The possibilities of technology in shaping healthcare professionals: (Re/De-)Professionalisation of pharmacists in England
Highlights
► We draw upon research into the introduction of the Electronic Prescription Service in Community Pharmacies in England. ► We illustrate the conditions that allow technology to shape healthcare professionals and the consequences of such shaping. ► New health technologies play into longstanding debates related to the social organisation of healthcare work. ► Technology can shape fundamental aspects of the pharmacy profession (work, values, roles, power, jurisdictions, boundaries). ► Technology opens up a field in which processes of de-professionalisation and re-professionalisation occur simultaneously.
Introduction
Governments across the globe are introducing information technology (IT) in their healthcare systems with the intention of transforming service organisation and delivery, especially in terms of resource utilisation, clinical decision making, patient satisfaction and service productivity and quality (Berg, 1997; Davidson & Chiasson, 2005). A number of studies evaluate the implementation of these initiatives and the realisation of espoused benefits (Cresswell et al., 2011; Greenhalgh et al., 2008, Greenhalgh et al., 2010; Robertson et al., 2010). Fewer studies investigate the unintended and perhaps more veiled consequences of IT for healthcare professionals (Aarts, Ash, & Berg, 2007; Barrett, Oborn, Orlikowski, & Yates, 2011; Cho, Mathiassen, & Nilsson, 2008; Nicolini, 2006). In this paper we discuss the possibilities technology provides for shaping the pharmacy profession – specifically its nature, roles, values, power, jurisdictions and boundaries – and the conditions that enable such shaping (Motulsky, Sicotte, Lamothe, Winslade, & Tamblyn, 2011).
Technological innovation in pharmacy is not new, and includes new medicines, devices and organisational systems (Barrett et al., 2011). Our paper examines the introduction of new IT within the English community pharmacy context. Community pharmacists serve the public in independent shops, chains of pharmacies, medical centres and supermarkets. They have an NHS contract for dispensing medicines and may offer other NHS funded services such as smoking cessation, minor ailments schemes and adherence support services. Suitably qualified pharmacists have the right to prescribe, although few in community pharmacy have this training. Pharmacies may be owned by non-pharmacists and over half the pharmacies in England are owned by large chains. Our paper does not focus on hospital pharmacists or pharmacists who work in research institutions and reference to pharmacy(-ists) will imply community pharmacy(-ists).
To examine the possibilities of technology in recreating community pharmacy, we focus on the adoption of the Electronic Prescription Service (EPS) in the English NHS. The EPS was initiated in 2005 as a part of the UK National Programme for IT (NPfIT), delivered by the Department of Health agency, Connecting for Health (CfH). EPS refers to the electronic generation, transmission and receipt of prescriptions from a prescribing authority (a doctor) to a dispensing authority (a pharmacist). EPS has been envisioned as a project that would bring about considerable benefits to pharmacists such as economic efficiencies, reduction of errors, faster dispensing process, faster access to information and time savings (Department of Health, 2008; NHS Connecting for Health, 2009).
We make two arguments in this paper. First, new health technologies play into longstanding debates related to the social organisation of healthcare work. Second, their consequences on healthcare professionals are neither unidirectional nor deterministic; technology conditions processes of re-professionalisation and de-professionalisation simultaneously. Taking an agential view of technology, our paper discusses possibilities rather than certainties of the future shaping of the pharmacy profession through IT. Understanding these possibilities is important not only for healthcare professionals but also for those who manage IT adoption and implementation in healthcare settings.
Section snippets
An agential view of technology
An agential view suggests technology has a form of agency in that it constrains, prescribes, enables and provokes consequences (intended and unintended) (Greenhalgh & Stones, 2010; Mort, Goodwin, Pope, & Pope, 2005). Agency is neither reduced to the technology nor to its use but is about the effects that technology-in-use produce (Nicolini, 2006). We highlight four aspects of this agential view in relation to how technology ‘regulates’, ‘governs’, ‘mediates’ and ‘represents’ humans and their
Organising and reorganising professional work?
When thinking about the implications of technological change within healthcare organisations particular consideration is needed of the interaction between technology and professional practice, in this case pharmacy practice. In seeking to distinguish ‘professions’ from other occupations social scientists have highlighted a range of ‘traits’, interactions, systems and institutional capabilities that explain professional status and power (Abbott, 1988; Macdonald, 1995). A common view is that
Background to EPS
The EPS is being rolled-out in two releases. The first release (EPS1), which included a barcode on the paper prescription, allowed pharmacists to scan and download prescriptions. EPS1 went live in implementer sites in February 2005 and, at the time of writing, 99% of General Practices (prescribers) can generate EPS1 prescriptions and 86% of pharmacies have the software to read them. EPS2 creates a potentially paperless and fully electronic transmission of prescriptions, including links to the
Research approach
Our study aimed to understand how different actors from various stakeholder groups, involved in community pharmacy, interpreted the ongoing introduction and use of EPS. From these different views it then aimed to consider the future possibilities for the pharmacy profession. In line with this aim, our study followed an interpretivist epistemology (Crotty, 1998). Specifically, we recognise that the perceptions of interviewees are inherently subjective, albeit within a wider socio-cultural
Potential changes in the nature of pharmaceutical work
EPS has the potential to transform pharmacists' work in several areas. Ideally, EPS substitutes paper with electronic prescription messages and automatically populates patients' demographic details reducing manual data entry. As a representative of the National Pharmaceutical Association (NPA) said: ‘I suppose people automatically thought, we’ll have a paperless system, because it's a logical step, having an electronic process you get rid of paper…’. In practice, however, paper is still
Discussion
Our findings reveal differences in how EPS is perceived by different actors, especially how it was seen as reconfiguring pharmacy practice. When analysed together these perceptions reveal possibilities for shaping the pharmacy profession. Specifically, we identify important changes for pharmacists in the ‘nature of work’, ‘values’, ‘roles’, ‘jurisdictions’, ‘boundaries’ and ‘power’ (see Table 1). These reflect key attributes of the early adoption of EPS within the pharmacy settings and specific
Conclusions
Our findings have not provided a clear indication of the consequences of EPS on the pharmacy profession. This is not merely because EPS was in its infancy during data collection, although this is a significant reason, but mainly because the consequences to (healthcare) professionals are long-term, opposing and open to interpretation. The introduction of technology into (healthcare) professional settings needs to be taken seriously, especially from the perceptions of those who interact with
Acknowledgements
The authors are indebted to Dr. Ralph Hibberd and Dr. Valentina Lichtner for their contribution to the collection of data and to Dr. Tony Cornford for his comments in an earlier draft of this paper. They are also grateful to all the interviewees that participated in this study.
The Evaluation of the Electronic Prescription Service in Primary Care is a collaboration between The School of Pharmacy – University of London, The London School of Economics and Political Science and The University of
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