Professions

1
Professions prescribing insights from nursing
pharmacy

• Paul Bissell
• Public Health
• ScHARR
• University of Sheffield

2
Background

• Medical sociologist / worked in pharmacy for over
  10 years
• Numerous evaluations community pharmacy practice
• Advice-giving in pharmacy
• Lay and professional perspectives on risk of
  non-prescription medicines
• Pharmacy supply of emergency hormonal
  contraception (EHC)
• Public health and pharmacy
• Social capital, inequalities and pharmacy
• Ethical dilemmas in community pharmacy
• Medicines management in community pharmacy
• Evaluation of supplementary prescribing in
  nursing and pharmacy

3
Overview

• Nursing pharmacy professions both make claim to
  be rightful heirs to non medical prescribing.
• Provide contrasting overlapping insights into
  sociology of professions / continuing dominance
  of medical profession around medicines usage.

4
Context for non-medical prescribing power of
medical profession

• Doctors have held a unique position of power
  over prescribed medications for some years, a
  role that has brought with it the control of the
  scope of practice of other health professionals.
  It is likely that some will be reluctant to
  abandon it. (Baird 2000 454)

5
Context for non-medical prescribing power of
medical profession

• The medical profession has an almost exclusive
  right to prescribe medicines but this right is
  being challenged byother health professions. It
  is argued that in British General Practice,
  prescribing is a battle ground on which the cause
  of clinical autonomy is defended. (Britten
  2001478)

6
Role of professions

• Classic theme in medical sociology.
• Friedsons Profession of Medicine
• medical power rests on autonomy over its own work
  activities and
• dominance / control over the work of others in
  the health care division of labour.

7
Medical Dominance

• organised autonomy is not merely freedom from
  the competition or regulation of other workers,
  but in the case of such a profession as
  medicineit is also a freedom to regulate other
  occupations. Where we find one occupation with
  organised autonomy in a division of labour, it
  dominates the others. Immune from legitimate
  regulation or evaluation from other occupations,
  it can legitimately evaluate the work of others.
  By its position in the division of labour we can
  designate it as a dominant profession (Friedson
  1988369).

8
Medical Dominance

• Last 30 years various arguments about decline of
  medical power
• Proleterianization clinical freedom under threat
  from state / HMOs
• Deprofessionalisation rise of assertive patients
  / narrowing of knowledge gap
• Nancarrow Borthwick (2005) discuss the fluid
  nature of professional boundaries in health care

9
Medical Dominance

• A consensus that medical power is being
  challenged, but not necessarily eroded
• Internal stratification within medical profession
• Cost awareness containment managerialism/
  audit / clinical governance
• Greater scrutiny regulation as a result of
  medical errors / abuse
• Consumerism / lay knowledge /greater
  assertiveness by patients
• Professionalisation and availability of CAM
• Lay scepticism towards expert systems more
  generally
• Boundary encroachment from other health
  professionals (eg. prescribing and medicines
  management nursing and pharmacy)

10
Prescribing medicines management in nursing and
pharmacy

• General consensus about a challenge to, if not an
  erosion of medical power.
• How has the medical profession reacted to nurse
  and pharmacist prescribing / medicines management
  roles?
• Has this translated into enhanced status for
  nursing and pharmacy as a result of involvement
  in prescribing / medicines management tasks?
• What are the implications for nursing and
  pharmacy professions?

11
Nurse Prescribing - overview

• Development reaction to nurse prescribing in
  the UK and US.
• Different experiences and responses by medical
  profession in UK and US.
• Evidence of considerable concern from the medical
  profession.

12
Nurse Prescribing

• UK - able to carry out both Independent and
  Supplementary prescribing.
• Independent prescribing began in 1994 almost
  opportunistically.
• Roots in DN diagnosis requiring rubber stamp
  / geographical distance from doctors require to
  sign / improvements in access.
• Strong political support for prescribing role
  from RCN alliances with BMA RPSGB / stressed
  partnership model.
• Push for private members bill (1992 Medicinal
  Products Prescription by Nurses etc Act).

13
Nurse Prescribing

• Conservative government concerned about cost.
• June Crown appointed to carry out review of non
  medical prescribing.
• Series of pilot sites set up rise of
  independent prescribing (from limited formulary)
• Pace of change speeded up post Labour victory
• Extended Independent Nurse Prescribing from 2001.
  
• Dependent, renamed supplementary prescribing (via
  Clinical Management Plan) implemented.

14
Nurse Prescribing - responses

• Numerous (HSR) studies, claiming nurse
  prescribing viewed positively by patients, is
  cost effective, is (viewed as) safe, improves
  access and does not waste doctors time.
• Jones - irrefutable proof that nurse
  prescribing was working on every criteria of
  safety, costs and effectiveness.
• By 2005 prescribing from whole formulary was
  announced (for both nurses and pharmacists) by
  Sec of State.

15
Nurse prescribing concerns from within
profession

• Lack / absence of formal supervision for nurse
  prescribers.
• Lack of incentives to assist with mentoring.
• Concern that it is driven by medical shortages /
  to reduce junior doctors hours / size of medical
  budget.
• Many nurses not prescribing despite completing
  training.
• Concern that nursing becomes medicalized / looses
  identity as a caring profession.
• Aidroos (2002) offer and drug and depart
  service.
• Will nurses be held to the same standards of care
  as other health professionals?
• Do nurses have choice about whether to prescribe
  evidence that employers alter job descriptions
  to include prescribing.
• Considerable scope to develop a sociological
  research agenda in these areas.

16
Nurse prescribing concerns from medical
profession

• BMA (2002) training nurses get is nothing like
  sufficient and will not give them the clinical
  knowledge they need to prescribe these drugs.
• Nurse prescribing - a dangerous uncontrolled
  experiment (Horton 2002) - also refers to
  prescribing entailing a loss of nurses identity.
• Criticism of nursing seen through lens of
  professional attributes.
• Others more cautiously optimistic about nurse
  prescribing (Avery and Pringle 2005).
• Concern about speed of change / availability of
  mentoring from GP / doctor / availability of
  role.
• Medical press (eg Pulse) maintaining pressure
  surveillance over nurse prescribing.
• Numerous concerns about pharmacology
  therapeutics training for nurses.

17
Safety nurse prescribing

• Systematic review of safety of nurse
  (supplementary) prescribing.
• Most published papers not based on empirical
  research / focus on adequacy of nurses training,
  knowledge skills.
• Review shows that doctors believe that Clinical
  Management Plan allows them to retain power /
  provides a framework for guiding decisions.
• Little empirical evidence that nurse prescribing
  is unsafe.
• Concerns tempered by awareness of scope / scale
  of nurse prescribing in England.

18
Overview of PACT data
Nurses Nurses Nurses
Year Item volume Net ingredient cost
2004 3.5 million 52.2 million
2005 4 million 58.9 million
2006 6.3 million 79.3 million
2007 (to end of September) 6.8 million 79.5 million
Pharmacists Pharmacists Pharmacists
Year Item volume Net ingredient cost
2004 2706 25,348
2005 11,458 96,846
2006 31,052 278,634
2007 (to end of September) 44,318 332,320
19
Nurse PACT Data
20
Nurse prescribing

• UK - establishing prescribing rights for nurses
  has involved some conflict with the medical
  profession.
• Not clear that supp rx based around CMP enhances
  status.
• CMP provides reassurance for doctors.
• Maintains status divisions between supp
  independent prescriber.
• Indeterminacy / technicality ratio supp rx
  based around CMP / maintains status hierarchies.
  
• Diagnosis / independent prescribing may result in
  rather more conflict.
• Different to situation in the US.

21
Nurse prescribing in US

• Development of nurse prescribing resulted in much
  more opposition in the US.
• Nurse prescribing grew out of nurse practitioner
  role in paediatrics / response to thin provision
  of care in rural areas.
• Creation of negative formularies for nurses /
  negotiation of independent prescribing in most
  states for NPs.

22
Nurse prescribing in US

• Mundinger et al (2000) combination of authority
  to prescribe drugs, direct reimbursement from
  most payers and hospital admitting privileges
  creates a situation in which NPs and primary care
  physicians can have equivalent responsibilities.
  
• NPs reimbursed at same rate as physicians in some
  states.
• Fennell argues inherent in the physician and
  pharmacist opposition to nurse midwives
  prescribing isan interest in their own economic
  survival.

23
Nurse prescribing in US

• Byrne Helman (2002) anti-competitive
  practices of health plans where consumers are
  instructed to use mail order/internet pharmacy
  services, many of which refuse to accept NPs
  prescription.
• Chen-Scarabelli (2002) various state medical
  associations lobby against nurse practitioners in
  a an attempt to maintain monopoly over health
  care management.

24
Nurse prescribing in US

• Edgley et al federal states reactive stance
  has opened the way for overt conflict between the
  professions as they fight it out over territory,
  rights and responsibilities.
• Professions responses to threats opportunities
  depends on organisational context.

25
Summary

• Nurses successfully developed prescribing role.
• Concerns from within nursing and from medical
  profession.
• Appears to be significantly more conflict in the
  US than UK.
• Medical profession able to mobilise arguments
  about appropriateness of nurse training, despite
  lack of evidence about risks / dangers /
  inappropriate prescribing / consideration of type
  of prescribing being undertaken.
• Likely that IP will evoke more conflict than SP.

26
Pharmacists roles in medicines management
prescribing

• Pharmacy - very different history response to
  challenges of non medical prescribing.
• Much slower engagement with prescribing agenda.
• IP only just getting started / several years of
  SP.
• Professional development shaped by commercial
  organisational environment (community) pharmacy
  operates in.
• Significant barriers to (community) pharmacists
  developing role in this area.
• Must overcome these barriers AND deal with
  potential opposition from medical profession vis
  a vis IP and SP.

27
Pharmacist prescribing?

• Eaton and Webb (1979) interviewing educators
  and policy makers
• I would draw the line at prescribing the
  pharmacist isnt trained to prescribe treatment.
• Well really I think lines may be drawn in terms
  of the medical degreeBut they (pharmacists) will
  never be involved in prescribing, at least in
  Britain, unless they have a medical degree. You
  cant sign a prescription which somebody will
  honour.

28
Community Pharmacy recent history

• Up to mid C20th legitimacy based on expertise in
  compounding / producing proprietary medicines.
• Original pack dispensing from 1960s onwards
  forced loss of role
• Pharmacy has long history of links with commerce
  / petit bourgeoisie.
• Ambiguous relationship with the NHS private
  provider in socialised system.
• Community pharmacies seen as dispensing
  factories considerable professional
  dissatisfaction.
• Pharmacists over qualified under utilised
  (Eaton Webb 1979) de-skilled.
• New roles for pharmacists essentially a quest
  for survival (Edmunds Calnan 2001).

29
Pharmacy sociology of the professions

• Denzin and Mettlin (1968) pharmacy viewed as a
  case of Incomplete professionalization.
• Pharmacy lacked control over the social object
  of practice - the medicine.
• Pharmacists guided by commercial interests at
  odds with the altruistic, service orientation of
  a profession.
• Essentially, a highly damaging critique / retains
  potency.

30
Pharmacy sociology of the professions

• Dingwall Wilson (1995)
• Critique of Denzin Mettlin (1968) position
• Other professions (e.g lawyers) associated with
  commerce, does not undermine professional status.
  
• Pharmacists transform objects (drugs medicines)
  and have a (Foucauldian inspired) role in
  surveillance around medicines usage.
• Hibbert et al (2002) weak role over medicines
  surveillance protocol driven role undermined by
  lay expertise / consumerism.
• Turner (1995) refers to pharmacy as tainted by
  petite bourgeoisie image.

31
Pharmacy sociology of the professions

• Pharmacists increasingly corporatised
  increasingly employees rather than independent
  practitioners.
• Key decisions not taken by pharmacists (tensions
  between superintendents marketing departments)
  / de-pharmacisation of chains / multiples.
• Lack autonomy over work practises / boundary
  encroachment from others.
• Small profession (45 000 registered pharmacists
  split between hospital and community.
• Considerable dissatisfaction with working
  practises in community pharmacy.

32
Re-professionalization project.

• Plethora of policy documents PIANA, Choosing
  Health Through Pharmacy, Pharmacy in the New NHS
• Some new roles identified
• smoking cessation,
• PBNX
• supervised methadone
• minor ailments schemes
• Supplying emergency contraception
• Chlamydia screening
• NHS contractual framework for pharmacy
  essential, advanced and enhanced.
• Prescribing and medicines management

33
Re-professionalization project.

• Continuing issues in community pharmacys
  re-professionalisation project
• Commercial environment in which pharmacy is
  practised
• Limited autonomy as employees
• Patient doubts about appropriateness of community
  pharmacy as a site for advice / medicines
  management / prescribing?
• Isolation from other professions / policy arena
• Subordination

34
Community Pharmacy Medicines Management Project
(CPMMP)

• Project developed / implemented by the
  Pharmaceutical Services Negotiating Committee
  (PSNC)
• Funded by DoH (2001-2004)
• Aim to evaluate the introduction of a community
  pharmacy led medicines management service for
  patients with coronary heart disease (CHD)
• Evaluated by independent research team using RCT
  qualitative research
• University of Aberdeen
• University of Nottingham
• Keele University

35
The CPMMP
36
Results- appropriateness
Intervention Baseline Intervention Follow up Control Baseline Control Follow-up P-value
Aspirin 82 80 76 78
Aspirin-related 95 94 91 93 0.24
Target cholesterol 59 58 57 55 1.00
Statin 73 79 68 77
BP 47 49 43 47 0.49
37
Explanations

• Qualitative interviews and focus groups with
  doctors, pharmacists and patients sheds
  considerable light on ways in which the doctors
  and pharmacists are working together?
• Informs a sociology of pharmacy.

38
Pharmacists views about medicines management

• Very positive about service
• Its wonderful to be able to talk to people
• Better patient care
• Were getting closer to some of the patients
  because they thinkfeel that youre taking more
  of an interest in them rather than oh, another
  customer! (P11/FG3)
• Using clinical skills
• It certainly is an extension of our role and a
  very worthwhile one, actually using our clinical
  skills for a change. (P16/FG4)

39
Pharmacists concerns GPs perceptions of their
subordinate status

• We work as a team but they (GP) think theyre
  the upper class we are the lower class you know
  (P13/FG8)
• They sort of think ofthey still think that a
  pharmacist is a class down, like you know you
  think of a shopkeeper. (P14/FG7)
• Because theyre not used to having their
  judgement questionedNot by someone that they
  perceive as being a shopkeeper. (P12/FG4)

40
Pharmacists concerns GPs feeling threatened

• I think its because they feel threatened its
  human nature isnt it? You are impinging on their
  territory. (P34/TI1)
• They might feel their opinion is being
  challenged, that they are being checked upon, or
  whatever because I suppose they are not used to
  it. It is a new thing for them really to have
  someone who is looking at the notes they have
  done themselves. (P09/FG2)

41
Commerce Pharmacy

• GPs concerned that community pharmacists advice
  influenced by commercial factors
• The difficulty I have really is trying to be
  certain that their advice is not commercially
  related (GP19)
• Resulted in GPs being suspicious of the clinical
  advice they received from community pharmacists.

42
Access to Medical Records

• I think the whole area then that opens up is
  all the areas of confidentiality and people who
  are not actually part of the GP primary care
  team, who have access to confidential medical
  records, which may include so and so is having an
  affair with so and so, who might happen to be the
  pharmacists neighbour you know. It may not, its
  a most unlikely scenario but our duty first and
  foremost is to all our patients is
  confidentiality. (GP15)

43
Pharmacists Changing Patients Medication

• Concerns about whether it was appropriate for
  community pharmacists to change patients
  medication.
• Do community pharmacists know patients well
  enough to undertake this service?
• Pharmacists involvement could cause fragmentation
  over patient care responsibility
• Patients could become confused if more than one
  person had responsibility for medication
• Pharmacists lack access to medical records when
  undertaking medicines management role

44
Pharmacists Changing Patients Medication

• I mean I think getting medication right is
  quite complicated and it depends on quite a lot
  of medical historical information and unless they
  have got the whole set of notes and they are
  sitting down with the patient and got to know
  them over a period of time they cant do that
  (GP15)
• Likely to be highly relevant to prescribing.

45
Reasons for GPs Concerns

• Professional boundaries
• Threateningchallenging management and
  criticism
• The whole area opens up areas of confidentiality
  and people who are not actually part of the
  primary care team

46
Summary

• Strong support for CPMMP in some areas, GPs
  highlighted many concerns
• Community pharmacists links with commerce
• Some resistance to pharmacists undertaking new
  roles boundary encroachment
• Some resistance to community pharmacists having
  access to patients medical records
• Distance from patients - concerns that
  pharmacists do not possess a detailed knowledge
  of the patient clinical histories
• Isolation from medical / nursing professions and
  primary care more generally.

47
Medicines Management A challenge to medical
dominance?

• Issues identified by Denzin Mettlin (1968)
  still relevant commerce / altruism /
  motivation.
• Strong discourse around community pharmacys
  subordinate position in health care division of
  labour.
• Distance from patients everyday care.
• GPs able to mobilise powerful arguments against
  pharmacists involvement. Eg commerce, access to
  records, confidentiality, knowledge of patient.
• Able to name / identify roles for pharmacists eg.
  compliance / repeat dispensing but NOT changing
  medication.
• Pharmacists collude to re-produce and sustain
  their own subordinate status. Eg. reference to
  shops deference to GPs.

48
Medicines Management patients views

• Patients views similar to GPs assessments of
  pharmacists involved.
• Cautiously welcoming talking to pharmacists
• But anxious about them making recommendations
  about treatment / changing medication.
• Concerns about the commercial environment /
  strong awareness of subordinate position of
  pharmacy.

49
Medicines Management patients views

• Commercial influences
• Im just not sure Im happy about it at all. I
  enjoyed talking to him, that wasnt the problem.
  Its just at the back of your mind, is it me, or
  is it a bit daft, you wonder about, well, you
  wonder about the drugs companies and all that,
  and all those promotions in the shopI came home
  from it, and we were talking, I said, is it the
  kind of place they should be doing this kind of
  thing? (R5)

50
Medicines Management patients views

• Subordinate position
• The pharmacists dont diagnose, dont they? The
  doctors do that. They put you on the treatment
  and the pharmacist just gives you it.
• Because you look at most prescriptionsIt says
  if you develop any of the following consult your
  GP. And this is from the chemical company. They
  dont say go to the pharmacist. They say go to
  the doctor.

51
Subordination isolation

• Coopers research around ethical loneliness of
  pharmacists.
• Draws on qualitative research with pharmacists
• Subordinate position
• I tend to feel that when I get a prescription,
  coming back to your point, that its the doctors
  responsibility ultimately and that Im just a
  tool of the doctor really. Im not happy with it,
  Im passing the buck and not accepting the
  responsibility that I should be taking.

52
Subordination isolation

• Isolation
• In a way we are isolated as pharmacists and we
  havent got anyone to chat to, to ask about
  things, to find out what other pharmacists
  think.
• Were all islands and were all competing
  against each other The only time when you
  come into contact with another pharmacist is when
  theres a conflict with something or when you
  want to borrow something.
• Habermas / Mead (discourse ethics) loneliness /
  isolation may be ethically problematic for
  pharmacists.

53
A sociologically informed research agenda for
pharmacy

• Commerce, altruism, isolation, subordination
  retain some force.
• Nancarrow Borthwick (2005) not clear that
  taking on new roles results in enhanced status.
• Moreover no examples of role changes that have
  removed the attributes that are associated with
  the professional labels.
• Community pharmacy remains a site tainted by
  commerce, isolation, subordination.
• To develop, pharmacists leave the commercial
  environment / undertake professional journeys /
  narratives of change.

54
Prescribing medical dominance?

• Britten (2001478) Prescribing and the defence
  of clinical autonomy
• The medical profession has an almost exclusive
  right to prescribe medicines, but this right is
  being challenged by the State, patients and other
  health care professionalsThese changes do not
  yet support the thesis of proletarianization or
  deprofessionalization as the medical profession
  continues to dominate the clinical agenda and
  responsibilities of other health care workers.