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Miranda Leontowitsch, Paul
Higgs, Fiona Stevenson and Ian
Rees Jones are researchers in ageing and health
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open to any reader. Contributions of around 1,100 words commenting
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Increasing longevity, improvements in health and greater affluence among retired people have changed the reality of old age in the UK over the past 30 years. It is expected that the projected increase in the numbers of people aged 60 and over will lead to a greater demand for both health care and medicines.
Health has long been recognised as a major determinant of quality of life,
and techniques to promote health have become a major focus of individual
activity. In addition, shifts in state involvement in health and social
care in the UK place greater emphasis on individual responsibility for
health. One area where this shift is particularly evident is in the deregulation
of medicines. In our research in community pharmacies we found that pharmacies
are an important and central venue for purchasing and finding out about
methods of health maintenance for older people but, at the same time, we
found that changes brought about by the new community pharmacy contract
are making it increasingly difficult for pharmacists to engage with their
customers.
Older people are frequent users of community pharmacies. Because prescribed
medicines are available free of charge to those over the age of 60, over-the-counter
(OTC) medicines use by this age group is considered to be low — older
people are thought to shy away from the extra cost. However, there has
been a growth in life-style supplementary medicines that are available
in pharmacies and these are increasingly aimed at older consumers.
At a more mundane level, pharmacies sell a wide range of merchandise that
is not necessarily health related, which attract pharmacy users who have
less access to means of transport and other shopping venues. The few studies
that have looked at the use of OTC products in later life found that older
pharmacy users chose to self-treat with a range of medicines, for a variety
of reasons, with some products in permanent and others in temporary use.
Both our own observations and the accounts of the pharmacists we worked
with support these findings. Moreover, we found that older customers preferred
the pharmacy as a first port of call for minor ailments and advice on medicines.
There is another “transaction” that takes place when older
people enter the pharmacy. Bissell and colleagues have pointed to the social
support pharmacists and technicians offer and the emotional facet of such
support appears to act as a pull-factor in older people’s use of
pharmacies.1 Older people often live in the same area for a long time and
often live alone. Their local pharmacy is a place where they know people
(staff as well as other users) and can interact with others.
Having observed interactions in pharmacies for many hours, we found that
older people were particularly keen on exchanging a few words with the
pharmacists. This could range from the pharmacist calling out greetings
from the dispensary to moving to the counter or shop floor to talk. This
specific behaviour that invokes a positive emotional response in the patient
has been described by Arlie Hochschild, professor of sociology at the University
of California, as “emotional labour”. She argues that clients
not only purchase a service in a commercial transaction they also engage
in a process that contributes to their personal well-being. Such personal
contact and community relations have long been recognised as central to
health and personal well-being.
The contract aims to promote community pharmacists as front-line health
experts, who offer more health care services and spend less time dispensing
prescribed medicines. The promotion of healthy lifestyles and self care
for patients with minor ailments, is much in line with the needs of a growing
health-conscious older population. However, at the level of enhanced services,
the focus to date is on medicines use reviews (MURs), in particular for
older people who are taking multiple prescribed medicines. Despite the
importance of such monitoring, the service is time consuming and there
have been concerns as to whether older people have understood and gained
from their MUR.
Although the community pharmacy contract was generally welcomed as a way
of enhancing professional status, increasing autonomy and potentially increasing
job satisfaction, its implementation
has come at a high cost for community
pharmacists, as described by Wendy Gidman (PJ, 19 August 2006, p218). She
poses the question whether or not the work intensification (workload, responsibility,
risk of litigation and exploitation) affects community pharmacists and
the services they provide. Her concerns chime with ours as we experienced
the transition pharmacists and their premises underwent in 2005.
Although every policy implementation suffers from some teething problems,
the broader aims of the contract might, in fact, distract pharmacists from
serving the multiple needs of their community. This is particularly true
in the light of the additional services that focus on public health campaigns,
which are decided in collaboration with primary care trusts. These appear
strongly to favour national health topics, such as diabetes, obesity and
high blood pressure.
But the MURs, too, with their emphasis on structured contact time put a
strain on pharmacists’ time and resources. If an MUR takes up to
20 minutes, little time is left to engage with older (or younger) customers
and their specific needs. Thus the new contract runs the risk of forcing
pharmacists to focus on policy targets rather than individual patient needs.
Maintaining health is increasingly important to older people as a way of
living an active later life and as a prophylactic to dependency. Engaging
with older customers beyond MURs, influenza vaccinations and other health
programmes should remain an integral part of pharmacy work. If the increased
work brought about by the contract makes this impossible to achieve, then
what will happen to the important yet less formalised role played by pharmacies
in older people’s self care in the future?
Unforeseen consequences resulting from the contract could emerge if the
new roles of pharmacists marginalise the less recognised role of informal
support for older people. Policy makers will have to consider seriously
whether or not they can afford to jeopardise the role of pharmacies and
pharmacists as a cost-effective avenue of self care for an ever growing
older population.
Reference
1. Bissell P, Ward P, Noyce P. Variation within community
pharmacy: (1) requesting over the counter medicines. Journal of Social
Administrative
Pharmacy 1997;14:1–15. |
The
Pharmaceutical Journal