The corporatization of community pharmacy:implications for service provision, the public health function, and pharmacy's claims to professional status in the United Kingdom

Background Pharmacy has experienced both incomplete professionalization and deprofessionalization. Since the late 1970s, a concerted attempt has been made to re-professionalize pharmacy in the United Kingdom (UK) through role extension—a key feature of which has been a drive for greater pharmacy involvement in public health. However, the continual corporatization of the UK community pharmacy sector may reduce the professional autonomy of pharmacists and may threaten to constrain attempts at reprofessionalization. Objectives The objectives of the research: to examine the public health activities of community pharmacists in the UK; to explore the attitudes of community pharmacists toward recent relevant UK policy and barriers to the development of their public health function; and, to investigate associations between activity, attitudes, and the type of community pharmacy worked in (eg, supermarket, chain, independent). Methods A self-completion postal questionnaire was sent to a random sample of practicing community pharmacists, stratified for country and sex, within Great Britain (n = 1998), with a follow-up to nonresponders 4 weeks later. Data were analyzed using SPSS (SPSS Inc., Chicago, IL, USA) (v12.0). A final response rate of 51% (n = 1023/1998) was achieved. Results The level of provision of emergency hormonal contraception on a patient group direction, supervised administration of medicines, and needle-exchange schemes was lower in supermarket pharmacies than in the other types of pharmacy. Respondents believed that supermarkets and the major multiple pharmacy chains held an advantageous position in terms of attracting financing for service development despite suggesting that the premises of such pharmacies may not be the most suitable for the provision of such services. Conclusions A mixed market in community pharmacy may be required to maintain a comprehensive range of pharmacy-based public health services and provide maximum benefit to all patients. Longitudinal monitoring is recommended to ensure that service provision is adequate across the pharmacy network.

Community pharmacists' engagement with public health in Great Britain

Objective - The objective of the research was to examine to what extent community pharmacists in Great Britain believed that their job was concerned with local public health issues. Methods - The project (Pharmacy and Public Health)received ethical approval from the Research Ethics Committee of the School of Life and Health Sciences at Aston University. After piloting, in August 2006 a self-completion postal questionnaire was sent to practicing community pharmacists in Great Britain (n=1998), with a follow-up to non-responders 4 weeks later. A final response rate of 51% (n=1023/1998) was achieved. Results - Respondents were asked to indicate their answer to the question “to what extent is your present job concerned with local public health issues?” on a three-point scale – “highly”, “slightly” or “not at all” concerned with public health. They were also asked to indicate whether they were pharmacy owners, employee pharmacists or self-employed locum pharmacists. Less than half (43%,n=384/898) of respondents answering both questions believed that their job was highly concerned with public health. A relationship was observed between employment status and the level to which a respondent believed that their job was concerned with public health (chi-square test with P=0.001). Over half of pharmacy owners (51%, n=68/134) considered that their job was highly concerned with public health compared to44% (n=193/443) of employee pharmacists and38% (n=123/321) of locum pharmacists. Conclusion - This research suggests that community pharmacists in Great Britain are not ‘fully engaged’ with public health. Pharmacy owners may feel more enfranchised in the public health movement than their employees and locums. Indeed, one-in-ten locums reported that their job was not at all concerned with public health which, as locum pharmacists constitute over a third of actively employed community pharmacists, could be limiting factor in any drive to strengthen the public health function of community pharmacists.

Community pharmacy in a commissioning-led NHS:can pharmacy compete effectively?

Introduction – The commissioning of services has been a core responsibility of English Primary Care Trusts (PCTs) since 2002. Primary care organisations (PCOs) in Scotland, Wales and Northern Ireland have also increased their commissioning activities but with, arguably, less fervour than their English counterparts. The commissioning function of English PCTs has been reinforced by the introduction of new contractual frameworks across primary care – for medical services, dentistry and pharmacy. The new pharmaceutical services contract for England and Wales introduced an “enhanced” category of services, the provision of which is dependent on the commissioning decisions of local PCTs. As the NHS, most pertinently in England, continues its transformation from a provider to a commissioner of healthcare, the ability of pharmacy to compete effectively for funding is likely to become increasingly important. Method - After piloting, in August 2006 a self-completion postal questionnaire was sent to a random sample of practising community pharmacists, stratified for country and sex, within Great Britain (n=1998), with a follow-up to non-responders 4 weeks later. Data were analysed using SPSS (v12.0). A final response rate of 51% (n=1023/1998) was achieved. Within the section of the questionnaire relating to service provision, respondents were asked “do you believe that pharmacy will be able to compete effectively with other healthcare providers for access to additional funding to develop services that address a public health need identified by your local Primary Care Organisation (PCO), e.g. PCT/LHB etc.?”. Answers were recorded on a three-point scale; pharmacy “will”, “may”, or “will not” be able to compete effectively for funding. Results - The attitudes of pharmacists showed variation depending on the type of pharmacy they worked in (supermarket, multiple (outlets (n)=200), large chain (200>n>20), small chain (20=n>5), or independent (n=5)) (?2 test with p=0.001). Over a third of survey pharmacists working in small chains and independents (37% (n=21/57) and 33% (n=113/341) respectively) believed that pharmacy would not be able to compete effectively for funding compared to 23% (n=15/65) for supermarket pharmacists, 22% (n=21/97) for pharmacists employed by large chains and just 18% (n=62/353) for pharmacists employed most regularly in multiples. Furthermore, attitudes also varied between the countries of residence of respondents (?2 test with p<0.05). 27% (n=242/893) of pharmacists resident in England and Wales believed that pharmacy would not be able to compete compared to 16% (n=18/116) of pharmacists resident in Scotland. Conclusions – It would appear that community pharmacists believe that the larger pharmacy chains and supermarkets will occupy an advantageous position in terms of attracting finance to develop services. This could have notable implications for service provision across the sector. If corporate pharmacy chains were to monopolise commissioning monies then the proportion of funding available to independents will be diminished; arguably further hastening their demise, as well as stifling the professional development of pharmacists employed within the independent sector. These findings, when combined with the variation observed between UK pharmacists operating under different contractual frameworks, may be a reflection of the divergent policy in the different administrations with developments in England, including the new pharmacy contract, reflecting a market-based approach with Scotland taking a near opposite stance with service integration and a commitment to new public health. However, it should be acknowledged that the questionnaire did not allow for detection of ambiguities in, or misunderstandings of, the survey question and this should be considered as a limitation of the research.

Post-registration learning trends of community pharmacists

Background: Some Australian pharmacists use continuing education to maintain knowledge and acquire new information. There has been a progression from continuing education to continuing professional development (CPD) - a mandatory requirement for pharmacists in all jurisdictions of Australia. Aim: To identify post-registration learning trends of community pharmacists in Western Australia. Method: A questionnaire was developed and administered by face-to-face interviews with community pharmacists in metropolitan Perth. Pharmacists registered for less than 12 months and pharmacists working in hospitals were excluded. Results: 103 pharmacists were approached with a response rate of 95%. Journals (41%), reference books (23%) and the Internet (18%) were the most commonly used educational resources cited by pharmacists. Keeping scientific information up-to-date (39%) and gathering practical knowledge (22%) were the leading motivators for pharmacists to participate in continuing education. Factors that hindered participation in continuing education included lack of time (34%), family commitments (21%) and business commitments (21%). 79% of pharmacists agreed with the concept of mandatory CPD. 47% of pharmacists suggested that the primary sanction for not complying with mandatory CPD should be counselling to determine reasons for non-compliance. Conclusion: Community pharmacists preferred educational resources that were easily accessible at convenient times. Most pharmacists were able to fulfil the requirements of CPD, however, further educational support and promotion would ensure the successful uptake of CPD by community pharmacists in Western Australia.

Provision of pharmaceutical care by community pharmacists:a comparison across Europe

Objective To investigate the provision of pharmaceutical care by community pharmacists across Europe and to examine the various factors that could affect its implementation. Methods A questionnaire-based survey of community pharmacies was conducted within 13 European countries. The questionnaire consisted of two sections. The first section focussed on demographic data and services provided in the pharmacy. The second section was a slightly adapted version of the Behavioral Pharmaceutical Care Scale (BPCS) which consists of three main dimensions (direct patient care activities, referral and consultation activities and instrumental activities). Results Response rates ranged from 10–71% between countries. The mean total score achieved by community pharmacists, expressed as a percentage of the total score achievable, ranged from 31.6 (Denmark) to 52.2% (Ireland). Even though different aspects of pharmaceutical care were implemented to different extents across Europe, it was noted that the lowest scores were consistently achieved in the direct patient care dimension (particularly those related to documentation, patient assessment and implementation of therapeutic objectives and monitoring plans) followed by performance evaluation and evaluation of patient satisfaction. Pharmacists who dispensed higher daily numbers of prescriptions in Ireland, Germany and Switzerland had significantly higher total BPCS scores. In addition, pharmacists in England and Ireland who were supported in their place of work by other pharmacists scored significantly higher on referral and consultation and had a higher overall provision of pharmaceutical care. Conclusion The present findings suggest that the provision of pharmaceutical care in community pharmacy is still limited within Europe. Pharmacists were routinely engaged in general activities such as patient record screening but were infrequently involved in patient centred professional activities such as the implementation of therapeutic objectives and monitoring plans, or in self-evaluation of performance.

Community pharmacist perceptions of the loss of resale price maintenance

Focal points: This study was designed to elicit the views of community pharmacists on any perceived business and professional changes following the loss of resale price maintenance (RPM)A piloted, 22-point self-completion questionnaire containing open, closed and scaled response questions was distributed to 35 independent (<10 stores), 13 multiple group and three supermarket-based pharmacies, and 40 responses were obtained (29 independent, eight multiple and three supermarket)Theme analysis indicated that 20 respondents felt that an increased range of services was now provided, 27 reported a decreased sales potential and 25 thought that patients now purchased more medicinesThe average price at which eight common over-the-counter medicines were offered was found to be £4.34 in independents, £4.37 in multiples and £4.22 in the supermarket pharmacies, compared with an average standard list price of £4.32There are indications that removal of RPM may have instigated changes in community pharmacy

The Ecumenical movement and the making of the European Community

The European Community has largely been considered a predominantly secular project, bringing together the economic and political realms, while failing to mobilise the public voice and imagination of churchmen and the faithful. Drawing on a wide range of archival sources, this is the first study to assess the political history of religious dialogue in the European Community. It challenges the widespread perception that churches started to engage with European institutions only after the 1979 elections to the European Parliament, by detailing close relations between churchmen and high-ranking officials in European institutions, immediately after the 1950 Schuman Declaration. Lucian N. Leustean demonstrates that Cold War divisions between East and West, and the very nature of the ecumenical movement, had a direct impact on the ways in which churches approached the European Community. He brings to light events and issues which have not previously been examined, such as the response of churches to the Schuman Plan, and the political mobilisation of church representations in Brussels, Strasbourg and Luxembourg. Leustean argues that the concept of a 'united Europe' has been impeded by competing national differences between religious and political institutions, having a long-standing legacy on the making of a fragmented European Community.

Modeling Optical Response of Thin Films: Choice of the Refractive Index Dispersion Law

Determination of the so-called optical constants (complex refractive index N, which is usually a function of the wavelength, and physical thickness D) of thin films from experimental data is a typical inverse non-linear problem. It is still a challenge to the scientific community because of the complexity of the problem and its basic and technological significance in optics. Usually, solutions are looked for models with 3-10 parameters. Best estimates of these parameters are obtained by minimization procedures. Herein, we discuss the choice of orthogonal polynomials for the dispersion law of the thin film refractive index. We show the advantage of their use, compared to the Selmeier, Lorentz or Cauchy models.

The MG Rover closure and policy response: an evaluation of the Task Force model in the UK

In recent years there have been a number of high-profile plant closures in the UK. In several cases, the policy response has included setting up a task force to deal with the impacts of the closure. It can be hypothesised that task force involving multi-level working across territorial boundaries and tiers of government is crucial to devising a policy response tailored to people's needs and to ensuring success in dealing with the immediate impacts of a closure. This suggests that leadership, and vision, partnership working and community engagement, and delivery of high quality services are important. This paper looks at the case of the MG Rover closure in 2005, to examine the extent to which the policy response to the closure at the national, regional and local levels dealt effectively with the immediate impacts of the closure, and the lessons that can be learned from the experience. Such lessons are of particular relevance given the closure of the LDV van plant in Birmingham in 2009 and more broadly – such as in the case of the downsizing of the Opel operation in Europe following its takeover by Magna.

Responses to racial segregation in a black Miami community

The present study examines the extent to which blacks are segregated in the suburban community of Coconut Grove, Florida. Hypersegregation, or the general tendency for blacks and whites to live apart, was examined in terms of four distinct dimensions: evenness, exposure, clustering, and concentration. Together, these dimensions define the geographic traits of the target area. Alone these indices can not capture the multi-dimensional levels of segregation and, therefore, by themselves underestimate the severity of segregation and isolation in this community. This study takes a contemporary view of segregation in a Dade County community to see if segregation is the catalyst to the sometime cited violent response of blacks. This study yields results that support the information in the literature review and the thesis research questions sections namely, that the blacks within the Grove do respond violently to the negative effects that racial segregation causes. This thesis is unique in two ways. It examines segregation in a suburban environment rather than an urban inner city, and it presents a responsive analysis of the individuals studied, rather than relying only on demographic and statistical data. ^

Living positive: Life in community among Puerto Rican men living with HIV in Boston

Negative experiences of stigmatization, discrimination, and rejection are common among people living with HIV in the United States, and particularly when they are also members of a minority group. Some three decades after the first cases of AIDS were identified, people infected with HIV continue to be perceived and characterized negatively. While an HIV/AIDS diagnosis is typically associated with negativity, this study investigates the extent to which collective experiences among HIV-positive people result in healthy responses and positive social adjustment. This study is focused on the ways in which HIV-positive Puerto Rican men in Boston live positive despite being diagnosed with HIV. Rather than wrapping themselves in the social stigma of HIV and the isolation that entails, they participate in processes that affirm themselves and their peers. In so doing, they help generate both healthy and meaningful lives for themselves and others. The study examines the process in which Puerto Rican men living with HIV in Boston participate, promote, and reaffirm an HIV community, la comunidad, as a social entity with a unique culture and identity. This study also investigates how this community influences, supports, and encourages the adoption of positive transformations for living long term with HIV. On the basis of nine months of field research, this qualitative study employed both focus groups and interviews with fifty HIV-positive Puerto Rican men in Boston. These men were recruited, using convenience sampling, from different community-based organizations (CBOs) that provide HIV/AIDS services in Boston. The study finds that HIV-positive Puerto Rican men in Boston build community, not in response to social exclusion, but built on shared positive practices and strategies for living healthy with HIV. These men come together to negotiate and form a unique cultural community expressed in norms, beliefs, and practices that, although centered on HIV, are designed for living healthy. These expressions reaffirm a sense of community in everyday settings and transform the lives of these men with positive behaviors and healthy lifestyles. The findings reveal that this transformation takes place in the context of a community, with the support, encouragement, and at times, policing of others. La comunidad is where the lives of these men are transformed as they learn, adopt, and experience living positive with HIV.

Experimental nutrient enrichment causes complex changes in seagrass, microalgae, and macroalgae community structure in Florida Bay

We evaluated how changes in nutrient supply altered the composition of epiphytic and benthic microalgal communities in a Thalassia testudinum (turtle grass) bed in Florida Bay. We established study plots at four sites in the bay and added nitrogen (N) and phosphorus (P) to the sediments in a factorial design. After 18, 24, and 30 months of fertilization we measured the pigment concentrations in the epiphytic and benthic microalgal assemblages using high performance liquid chromatography. Overall, the epiphytic assemblage was P-limited in the eastern portion of the bay, but each phototrophic group displayed unique spatial and temporal responses to N and P addition. Epiphytic chlorophyll a, an indicator of total microalgal load, and epiphytic fucoxanthin, an indicator of diatoms, increased in response to P addition at one eastern bay site, decreased at another eastern bay site, and were not affected by P or N addition at two western bay sites. Epiphytic zeaxanthin, an indicator of the cyanobacteria/coralline red algae complex, and epiphytic chlorophyll b, an indicator of green algae, generally increased in response to P addition at both eastern bay sites but did not respond to P or N addition in the western bay. Benthic chlorophyll a, chlorophyll b, fucoxanthin, and zeaxanthin showed complex responses to N and P addition in the eastern bay, suggesting that the benthic assemblage is limited by both N and P. Benthic assemblages in the western bay were variable over time and displayed few responses to N or P addition. The contrasting nutrient limitation patterns between the epiphytic and benthic communities in the eastern bay suggest that altering nutrient input to the bay, as might occur during Everglades restoration, can shift microalgal community structure, which may subsequently alter food web support for upper trophic levels.

Developing performance measures of mangrove wetlands using simulation models of hydrology, nutrient biogeochemistry, and community dynamics

The goal of mangrove restoration projects should be to improve community structure and ecosystem function of degraded coastal landscapes. This requires the ability to forecast how mangrove structure and function will respond to prescribed changes in site conditions including hydrology, topography, and geophysical energies. There are global, regional, and local factors that can explain gradients of regulators (e.g., salinity, sulfides), resources (nutrients, light, water), and hydroperiod (frequency, duration of flooding) that collectively account for stressors that result in diverse patterns of mangrove properties across a variety of environmental settings. Simulation models of hydrology, nutrient biogeochemistry, and vegetation dynamics have been developed to forecast patterns in mangroves in the Florida Coastal Everglades. These models provide insight to mangrove response to specific restoration alternatives, testing causal mechanisms of system degradation. We propose that these models can also assist in selecting performance measures for monitoring programs that evaluate project effectiveness. This selection process in turn improves model development and calibration for forecasting mangrove response to restoration alternatives. Hydrologic performance measures include soil regulators, particularly soil salinity, surface topography of mangrove landscape, and hydroperiod, including both the frequency and duration of flooding. Estuarine performance measures should include salinity of the bay, tidal amplitude, and conditions of fresh water discharge (included in the salinity value). The most important performance measures from the mangrove biogeochemistry model should include soil resources (bulk density, total nitrogen, and phosphorus) and soil accretion. Mangrove ecology performance measures should include forest dimension analysis (transects and/or plots), sapling recruitment, leaf area index, and faunal relationships. Estuarine ecology performance measures should include the habitat function of mangroves, which can be evaluated with growth rate of key species, habitat suitability analysis, isotope abundance of indicator species, and bird census. The list of performance measures can be modified according to the model output that is used to define the scientific goals during the restoration planning process that reflect specific goals of the project.

Projected Reorganization of Florida Bay Seagrass Communities in Response to the Increased Freshwater Inflow of Everglades Restoration

Historic changes in water-use management in the Florida Everglades have caused the quantity of freshwater inflow to Florida Bay to decline by approximately 60% while altering its timing and spatial distribution. Two consequences have been (1) increased salinity throughout the bay, including occurrences of hypersalinity, coupled with a decrease in salinity variability, and (2) change in benthic habitat structure. Restoration goals have been proposed to return the salinity climates (salinity and its variability) of Florida Bay to more estuarine conditions through changes in upstream water management, thereby returning seagrass species cover to a more historic state. To assess the potential for meeting those goals, we used two modeling approaches and long-term monitoring data. First, we applied the hydrological mass balance model FATHOM to predict salinity climate changes in sub-basins throughout the bay in response to a broad range of freshwater inflow from the Everglades. Second, because seagrass species exhibit different sensitivities to salinity climates, we used the FATHOM-modeled salinity climates as input to a statistical discriminant function model that associates eight seagrass community types with water quality variables including salinity, salinity variability, total organic carbon, total phosphorus, nitrate, and ammonium, as well as sediment depth and light reaching the benthos. Salinity climates in the western sub-basins bordering the Gulf of Mexico were insensitive to even the largest (5-fold) modeled increases in freshwater inflow. However, the north, northeastern, and eastern sub-basins were highly sensitive to freshwater inflow and responded to comparatively small increases with decreased salinity and increased salinity variability. The discriminant function model predicted increased occurrences ofHalodule wrightii communities and decreased occurrences of Thalassia testudinum communities in response to the more estuarine salinity climates. The shift in community composition represents a return to the historically observed state and suggests that restoration goals for Florida Bay can be achieved through restoration of freshwater inflow from the Everglades.

Nutrient effects on seagrass epiphyte community structure in Florida Bay

A field experiment was employed in Florida Bay investigating the response of seagrass epiphyte communities to nitrogen (N) and phosphorus (P) additions. While most of the variability in epiphyte community structure was related to uncontrolled temporal and spatial environmental heterogeneity, P additions increased the relative abundance of the red algae–cyanobacterial complex and green algae, with a concomitant decrease in diatoms. When N was added along with P, the observed changes to the diatoms and the red algae–cyanobacterial complex were in the same direction as P-only treatments, but the responses were decreased in magnitude. Within the diatom community, species relative abundances, species richness, and diversity responded weakly to nutrient addition. P additions produced changes in diatom community structure that were limited to summer and were stronger in eastern Florida Bay than in the western bay. These changes were consistent with well-established temporal and spatial patterns of P limitation. Despite the significant change in community structure resulting from P addition, diatom communities from the same site and time, regardless of nutrient treatment, remained more similar to one another than to the diatom communities subject to identical nutrient treatments from different sites and times. Overall, epiphyte communities exhibited responses to P addition that were most evident at the division level.