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    Community Pharmacy Businesses and Community Pharmacists

    JAMES EDWARD DAVIES

    A thesis submitted to the UCL School of Pharmacy for the degree of Doctor of Philosophy in

    the Department of Practice and Policy

    JANUARY 2013

    UCL SCHOOL OF PHARMACY

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    PLAGARISM STATEMENT

    This thesis describes research conducted in the UCL School of Pharmacy between October

    2009 and November 2012 under the supervision of Professor David Taylor and Professor

    Nicholas Barber. I certify that the research described is original and that any parts of the

    work that have been conducted by collaboration are clearly indicated. I also certify that I

    have written all the text herein and have clearly indicated by suitable citation any part of

    this dissertation that has already appeared in publication.

    Signature:

    Date:

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    PUBLICATIONS FROM THIS RESEARCH

    Thum-Bonanno, S., J. Gill, J.E. Davies et al. (2012). From making medicines to optimising

    outcomes: The evolution of a profession 1912-2012, Federation Internationale

    Pharmaceutique.

    Davies, J.E, R.Hamilton et al (2012) The imbalance between pre-registration training and

    undergraduate pharmacy student numbers. A BPSA discussion paper, The British

    Pharmaceutical Students Association. London.

    Davies, J. E. and D. G. Taylor (2012). "Individualisation or standardisation: trends in National

    Health Service prescription durations in England 19982009." Primary Health Care

    Research & Development FirstView: 1-11.

    Davies, J. E., S. Neidle, et al. (2012). "Developing and paying for medicines for orphan

    indications in oncology: utilitarian regulation vs equitable care?" British Journal of Cancer

    106(1): 14-17.

    Forbes, A., J. Davies, et al. (2011). "Dispensing substitution: avoid the impression of

    therapeutic chaos." The Pharmaceutical Journal 286: 129.

    Davies, J. E. (2010). "Telepharmacy - Friend of Foe?" British Journal Clinical Pharmacy July

    2010.

    Davies, J. E. and D. Taylor (2010). Making a difference. London, The School of Pharmacy.

    Davies, J. E., K. Cottrell, et al. (2010). "Improving patient safety through electronic transfer

    of prescriptions and automation: an audit of near miss errors." International Journal of

    Pharmacy Practice 18(Supplement 2): R57.

    Davies, J. E. and D. Taylor (2010). "The Uncertain future: a pilot study if pharmacy student

    views." International Journal of Pharmacy Practice 18(Supplement 2): R78.

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    ABSTRACT

    The change in community pharmacists practice from compounding and effectively

    unregulated medicines supply through to the highly regulated and largely automated high-

    volume dispensing process of today has been challenging. The economic and social

    standing of community pharmacy was transformed creating a need for further adaptation.

    This thesis explores how business and professional practice models for community

    pharmacy in England in ten to twenty years are likely to be structured?. It has six sections,

    plus an overarching discussion.

    A work sampling study of ten community pharmacies found that pharmacists continue to

    spend two-thirds of their time on dispensing related activities, compared to one tenth on

    counselling. The accompanying analysis links this to an increase in prescription volumes

    and payments that have incentivised pharmacy contractors to focus on medicines supply. A

    significant decrease in the average prescription duration for eight chronic disease

    medications over the past decade is revealed, and its desirability questioned.

    Using the Kingdon model of the policy process as an evaluative framework, 16 interviews

    with policy leaders provided insight into how seven factors (identified from a structured

    thematic review of the implementation of Medicines Use Reviews) have influenced the

    implementation of the New Medicines Service. In addition, role theory-based thematic

    analysis involving 17 stakeholders in pharmacy policy highlighted the tensions between

    community pharmacists roles as shopkeepers, clinicians and businessmen, and the effects

    that new technologies will have on them. The analysis identifies a need for pharmacy to

    embrace a new strategic direction that enhances pharmacys contributions to health

    outcomes.

    In conclusion, community pharmacy in England should offer timelier and economically

    efficient ways of solving contemporary health problems. The evidence presented here

    suggests that without stronger internal leadership and robust external stakeholder support

    medicines supply will split from the provision of clinical pharmacy in the community

    setting, leaving community pharmacies as commodity cost, low return medicines

    suppliers.

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    ACKNOWLEDGEMENTS

    There are many people who have helped shape not only this thesis, but also me as a

    person, over the last few years.

    My sincere thanks go to Dr Phillip Brown, not only for his financial support of this research,

    but also for the valuable insight that he has provided throughout the synthesis and

    development of this research. His pharmacy team have been a great help in sense checking

    the findings presented here and for providing insight into the pressures that pharmacists

    face.

    Professor David Taylor has not only been a supervisor to this program of research but also

    a friend. He has assisted my personal development and helped to take me out of the rigid

    pharmacist mindset to which I first approached this project. Invariably the many

    distractions that David threw my way ended up helping to shape and form this final piece

    of work. I am genuinely grateful for all of the help and support that he has provided me

    with over the years. Thank you for gently assisting me to achieve a more thoughtful gaze on

    the world.

    Professor Nick Barber has provided the framework and the pharmacy base to this thesis.

    Thank you Nick for your insight, your wisdom and your help in getting this finished.

    As with any research project, I am indebted to all those participants who gave up their time

    so willingly to help me carry out these projects. This includes all of the pharmacists at work

    sampling sites and the different stakeholders who gave their time for interviews. While

    your names remain anonymous your efforts do not go unrewarded.

    Several students Saira Aslam, Folake Olafare, Rukeya Begum, Thusanth Thayaparan,

    Gursharan Sira, Mohammad Mansoor Hashemi, Umara Uddin, Zainab Shafiq and Sarah

    Khan were invaluable for their help in data collection and entry.

    Many other people in this practice and policy department have helped me along the way.

    Thank you to Felicity, Andreia, Ralph, Christina, Lina, Kirsty, Jenny, Jen, and Eman for all

    their humour, conversation and distinctively individual contributions.

    I am particular indebted to my parents, my brother and my grandmother for their financial

    support as well as their tolerance and understanding.

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    Finally, a huge thanks to my wife Helen, who has been my rock over the last few years. She

    did much more than look after me at home, but proofed much of my written work (and

    pointed out the distinction between s and s) and provided a useful sounding board for

    many of my ideas. To you I give both my love and gratitude.

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    ABBREVIATIONS

    AESGP Association of the European Self-medication industry APPG All Party Pharmacy Group BMA British Medical Association BPC British Pharmaceutical Conference (now the RPS conference) BPSA British Pharmaceutical Students Association CCA Company Chemists Association CHD Coronary Heart Disease CPPE Centre for Pharmacy Postgraduate Education DH Department of Health DHSC Department for Health and Social Case EHC Emergency Hormonal Contraception EPS Electronic Prescribing Service FIP International Pharmacy Federation (Fdration Internationale de Pharmaceutique) GDP Gross Domestic Product GMC General Medical Council GMS General Medical Services GP General Practitioner GPC General Practitioners Committee (of the BMA) GPhC General Pharmaceutical Council GSL General Sales List (medicine) HLP Healthy Living Pharmacy IPA Interpretative Phenomenological Analysis IQR Inter Quartile Range KNMP Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie (Dutch

    Pharmacy Association) LMC Local Medical Committee LPC Local Pharmaceutical Committee LPS Local Pharmaceutical Services MCA Medicines Control Agency (now the MHRA) MHRA Medicines and Healthcare Products Regulatory Agency MUR Medicines Use Review NAO National Audit Office NCCSDO National Co-ordinating Centre for NHS service Delivery and Organisation NHS National Health Service NHSCB NHS Commissioning Board NHSE NHS Employers NICE National Institute for Health and Clinical Excellence NMS New Medicines Service NPA National Pharmacy Association NSF National Service Framework OFT Office of Fair Trading OTC Over the Counter (Medicines) P Pharmacy only (medicines) PAGB The Proprietary Association of Great Britain PCA Prescription Cost Analysis PCPA Primary Care Pharmacists Association PCT Primary Care Trust PGD Patient Group Direction PHE Public Health England PIANA Pharmacy in a new age PIL Patient Information Leaflet PMR Patient Medication Record

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    POM Prescription only Medicine PPRS Pharmaceutical Price Regulation Scheme PRLOG Pharmacy Regulation and Leadership Oversig

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