| Pharmacists perform a routine task for patients that could be
carried out without intellectual guidance and regulation from politicians,
academics
or their peers.
When chemists and druggists first emerged during the mid-1750s, they
were not constrained by government policies, philosophies of care or
professional ethics. Indeed, they were simply independent proprietors
who filled a gap in the market for medical services left by apothecaries,
who started to favour diagnosis and prescribing to compounding and dispensing.
By joining the Pharmaceutical Society, chemists and druggists sacrificed
commercial and personal freedoms for the benefits of professional association.
Although this step was constraining, the passage of time has created
further laws, regulations and codes of conducts for working pharmacists.
Notably, both the inception of the NHS in 1948 and the introduction of
the 1968 Medicines Act did much to limit the profession’s freedoms.
Against this background, this article examines the philosophical constraints
that different groups have tried to impose on pharmacy practice since
Jacob Bell began the process of professionalisation. By examining different
philosophies of pharmacy practice, we suggest that the existing approaches
of traditional dispensing, pharmaceutical care and medicines management
have limited shelf lives.
Scientific communities
According to Thomas Kuhn, scientific communities consist of practitioners
of identifiable specialisms who have undergone similar educations and
professional initiations.1
In the 1840s, Jacob Bell initiated a network of proprietor chemists
and druggists who believed in standardised education and professional
practice.
Similarly, most pharmacy practice academics belong to an international
community of scientists who have their own conferences, journals, textbooks
and communication networks.
In keeping with Kuhn’s ideas, Randall Collins argued that intellectual
life often consists of a “small number of warring camps” whose
members are stratified in the following pyramid structure:2
· Intellectual stars — one or two leading thinkers at the top
of the field
· Inner core — small number of researchers applying this leading
thinking
· Outer core — larger population of less committed researchers
· Transients — bigger group involved in research on one-off or
invariable basis
· Audience and maybe recruits — existing and possible students
of approach
In relation to pharmacy, history suggests that Jacob Bell was an intellectual
star who worked with an inner core to initiate an
intergenerational network of pharmacists.
For Bell, his original audience were members of the Pharmaceutical Society,
while his may-be recruits were druggists who were not
convinced of the benefits of professional constraint.
Due to Bell’s brilliance, the dominance of this network continued
almost unchallenged until the end of the 1939–45 war, when the
apprenticeship system died and higher education became the professional
norm.
As employees of universities and polytechnics, rather than the Society,
the new breed of pharmacy academics that emerged during the post-war
period could free themselves and their students from the ideological
dominance of the Bell-initiated network. As a result, this new camp of
thinkers had the opportunity to create the conflict and the disagreement
over the appropriate role for pharmacists that Randall Collins believes
necessary for productive intellectual life.
Professional paradigm
According to Kuhn, different groups of scientists often work in competing “paradigms”,
which he defined as “the entire constellation of beliefs, values,
techniques and so on shared by the members of a given community”.
The evidence suggests that the professional network initiated by Jacob
Bell and that of UK-based pharmacy practice academics have developed
separate, but increasingly overlapping paradigms. As this dynamic situation
is complex to analyse, it is useful to refer to the work of Imre Lakatos,
who explained that scientific communities work with clusters of interconnected
theories similar to paradigms, which he termed scientific research programmes
(SRPs).3
Theoretically, all SRPs may be characterised as having an unchangeable “hard
core” consisting of beliefs and lists of “dos and don’ts” that
are treated as irrefutable or set in stone by community members. For
instance, apothecaries had the hard core belief that they should both
prescribe and dispense, which involved diagnosis, drug choice, compounding
and supply. In response, Bell consciously decided to adopt the contemporary
French and German pharmacy model, which specified that pharmacists should
specialise in dispensing.
Given this choice, the hard core of Bell’s system was outlined
in the original aims of the Pharmaceutical Society: “The Pharmaceutical
Society is instituted, for the purpose of uniting the chemists and druggists
into one ostensible, recognised, and independent body — for protecting
their general interests — and for the advancement of pharmacy,
by furnishing such a uniform system of education, as shall secure to
the profession and the public the safest and most efficient administration
of medicines.”4
Given that these aims were fundamental to Bell’s original vision,
they automatically became the centre around which the constellation of
beliefs, values and techniques of the professional pharmacy network subsequently
evolved. Pharmaceutical care
Since they were open to influence from thinking from other subjects
and other countries, during the 1970s pharmacy practice academics began
to search for their own alternative philosophy. During the 1990s, the
search was given a boost by the arrival on these shores of the concept
of “pharmaceutical care”, promoted in the US by Hepler
and Strand.5
Initially in the UK, pharmaceutical care was an idea, not a paradigm,
because it started as an individual concept not a living constellation
of beliefs, values and techniques. Although Hepler recently acknowledged
that pharmaceutical care is not yet a complete philosophy, in 1993 the
American Society of Hospital Pharmacists outlined its core: “The
principal elements of pharmaceutical care are that it is medication related;
it is care that is directly provided to the patient; it is provided to
produce definite outcomes; these outcomes are intended to improve the
patient’s quality of life; and the provider accepts personal responsibility
for the outcomes.”6
For pharmacists working within the Bell paradigm, the move to pharmaceutical
care requires the relinquishing of many commercial and professional freedoms.
For instance, Linda Strand clearly specifies that pharmacists working
within this new framework should not dispense.7 Given
these fundamental beliefs, pharmaceutical care clearly conflicts with
the inner core of
the Bell-initiated paradigm. Evolving NHS
According to Thomas Kuhn, identifiable communities of researchers focus
on specific problems. For instance, the Bell-initiated paradigm focused
on developing a professional monopoly over medicines supply, while pharmacy
practice academics concentrated on extending professional roles.
While these two communities debated the future of their profession, at
the end of the 1980s the government began to reform the prescribing side
of the medicines supply equation. In an attempt to control the NHS drugs
bill, the prescribing analysis and cost database was introduced in 1988,
followed in 1991 by pharmaceutical budgets under the auspices of the
fundholding and indicative prescribing schemes. With the introduction
of new information and incentives, many prescribers became concerned
with their drug costs and pharmacists began to be employed by the NHS
as pharmaceutical advisers in many areas.
As this trend continued, the National Prescribing Centre (NPC) developed,
prescribing cost management became a topic for academic study, and a
community of interested practitioners and academics evolved. Like the
pharmacy practice community, this emerging network of practitioners and
researchers wrote their own articles and textbooks, held their own conference
and developed their own beliefs, values and techniques.
As the network matured, the name “management of medicines” emerged,
with the result that the loosely defined, but politically acceptable
concept of “medicines management” appeared in “Pharmacy
in the future” in 2000. Although pharmacists struggled to define
precisely this new concept, the NPC clearly stated that: “Successful
medicines management services will ensure that patients, professionals
and the NHS get maximum benefit from the use of medicines. This development
will require change to existing mindsets and services. Professional time
is a scarce resource and there is a need to reconsider the way many people
work. Developing medicines management services will lead to more effective
use of both financial and staffing resources, whilst also achieving the
wider goals set out in the NHS plan.”8
Despite attempts to claim that medicines management is simply a type
of pharmaceutical care, the above definition suggests otherwise. At its
core, medicines management differs from pharmaceutical care because the
former treats pharmacists as an NHS resource who can be allocated in
the same way as financial spending, while the latter respects their professional
autonomy. Given this fundamental difference, pharmaceutical care gives
pharmacists the freedom to form working relationships with patients regarding
medicines use, but impinges on their right to dispense.
Medicines management, on the other hand, has no strong beliefs about
the appropriateness of any particular task for the profession, but simply
states that individual pharmacists should become resources at the disposal
of the NHS. Given this intention, the new pharmacy contract is designed
to give primary care trusts the powers they need to transform community
pharmacists from an independent, self-directing group of professionals
into controlled, dependent individuals.
Given that pharmacy practice can be organised in many different ways,
acceptance of the new contract is acceptance of greater constraints on
the ways the profession works. The new apothecaries
Although medicines management unexpectedly appeared as the favoured
ideology for organising pharmaceutical services, during this time supplementary
prescribing quietly emerged as a new issue for pharmacy practice.
Initially, supplementary prescribing developed from a network within
nursing, as a means of extending their professional roles and stopping
the illegal administration of some medicines. Next, June Crown was chosen
to respond to the issues raised by this network by chairing a formal
government inquiry, which unexpectedly created the need for new legislation
and appropriate NHS policy. Although the Crown reports were published
under a Conservative
government with Labour policy-makers implementing their recommendations,
supplementary prescribing was never mainstream policy for either party.
Similarly, supplementary prescribing was never a major issue of debate
among the main pharmacy networks before the work of June Crown. Nevertheless,
since government-funded training has become available, a new network
of practitioners and academics has begun to develop in this area.
Given the potential — and the problems — offered by greater
prescribing rights for pharmacists, we predict that a new paradigm for
pharmacy practice may soon emerge. As this developing approach will involve
issues related to both prescribing and dispensing, we suggest the working
title of “new apothecaries” for the paradigm that will emerge.
The rise of new apothecaries will require the revision of ethics, policy
and funding because existing approaches to pharmacy practice only consider
dispensing or controlling medicines use. Indeed, as the dual role of
prescriber and dispenser becomes widespread, ethical, policy and financial
dilemmas will arise that would not have occurred if pharmacists solely
dispensed or managed medicines without supply.
In theory, prescribing and dispensing are tasks that can be performed
under different philosophies of practice and care.
For pharmacists, their profession only came into being because Jacob
Bell developed a clear vision that controlled the ways druggists worked.
Although this paradigm convinced legislators to grant monopoly status
to the profession, in recent years pharmacy practice academics and government
policy-makers have questioned the continuing suitability of this approach.9 Similarly, it appears that members and employees of the Society that
Jacob Bell founded have also began to doubt the relevance of his initial
vision, and started looking elsewhere for ideas on the way ahead.
Against this background, pharmaceutical care offered much promise, but
was pushed aside by government policy-makers who wished to increase the
control NHS managers have over individual pharmacists. If this agenda
comes to fruition with the acceptance of a new contract, the immediate
future of pharmacy could see the death of existing models of pharmacy
practice. As more control is gained over them, pharmacists will be viewed
as NHS resources and be measured as inputs into cost-benefit calculations
performed by primary care trusts. In response, frustrated pharmacists
will search for a new practice paradigm that restores some of the freedoms
and benefits professionalisation gave them in the past.
As a result, we conclude that a new model based upon the traditional
roles performed by apothecaries may be the best way ahead if pharmacists
wish to protect their personal independence within an evolving NHS. However,
experience to date suggests that a new paradigm will only emerge if a
community of practitioners and researchers actively adopt the development
of a new apothecary model as a serious and sustained area of research. Acknowledgements The authors thank Sydney Holloway for his insightful
comments on an earlier draft of this paper.
References
1. Kuhn TS. The structure of scientific revolutions, 2nd edition. Chicago:
University of Chicago Press; 1996.
2. Collins R. The sociology of philosophers: A global theory of intellectual
change. Cambridge, US: Harvard University Press; 2000.
3. Lakatos I. The methodology of scientific research programs, philosophical
papers. Volume 1, edited by John Worrall and Gregory Currie. Cambridge,
UK: Cambridge University Press; 1978.
4. Holloway SWF. Royal Pharmaceutical Society of Great Britain 1841–1991:
a political and social history. London: Pharmaceutical Press; 1991.
5. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical
care. American Journal of Hospital Pharmacy 1990;47:533–43.
6. American Society of Hospital Pharmacists. ASHP position statement
on pharmaceutical care. American Journal of Hospital Pharmacy 1993;50:1720–3.
7. Strand L. Building a practice in pharmaceutical care. The Pharmaceutical
Journal 1998;260:874–6.
8. National Prescribing Centre/National Primary Care Research and Development
Centre. Modernising medicines management: a guide to achieving benefits
for patients, professionals and the NHS. Liverpool: NPC/NPRDC; 2002.
9. Holloway SWF, Jewson ND, Mason DJ. “Reprofessionalisation” or “occupational
imperialism”? Some reflections on pharmacy in Britain. Social Science and Medicines 1986;23:323–32. |
The
Pharmaceutical Journal