The Pharmaceutical Journal
Vol 277 No 7415 p256-257
26 August 2006

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Pharmacy in a New Age: start of a new era?

A decade ago, the Royal Pharmaceutical Society's Pharmacy in a New Age project created a vision of the future for the profession. Marcus Longley looks at how successful Pharmacy in a New Age was and what can be learnt from it

It has been claimed that Pharmacy in a New Age — commonly shortened to PIANA — was the most successful project ever conducted by the Royal Pharmaceutical Society. Standing alongside the Nuffield report of 10 years earlier, it created a vision of the future for the profession which, in the following years, was pretty much adopted in full by governments throughout Britain, and provided the profession with a standard around which it could rally. Was this really what happened, or is this a case of rose-tinted spectacles?

Origins of PIANA

It seems like another age, and to some extent it was. Pharmacy in a New Age was launched more than 10 years ago, at the British Pharmaceutical Conference in September 1995 and continued until early in 1999. The topical issues of the day can be gathered from headlines in The Pharmaceutical Journal at the time – a mixture of the past and the perennial: “Market testing of hospital pharmacy” (5 August 1995); “Asda threatens RPM on medicines” (21 October 1995); “RPM on medicines to be reviewed” (28 October 1995); “Patient medication record use in community pharmacy” (3 February 1996); “Data being sought to rebut Which? report” (2 March 1996); “The new NHS structure in England” (23 March 1996); “Managed care on health authorities’ agenda” (29 June1996); “OFT issues RPM consultation paper” (3 August 1996); “A prescribing role for hospital pharmacists” (31 August 1996).

The origins of PIANA are now somewhat shrouded in mystery, but by the beginning of 1995 a number of key people in the Society had become convinced that the profession needed a vision of its future which both met pharmacists’ aspirations and also had a chance of convincing the Government to pay for it. The medical and nursing professions had both been having similar discussions for some time, and they seemed to be gaining two things. First, the very process of discussing the future helped stimulate thinking in the profession and brought it together. Secondly, it was much easier to influence government if you could convince them that you had a coherent view of the future of the profession, and it could be seen that various individual policy initiatives added up to a better future.

Pharmacy also had a bit of an image problem. As those headlines suggest, many non-pharmacists thought of the profession as being somewhat locked in the past, trying to preserve its privileges against competition, not being committed to the health agenda, and condoning poor performance. An attractive vision of the future, outward-looking and open to change, could only help in redressing this.

During the first half of 1995, the Council had a series of meetings behind closed doors as it wrestled with the idea of PIANA and gave shape to it. There were obvious risks in having the debate in the open. Would the profession reveal its divisions? Was there a viable future? But these risks were set aside.

As one who helped facilitate many of these discussions, I was struck by the fact that PIANA was so obviously an idea whose time had come. Council members knew (from a variety of perspectives) that the status quo was not an option for the profession, and that chances would be missed if they did not act. Above all, the Council felt that it badly needed a way of re-engaging with the profession — both those at the cutting edge wanting major change and those simply concerned with protecting all that was good in pharmacy.

Four stages

PIANA dominated the Society’s policy development for almost four years from 1995 until early 1999. It went through four annual “iterations” during this period, as directions and targets were reassessed, and new ones set:

· October 1995 “Pharmacy in a New Age: developing a strategy for the future of pharmacy”; consultation; preliminary feedback to branch representatives’ meeting in May 1996
· September 1996 “Summary of responses”; “The new horizon: agenda for action 1996–97”
· September 1997 “Building the future: targets for 1997–98”
· September 1998 “Over to you”

The first year was the crucial one, in that it brought the profession on board, got people talking about the future, and set the broad themes for subsequent years.

As with all good engagement exercises, there were several elements to it. First was an unequivocal commitment from the President, the Council and all parts of the Society’s headquarters. This was clearly the major issue of the time, and attention and resources were devoted to it.

Secondly, there was a leaflet and consultation document which set out the issues in a clear and accessible manner, supported by six briefing papers published in The Pharmaceutical Journal between October 1995 and January 1996 (and subsequently reprinted as a collection by The Journal).

Thirdly, the Society activated its own infrastructure. All branches and regions and the Scottish and Welsh Executives, were asked to devote at least one meeting during the year to discussing and responding to PIANA.

Fourthly, an infrastructure devoted to PIANA was created. Almost 40 local co-ordinators were briefed and equipped to lead local discussions, and a national help desk and co-ordinator managed the consultation and handled responses to it.

Finally, PIANA was a cohesive project. The key messages and questions were condensed and refined, and all those acting as ambassadors for PIANA (the local co-ordinators, Council members and senior staff) were provided with a common presentation and standard script. There was also distinctive branding for everything to do with the exercise.

Years 2 and 3 (1996–98) were mainly focused on translating the broad objectives of year 1 into detailed action plans and targets.

The final iteration was summed up in the title of the document that launched it: “Over to you”. The aim now was to mainstream PIANA, to ensure that it was an integral part of everyone’s business and not a discrete, nationally led project. As “Over to you” put it: “Having laid the foundations, the Council wants to provide more support for pharmacists working towards the new age. Over the next year, the programme will focus on practical ways of helping you take up the new age philosophy as part of your professional development and working lives.”

To some at the time, this seem liked the Society was washing its hands of the strategy, and there was some confusion about what exactly was supposed to happen next.

Enthusiasts and critics

Even within the pharmacy profession, though, PIANA did not command universal support at the time. The correspondence columns of The Journal reveal dissenting (as well as supportive) voices. Some, for example, had little faith in the ability of their colleagues to rise to the occasion: “The views of the membership on [the future] may prove diverting but are more likely to provide an insight into the membership itself, rather than the future.”

Although about 5,000 pharmacists responded to the consultation in one way or another, some participants reported thin attendance at PIANA meetings. One pharmacist from Bristol wrote to the PJ: “‘Earlier this month I attended my first branch meeting for three years … to discuss … ideas on the next 20 years for pharmacy practice … 436 out of 450 branch members are content to leave the future direction of the profession to 14 movers and shakers!”

Others did not appear to have accepted some of the key premises of PIANA. For them, the status quo if anything appeared a little too modern: “I believe [the] ‘good old days’ when pharmacists had authority over their customers are actually within our reach today.”

But, at least in the first year, the response was generally positive. Some real enthusiasts wrote to The Journal, delighted at the opportunity for “ordinary” pharmacists to take part in the debate. Many were encouraged that employee and locum pharmacists — so often shut out of the key decision-making forums — could now join in: “[PIANA] has been designed to encourage all pharmacists, irrespective of their mode of employment, to contribute their ideas to shape the profession and I strongly urge colleagues to support the many meetings arranged throughout the country.”

Another pharmacist wrote: “I am not an academic, do not profess to be an ‘intellectual’ and am not fond of partaking in glorious fantasies! The extended roles being discussed within Pharmacy in a New Age are very real prospects that members of the profession have submitted to the Society. I participated in an extremely productive consultation meeting which bore fruit in relation to many of the ideas within the Pharmacy in a New Age document.”

Some even advocated that the process of engagement pioneered in PIANA should be repeated at regular intervals: “I would like to see the Society consult its membership in a similar manner every five years, at which time it would also update and evaluate on progress so far. After all, this would only mean the Society following its own principles of continuing professional audit.”

As the first year came to a close, though, dissenting voices became more prominent. Some were concerned that the consultation process had ended, and that the Society was now going to retreat to making policy behind closed doors: “‘Let the membership play a part in devising strategies for bringing some of the innovative ideas in the document to fruition.”

Impact

As the PIANA baton was passed “Over to you”, the new Labour government was starting to get its feet under the table, and a strategy for community pharmacy was in the offing. When it came out, it clearly embraced many of the ambitions of PIANA. Subsequent developments, such as extended prescribing rights for pharmacists and a community pharmacy contract that rewarded new age-type roles, also appeared to endorse the vision for the profession contained in PIANA.

The impact went beyond specific changes in government policy. People at the time spoke of the “PIANA philosophy” as a way of describing a more confident, outward-looking profession, keen to work out how it could help the broader NHS, and willing to change in order to do so. Schools of pharmacy made sure that they mentioned PIANA in their curriculum design documents. In short, it seemed to fit well with the prevailing notion of health service “modernisation” and all that that entailed.

Clearly, changes in government policy did not come about simply because of PIANA. But PIANA did make a major contribution to shaping policy:

· It raised the profile of the profession, and helped show policy makers and lay people something of its under-utilised potential.

· It helped convince people that the pharmacy profession wanted to make a contribution to the broader agenda.

· It provided politicians with some practical solutions to the problems facing them — eg, it provided a way of relieving pressure on other parts of the NHS, and offered choices to patients.

· It managed to address lasting issues and avoid the short-term vagaries of politics — after all, it was launched under a Conservative government, and embraced by a Labour one.

PIANA documentation was helpful in all these respects. It seemed to hit the right note. For example, one of the key outputs to emerge at the end of the first year of PIANA was a clear definition of what pharmacy was for (Table 1). This was not rocket science, but for many it was the first concise, comprehensive and definitive statement of what pharmacy could contribute, couched in terms that could be readily understood (see Table).

Pharmacists often underestimate how much lay people know about their profession: this definition (and the supporting PIANA material) provided a powerful information tool which lasted beyond the formal end of PIANA.

Lessons for the future

Ten key lessons for future initiatives can be distilled from this recent piece of history:

Priority If it is important, make sure it is visibly a high priority for all the relevant parts of the organisation, including the President, Council members and senior Society staff.

Profile Almost by definition there cannot be lots of high priority items, so keep them to an absolute minimum — PIANA had the huge advantage that it was the only such exercise at the time.

Use the Society’s infrastructure The Society has effective infrastructure which it can use to engage within and outside the profession, both formal (regions, branches, public relations staff) and informal (thousands of contacts between pharmacists and politicians, the NHS at all levels, and other professions) — it should be geared up to best effect.

Create dedicated infrastructure In addition to 3 above, the administrative implications require a dedicate staff resource, and a suitably trained and equipped ‘field force’ of volunteer local facilitators who can stimulate and attend meetings and be available to further the debate.

Accessible consultation documents Attractive, simple but not simplistic documentation which will appeal to “normal” pharmacists and interested outsiders.

Consistency of message The key messages or questions must be worked out in advance, reduced to their essence, and used consistently in all communications; they can be usefully reinforced by common branding.

Consider other pharmacy interests The profession clearly has different interest groups within it, and there is a danger that any initiative might be seen to compromise one or other position unless the issues have been discussed with them in advance.

Seek out the hard-to-reach Many pharmacists who do not usually take part in formal consultations will nevertheless willingly engage in discussions if a forum is created which suits their circumstances — a variety of different forums is therefore desirable.

Think about the exit strategy Consultations raise expectations, and consideration should be given at the start to issues such as regular feedback and the creation of ongoing opportunities for involvement.

Stick with it It can take many months of effort to raise awareness, get people informed, and allow them to contribute. Be prepared for a long haul.