Research in Social and Administrative Pharmacy 11 (2015) 531–544

Original Research

Community, autonomy and bespoke services: Independent community pharmacy practice in hyperdiverse, London communities Kathryn Duckett, Ph.D.*,1 London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London WC1E 7HT, United Kingdom

Abstract Background: The landscape of pharmacy continues to evolve including in Great Britain, where, by 2012, almost 50% of pharmacy contracts were held by just 9 national chains. Objective: To further explicate the concept of ‘independence’ as it was positioned by independent pharmacists, particularly examining personal interpretations of their role in contemporary pharmacy and health care delivery. Methods: Research was situated in East and South-east London between 2008 and 2009. The study took an ethnographic approach; combining participant observation within 7 pharmacies and 36 active interviews with pharmacists. Recruitment criteria demanded that pharmacists self-identified as independent and were either owners or managers in sole-owned or independent chain pharmacies. Results: Independence was expressed through a framework of three overarching themes: autonomy, engagement and bespoke practice. Autonomy formed the basis of professional expression ultimately enabling pharmacists to exercise control over customer relationships. This facilitated engagement with communities and individuals and ultimately made possible an offering of a bespoke ‘personal’ service. The diverse urban environment was a space where independence was seen to be of particular value. The complexity of this setting was used symbolically to support the need for independent thinking. These themes are examined through stories of ‘acceptance’ and developing pharmacy ‘communities’ alongside the practise of maintaining personal relationships to provide a distinct service offer. Conclusions: This study highlights distinct ‘independent’ expression of professional identity and suggests the need to assess the value of independent community pharmacy as being different from but complementary to the service provided by multiples/large chains. Ó 2015 Elsevier Inc. All rights reserved. Keywords: Rhetoric; London; Independent; Community; Ethnography

Funding body: Economic and Social Research Council, Polaris House, North Star Avenue, Swindon SN2 1UJ. * Corresponding author. Tel.: þ447950933255. 1 Present address: 3 Ridgewood Close, 08-04 Lunalilio Rise, 276694, Singapore. E-mail address: [email protected]. 1551-7411/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.sapharm.2014.10.009

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Introduction Community pharmacies in Great Britain operate as private, retail businesses providing National Health Service (NHS) services on a contract basis. The sector includes businesses built on a variety of different models but is crudely split between ‘independents,’ and ‘multiple’ pharmacies. Independent pharmacies described here are businesses that are sole owned or part of a chain that has no more than 5 retail outlets. Small independent chains/independent multiples also represented in this research are chains of 5 or more shops that are eligible for membership of the Association of Independent Multiples.1 The ‘multiples’ meanwhile include large chains of greater than 300 outlets dominated by the companies that make up the Company Chemists Association (CCA).2 The number of independently owned pharmacies in England and Wales is in decline; between 1998 and 2008, leading up to the period of study of this research, the percentage of pharmacies comprising 5 or fewer outlets fell from 57% to 39%.3 By contrast, the nine companies of the CCA alone owned approximately 50% of community pharmacies in Great Britain by 2012.2 The fundamentally different approach to business taken by independents and multiples has been described in previous research: “corporate pharmacies maximize profit through economies of scale and rationalization, independents pursue profit maximization primarily by service delivery.”4 Other studies describe how this emerging “corporatization of the community pharmacy sector” has seen the multiples rise to dominate delivery of pharmaceutical services.5 It has also been suggested that this shift in the marketplace will affect both service provision and attempts to expand the pharmacists’ professional role.6 Framing the pharmacists understanding of their position in the world was the continuing background of change within community pharmacy in England and Wales. The seeds of change were sown when, in 2003 the Department of Health published A Vision for Pharmacy.7,8 In the same year the 2003 General Medical Services (GMS) contract9 came into force allowing services previously carried out in general practice to be contracted to other providers including pharmacists.6 A new contract for pharmacy was published in 2004 taking on board these recommendations and implementation began in April 2005. The reformed contract was designed to lessen reliance on dispensing and to encourage

the undertaking of a range of other services which include locally commissioned activities such as needle exchange, smoking cessation programs and minor ailment schemes.10 Professional personhoods To begin an exploration of independence in a ‘modern’ pharmacy setting, this account concentrates on the figure of the independent community pharmacist, investigating the experience of practice as it is positioned by pharmacists themselves. There has been an ongoing struggle in defining a professional remit for the community pharmacist, stemming in large part from a longstanding dispute with members of the medical profession over a mandated professional territory and subordination to the physician through the latter’s control of the prescription.11 The duality of the community pharmacist’s role as businessman/ health care provider has also proved hard to negotiate.12 The profession has looked to re-describe it’s remit and in doing so it has been suggested that the community pharmacist’s role should move from a ‘technical’ position founded in dispensing and compounding to a ‘cognitive’ one; expanded to include a more clinical element and involving patient counseling.13 This attempted expansion has resulted in the movement away from a medicines based role to a disease and patient oriented function and development of new pharmaceutical services such as those described in the pharmacy contract.14 Alongside the shift in emphasis described in the pharmacy contract this movement will be referred to as the ‘dominant discourse’ within British community pharmacy. This study was concerned with understanding the professional role of ‘the pharmacist’ and how pharmacists describe and occupy this particular position. The concept of ‘personhood’ is useful in helping us to consider this concept precisely. ‘Personhood’ refers specifically to a social role, “acted out within a wider cultural context.”15 It has been suggested that rather than being fixed over time, personhoods are self conscious projects that take into account the options available to a particular person at any given moment and are dependent on the situation that they find themselves in.16 Personhoods are therefore constructed through the way in which individuals both act and are acted upon, at a particular point in time.17 In investigating this interplay of behavior and influence it is possible to explore how pharmacists

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have, or have not, attempted to incorporate the efforts of the professional bodies and policy makers to refashion their role into their professional personhoods, it also enables understanding of how they rationalize the collective professional tensions surrounding the status of independent community pharmacy through individual experiences. Research was conducted in four East and South-East London boroughs and the pharmacists’ rhetoric is embedded in accounts of the inner-city, referencing urban places and people. These boroughs have in common a population that suffers from multiple deprivations and in which nearly half of all residents describe themselves as being from ethnic minority groups.18 The term ‘hyperdiverse’ has been used throughout this account as it portrays the extreme, but not extraordinary, urban setting where diversity is simply a fact of life. It is employed to evoke an expansive idea of diversity, including different ages, educational and socio-economic factors as well as simply ethnic background.19 Rather than prioritizing the discourse of policy makers and professional bodies, this research aims to explore the role and value of the independent pharmacist as it is expressed by pharmacists themselves in this urban environment. It aims to investigate personal interpretations of independent professional personhood within the microcosm of the pharmacy. Methods This ethnography included participant observation carried out within 7 pharmacies and active interviews with 36 other pharmacists. A pilot interview study was conducted in August 2007. Subsequent research was carried out between October 2008 and August 2009 in which the two methodological processes occurred in parallel. All research and analysis was carried out by the author. The NHS Choices ‘find a pharmacist’ webpage20 and the Pharmacy Register21 were used to identify all of the independent and independent chain pharmacies in the target boroughs. Of a possible 143 independent/small independent chain pharmacies across four East and South East London boroughs 109 were contacted in total, through personal visit to the pharmacy or by telephone. Purposive sampling was used to select pharmacists. Using this method respondents are chosen on the basis of previously identified

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characteristics to select “information rich cases for in depth study.”22 In other words the sample is “intentionally biased in order to get answers to questions of practical importance.”23 In this case the sample was chosen to reflect as even a spread as possible across the localities in the study area based on willingness to participate. Recruitment stopped once theoretical saturation had been reached. Twenty pharmacy owners and 23 employee pharmacy managers who identified themselves as independent pharmacists took part in this research representing a spread of experience from 18 months to 50 years post-qualification. ‘Owners’ in this context is used to refer to pharmacists who own the business in which they practice as a pharmacist. Managers were pharmacists who had a management role within the pharmacy business i.e. took responsibility for the day to day running of the business as well as pharmacy work but did not own the shop they worked in. Non-permanent staff were excluded from the study. Strictly defining ‘independence’ is not as straightforward as it might at first sound. The study could have been limited to pharmacists working in individual pharmacies that were sole owned. However many pharmacists own two or more shops and these ‘small chains’ have much more in common with sole owned pharmacies than the multiples. Even sole owned pharmacies however may employ pharmacy managers to run the shops on a regular, perhaps daily basis. Are these managers ‘independent pharmacists’? Limiting this definition would have failed to take into account the fact that these manager pharmacists working for independent chains can feel quite distinctively part of the independent sector and expressed very strongly that their way of working was consistent with being ‘independent.’ To the other extreme the sample could have included pharmacists working in chains of up to 300 shops that are described as ‘independent multiples’ but which have corporate branding, sophisticated in-house training programs, and practice standards that align their way of working more closely with the multiples. For the purposes of this research therefore any pharmacist owner or manager working in a pharmacy that was part of a chain of 5 or less pharmacies or a member of AIMp could be included in the study. Pharmacists working for multiples that were members of the CCA were

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excluded. Beyond this however, as the research was concerned primarily with how the pharmacists presented themselves as professionals it took the pharmacists’ impression of their status as an ‘independent’ as the most important signifier that made them (rather than necessarily their pharmacy) eligible for inclusion. Using this criteria, the largest chain represented in this research consisted of 38 branches, the majority of which were based in London and the South East. Participant observation aimed to collect data on behavior and interactions. Although the researcher did not have a specific role within the pharmacy environment, distinct relationships with the actors within the pharmacy were established. The researcher participated in everyday pharmacy life in a general sense, making tea, making conversation with customers and staff however as the researcher had no formal pharmacy training she did not take part in the work of the pharmacy. Research took place over a period of one month within each pharmacy. Within this period observation sessions were agreed with the pharmacist to cover to the range of opening hours of the pharmacy in order to get a sense of the business at different times. Sessions were usually around 4–5 h a day after which the researcher would write up the days findings. Observation facilitated an understanding of the ‘public’ presentation of the role of the pharmacist. While a concentration on such a specific location does not enable a contextual account it does allow for examination in detail of a particular social world. Observations were recorded in the field using logs of daily activities, a personal diary and methodological and descriptive field notes. Face-to-face interviews were conducted to inform observations and to collect cognitive data (data on beliefs, attitudes, decision making and problem solving approaches). Although a general topic guide was used the interviews were ‘active.’ An active interview emphasizes a more conversational structure and fluid negotiation of meaning.24 All interviews were audio recorded and subsequently transcribed verbatim. Data were analyzed using a constant comparative method taking a “reflexive, constructivist approach” informed by grounded theory methods.25 Interview data and observation data were initially analyzed separately. At the thematic stage results from both inputs were reviewed together.

In practical terms this approach involves an iterative process of careful reading and re-reading of notes and transcripts, annotating thoughts and coding the data into themes. The process begins as soon as the first transcripts and field notes are written up. One advantage in beginning analysis while still collecting data is the ability to take ideas back into the field and explore and refine concepts. Coding was initially produced within individual interview transcripts/notes examining the content line by line to develop a provisional coding scheme (open coding). This scheme developed from early data could then be applied as a focus and developed when looking at subsequent input. The next step was to re-interrogate the data and explore ideas both within and across accounts, looking to find relationships between categories and develop initial ideas into more complex themes. The researcher then continued to read and re-read the data until no additional themes felt apparent. Paying attention to ‘deviant cases’ within the research, i.e. being concerned with differences as well as similarities, is particularly important to interrogating and questioning findings.26 Throughout analysis responses/situations that appeared to fall outside the ‘norm’ were highlighted and used as comparison to further refine ideas. It is important to highlight that the work presented here represents part of a wider study. In exploring this particular subject focusing on personal belief and attitude toward independence the data presented draws heavily on the interview data. Observation work however was crucial to gaining a contextual understanding of these personal narratives and so although less heavily weighted in the findings remains crucial to the analysis. Numerical identifiers have been assigned to interview respondents in the following text and pharmacists/pharmacies taking part in the observation work are assigned identifiers A–G in order to maintain respondent anonymity. Results These findings represent the perception of the pharmacists interviewed and are intended to reflect their personal perception of independence and their personal perceptions of the difference between independents and multiple pharmacies.

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The independent experience: autonomy “And why did you move from the multiples to your own practice? You want to be independent. Just for that independence? Independence, that’s it isn’t it?” Pharmacist 30

In response to questions around the attraction to and the value of or benefits of, independence answers included: “being my own boss” and “I am in charge of my own destiny,” even for those who were pharmacy managers rather than owners. One of the biggest benefits of independence was simply stated as the freedom to make practical, personal decisions much like the single handed General Practitioners (GPs) in Green’s research.27 These “small freedoms” were often expressed in relative terms and the antithesis of being an independent was positioned as working for a large multiple. In total 22 of the 43 pharmacists had professional experience of working for multiples prior to entering the independent sector, either on permanent contract or as locums. Their stories contrasted the restriction of a feeling of being under a weight of corporate rules and regulations, with the ability to be the decision maker and instigate change: “( . ) it was the frustration that set in. When you saw a good idea, it wasn’t [a good idea] ’cause you had to go to Head Office for sign-off and they always said, “No.” Whereas here, if I want to change the prices of ten lines just like that, I can do it now and then I can go back, and I can see the fruits of that really quickly, and it gives you a drive” Pharmacist 29

Pharmacist 27, who was a pharmacy manager in a small chain, had recent experience of working for multiples. He articulated the sense of restriction he felt in terms of “less room for manoeuvre”: “(. ) in the multiples you have got essentially directives thrown out from head office which can’t be helped but there is less room for manoeuvre around those. (. ) and there is a lot more paperwork and more to-ing and fro-ing between, much more corporate basically” Pharmacist 27

By contrast independent practitioners positioned themselves as positively overcoming

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challenges. These perceived challenges included having fewer resources, both financial and in terms of premises and staff. Self sufficiency and independence therefore existed hand-in-hand with a sense of greater administrative responsibility. The apparent lack of structure in independent pharmacy however is not always seen as a positive. One pharmacist for example had recently joined an independent store as a pharmacy manager but was considering a move back to a multiple in order to regain a sense of ‘organization and control.’ The sense of autonomy so keenly felt by the independents and the driving force in their professional identities may not come as a surprise when discussing pharmacy owners. Nonetheless, employee pharmacists in this study, such as pharmacist 18, also felt they had professional autonomy in a way that they would not if they are working for one of the multiples: “So yeah, it’s – you’ve got flexibility. Yeah, it’s much freer; you can do things on your own” Pharmacist 18

“I think we’re the last of the Mohicans” pharmacist 16 said during his interview. In his view independence was being overtaken by a dominant multiple sector and that this was leading to increasing professional marginality. As such for him and for a number of other pharmacists in this study, independence although associated with a sense of freedom and creativity, was also linked to isolation. Professional isolation was also articulated through a sense of being on the margins of the NHS and “lack of voice.” The challenges of being on the margins were met with two very different strategies. For some, this struggle manifested itself as a negative narrative of survival against the odds in a harsh world. Those pharmacists who were more fatalistic about their future felt that as independents they would be slowly and inevitably squeezed out of business, unable to compete and increasingly irrelevant. “But I think the way government policies are towards pharmacy means that they are going to be in decline. I think the amount of multiple owned pharmacies is now 65% so gradually all the independents are selling up” Pharmacist 8

For others the future was a positive challenge and the changing landscape of pharmacy offered them a chance to take on a different role and seek out new opportunities. This latter group, were

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most likely to view their participation in this research as a chance to promote independent pharmacy and to publicize the need for variety and choice on the high street. Reflecting this dichotomy there was also a range of interpretations of the ‘modern’ independent pharmacist; from those who connected fully with the idea and presented themselves “almost like doctors”28 to those who rejected the new more clinical remit in favor of maintaining the “friendly pharmacy” focused on efficient dispensing. Those pharmacists who favored a more clinical persona tended to consciously emphasize medicines and medical products and services in store. Like pharmacist 28 they often contrasted their pharmacies with “old fashioned” or “less professional” independents: “There are some pharmacies that I just really wouldn’t want to work in ever, not ’cause they’re dirty, just ’cause of the amount of rubbish they keep and there’s quite a lot of them that are just plainly cluttered and not thought out” Pharmacist 28

New services were seen as having the potential to increase professionalism and showcase the potential of pharmacy. “I think it’s very good that they’re pushing so many enhanced services into practice, which is very good, and I like it, you know. And then people beginning to know, understand, what pharmacy’s all about, because before they think we’re just a shop (. ), but now they have seen what other services pharmacy can provide (. ). We feel a bit of pride” Pharmacist 25

For other pharmacists the more clinical role was unappealing. Priority in these shops was given to being comfortable and familiar. “It feels a lot more intimate dealing with a general independent rather than going in to somewhere like [ Multiple X] or [Multiple Y]. Which tend to have like an overly clinical or official like feel about it. I think that we have to be there to listen and sometimes just the ability of a client to come and talk to you, they will go away feeling better”

concerning their clinical remit, preferring to focus on their role as “an expert technician.”29 “Yes, you have to be away from the basic dispensing process and you can’t do that because it is the core, you can’t ignore it (. ) if we don’t provide that service, (. ) [customers] are not willing to come back” Pharmacist 11

Consistent with other studies11,30 the business aspect of independence could be polarizing. For some pharmacists, the idea of not working for someone else and having direct accountability as a businessman as well as a health care professional was motivating and key to their sense of autonomy. Others however viewed business as a “necessary evil.” Running a profitable shop and being proficient in business were simply requirements for being a “good pharmacist” and some of those with the greatest interest in presenting themselves as health care professionals also stated quite clearly a strong interest in business. Pharmacists who were not businesslike could be viewed as “shoddy” or “inefficient” by those who were running a good pharmacy. “I look at myself as a businessman as well, not just a pharmacist, this is one of the unique professions where you are able to combine the two and play around with it, I can return to being just a pharmacist on its own if I like but the whole idea is that I have contact with the public” Pharmacist 9

Engagement: locating community The pharmacists directly related ‘localness’ to independence due to the reliance of independents (even within independent chains) on custom from people resident in their immediate surroundings for business survival. “If you look at it, that was how the independents were built, they were supposed to be in the centre of the community, that is the way, so they try to shorten the bridge, that bridge, that gap (. ) in a big company it is different. It is not the same. That is how it is” Pharmacist 24

Pharmacist 7

For these pharmacists there was a desire to create a less ‘medical’ or ‘clinical’ pharmacy on the grounds that it was potentially alienating, and even inappropriate in a community pharmacy environment. Their approach was more restrained

“ . it is like the local post office in some ways especially down here we get so many people who are local who would definitely miss it; they like to have a local personal service” Pharmacist 21

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Local knowledge based on an intimate understanding of their surroundings was discussed with the researcher in the observation setting. Pharmacists used descriptions of ‘round here’ in order to emphasize their connection to place and local communities. For example, in pharmacy D a group of teenage boys came into the shop. The pharmacist came to the counter and addressed them directly asking them to “move on” and telling them they needed to be careful. Once they had left the shop he explained to me that they were “harmless lads” really, that he knew their mothers and he had known them all “since they were in their prams.” Meanwhile Pharmacist 24 was keen to highlight a positive perspective of his local community: “We have nice people in the community, you hardly ever find people coming in and shouting in the shop or whatever. I mean when I tell people I am living in [this area] they are always like whoa, but for example . I got in a locum.... she was like ‘will I be able to find a safe place to park?’ ‘Do you think my car will be safe?’ I said ‘come, what car do you drive? When you come here the cars they drive here are better than your car, nobody will be worrying about your car!” Pharmacist 24

Community and a shared sense of locality also feature strongly in narratives of setting out on a career. For those who wish to open their own shop, restrictions on the opening of new pharmacies and the high degree of competition for existing contracts means that the major motivating factor in finding a place to practise can be pragmatic opportunism. A significant number of others however included in their reasoning the fact that they chose to practise in East or South-East London due to the demographics of the potential customer base. For example, pharmacist 2 discussed his decision to practise in an area based on the local community: “Because, well, a) it is a heavily ethnic area, b) there is a mosque around the corner and I am Muslim erm c) it was on the market”

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“I mean, I know the area. I know the types of patients and I know the languages, so – and the – as a result the culture as well, I can understand the culture of different communities there, so, yeah, it’s – that’s a great benefit as well” Pharmacist 1

The idea of the fully engaged community pharmacist was often presented as the ‘ultimate’ achievement for the independent. Becoming “the full package” as described by pharmacist 15 was defined by being more than “just” a pharmacist and included taking a “leadership” role in the community: “He [the owner of this pharmacy] is a Dad figure, that’s s it. (. ) he is involved in the church you know, and things like that, always into fund raising, community services, going to charity events, many other things, not just pharmacy. He is that full package” Pharmacist 15

To manage the requirements of all the individuals that use the pharmacy pharmacists articulated a need for what might be described as personalized pharmacy, rooted in the creation of relationships with individual customers. The long lasting personal relationship in particular remains extremely important to independent pharmacy, and this relationship was consistently presented as an ideal. This did not mean that pharmacists needed to form deep or lasting relationships with every customer; it did mean however that they felt that they must be adept at opening up this possibility but also able to deal with customers who wished to maintain a transactional relationship. The “art” of the individual as Pharmacist 15 went on to discuss forms the foundation for practice: “Oh yes, you have to be different with everyone. You have individual customers. That is an art, that is, an art you know (.) people are different. It is important, the way you speak to them, even body language, social forms, all of these things are really important, otherwise they are not happy” Pharmacist 15

Pharmacist 2

There was a particular emphasis on choosing a place to practise in which they were able to make immediate connections with customers through a sense of shared experience.31

Pharmacy customers are in a position of relative power through their ability to exercise control over which pharmacy they choose to use. This is heightened in the urban setting where other options are freely available with little additional

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effort for many customers. Pharmacists recognized and actively built on this empowered customer status. They framed the basis for oneto-one engagement in the pharmacy by locating the customer in a position of choice and the pharmacist as being dependent on that choice to maintain business: “They can go somewhere else (.). So this has made the pharmacist, you know, I don’t know, the way we are trained is really show everybody the same respect and you have time for them ., but I must admit when I used to work for a [multiple] company I didn’t care so much” Pharmacist 19

Continuity of staff enabled pharmacists to move from brief interactions to close, personal relationships. The perception was that multiples often have regular locums, staff rotation policies and pharmacists who choose to move from store to store in order to progress careers. Continuity therefore becomes something that independents can excel at. This continuity, coupled with the ability of the pharmacists working within independent pharmacies to leave the dispensary and talk to customers allowed pharmacists to become “human” and engage with customers over a period of time. The pharmacists felt that this was particularly possible in independent community pharmacy as a direct result of having autonomy over their time and being able to control the type of relationships they wished to build, again in direct contrast to their experiences in the multiples: “If you’re hiding behind that counter that’s no good. I’ve done it in Supermarket X and Supermarket Y, and you hide behind the counter and you don’t know people. They just come and take it like a machine; you are a robot. Here you are human”

“You have got to want to help solve problems. All sorts of random stuff really, sometimes you have to be really flexible and do stuff that is totally off key with what you would normally do, but that is what makes a good pharmacist. You have got to be a bit different, you can’t be just doing things straight from the book, you have to go that extra mile for people. That is why they come back” Pharmacist G

As described in more detail in previous outputs of this research two ways in which this bespoke service manifests include stock and staffing. The multiples are inevitably able to provide customers with lower prices on household goods, General Sales List and over-the counter-medicines due to their bulk purchasing power. What pharmacists in larger stores are less able to do however is to source hard to find or less commonly used items for customers. Many of the pharmacies followed the lead of surrounding small businesses and concentrated on the provision of stock to serve particular ethnic groups.31 In the hyperdiverse setting pharmacists often did not understand every transaction that occurred in their pharmacy due to the wide variety of languages spoken.31 They frequently found themselves relying on other members of staff or family members/friends of the customer to translate for them. The interpreted consultation however raises concerns in ensuring the correct information is passed on. In order to overcome these difficulties another aspect of a specialist service was the active employment of multi-lingual staff, covering as many of the locally commonly spoken languages as possible31: “( . ) it is a major, major challenge. The people I employ have to understand a lot of the different languages. I mean I don’t speak all of them, but we have Bengali here, Gujarati, Punjabi, Urdu, Hindi you know, Tamil, you know ( . ) I mean the GPs in this area will phone me and just start speaking Hindi, that must just say it all really”

Pharmacist 16

A bespoke service: autonomy in action It was through the delivery of creative, practical solutions that the pharmacists best demonstrated control over their surroundings and made the most of their relationships with customers. “Being flexible” and “being different” were qualities associated with “good” independent pharmacists. This kind of flexible and responsive service was reported with equal frequency by managers working for independent chains as it was by owners.

Pharmacist 2

A third, and equally important way of providing a bespoke service was through “sorting things out”. One example of this ‘fixing’ behavior was helping customers when they had not been organized in getting repeat prescriptions or follow up appointments or perhaps had run out of medication due to particular crisis situations. For example, a customer came into pharmacy C in great distress having dropped the last tablet of her packet under the fridge. The pharmacist

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provided her with an emergency supply of her tablets and reminded her to make an appointment to get a repeat prescription the next morning. In pharmacy F an elderly customer requested a smaller packet of paracetamol as he did not have enough money with him to buy the larger pack size. In this case the pharmacist waived the extra 49 pence saying “just pay me back another time.” Both of these examples were cited as being behaviors that these pharmacists felt would not be possible in a multiple pharmacy due to company protocol. ’Sorting things out’ also takes on the form of either educating customers or negotiating on their behalf, helping them to navigate ‘the system.’ Pharmacists located a particular need for this service not only in terms of difficulties caused by cross cultural and communication problems but also due to the socio-economic circumstances of the population they serve. “A lot of people don’t know how to access the health care or the services that are available. You know, they are still sort of stuck ( . ) well, not stuck but just don’t know about stuff. Obviously being East End, they are set in their ways. Not uneducated but they are working class” Pharmacist G “You have got to manage all sorts of views of particular needs and things that you just never, you wouldn’t actually have considered until they mention it. (. ) I have worked outside London where you may get the people that you see on any given day will pretty much be from the same circle, from the same ethnic background, now that is not to say that you treat them as if they are all the same but you know they are from much the same ethnic and social strata where here it is much more challenging” Pharmacist 27

Supporting the work of previous studies,32,33 pharmacists rarely expanded on product advice to give general health advice in association with purchases or prescriptions largely because they lacked ‘permission’ from the customer to enter into a discussion at this point. More expansive discussion was most often observed outside the formal medicines advice-giving role. Pharmacists used their ‘independence’ to create different situations for interaction, opening up possibilities in the pharmacy. Building on their understanding of customers needs and creating a space in the ‘pause’ before or after the formal transaction, they were able to engage customers in discussions

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that touched on broader concepts of wellbeing. In pharmacy B for example the pharmacist came out from the dispensary to help an elderly customer select some new reading glasses. The informal conversation that followed also provided an opportunity to check if the customer was being visited by her grandchildren and what support she had around the home. It is also in these informal interactions that a reportedly different, independent approach to managing time in the pharmacy becomes relevant and valuable. “You hear everything about their lives and because our pace of work and nature of work is different [to the multiples], we can help in different ways” Pharmacist 28

While this idea of accessibility and an expansive sense of time in the pharmacy characterized discussion of pharmacy relationships, time is also contested. The ability of the independent pharmacist to take time to build a relationship with customers was also perceived to be under threat from contract services which call for which place additional demands on pharmacists time and draw the pharmacist away from the dispensary/ counter. A common trope throughout the interviews in particular was a lack of quality time in the pharmacy, again echoing previous studies.33

Discussion The self-identified independent pharmacists represented in this study describe professional personhoods through the rhetorical use of three overarching and connected themes of autonomy, engagement and bespoke service. Autonomy forms the basis of professional personhoods and enables the pharmacist to exercise control over the development of customer relationships. This ability facilitates engagement with communities and individuals and ultimately makes possible a pharmacy offering that is based upon a bespoke ‘personal’ service. Together these rhetorical themes are used to identify with a collective interpretation of an ideal independent practitioner. These three themes are also used rhetorically to influence behavior; either to suit or refute the dominant discourse, revealing how these independent pharmacists reacted to a prevailing ideology in terms of policy making and in terms of the development of pharmacy services which encourages pharmacists to be more clinically oriented and patient focused.

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Pharmacists draw on features of their urban environment, especially the diverse urban communities that they serve. Their particular urban setting provides a context for the expression of relationships with customers and their particular needs. The complexity of this setting is used symbolically to support the need for independent thinking. Pharmacists suggest that they are able to preferentially service the needs of the hyperdiverse inner city through their ability to:  Contend with ambiguity through the use of professional judgment  Be available and have control over their use of time  Identify with urban lives In presenting these challenges as being something that the multiples are unable or unwilling to address, the urban context serves to give these pharmacists a sense of exclusivity over a field of practice. It becomes a particular situation within which independent pharmacy can, in their eyes, be utilized to its full advantage. The most powerful persuasive tool in describing the value of independence is the ability to act with autonomy and the idea of being an autonomous practitioner united pharmacists with very different approaches to practice. For these pharmacists autonomy, even in a limited sense, gives them a moral agency that renders them ‘more professional’ than those working for multiples. This moral agency was stressed in particular in comparison to pharmacists practicing in multiples who are subject corporate rules and restrictions. The involvement of a corporate ‘way of doing things’ was positioned as an additional layer of bureaucracy that blunts the potential of the pharmacist to take a dynamic role in the direction of the pharmacy. In comparison to these colleagues, pharmacists felt more able to exercise personal professional judgment. Pharmacists working for the multiples are considered to be ‘twice subordinated’ (to the GP and to the corporate brand name) whereas independents’ cling to a notion of autonomy in order to maintain their value versus the competition. The traditional ’Janus-faced’ community pharmacist is torn between a personality as a health care professional and one as a businessman. In practice these two aspects of the pharmacist’s character were not always in opposition. While a minority of the pharmacists articulated their position through this narrative, most, even those who did not enjoy business, found an effective

way of rationalizing both faces. Rather, what emerged in practice was a remaking of the fundamental tension in pharmaceutical identities, focusing on those who did and those who did not accept the dominant discourse that requires a shift toward a more clinically involved persona. ‘Independence’ can be used as a strategy either to resist or to embrace change. This leads to a contemporary professional tension that sees some independent pharmacists embracing the new direction of pharmacy, drawing on elements of the dominant rhetorical framework in describing professional personhoods. On the other hand, rejecters of the dominant discourse utilize this opposition to create a professional sense of self that references traditional pharmacy values founded in dispensing. At the time of my research this distinction was best demonstrated in practice by the physical means through which pharmacists are able to project a professional persona in the shop and through their relative uptake of new pharmacy services. ‘More clinical’ pharmacists are likely to describe themselves as being part of an integrated NHS and self consciously express expertise through alignment with medical authority and the new pharmacy mandate. They were often keen to take part in PCT level decision making and likely to assume a positive future outlook for independent pharmacy. ‘Less clinical’ pharmacists meanwhile were more likely to describe themselves as being in an isolated business. These different tones of voices from independent community pharmacy are reflected in the National Pharmacy Association’s 2014 listening sessions. In these sessions pharmacists described challenges facing the independent sector including squeezed income streams and red tape, while at the same time stressing that the aspiration of independents is not simply to survive but to progress.34 Expertise for these less clinical pharmacists is expressed through control over a traditional dispensing focused pharmacy mandate and they were more likely to assume a pessimistic future outlook. Those at this end of the spectrum could be dismissed as being ‘nostalgic.’ In the critique of independent pharmacy there is a sense that nostalgic idealization of the past is used to protect independent pharmacy from embracing its future and that independence can prevent practitioners from embracing change and being truly ‘modern’ members of their profession. Nonetheless these ‘less clinical’ pharmacists do provide a counterbalancing argument that suggests their role as an

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autonomous mediator is increasingly under threat as they are pulled into the NHS family. If this development entails giving up their outsider status, these pharmacists suggest that they could lose their true independence and hence perhaps their true value. An attachment to locality was often used by independent pharmacists to set them apart from the multiples; however, the relationship between pharmacists and community is not necessarily straightforward. Much of the pharmacists’ discourse around community centered on the topic of ‘acceptance’ and ’fitting in’ shaped their approach to the hyperdiverse, urban environment.31 This understanding of their capacity to function as a ‘good’ local community pharmacist and engage with customers had a significant impact on their choice of practice. Community status is not automatic and cannot be artificially imposed. The need for pharmacists to engage with communities shows that they are not only subject to a dominant rhetorical frame but also subject to acceptance from the general public. The pharmacists’ presentations of professional personhoods take this into account and being perceived to be socially close to the customers they serve is positioned as being of critical importance in creating successful acceptance into a community. This idea of community acceptance of independent pharmacy is echoed in recent research commissioned by the Independent Pharmacy Federation in which customers stated that they believed that they were supporting their local community by using independent pharmacy.35 The pharmacist’s cultural capital could be used in two distinct ways in developing professional personhoods. Firstly to identify shared experiences with their customer base. This created a ‘connectedness’ which allowed for greater intimacy and a more personal interaction. Secondly the pharmacists take on the role of a social ‘broker’ (able to ‘transmit values of society to new comers’), or a ‘patron’ (able to ‘dispense favors’), ‘negotiating the boundary between community and the health care system.’31,36 The idea of independent pharmacy as a space for trustful, close relationships served to shape the narrative of the independent pharmacy. Almost more important than the reality of having a close relationship with every customer was the idea that a relationship had the potential to develop in such an intimate way. The value placed on relationships is reflected back by

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customers with those using independents prioritizing staff and relationship as critical factors driving their choice.35 This study shows that independent pharmacists were very good at exploiting their potential as specialist-generalists in building relationships. In using language skills or stocking decisions to grow special interests within the pharmacy, pharmacists create a distinctive practice. Small pharmacies can survive by becoming destinations, places people will choose to go out of their way to visit. The rhetorical play on the idea of specialism is used to contrast their services with the multiples’ one-size-fits-all approach. Deploying time as part of the performance of pharmacy is also an important persuasive act influencing “bottom-up” (driven by the customer) power relationships.17,37 This study found that in spite of previously observed failures to maximize the use of time in advice-giving surrounding medicines and health,7,32,33 pharmacists did utilize time to create informal spaces for non-clinical advice-giving and in ‘sorting out’ problems. These informal services are of particular significance in differentiating the role of the independent from the multiple and rely on the exercise of autonomy and the use of professional judgment.38 They also formed an important but perhaps not acknowledged part of the pharmacist’s ’community health’ value. A paradox revealed in this research however was that pharmacists simultaneously report a lack of time. This time pressure is cited both in this and other studies33 as being a significant barrier to being able to engage in advice-giving services. In stating that they are unable to find time to devote to public health messages in pharmacy it is possible that independent pharmacists themselves are obscuring the work that they already do. There are parallels between this ’hidden’ skill and the under reported non-verbal communication skills within the pharmacy that Stevenson discusses in investigating the multi-lingual pharmacy. These findings highlight the need to consider all aspects of pharmacy communication when evaluating the potential of pharmacy/customer relationship.39

Limitations Ethnographic studies are often criticized for a lack of generalizability. These claims are countered by suggesting that ethnographies produce descriptive and explanatory elements which can be

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generalized to a larger population or can be more generally valuable through theoretical inference. The research methodology used renders this account a partial one and further investigation might reveal different sides to this story. It is also partial in the sense that there is always selectivity in what respondents choose to reveal. This work, concentrated on a group of pharmacists who self identified as independent. Future research might go further in attempting to understand how or when and if pharmacists stop being able to think of themselves as independent (the limits of independence) and the perceptions of pharmacists working for the multiples. Inevitably the performance of research within the pharmacy environment had an impact on what was observed and on the interactions that took place, highlighting the point that research is a mutually derived process. As a non-pharmacist the researcher was not an expert in the field and so there are clear limitations in understanding however this comes alongside the benefit of an outsiders perspective. A particularly important point that shaped discussion was the position of the researcher status as either a ‘student’ or as a ‘researcher.’ While not aware of consciously adopting either of these roles later analysis showed that in interactions with the pharmacists the researcher assumed these positions as talk progressed, creating a foil for their stories. The process of being ‘researched’ also potentially has an impact on behavior, consciously or subconsciously on pharmacists and their staff. During observation work it was very hard to measure what impact the presence of an observer had on the pharmacists and their work. At times the researcher was aware of pharmacists being extra vigilant and perhaps spending more time than they might usually have done in explaining medicines to customers or being more conscientious about pharmacy processes. Refusal to participate was in all cases reported as being due to restricted time. A further limitation of this approach is that the pharmacists who chose to take part may have been pre-disposed to describe the importance of independence. They may also have chosen to work as an independent following a bad experience in the multiple setting.

Conclusion This research highlights the figure of the independent pharmacist and, in exploring the

construction of pharmacist personhoods, reveals a particular way of being that makes a valuable contribution to the delivery of care. Being ’independent’ framed the creation of professional personhoods beyond simply indicating the trading status of the pharmacy within which these pharmacists work. Independence becomes a value that can be adopted as being personally representative, something to be proud of and something to defend. It was also an idea with contemporary relevance and was discussed with equal potency by those pharmacists who had recently qualified as well as by those who had been practicing for many years. Independence influences the nature of services provided and this in turn raises questions regarding independent pharmacy and the relationship between the services it provides versus the multiples. This suggestion of a particular and different type of pharmacy service provision supports findings by those who conclude that a variety of different community pharmacy models may be required to give maximum benefit to all patients.

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Appendix Active interview guide Please note that due to the active nature of the interviews this guide was used as a flexible outline to guide conversation rather than as a formal guide. The following is NOT intended to represent an exhaustive list of questions, rather it indicates some initial suggestions which provided a starting point in questioning around each of the topics: Topic 1. Practical implementation Themes: practical competence, physical doing and being, descriptions of encounters, perceived skill levels, understanding of consultation process, relationship with customers  How would you describe your pharmacy practice?  How would you describe the community that you serve?  How would you describe your job? Probe: what do you do as a pharmacist, what does your work entail, what are your responsibilities?  How would you describe your relationship with your customers?  How do you think your customers perceive pharmacy/pharmacists? Probe: as compared to a General Practitioner (GP)/Practice Nurse, is that different for different members of the community?  What do you think pharmacy offers as compared to going to see a GP/Practice Nurse?  What is the role of your pharmacy in the community? Topic 2. Knowledge and understanding Themes: understanding of local community, structure, influences, needs, perceptions of the multiethnic community, role of pharmacy in multiethnic environment, awareness of policy initiatives  What are the challenges of working in this area? Probe: Are there particular needs related to the multiethnic community you serve?  What do you do to try to address these needs?  People in this community have been exposed to a range of different medical traditions and medical systems, how does that impact on your practice? Probe: use of ‘non western medicine’  Do people have different expectations of pharmacy if they have experience of how it is used in other countries?

 When people first arrive in the country how do they use the pharmacy? Probe: Do they have particular needs? How do they negotiate the health care system here? Topic 3. Personal relevance Themes: engagement with local community and policy initiatives, relation to wider societal goals, relevance of culturally competent care or equality and diversity strategies  What do the terms: ‘health inequalities’, ‘culturally competent care’, ‘equality and diversity’ mean to you?  Are you aware of Department of Health/local strategies for providing care through pharmacy to address ‘health inequalities’ or specific initiatives for multiethnic communities?  To what extent do you think pharmacy should be responsible for providing health services tailored to different ethnic communities?  How should this fit with your contractual requirements?  Do you feel you have a voice within the Primary Care Trust (or beyond) in terms of how policies are implemented?  What is your opinion of current initiatives aimed at addressing health inequalities?  Could you be better supported? How? Topic 4. Self awareness Themes: exploration of cultural and professional background, fluid nature of identities/plural identities, multilingual identities, the role of the pharmacist  How do you feel that independent community pharmacy is viewed today within the profession/by other health care professionals/by policy makers?  Why did you go into pharmacy? Why Independent pharmacy? Why did you choose to work here?  How would you describe yourself professionally, what is your persona in the pharmacy?  How do you feel about the role you play within this community?  How would you describe your ethnicity? Would you change that description in different settings for example if you were with your family and friends or if you were at a professional meeting?  How do you think this influences your practice? Your relationship with customers?