46 Derek Hibbert, Paul Bissell and Paul R. Ward Sociology of Health & Illness Vol. 24 No. 1 2002 ISSN 0141–9889, pp. 46–65
Consumerism and professional work in the community pharmacy Derek Hibbert1, Paul Bissell2 and Paul R. Ward3 1
Department of Primary Care, University of Liverpool The Pharmacy School, University of Nottingham 3 School of Pharmacy and Pharmaceutical Sciences, University of Manchester 2
Abstract
In this paper we consider the professional role and status of the community pharmacist (chemist) in the context of consumerist health care. The sociological perspective of pharmacy as an incomplete or marginal profession has been challenged in more recent work, which describes how pharmacists act to ‘transform’ natural objects (drugs) into more valued social objects (medicines). We consider this process as it applies to the everyday and ‘taken-for-granted’ act of buying medicines in the pharmacy. We draw on focus group and interview data from a study involving consumers and pharmacy staff in the North West of England. The consumers had purchased one of a group of ‘deregulated’ medicines, which were previously available only with a doctor’s prescription. One way in which pharmacists have sought to develop their professional role is by trying to formalise their involvement in the surveillance of medicine sales. We show how this professionalising strategy is challenged by the consumer’s power in the commercial transaction and perceived expertise in the management of minor illness. This challenge forms a boundary to the pharmacists’ ‘transformatory’ work, and forms part of an ongoing negotiation of the meaning and relevance of their expertise. We present the strategies adopted by consumers and pharmacy staff to (respectively) obtain the desired medicines and fulfil professional responsibilities against a background of differing and contested assessments of the risks associated with medicines use.
Keywords: Consumer, medicines, pharmacy, pharmacist, professions © Blackwell Publishing/Editorial Board 2002. 2002 Published by Blackwell Publishers, 108 Cowley Road, Oxford OX4 1JE, UK and 350 Main Street, Malden MA 02148, USA.
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Introduction Community pharmacy in the UK is represented by the ‘high street chemist’ branch of the profession. The chief health-related services it provides are the dispensing of GP prescriptions and, the focus of the present paper, the sale of ‘over-the-counter’ medicines. Buying a medicine from the pharmacy is in many respects a mundane activity, but it forms an important strand of everyday health care by enabling people to manage common ailments. Given the commercial ethos of the community pharmacy, it also presents an opportunity to explore an example of overt consumerism in a health care setting. In this paper, we describe how aspects of consumerism and lay expertise in the management of minor ailments impact on attempts to develop the pharmacist’s role in the supervision and sale of medicines. In doing so, we refer to recent accounts of community pharmacy drawn from the sociology of the professions. The patient as consumer The rise of consumerism is regarded as one of the fundamental developments shaping health service delivery within the UK (Nettleton 1995). Health policy initiatives over the last two decades appear to endorse a view of service users who are becoming more ‘empowered’ in their relationships with health professionals (Department of Health 1989, 1991, NHS Executive 1996, 1997). This is evident in the setting up of the Department of Health’s Expert Patients Taskforce, and is mirrored by the increase in research activity around the concepts of patient-centred care (Laine and Davidoff 1996, Kinmonth et al. 1998) and shared clinical decision-making (Coulter 1997, Charles et al. 1997, 1999). The sociological literature outlines some of the conceptual distinctions which can be made between the respective roles of the ‘patient’ and the ‘consumer’ of health care. The patient has been regarded historically as occupying a subject position, with implications of dependency and unquestioning compliance with medical expertise. However, this emphasis on social control and the ‘docile’ body is felt to be less appropriate when considering the present day ‘consumer’ of health care services. As Williams and Calnan observe: The structure of lay thought and perceptions of modern medicine is complex, subtle and sophisticated, and individuals are not simply passive consumers who are duped by medical ideology. Rather they are critical reflexive agents who are active in the face of modern medicine and technological developments (1996: 1613). Lupton (1997) has critically discussed the idea of ‘the consumer’ in light of Giddens’ reflexive project of the self. The consumer, as a reflexive actor, is © Blackwell Publishing/Editorial Board 2002
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viewed as a dispassionate, rational and calculating person who no longer accepts at face value the authority of science and medicine. ‘Expert’ systems are regarded sceptically as part of a general process of professional demystification. This has been linked with their perceived inability to provide clear, objective guidance and with the consumer’s developing awareness of uncertainty in the assessment of medical, and other, risks (Haug 1973, Beck 1992, Gabe et al. 1994). The challenge to medical dominance has been fuelled by the increasingly rich and diverse sources of information available to the lay populace (Hardey 1999). The proliferation of information for ‘the consumer’ has been regarded as one element in the process of lay re-skilling. It has been suggested that the myriad sources of information provide lay people with the resources to ‘take back their bodies’ and re-appropriate knowledge and skills from the exclusive domain of the medical profession (Giddens 1991). The moves toward lay re-skilling and consumerist health care are complemented by an evolving sociological discourse centred on claims for equal weight for lay voices vis-a-vis those of health professionals (Popay and Williams 1996, Williams and Calnan 1996, Coulter 1997). With regard to the use of medicines, for example, it has become less acceptable to talk of ‘compliance’ with the doctor’s orders. Instead, health professionals are asked to consider how lay and professional expertise can best be shared in a more concordant relationship (Working Group 1997). This privileging of lay voices is regarded as a dominant cultural motif, which underpins relations between the lay populace and medicine in the late modern era (Williams and Calnan 1996). While this, and the relationship between professional and lay forms of knowledge, have been explored in terms of challenges to medical authority (Calnan and Gabe 1991, Flynn 1992, Gabe et al. 1994, Popay and Williams 1996, Weiss and Fitzpatrick 1997), there has been little consideration of their relevance to the work of the community pharmacy. How consumerism itself is manifest in the pharmacy is also, surprisingly, under-explored. The consumer in the pharmacy Chemists and druggists, the historical forerunners of the present-day pharmacist, developed in tandem with the advent of consumerism during the 18th century. Their success depended on how well they were able to meet their customers’ needs, and the ‘sovereignty’ of the consumer was an abiding principle of their work (Holloway 1991: 44). Until the following century, the public was allowed to purchase whatever medication it saw fit. This liberty, however, has since been eroded by increasing medicines legislation. In the present day, the main constraint on the consumer’s freedom to purchase medicines in the UK is the Medicines Act (1968). This specifies where medicines can be sold and in some cases, such as aspirin and paracetamol, how much can be sold at any one time. The Act establishes three distinct classes of medicine: prescription-only medicines (POM), which can only be obtained via a prescription, pharmacy medicines (P) which can only be purchased from a community pharmacy under the supervision of a pharmacist and © Blackwell Publishing/Editorial Board 2002
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general sales list medicines (GSL) which are available from any retail outlet, including community pharmacies. Recent years have seen some lessening of restriction (‘deregulation’), which has increased the range of therapeutically powerful ‘prescription’ medicines available for purchase (Blenkinsopp and Bradley 1996, Thomas and Noyce 1996). This has offered new opportunities for the self-treatment of ailments as diverse as vaginal thrush, hay fever and irritable bowel syndrome. More controversially, emergency hormonal contraception has been added to this list of deregulated products. Although access to medicines in general remains under close legal control, deregulation offers the consumer a degree of reempowerment in terms of extending the range of treatments available for purchase (Prayle and Brazier 1998). It also provides scope for the development of a social – rather than professional – model of health and illness management (Chewning and Sleath 1996, Bissell et al. 2001). The use of medicines in the self-care setting, with its (by definition) limited opportunity for professional surveillance, has raised concerns about the potential for ‘inappropriate’ use (Oster et al. 1990, Barber 1993, Consumers’ Association 1999). It has been noted that direct advertising to the public, while raising consumer awareness of medicines, typically emphasises their beneficial aspects rather than associated risks (Gray et al. 1998). Such risks include iatrogenic harm, misdiagnosis, the masking of more serious conditions and harmful interactions with other medicines being taken. Alongside continuing medicines legislation, pharmacists and their staff have been enlisted in the management of these public health risks through professional interventions at the point of sale. The professionalising pharmacist Interventions designed to manage the risk of deregulated products can be viewed in the context of an historical debate about the pharmacist’s professional status. In the past, this has been contested in sociological accounts by reference to compromising ‘traits’ such as commercialism, poor occupational cohesion and a lack of autonomy over work activities (Denzin and Mettlin 1968, Wardwell 1979). The view of pharmacy as an ‘incomplete’ profession remains prevalent in some quarters, despite arguments that commercial and professional imperatives need not necessarily conflict (Holloway et al. 1986). For example, Turner speaks of a professionalisation ‘limited by the petty bourgeois image of retail pharmacy’ (1995: 141). The re-branding of ‘retail pharmacy’ as ‘community pharmacy’ suggests the profession’s own awareness of a tension between commerce and professionalism. The pharmacists’ professional standing is treated more positively in some recent sociological work. This describes their involvement in processes which imbue medicines with social significance (Dingwall and Wilson 1995, Harding and Taylor 1997). Denzin and Mettlin’s (1968) argument that pharmacy lacked control over the social object of its activities is criticised on the grounds that it fails to distinguish between the drug as a material object and the drug ‘as © Blackwell Publishing/Editorial Board 2002
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a basis for social action’. The distinctive social object of pharmacy’s practice is re-framed as the ‘symbolic transformation of the inert chemical into the drug’ (Dingwall and Wilson 1995: 125). The transformation is achieved by pharmacists using their knowledge of individual patients, giving advice to patients about the use of medicines and warning about drug interactions and adverse effects. Along similar lines, Harding and Taylor (1997: 554) suggest that pharmacists possess a publicly recognised authority to ‘inscribe prescribed or purchased drugs with a particular meaning for a user’ and that ‘this process may benefit the public by investing a product with added value, in that a specific drug is targeted to their specific requirements’. In their view, medicines deregulation presents a key opportunity for pharmacists to accomplish the symbolic transformation of drugs into medicines, thereby consolidating their role as experts in medicines, and anchoring their professional status. These views find some echoes within a professional discourse, which argues that medicines form a special category of goods, and should not be marketed and advertised as are other ‘ordinary’ items of commerce (National Pharmaceutical Association 1998). The following, taken from a 1941 report by the pharmacists’ main professional body, has been used more recently as part of a professionalising rhetoric (Blyth 1996): Drugs and medicines are not ordinary commercial articles for which the limit of the market may safely be the desire and capacity of the public to purchase them. Moreover, medicines are products of which the public are unable to judge the quality and suitability for their purpose . . . Pharmaceutical Society’s Report of the Committee of Inquiry 1941 (Part 2). Given the requirement for professional expert surveillance, this view promotes and emphasises distinctions between the pharmacy and other retail outlets selling medicines, such as supermarkets or newsagents. To ensure that this distinction is achieved and made evident in practice, formal in-store protocols on the sale of medicines in pharmacies have been introduced. In 1995 the Royal Pharmaceutical Society asked all community pharmacists to implement protocols covering the procedures to be undertaken, if any, when customers request medicines. This strategy provided an opportunity for pharmacists and pharmacy staff to enhance their role as gatekeepers or intermediaries, with whom the consumer would need to negotiate access to medicines. The protocols are supported by the statutory requirement that pharmacists should supervise the sale of all pharmacy-only medicines, although there is still scope for individual interpretation of what this means in practice. The guidance offered by the pharmacists’ Code of Ethics and Professional Standards (Royal Pharmaceutical Society 2000) is that, when consumers ask for medicines by name: The pharmacist or assistant should obtain sufficient information to allow an assessment to be made that the medicine is likely to be © Blackwell Publishing/Editorial Board 2002
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appropriate for the person concerned. This will normally include information about whether other medication is being used which could interact adversely with the product requested or make that product inappropriate. The pharmacist or assistant must provide any advice which is considered appropriate to the product and the intended consumer. A potential conflict therefore becomes apparent, between the interests of the pharmacy profession and those of the powerful and reflexive consumer. A key component of this conflict is that pharmacists and consumers may have divergent views about the risks associated with medicines for specific ailments. For example, some pharmacists have expressed unease about the deregulation of H2 antagonist medicines for indigestion, given the drugs’ potential to mask more serious conditions (Anderson and Schou 1994). Consumers do not necessarily share these concerns and, furthermore, do not always expect to be informed about such risks at the point of sale (Ward et al. 2000, Bissell et al. 2001). The pharmaceutical manufacturers, for their part, might be expected to work in favour of wider availability of medicines, and a successful application has been made to the Medicines Control Agency to make one H2 antagonist available from general (i.e. non-pharmacy) retail outlets (Anon 1999). The diverse literatures considered here indicate competing or conflicting discourses around the risks of medicines and the concomitant need for surveillance within the pharmacy. However, to date we have few empirical insights into consumer orientations towards purchased medicines, and the influence these might have in shaping relationships in the pharmacy. The present paper uses the findings from a study that explored the impact which these differing discourses may have on the work of the pharmacy and the professional progress of the community pharmacist. The study and method Our qualitative study adopted the dual strategy used in previous studies of advice-giving in community pharmacies (Bissell et al. 1997a and b). The first component consisted of five days of non-participant observation in each of 10 community pharmacies. This was supplemented by a series of focus groups and interviews with consumers who had purchased deregulated medicines in the pharmacies, and by interviews with the staff who had sold the medicines. We have drawn mainly on the focus group and interview data for this paper. The rationale for using focus groups in addition to interviews was based on their potential for enabling participants to construct and argue their view on an issue (Morgan 1993). This was thought particularly relevant for the topic of buying medicines, given its everyday or taken-for-granted nature. The research was conducted in the spring and summer of 1997 in seven independent and three large chain pharmacies. These were selected purposively © Blackwell Publishing/Editorial Board 2002
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from lists of all community pharmacies in two health authorities in the North West of England. Given that patterns of medicines purchase were likely to be influenced by whether or not people have to pay for their prescriptions (Bissell et al. 1997b, Payne et al. 1998), we carried out the research in pharmacies located both in materially deprived and relatively prosperous areas. Consumers were approached by the researcher after they had purchased a deregulated medicine, and asked to take part in either a focus group or a face-to-face interview. At this stage, around one in three people declined. Their reasons, where given, usually involved lack of time, lack of interest in the subject or an unwillingness to take part in what they felt might be market research. Interviewees were not recompensed, but focus group participants received a small payment to cover travelling expenses. A total of 94 interviews and seven focus groups were conducted with consumers. The age of respondents ranged from 16 to 76 years, with 15 per cent aged under 25 years, 61 per cent between 25 and 45 years and the remaining 24 per cent aged over 45 years. Fifty-eight per cent of those interviewed or taking part in the focus groups were women. The large majority (94 per cent) of respondents described themselves as ‘white’, the rest as being of Pakistani origin. Just over one-third of respondents were recruited from town-centre pharmacies, the remainder from suburban pharmacies. Interviews were also conducted with the 10 participating pharmacists, and four focus groups were carried out with medicines counter assistants from the study pharmacies. The interviews and focus groups were conducted by two of the authors (PB and PW), and respondents were told beforehand that the aim was to understand people’s views and behaviour in relation to purchased medicines. The consumer interviews and focus groups typically began by asking people about their general approach to managing minor ailments. We felt it was important for establishing trust that we were not seen to be, as indeed we were not, trying to assess the ‘appropriateness’ of their use of medicines. The interviews and focus groups were tape-recorded and transcribed for analysis. Some of the general features of qualitative data analysis have been described by Plummer (quoted by Chapple and Rogers): This [analysis] is the truly creative part of the work – it entails brooding and reflecting upon mounds of data for long periods of time until it ‘makes sense’ and ‘feels right’, and key ideas and themes flow from it. It is also the hardest part to describe (1998: 559). For our analysis we used data from the focus groups and interviews to construct conceptual categories which characterised major themes or issues. It was our intention that any generalised theoretical statements would be grounded in these thematic categories, which in turn were derived from the data. We did not adopt the ‘grounded theory’ approach in a prescriptive sense (Glaser and Strauss 1967), although our analysis drew on the associated © Blackwell Publishing/Editorial Board 2002
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technique of constant comparison. We began by making associations between quotations touching on similar themes, which we grouped together. Following this, more refined categories and sub-categories were developed and checked for verification, or otherwise, against additional cases. Any generalisations we made were modified to accommodate negative or deviant findings. The transcripts were repeatedly read and discussed among ourselves in relation to the key theoretical areas identified. In interpreting and analysing the data, we have tried to remain aware of the influence of the research process on the accounts obtained. We acknowledge that many factors, such as the researchers’ gender (male), age (26 and 33), ethnicity (white, British) and social class (middle class) may have shaped the eventual output. We see the findings as a product of a process of construction between the respondents and the researchers, as not representing a single ‘truth’, but rather one possible story amongst many. Findings In the following sections, we describe some of the main themes that emerged from the focus groups and interviews. From the consumer data we highlight two which we see as particularly relevant to a discussion of consumerism in pharmacy: lay expertise in the management of minor ailments and consumer views of the risks of deregulated medicines. While our findings mainly concern aspects of the consumers’ accounts, we will end with some reference to the views of the pharmacy staff involved in selling medicines and providing advice and information. The importance of lay expertise One of the main themes identified in the consumer interviews and focus groups was the role which lay expertise played in the treatment of minor ailments. Specifically, many consumers conveyed a strong sense of their ability to self-manage specific conditions using purchased medicines. Their confidence stemmed, in some cases, from long personal experience of successful self-treatment. One respondent made a connection between her own experience of managing vaginal thrush and the need for professional support: I don’t have a problem with it [Canestan] because I’ve been using it for years, and I know how it works and what it does to my body . . . I might not know the chemistry of it or what not . . . but I know where to put it and how to use it. It works . . . and I don’t need any chemist telling me what to do (R2). This preference to purchase medicines in the absence of formal intervention or advice was expressed by other women with recurrent thrush. A number of these commented positively on being able to obtain the treatment direct from the pharmacy instead of having to visit their GP: © Blackwell Publishing/Editorial Board 2002
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When I’ve got thrush I know what I need to do. And I need to do it fast. I’ve had that agony too often. So, when it [Canestan] went on the shelves I was delighted. I haven’t the time to go to the doctor and I need Canestan immediately. Being able to go straight to the chemists and get it is great (R14). The way in which easier access to the necessary medicine facilitates self-care can be seen as offering a degree of consumer empowerment in addition to straightforward convenience. We found a similar picture of confident self-care in other medical conditions, such as migraine: I can tell you everything you want to know about migraines . . . I’ve seen my doctor, and I know what I want. I’ve got to get [relief ] quick, and I don’t want to talk to the chemist or whatever. I’ve spent years with migraines, I’ve read up on it, everything. I know enough and I know what product I need (R33). We argue that the level of perceived expertise displayed here offers a direct challenge to the exercise of professional expertise and surveillance in the sale of medicines, and reduces the scope for transformational work in the pharmacy. In passing, we would note the traces of what may be comparable work undertaken by the consumer’s GP (‘I’ve seen my doctor’) who originally prescribed, and hence endorsed, the medicine now used for self-treatment. In other cases the initial product selection was made by consumers themselves. For example, one respondent reported that he had never consulted the GP about his hay fever. He arrived at his own diagnosis after consulting other lay experts, and had found the right treatment using a trial-and-error approach: I’ve had hay fever for eight years – it just started one year. Streaming eyes, blocked-up nose. A few people at work told me it was hay fever, and I didn’t want to bother the doctor for something like that. So, I just tried a number of over-the-counter hay fever remedies until I found one that works . . . I wanted something that didn’t make you sleepy. And I tried a few and settled on one that works (R21). This consumer’s diagnosis and treatment selection took place almost exclusively within a lay network, and this was not uncommon in people’s accounts of managing minor ailments. Lay sources, in which we would include news media, the Internet, magazines, television, as well as friends and family, were a common means of acquiring information to support self-diagnosis and treatment. In terms of asking the pharmacist, some respondents’ offered their prior experience of the pharmacist’s involvement as justification for not accessing them more often: © Blackwell Publishing/Editorial Board 2002
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I don’t know about you, but I only ever see the assistant when I get HC45 (a skin cream), or when I get my hay fever tablets. And they shout ‘Zirtec’ to the pharmacist and he doesn’t even look up, so I don’t know why they’re doing that (R11). This was one of a number of critical observations on the enactment of the pharmacy staff ’s surveillance function. There were relatively few examples of encounters involving detailed or meaningful surveillance activities, with some respondents making an additional point that medicines were often sold without any advice and information. As the previous quote suggests, there was an awareness on the part of consumers of some inconsistency of message about the special nature of medicines, particularly in terms of their potential harm. On one hand there was an attempt to depict deregulated medicines as risky products requiring expert supervision – supported by the assistant’s act of formally drawing the pharmacist’s attention to the sale. On the other, the explicit components of that supervision, at least as interpreted and assessed within the consumer’s ‘gaze’, did not convincingly carry through this idea. In a previous study of pharmacy advice-giving, the authors noted that the way in which customers were questioned by counter staff sometimes came across as routinised and perfunctory in nature (Bissell et al. 1997b). This was echoed by consumers in the present study, who felt that staff sometimes seemed to have little interest in asking questions. Some consumers had learnt how the process might be circumvented so as to achieve the desired outcome: All you’ve got to say is yes, you’ve used it before – even if you haven’t, and no, you’re not taking anything else, and they’ll sell it you. It’s a bit pointless really (R49). ‘Consumer’ expertise might therefore encompass the skills evident in these answering strategies, in addition to any experience and knowledge of the treatments themselves. Our final quote in this section combines the concepts of lay expertise and consumer assertiveness, and encapsulates the key findings so far. However, in this example it can be seen that the respondent is at some pains to retain the option of a professional service which might be accessed by the lay ‘novice’. We will return to this aspect of the consumer voice later in the paper: I do see why they ask you things . . . and of course they don’t always. But I don’t need it. I’m glad they’re there – to ask and everything, if you need to ask them, but I don’t need to be asked questions or told stuff, not about my hay fever. That’s for people who haven’t used it before, and I understand that. But I know how to look after myself (R9). Consumer views of purchased medicines A review of the literature on patients’ views of medicines has noted the relative absence of studies focusing on purchased medicines (Blaxter and Britten 1996). © Blackwell Publishing/Editorial Board 2002
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It cannot be assumed that these are understood in the same ways as medicines prescribed for chronic illness (as outlined, for example, by Arluke 1980, Conrad 1985, Fallsberg 1991, Britten 1996). In this study, we wanted to explore consumers’ views of purchased medicines for any insights that these might offer for the consumer-professional interaction. The idea of lay expertise is familiar from sociological accounts of health and illness experience in diverse settings (Bury 1982, Conrad 1985, Gabe et al. 1994), and has sometimes been presented as forming an epistemological challenge to professional ways of knowing (Popay and Williams 1996). In this context we were interested in the role of lay knowledge in shaping social relations in the pharmacy, and whether, and how, this might underpin the examples of conflict described above. We have already described a professional discourse which centres on the risks of medicines as a basis for professional surveillance. Talking with the consumer respondents in this study, we found them to be focused rather on the benefits of purchased medicines. They rarely mentioned the risks or dangers of medication until prompted by the researcher. As one hay fever sufferer said: Look when my eyes are streaming and my nose is streaming, how can I teach? I need some relief. And I need it fast, so I’m glad I can just nip to the chemist to get my tablets (R21). Asked if he had ever considered whether his hay fever remedy presented any risks or dangers, he said: Apart from drowsiness, which I know about, and I don’t buy that one. No, to be honest I hadn’t thought about the risks (R21). These views were shared by other respondents who seemed not to have considered the issue of risk in this context. The following consumer suggests that the route of supply of the medicine, in terms of the relative availability of ‘over-the-counter’ medicines, has some bearing on risk perceptions: I thought someone sorted all that out anyway. We know they’re not going to put anything unsafe on the shelves are they? Well, not something really dangerous anyway. To be honest, I hadn’t given the issue that much thought (FG3, R4). We specifically asked consumers to consider medicines that had recently been deregulated, and whether their increased availability might alter views of risk and benefit. In response, some thought that they must carry some degree of risk, because they had previously been available on prescription. Others felt that because they were available on the shelves they must, by definition, be safe. This led to some interesting exchanges in the group © Blackwell Publishing/Editorial Board 2002
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discussions, with some consumers changing their minds, usually in the direction of a heightened risk assessment for deregulated medicines. Some participants expressed general concerns about the potential safety implications of any further lessening of control on the availability of medicines. This was usually couched in terms of the dangers of promoting a ‘pill for every ill culture’ and fostering excessive, potentially inappropriate, use. Among the various prescription-only medicines, there were particular anxieties and doubts about deregulating antibiotics: I wouldn’t like to see antibiotics made available. Doctors use them too much already, and we know they lose their strength when they’re used too much. I know about those superbugs which are immune to antibiotics (FG4, R25). Yes, and people would use them for everything – coughs and colds, ‘flus. They’d be using them if they sneezed (FG4, R27). While many consumers judged their own use of medicines to be both safe and appropriate, they expressed fears about the ability of the general population, or of certain groups within this, to self-medicate safely: I think about the people I am in contact with at school. If they could get hold of medicines willy-nilly. Just from anywhere. It would be disastrous. There’s got to be some control over medicines, somewhere. We can’t have a free-for-all (FG5, R30). Thus, although examples given in the previous section imply that medicines should be sold straightforwardly in response to consumer demand, some respondents voiced concerns about the implications of this. These latter concerns are more in line with the professional view of medicines as a special category of retail product requiring expert surveillance. They might also be seen as forming part of the respondents’ rhetorical work. Billig (1992) has written previously of ‘Contrastive Others’ which can be used by the respondent to emphasise his or her personal expertise. The professional response to consumer expertise We turn now to consider the perspective of staff involved in the sale of deregulated medicines. It was apparent from our earlier observational work that the overwhelming majority of medicine sales (90 per cent) were made by counter staff rather than pharmacists (Ward et al. 1998), although the pharmacist was potentially available to answer questions and satisfy formal requirements for supervision. The front-line status of counter staff has tended to be ignored in sociological debates about the pharmacist’s role and status, despite important implications for the scope of their professional involvement. Considering protocol questioning in particular, the counter © Blackwell Publishing/Editorial Board 2002
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assistants have a key role in putting into effect the pharmacist’s surveillance strategy. In our interview and focus groups with the counter staff, we found a general expression of what might be regarded as an orthodox professional view of medicines. So, for example, they spoke of the need for questioning to help avoid drug-interactions and contra-indications, and also of the importance of differentiating medicines from other items of trade. However, we also found a level of concern about providing ‘superfluous’ information to consumers who did not want it. Respondents reported negative reactions from consumers when attempting to ask questions or provide simple advice about medication use: I mean a lot of the responses we get are negative. You know the kind of thing – I’ve had them before, I know what I’m doing. I think they think that we think they are stupid, and they don’t realise it’s just general advice we are giving out to everyone (FG1, R6). The staff spoke of intervention in medicine sales as an often contentious undertaking, in which the meaning and purpose of the interventions was open to potential challenge by consumers. For example, it was said that consumers were increasingly aware of the types of surveillance questions routinely employed when selling medicines. Their observations were in agreement with comments made by consumers themselves about the ease with which questions could be circumvented: I can see them coming up for their Zantac [an H2 antagonist] or whatever, and you can see that they already know you’re going to ask them: how long have you had it, have you taken these before . . . they’re ready with all the pat answers. Even if we suspect they may not be telling the truth, there isn’t much we can do (FG1, R3). There was therefore some reciprocal acknowledgement that the surveillance of medicines sales by means of protocol questioning might be ineffectual. Perceptions of increasing contact with what one counter assistant called the ‘smart consumer’ could have an undermining effect on surveillance activities. The meaning and purpose of questioning could also be diluted by an underlying awareness that, should they decide to refuse the sale, the consumer might be able to obtain the medicine at other high-street pharmacies. The accounts from the counter staff show how they are required to negotiate their involvement, and how they might actively modulate their questioning strategies in light of the consumer’s response and their understanding of what consumers will allow. On a theoretical level, we might see questioning by protocol as a problematic strategy for enhancing professional status. Work in the sociology of the professions has previously regarded indeterminacy within the professional-client relationship as promoting social distance, client helplessness © Blackwell Publishing/Editorial Board 2002
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and hence professional autonomy and status (Johnson 1982). Protocol questioning would seem to routinise the pharmacist’s knowledge base, such that aspects of the questioning can be delegated to less qualified staff. It does not therefore automatically equate with increased scope for interpretative responses to individual consumers or greater opportunities to practice the professional ‘art’. It is notable in this context that the relative absence of social distance between consumers and staff has previously been regarded as one of the strengths of the pharmacy service (Cunningham-Burley and Maclean 1987).
Discussion Challenging and permissive consumer voices In our findings we have identified two aspects of the pharmacy consumers’ accounts, which are polarised in terms of their alignment with an orthodox professional perspective. We might summarise these as ‘permissive’ and ‘challenging’ consumer voices. We should note, however, that consumers in the study did not fall consistently into one or other of these representations: the same respondent could express both views during the course of an interview or focus group in response to different subjects and issues. In the same way we would expect that interactions in the pharmacy might also vary according to the context of the consumer’s need at the time. The permissive consumer perspective allows a role for professional regulation in medicine sales. Such views as were evident in the present study were more often heard in the focus group data, where consumers did argue for the need for caution in the wider availability of medicines and a need for surveillance – if not for them, for less ‘expert’ or first-time users. The concept of the risks associated with medicines was more evident here, in terms of the public health dangers associated with misuse of medication by other people. This is fairly congruent with the professional agenda, and was associated with consumer support for the need for professional supervision in the pharmacy. In terms of our overall findings, we might regard the permissive consumer view as our negative case, and it was the challenging consumer stance which was more evident among our respondents. Challenging consumers were reluctant to be questioned, and generally felt they had sufficient knowledge through their experience of the treatment of the particular minor ailment. The focus was on buying a product rather than obtaining a professional service. In the examples discussed there seemed to be relatively little scope for a professional contribution, in terms of tailoring the treatment to the individual consumer and giving individualised risk information. The challenge constrained both the pharmacist’s discursive strategy, which might aim to imbue the drug with distinctive, individualised meanings and their involvement in Foucauldian-type surveillance activities. © Blackwell Publishing/Editorial Board 2002
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Deregulated and ‘de-risked’ medicines? The seemingly scant attention which consumers gave to the risks of treatment in the present study is at some variance with previous research, which has focused largely on prescription medicines. Such studies suggest considerable concern about negative aspects of medicines (Fallsberg 1991, Blaxter and Britten 1996, Britten 1996). The absence of concerns about risks or side effects may be a function of the study focus on deregulated medicines, which are usually indicated for the short-term treatment of acute conditions. To this can be added the consumers’ previous experience of using treatments successfully in the absence of attributed side-effects. Furthermore, we have some evidence that the loosening of previous legal restrictions on the availability of these products can foster assumptions about ‘low risk’ status. The consumers’ understandings of risk, and the role of the pharmacy staff in managing that risk, are subject to potentially conflicting messages from advertising, legal changes and what actually happens in the pharmacy. The professional view that medicines are special products requiring expert surveillance and control is one message amongst many competing for the consumer’s ear. These messages do not consistently support the view of medicines as being fundamentally different from other retail products. The expertise and power of the pharmacy consumer Historically, self-care within the lay sector has been seen as having an oppositional relationship to professional medical authority. In the middle of the 19th century, medical practitioners objected to the sale of proprietary medicines on the grounds that significant portions of health care were escaping their control. (Holloway 1991: 57). Not all of the examples of challenging consumer from the present study can be read as part of an agenda which explicitly rejects professional expertise. In a sense, the consumer’s own expertise can be seen as a product of the sedimentation and accretion of a body of medical knowledge. As the findings concern deregulated medicines, rather than proprietary medicines in general, the consumers’ experience and knowledge has been gained in many cases through a broadly medically sanctioned use of the products, albeit augmented by personal experience of using the treatments. Consumer expertise therefore does not seem wholly equivalent with ‘lay’ expertise, at least in any non-professional sense or in the definitions articulated by Popay and Williams (1996). If we allow that the views of the Consumers’ Association have relevance in the context of the everyday consumer, we can note that it has usually relied on professional criteria to assess advice-giving in the pharmacy (Consumers’ Association 1996, 1999). We also do not feel that consumers in this study are challenging the pharmacy staff’s interventions because they feel they have an equivalent professional expertise (as one consumer said, ‘I might not know the chemistry of it or what not’). Their challenge was based rather on questioning the relevance or usefulness of this knowledge to their personal use of medicines. There is an underlying aspect of our research which might have informed © Blackwell Publishing/Editorial Board 2002
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the generally assertive expression of consumer expertise. As outlined in our introduction, the study has been carried out during a time when pharmacists are re-negotiating their professional roles with consumers, among others. When as researchers we ask people, however ‘neutrally’, to consider the present or potential role of pharmacy staff in medicine sales, we are also playing a part in this re-negotiation of professional status. It is possible that our respondents may have understood the research partly in terms of an implicit, though unintended, professionalising agenda. The consumers may therefore have felt it necessary to mount some defence against what they saw as imputed deficiencies in their expertise. Our findings have focused particularly on antagonism between the consumer and the professionalising pharmacist, and on examples where the pharmacist’s expertise in assisting self-care is not able to be fully expressed or articulated. In doing so, we have considered one specific aspect of the pharmacist’s work, to the exclusion of many others. For the broader picture, our paper should be set alongside the previously mentioned sociological accounts, which describe specific ways in which pharmacists enhance the medicines they supply, and also alongside research into consumer views of the pharmacy service in general (such as Jepson et al. 1991, Hibbert and Elliott 1996). While we have described the bounded nature of professional involvement in a specific aspect of their work, we would not dispute the underlying ‘transforming’ capability of the pharmacy staff. People, however, necessarily utilise a wide variety of networks to manage their health, and drug-to-medicine transformation may be accomplished not only by pharmacy staff, but by GPs and in lay networks. The diffuse nature of this transformational network means that community pharmacy staff are not always a key or essential component in the social enhancement of the particular drug or chemical. It appears that the principle of the ‘sovereignty’ of the customer still has currency in the context of purchasing deregulated medicines in the pharmacy. Elsewhere in the NHS, the verdict has often been that the reality of consumer choice has not always matched the rhetoric, being largely confined to the ‘supermarket’ model of consumerism (Nettleton 1995). In the GP consultation, however, Weiss and Fitzpatrick (1997) show how the patients’ demands for medication can pose a significant challenge to the prescribing practices of general practitioners. This is in spite of the GPs’ more defined function as gatekeepers of prescription-only medicines: if the patient cannot obtain the treatment or medicines they require from that source, they do not have easy recourse to any other prescribing body. Consumers could be said to hold relatively more power in the pharmacy situation, since, if the sale is refused, they may be able to buy the medicine at another pharmacy. The self-care of illness has particular relevance at a time when the state might wish to foster individual responsibility for health, and refine further the parameters of ‘governmentality’ (Dean 1994, Higgs 1998). It offers the © Blackwell Publishing/Editorial Board 2002
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potential to reduce health care costs and provides a means to ‘discipline’ a population caught between the contradictory impulses of production and consumption (Crawford 2000). The shifting responsibilities for health maintenance, as illustrated by the deregulation of medicines, present the community pharmacy service with opportunities to claim a more prominent role in health care. Our analysis of the strategies which underpin the everyday act of buying medicines suggests that consumerism represents a significant challenge to the accomplishment of medicines surveillance and professional work in the community pharmacy. Address for correspondence: Derek Hibbert, Department of Primary Care, University of Liverpool, Brownlow Hill, Liverpool L69 3GB e-mail:
[email protected]
Acknowledgements The study reported in the paper was undertaken when the authors were based at the School of Pharmacy and Pharmaceutical Sciences, Manchester University. The authors would like to thank North Thames NHS Executive for funding the project from the National Research and Development Programme Evaluating Methods to Promote the Implementation of Research Findings. We would also like to thank all pharmacy staff and consumers who took part in the study.
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