the responsibility for addressing the image of the profession has to be interpreted in light of this variation. The call for individual pharmacists to take the lead is likely to be heeded by pharmacists who are already performing well. I would suggest that, as a profession, pharmacists need to develop strategies to help the bulk of pharmacists (who are in the middle of the curve) to improve their performance. They also need to decide what to do about those at the bottom. What level of professional performance is necessary to practise as a pharmacist? How should this be detected? And what remedial actions should be taken?

As a researcher, it seems to me that an iterative process of research and intervention is needed to address performance issues. That is, we need to find out why some pharmacists are not providing counselling or other professional services, develop interventions to address these issues, evaluate whether these work (and why or why not), and use this information to develop further interventions. For example, many pharmacists believe that patients do not want counselling. Strategies to address this could include a public campaign to explain why pharmacists give counselling, what questions people should expect pharmacists to ask, and what information patients should volunteer. But this must be more than public relations. Strategies must also be put in place to ensure that pharmacists can respond appropriately to information that is volunteered by patients.

One of the roles which pharmacists could develop further is, as Dr Matowe pointed out, selecting drugs for patients. However, this must include suggesting where drugs are inappropriate. This points to a major problem for pharmacists' professional status: they are tied too closely to drugs. Whenever pharmacists' incomes are dependent on the quantity of drugs they supply, they are unlikely to be seen as independent professional advisers. This is particularly the case now when governments are attempting to tackle burgeoning drug expenditure, the economists' view that financial incentives determine behaviour is so widely accepted, and policy formulation involves "aligning incentives" (making sure people get paid for what policy-makers want them to do). Having a clear incentive to dispense or sell more drugs is not conducive to developing a public image as a drug expert. Pharmacists need to develop roles where they are paid a salary or a professional fee which is unrelated to the quantity of drugs they supply.

Whatever strategy is adopted to extend pharmacists' roles and to communicate these to the public, it seems to me there is a limit to how much individual pharmacists can contribute. A strong and courageous professional organisation is also required to tackle these issues.