Advice-giving in community pharmacy: variations between pharmacies in different locations

Abstract

The advice and services provided by community pharmacies are viewed by policy makers as having an increasingly important contribution to make as a primary health care resource to local populations. However, little attention has been given to the variations which may exist between pharmacies operating in different localities. Findings from an ethnographic study of pharmacies illuminate differences in the nature and quality of advice and services provided by pharmacies operating in disparate localities. Analysis of qualitative data suggests that differences in the environment within which pharmacies are located and organised influence the type of service provided to local populations. The possibility of an inverse care law operating in relation to the nature of services in poor urban localities compared to those in rural areas is also discussed.

Introduction

Community pharmacies in the United Kingdom, of which there are just over 12 000, provide a network for the distribution of medicines and the provision of health advice to the public and health professionals (Bond and Bradley, 1996). With the growing importance of self care, de-regulation of medicines and the perceived need to reduce the workload of general practitioners (GPs), community pharmacists have, in the last decade, sought to establish themselves as advice-givers about medicine usage and symptom management. For nearly a decade government health policy has highlighted the advice-giving potential of pharmacists and their strategic importance for the primary health care system (Turner, 1986). Recent primary care policy has supported the notion of community pharmacists being used as the first port of call for minor ailments (Nuffield Foundation, 1986; DoH, 1996). A reason for the encouragement of this pharmacist-as-advisor role has been the need to reduce the `burden of demand' on GPs. Others have noted the importance of pharmacists in identifying and meeting the needs of particular customers, for example, drug addicts who might otherwise have little contact with mainstream medical services (Mulleady and Green, 1985). Within this officially endorsed extended role (DoH/RPSGB, 1992; DoH, 1996) equitable access to and provision of pharmacy services in the UK become increasingly important issues to examine. In the field of pharmacy practice, relevant research has been confined to a few exploratory studies. A small scale study, using structured observation in pharmacies in two areas with opposing extremes on the Jarman Index, found that clients visiting pharmacies in a poorly doctored area were more likely to be offered clinical advice about both prescriptions and `over the counter medicines' (OTCs) than those in a well doctored area. It was also noted that pharmacists in the poorly doctored area did more clinical work than those in the well doctored area (Mukerjee and Blane, 1990). Access to and the siting of pharmacies have recently been identified as having importance for planning levels of pharmaceutical care provided to populations. It has been pointed out that the distribution of community pharmacies may not reflect patient needs, even though proximity to a pharmacy tends to be greater in more deprived areas (Hirschfield et al., 1994). However to date there has been little acknowledgement that community pharmacy provision might be influenced by features of the locations within which they operate or the populations they serve. Moreover, whilst pharmacy research acknowledges variations in the provision of advice (Tully et al., 1997), to date research has not addressed how the locational context or internal environment of the pharmacy might influence the nature and quality of advice-giving. Rather there is a taken for granted assumption that the pharmacy ipso facto provides a suitable environment for this activity (Hirschfield et al., 1994). The research reported here examines the way in which advice-giving is expressed within specific localities and pharmacy environments. In so doing, it highlights some of the subtle differences in the nature of services delivered and the way in which pharmacies are used by different groups in the population.