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Peter Magirr is head of community pharmacy development,
South East Sheffield Primary Care Trust
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Our profession and the Government are united in their efforts to ensure
that patients receive the highest quality of pharmaceutical care and
this objective has become firmly embedded within policies from both sources
over recent years. Increasingly, clinical governance is seen as the means
of achieving and assuring high quality clinical care and, to this end,
a comprehensive clinical governance framework forms an important component
of the new pharmacy contract.
Ensuring that robust systems and processes are in place is crucial to
patient care in general and also to the outcome for individual patients.
However, it must be acknowledged that other factors also contribute to
individual patient outcomes. One of these, which until now has received
little attention, is the clinical autonomy of pharmacists. For community
pharmacists this may be regarded as the ability to use their professional
judgement, within their practice setting, to secure the best outcome
for patients with respect to the wide range of conditions upon which
they consult.
The ability to exercise clinical autonomy is a defining attribute of
any health care profession and underpins pharmacy’s claim to professional
status. It is extremely important for patients, who rely upon pharmacists’ deployment
of their training and expertise on their behalf. It is also important
to the Government since it seeks to make better use of the clinical resources
of the profession seen for example, within the new pharmacy contract.
The extent, therefore, to which community pharmacists are able to apply
their clinical expertise in dealings with patients in their workplace
is a matter of fundamental importance.
Research, published in the December issue of the International Journal
of Pharmacy Practice,1,2 suggests that community pharmacists differ significantly
with regard to the degree of clinical autonomy they perceive they have,
leading to actions that produce a range of outcomes for patients. In
an attempt to understand and characterise these differences a range of
variables were examined for correlation with perceived clinical autonomy.
These included: gender, number of years’ qualified; full- or part-time
employment; occupational status (contractor, employee, locum); size of
organisation (number of contracts held); and type of location (city centre,
health centre, supermarket, suburban, rural).
The research methodology involved the use of a focus group of practising
community pharmacists to develop a questionnaire, at the heart of which
were 12 scenarios each focusing on a “critical incident” within
community pharmacy. The results obtained showed that there was a strong
association between those responders who opted for high autonomy responses
and their occupational status and work patterns. In terms of occupational
status contractor pharmacists exhibited the greatest propensity for high
autonomy responses. Employee pharmacists occupied an intermediate position
and locum pharmacists the least. These correlations were strong and were
still clear after excluding the influence of other variables.
In terms of work pattern there was a significant difference with regard
to full- and part-time work. There was a marked tendency for pharmacists
working full time to opt for high autonomy responses, with part-time
pharmacists consistently choosing low autonomy responses. Again, these
correlations were still strong after excluding the influence of the other
variables. To complete the picture little association was found between
respondents who had opted for high autonomy responses and gender, number
of years qualified, size of organisation or type of location.
This research highlights that although some elements of the practice
setting and pharmacist characteristics do not appear to act as a constraint
upon pharmacists perceiving that they can exercise professional judgement
on behalf of their patients, others clearly do. Moreover, the National
Workforce Census, carried out in 2003, has shown that increasing numbers
of pharmacists are choosing to work within those categories associated
with low clinical autonomy, namely as locums and pharmacists employed
on a part-time basis. The locum grouping now makes up the largest single
component (around 38 per cent) of the community pharmacy workforce and
appears to be gaining in popularity as a mode of employment. Part-time
pharmacists also comprise a significant proportion of the pharmacy workforce,
with over a quarter of those on the register working in this way.
In contrast, when we look at the grouping associated with the highest
levels of perceived clinical autonomy, namely contractors, we have to
acknowledge that this section of the pharmacy workforce is rapidly declining.
Figures from the 2002 pharmacy workforce census indicate that only 18
per cent of the workforce are now classified as pharmacy owners.
The 64,000-dollar question for the pharmacy profession is: “Does
this matter?” The answer, I would suggest, is “yes”.
Moreover, the impact is likely to be profound, from three key perspectives:
professional, commercial and public policy.
From a professional perspective, variations in autonomy give rise to
the concern that practitioners may be unable to use their expertise to
the full. In extremis, the effect of this type of limitation upon the
ability of pharmacists to act within their sphere of competence may be
regarded as undermining one of their key claims for full professional
status. Until now, the profession has been relatively relaxed in allowing
differing models of professional practice to develop. In the light of
the findings reported above it may be that this attitude should now be
re-evaluated.
From a commercial perspective, variations in autonomy will impact upon
patient satisfaction and this is likely to have the greatest effect in
locations where competition is most intense. Until now the limitations
on control of entry have largely shielded businesses from such an impact.
In addition, the service delivered under the current contract is largely
uniform in nature. All of this is due to change markedly next year with
the new control of entry regulations, which will promote competition
and choice, and a new contract, which will support the development of
a range of enhanced services. From the commercial perspective it seems
appropriate to question whether the pharmacy workforce is in a position
to respond to the challenges and opportunities that lie ahead.
From a public policy perspective, there has been an implicit assumption
that community pharmacists are in a similar position with regard to discharging
their professional responsibilities. Policy predicated upon this assumption
is being developed with an enhanced role envisaged in which the untapped
potential of community pharmacy will be liberated to make a greater contribution
to health care and benefit patients by providing a wider range of convenient
local services. It is clear that expectations are being raised, within
the profession, within the health community and among the public. It
is also clear that many of these services will depend upon pharmacists
exercising their clinical autonomy to the full to ensure that patients
receive the maximum benefit from their expertise and training. From the
policy perspective too, it seems appropriate to ask whether the workforce
have the necessary clinical autonomy to deliver.
References
1. Magirr P, Grimsley M, Ottewil R, Noyce P. The clinical autonomy
of community pharmacists in England: (1) Designing and testing a survey
instrument. The International Journal of Pharmacy Practice 2004;12:223–9.
2. Magirr P, Grimsley M, Ottewil R, Noyce P. The clinical autonomy of
community pharmacists in England: (2) Key findings. The International
Journal of Pharmacy Practice 2004;12:231–8. |
The
Pharmaceutical Journal