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Malcolm E. Brown, PhD, MRPharmS,
is a pharmacist and sociologist from Beccles, Suffolk
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From April, the NHS will remunerate pharmacists for medicines use review
(MUR). The very description “advanced service” proclaims
it to be prestigious practice: pharmacists will advise on doctors’ prescribing.
To create time for this MUR and other new roles, pharmacists are “sloughing
off” their less prestigious dispensing to pharmacy technicians.
Perhaps, in time, all dispensing will become beneath pharmacists’ dignity.
Dirty work
Perhaps they will feel that they should be a little ashamed of dispensing,
because it is “dirty work”. All occupations, not just,
for example, the sewer cleaner, have dirty work; such work is demeaning
but must be undertaken.1 But are pharmacists
jettisoning one wodge of dirty work only to be lumbered with another?
On the surface, advanced service does seem a splendid opportunity for
community pharmacists. However, situations may not be as simple as they
appear on the surface.
Perhaps the vision is to smash off the chains shackling pharmacists to
the dispensary workbench and “counter face” and their associated
dirty work. No more snipping, licking and pouring. No more routine, unchallenging
work that pollutes pharmacists’ potential. No more slopping around
with ointments, creams or smelly coal tar. No more bottle caps cemented
tight by sticky drips. No more splattering of pharmacists’ clean,
dark suits when someone drops a bottle of Gaviscon. No more extemporaneous
dispensing; although its practitioners were punctilious, it was but a
craft.
Moreover, while “advanced” pharmacists will be cocooned in
their counselling rooms, they will be distanced from the dirt of the
more blatant retailing that makes some pharmacists feel queasy and despairing.
Goodbye, peddling of hot water bottles, toilet bags, chicken with sage
stuffing sandwiches, cuddly toucans, reading glasses, tights, teapots,
oven cleaner and knitting patterns. Goodbye, flamboyant window displays.
Goodbye, alcohol, tobacco and chocolates. Goodbye loyalty points, cheque
encashment and cash back. Goodbye perfumes, aftershaves, ear piercing
and thongs.
The final form of dirty work is perhaps the most blatant and in-your-face.
It is the handling of cash.
First, cash is empirically, microbiologically dirty. Second, it stigmatises
the cashier as a shopkeeper. A shopkeeper has customers, not patients.
A shopkeeper may utter, “the customer is always right”. I
have heard several pharmacists say it. Nothing brands the speaker more
clearly as primarily a trader instead of a professional.
There is nothing new about these observations. Some pharmacists have
railed against these bazaar tendencies for generations. Hospital pharmacists
have generally long escaped routine dispensing, preparation, merchandising
non-pharmaceutical bric-a-brac and handling cash.
What is new is the opportunity for “ordinary” community pharmacists — who
still, by far, comprise the majority of the profession — to distance
themselves from those sorts of dirty work. And yet…
Before you become too smug and perky in anticipation of that glittering
future, I suggest you bear in mind some less obvious perspectives.
First, pharmacists might distance themselves from direct handling of
cash and credit cards, instead receiving discreet payment by bank transfer
or cheques received through the post.
Pharmacists might practise less under the “Three for two!” and “Buy
one get one free!” banners and other raucous propaganda of the
merchant, instead receiving fees from government. Such changes would,
indeed, fit professionals better.
But where do you think such money comes from? The NHS and other public
services can be perceived as parasites on the profits of industry. Industry
is taxed for redistribution. Taxes partially originate from the risk-taking
companies, from the “grubby” pistons of commerce. They include
arms sales to countries possessing political systems that may mismatch
ours. Commerce includes the manufacture of alcohol, tobacco, chocolate
and cuddly toys. It encourages business people to work to boundaries
that differ from those of many citizens. For example, the executive,
in order to be rewarded with a personal bonus, must maximise company
profit — regardless of the human cost — perhaps by making
loyal workers redundant.
Another type of dirty work involves “guilty knowledge”. Pharmacists
already possess some. Examples are knowing which patients would, without
assistance, be impotent, in agony, barren, close to death or recently
suffering the misfortune of a split condom. Pharmacists know which patients
on oral methadone regularly take needle exchange packs, presumably because
they are still misusing non-prescribed substances.
In the quiet “confessionals” of the pharmacists’ counselling
rooms, what fresh, shameful secrets will patients divulge? Proverbially,
a priest sees people at their best and a lawyer at their worst; but a
doctor sees them as they really are. I suspect that MUR by pharmacists
will offer a watered-down version of that clinical, guilty knowledge
already familiar to nurses and doctors. Their dirtiest work is perhaps
the breaking of grave news; they are trained to “bracket it off” to
avoid excessive, personal, psychological damage. Moreover, doctors’ work
is, presently, physically dirtier than pharmacists’. Pharmacy: the “clean” face of medicine
Doctors and nurses, at their gore face, encounter dread-producing,
HIV-infected blood, fishy-smelling urine, explosive diarrhoea and other
physically
disgusting bodily components.2 Within
the operating theatre, after the gut of any patient is cut, whether
bishop, beggar, monarch or murderer,
the noses of staff wrinkle with the stench of the sewer.
Aseptic technique may be applied more meticulously than is microbiologically
essential. Sociology may help us understand those “ultra-hygenic” measures.
They are a ritual to keep at bay the “abominations” of “dirty” patients.
Indeed, such extreme ritual confers the situation with phenomenal power.3
The sewer suggests another perspective. The sewer cleaners’ dirty
work underpins our public health infrastructure and keeps water-borne
diseases such as cholera at bay. That arguably contributes more to health
than do doctors, nurses — and pharmacists. So ponder this…
The dirtiest of work can be good. Are pharmacists certain that they
will contribute more by MUR than pharmacy technicians will, plodding
away
providing the physical medicine? I suspect that, had patients to choose
between medicine review and getting their medicine, they would choose
the latter.
So maybe pharmacists should hang on
like limpets to the ultimate control of dispensing.
Evidently, within diverse dirt, rich pay dirt may sparkle. This year,
pharmacists’ problem is, perhaps, being spoilt for choice. But
we must be careful what we say, for, with the overwhelming wallop of
the self-fulfilling prophecy, it may come to pass.
References
1. Hughes EC. Men and their work. London: The Free Press of Glenco;
1958.
2. Strauss AL, Fagerhaugh S, Suczek B, Weiner C. Social organisation
of medical work. New Brunswick:Transaction Publishers;1997.
3. Douglas M. Purity and danger — an analysis of the concepts of
pollution and taboo. London: Ark; 1984. |
The
Pharmaceutical Journal