The Pharmaceutical Journal
Vol 270 No 7236 p223
15 February 2003

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Does corporate pharmacy threaten evidence-based practice and policy?

By Kevin Taylor and Geoffrey Harding

Evidence-based health care is an inescapable mantra of 21st century life for health professionals. This evidence base derives from research, which in the case of pharmacy has, in recent decades, grown considerably in both quantity and quality. Research informs practice — identifying, delineating and evaluating new and existing roles and services — and should ideally underpin continuing and future developments in the nature and delivery of pharmaceutical services. Research purely in pursuit of "knowledge" is increasingly viewed as being less valid than research having either a direct commercial or practical application. Thus, pharmacy practice research can be considered a quintessentially valid activity, with research findings potentially impacting directly on professional practice. However, pharmacists' practice and the policies which shape that practice are constantly evolving, and this evolutionary process is governed not simply by research evidence but by other factors — the forces of political economy. These forces, within Western societies, enable "pursuit of profit", large corporations, such as pharmacy chains, to exert political influence to protect their economic interests.

In Britain, the proportion of pharmacies in chains of five or more has increased from a third to a half in the past decade. If this trend continues — and recent proposals to deregulate the awarding of pharmacy contracts suggests this is likely — the implications of the burgeoning "corporatisation" of pharmacy is cause for concern for consumers, pharmacists and practice researchers alike.

Large corporations maximise profit by ruthlessly rationalising and standardising products and services. Within pharmacies this is achieved by imposing routines on processes such as dispensing, by standardising products, services and store design, by emphasising cost rather than quality and by ensuring employees undertake simple tasks, follow written procedures and use computer technology where possible. Pharmacists, as health professionals with unique skills and knowledge, sit awkwardly with this relentless rationalisation and standardisation, and the opportunities for them to exercise independent professional judgement are reduced as they are required to comply with approved protocols and "company policy". At the same time, the ability of individual pharmacists, researchers, and pharmacists' professional body to shape the development of services is markedly hindered.

So what are the implications for policy makers and researchers? Corporate strategies pursuing rationalised economies of scale pose a considerable threat to the idea of pharmacists as professionals, deskilling them and threatening their traditional entitlement to privileged occupational status, remuneration and auto-nomous action. Imposition of routines is now so endemic within pharmacy that, although the dispensing of prescribed medicines is pharmacists' major activity and the basis for the majority of independent community pharmacists' income, "practical" and even supervisory aspects of dispensing are now considered codifiable, technical activities, and therefore the province of technicians, not pharmacists. Indeed, the recent Government discussion paper, "Pharmacy workforce in the new NHS", states: "The modern pharmacist's professional role is not primarily to undertake detailed supervision of the dispensing and sale of medicines. Experience in the hospital sector has shown that these tasks can be delegated to suitably trained staff."

Yet imposition of routines in dispensing undoubtedly creates opportunities for pharmacists to develop and extend their professional activities. Indeed, research has shown that pharmacists see this as essential for their professional survival. Initiatives by the Royal Pharmaceutical Society, in particular "Pharmacy in a new age" have sought to promote pharmacists' activities beyond dispensing, through concepts such as pharmaceutical care and medicines management. However, these initiatives and policies are intended to be delivered by a sector of pharmacy with two counterpoised approaches to service delivery, each in tension with the other: profit maximisation by economies of scale, and rationalisation versus profit maximisation primarily by service delivery. Change and development will not take place without the explicit support of the corporate bodies; moreover, it must be evident to all those shaping policy that the "demands" of corporate pharmacies cannot be ignored. Secondly, some corporate pharmacies pursue an agenda which is ultimately driven by maximisation of profit, rather than professional service development. For instance, lobbying for the removal of resale price maintenance was most vociferously undertaken by supermarkets seeking to expand the number of in-store pharmacies. This occurred, despite orchestrated and widely publicised opposition by both the Society and independent pharmacies.

Since corporate pharmacies predominate, and the Society tries to represent and reconcile the views and interests of its members in both the corporate and independent sectors, it risks being seen as ineffectual and ultimately irrelevant. Thus, although the recommendation of the Office of Fair Trading report on "retail pharmacy services" undoubtedly represent a major threat to the livelihood of many independent community pharmacists, it was not, and perhaps could not, be condemned "out of hand" by the Society, in spite of a headline in this journal, "Society says: 'Not in the public interest'" (PJ, 25 January, p108). Rather, in a cautiously worded letter to the Health Minister, and in the subsequent news release, the President, on behalf of the Society, says only that "any move to free entry controls may not be in the public interest".

Change within community pharmacy is increasingly being driven by the commercial interests of the corporate sector. Yet paradoxically, this occurs at a time when the pharmacy practice research community has established itself with a clear identity, generating a body of research evidence which should directly inform pharmacy and health policy. Ultimately, researchers and policy makers must consider whether practice within community pharmacy per se can be influenced or changed by research evidence, if any proposed change is not supported by those determining the strategic development of corporate pharmacies. The question then arises as to whether future developments in community pharmacy services will be triggered by evidence or commercial expediency.

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