Advice-giving in community pharmacy: variations between pharmacies in different locations

Advice-giving in communitypharmacy: variations betweenpharmacies in di�erent locations

Anne Rogers,* Karen Hassell,*$ Peter Noyce$ andJennifer Harris%*NPCRDC, Williamson Building, University of Manchester, Manchester M13 9PL, UK$Department of Pharmacy and Pharmaceutical Sciences, University of Manchester, Manchester M13 9PL,UK%Department of Social Work, University of Central Lancashire, Preston, UK

The advice and services provided by community pharmacies are viewed by policy makers as hav-ing an increasingly important contribution to make as a primary health care resource to localpopulations. However, little attention has been given to the variations which may exist betweenpharmacies operating in di�erent localities. Findings from an ethnographic study of pharmaciesilluminate di�erences in the nature and quality of advice and services provided by pharmaciesoperating in disparate localities. Analysis of qualitative data suggests that di�erences in the en-vironment within which pharmacies are located and organised in¯uence the type of service pro-vided to local populations. The possibility of an inverse care law operating in relation to thenature of services in poor urban localities compared to those in rural areas is also discussed. #1998 Elsevier Science Ltd. All rights reserved

Keywords: advice-giving, community pharmacy, equity, locality, ethnography

Introduction

Community pharmacies in the United Kingdom,of which there are just over 12 000, provide a net-work for the distribution of medicines and theprovision of health advice to the public andhealth professionals (Bond and Bradley, 1996).With the growing importance of self care, de-regulation of medicines and the perceived need toreduce the workload of general practitioners(GPs), community pharmacists have, in the lastdecade, sought to establish themselves as advice-givers about medicine usage and symptom man-agement. For nearly a decade government healthpolicy has highlighted the advice-giving potentialof pharmacists and their strategic importance forthe primary health care system (Turner, 1986).Recent primary care policy has supported thenotion of community pharmacists being used asthe ®rst port of call for minor ailments (Nu�eld

Foundation, 1986; DoH, 1996). A reason for theencouragement of this pharmacist-as-advisor rolehas been the need to reduce the `burden ofdemand' on GPs. Others have noted the import-ance of pharmacists in identifying and meetingthe needs of particular customers, for example,drug addicts who might otherwise have little con-tact with mainstream medical services (Mulleadyand Green, 1985). Within this o�cially endorsedextended role (DoH/RPSGB, 1992; DoH, 1996)equitable access to and provision of pharmacyservices in the UK become increasingly importantissues to examine. In the ®eld of pharmacy prac-tice, relevant research has been con®ned to a fewexploratory studies. A small scale study, usingstructured observation in pharmacies in twoareas with opposing extremes on the JarmanIndex, found that clients visiting pharmacies in apoorly doctored area were more likely to beo�ered clinical advice about both prescriptionsand `over the counter medicines' (OTCs) thanthose in a well doctored area. It was also noted

Health & Place, Vol. 4, No. 4, pp. 365±373, 1998

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365

that pharmacists in the poorly doctored area didmore clinical work than those in the well doc-tored area (Mukerjee and Blane, 1990). Access toand the siting of pharmacies have recently beenidenti®ed as having importance for planninglevels of pharmaceutical care provided to popu-lations. It has been pointed out that the distri-bution of community pharmacies may not re¯ectpatient needs, even though proximity to a phar-macy tends to be greater in more deprived areas(Hirsch®eld et al., 1994). However to date therehas been little acknowledgement that communitypharmacy provision might be in¯uenced by fea-tures of the locations within which they operateor the populations they serve. Moreover, whilstpharmacy research acknowledges variations inthe provision of advice (Tully et al., 1997), todate research has not addressed how the loca-tional context or internal environment of thepharmacy might in¯uence the nature and qualityof advice-giving. Rather there is a taken forgranted assumption that the pharmacy ipso factoprovides a suitable environment for this activity(Hirsch®eld et al., 1994). The research reportedhere examines the way in which advice-giving isexpressed within speci®c localities and pharmacyenvironments. In so doing, it highlights some ofthe subtle di�erences in the nature of servicesdelivered and the way in which pharmacies areused by di�erent groups in the population.

Analysing place in the context of communitypharmacy

As a type of organisation which is situated at theboundary of pro®t-making enterprise and pub-licly provided health care, community pharmacyprovides a critical case for understanding thecomplex interaction of dimensions of place andspace that has been a feature of recent researchand policy in the health ®eld (Philimore, 1993;Moon, 1995; Sooman and Macintyre, 1995). Twodimensions of place and space have particularrelevance to the study reported here: ®rstly, theimmediate localities within which the pharmaciesare located (external location) and secondly, in-ternal spatial arrangements. With regard to the®rst of these, the external location implicates fea-tures of populations and places and a number ofthem have been considered to be important inunderstanding health in a locality (Macintyre etal., 1993). These include: the physical features ofthe environment, the availability of a healthydomestic, work and play environment, publiclyand privately provided services which supportpeople in their daily lives (including health andwelfare services), the social and cultural featuresof neighbourhoods (e.g. political, economic, eth-nic and religious histories, the extent of commu-

nity integration), levels of crime, perceivedthreats to safety and the reputation of a neigh-bourhood (e.g. how areas are perceived by resi-dents and outsiders).

A further way of analysing the spaciality ofsocial relationships relevant to community phar-macy is with reference to the concept of `locale'which has been used as a means of examiningchanges and the e�ects of `structuration'1 inurban and rural areas (Duncan and Savage,1989). According to Giddens, locale is:

``a setting which is not just a spatial parameter, andphysical environment, in which interaction occurs:

it is these elements mobilised as part of the inter-action. Features of the setting of interaction, includ-ing its spatial and physical aspect . . .are routinely

drawn upon by social actors in the sustaining ofcommunication'' (Giddens, 1979, p. 206)

This concept provides an analytical bridge indrawing together the external locational featureswith an analysis of the internal spatial arrange-ments of pharmacies within particular localities.The latter is important in identifying the relation-ships between action and structure which charac-terise the nature and type of activities andpractices taking place within the internal space ofan organisation (Stimson, 1986). The subsequentanalysis of data will focus on the way in whichdimensions of place and space relate to the socialaction and interaction that occurs within thepharmacy, the way in which the spatial arrange-ments of the pharmacy enforce, encourage, dis-courage or preclude certain ways of behavingand how these are connected to characteristics ofthe external location.

The study and methods

The main aims of the study were to describe thenature of advice giving in a community phar-macy context and to explore the organisationaland other factors which a�ect the nature andtype of advice provided. Ten pharmacies in theNorth West of England were chosen to representas far as possible the diversity of pharmacy types(i.e. multiple or independent ownership), lo-cations (i.e. rural, suburban, inner city, small andlarge town), and pharmacist characteristics (i.e.manager or owner, gender and age). Data werecollected through the observation of routinepractice in each of the ten pharmacies over a fullworking week. Sta�±customer interactions thatinvolved the selling or dispensing of medicinesand more general health related advice wererecorded and transcribed verbatim. Interactionswhich involved the purchase of commercial pro-ducts were not recorded. Pharmacists and coun-ter sta� were interviewed about their advice

Advice-giving in community pharmacies: A. Rogers et al.

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giving role and one thousand customers inter-viewed in-store about the reason for their visit,frequency of visits and customer social demo-graphic details. Follow up telephone interviewswere conducted with 44 customers who hadreceived advice. Although chosen at randomthese customers were nevertheless self-selecting.One of the main objectives of this study was toexamine if advice giving di�ered between phar-macies.

The nature of advice giving in communitypharmacy

Overall it was found that the pharmacies wereprimarily used as a supply source for medicinesand other goods. Most people (60%) visited thepharmacy to get a prescription dispensed. Justover a quarter went to buy a non-medical pro-duct (e.g. toiletries) and a ®fth purchased an`over the counter' product. The nature of advicesought and obtained was inextricably bound upwith these core activities. There was little generaladvice given about health and illness that wasindependent of the function of the selling or dis-pensing of medication, with only 1.3% of custo-mers attending speci®cally for advice onmedication or a medical problem. The dispensingor purchase of medication entailed a range ofadvisory elements which included recommen-dation, reassurance, instruction, information orreferral. By demanding a product users of com-munity pharmacies were more likely to act asconsumers, rather than as patients, whoapproach the pharmacist in an open ended wayfor advice. Over and above these features ofadvice giving common to all the pharmacy set-tings observed there were variations according tolocation and context. Data presented in Table 1suggest that the reasons for attendance and fre-quency of visits di�ered according to the locationof the pharmacy.

The lowest level of OTC medicine purchaseswas recorded in the inner city multiple whilst the

Table 1. Observed episodes and proportions of key activities over one working week in each of the ten pharmacies studied

Location % Script

% OTCProductDemands

% Symptompresentation % other

Total No. ofincidents

% of episodesreferred to GP

City Independent 86% 8% 3% 2% 242 12%Rural Small chain 61% 33% 2% 5% 192 5%Rural Independent 46% 47% 7% ± 104 2%Small town Medium chain 21% 64% 7% 8% 283 2%Small town Independent 64% 27% 5% 4% 247 8%Large town Small chain 41% 37% 6% 16% 172 5%Large town Independent 49% 38% 10% 3% 220 12%City Chain 76% 5% ± 19% 234 2%Suburb Independent 81% 11% 3% 5% 453 11%Suburb Large Chain 48% 41% 8% 3% 232 9%

All 60% 29% 5% 5% 2379 6%

highest levels were found in the rural pharmaciesand the small town multiple. Activities in the`city independent' and `suburban independent'pharmacy, both of which were situated in closeproximity to a health centre, were dominated bythe dispensing of prescriptions. Thus, these phar-macies acted more as dispensaries attached tohealth centres than the more usual independentpharmacy outlets located elsewhere. In contrast,observations in the `small town' multiple, whichwas situated in a shopping precinct far awayfrom any health centre, revealed the greatestnumber of product demands and lowest numberof dispensed prescriptions.

Observing pharmacy activities in di�erentlocalities

Whilst the quantitative data shows the overallpatterns of activities, the content of interactionsand observational data is useful for examiningthe more ®ne grain aspects of pharmacy activitiesrelated to location. This is illustrated by drawinga comparison between pharmacies in inner city,small town and rural localities. The pharmaciesin the inner city area and the small town werepart of the same multiple group. Both localitieshad high rates of unemployment and a repu-tation for high methadone use. However, thepharmacy located in the inner city area served ahigher proportion of people from ethnic min-orities and younger people than the small townpharmacy, which had a higher than average pro-portion of elderly people. The rural pharmacieswere located in small villages serving a predomi-nantly a�uent local population.

The inner-city pharmacyÐthe `Fortress'

In terms of both its external location and internalfeatures, the inner city pharmacy stood out fromall of the other pharmacies. Field notes indicate


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that externally:

`` . . .there is a high razored fence around the wholeof the building which is within the health centre

compound. There are metal shutters on all the glasswindows and door and iron bars at the high win-dows . . . There are no nearby shops . . . the housinglooks almost brand new but the area looks as

though it is under siege. The shops are all boardedup or have grilles on the windows and doors. LargeAlsatian dogs are barking through the pub fence.

The shops are a pub, an insurance o�ce, 2 grocers,sandwich shop and the rest are boarded up''.

Things had not always been this way. Thisarea was described by pharmacy sta� as pre-viously having a range of food and clothingshops ``but now they have all gone and you haveto go right into the centre of the city to geteverything''. The isolation of this pharmacy awayfrom other retail outlets meant that people livingin the vicinity relied solely on this pharmacy. Thebad reputation of the area was a reason given forproblems with sta� recruitment. Counter assist-ants commented on the fact that the presentlocum pharmacist was the only pharmacist whowould work there: ``all the others refuse . . . ''.

The reputation of the local area was re¯ectedin a history of adverse events within the phar-macy. Sta� emphasised the perceived dangerous-ness and criminality of the area. The countersta� were mainly female and their stories aboutviolence concerned local men. One story re-counted was of two years previously when menhad broken in through the roof to steal temaze-pam. Another story was about a nappy thief whohad habitually stolen large amounts on Thursdayafternoons when the pharmacy was quiet.Another was about how two men had jumpedover the counter to steal the till. Rather thanreceding into the background with the passing oftime, concern with security was instead a majorpre-occupation, with these stories forming thebackdrop to the introduction of special internalarrangements. The pharmacy was not organisedalong the traditional `shop' model. The ®eldnotes describe something quite unusual:

``There is a small waiting area when you enter.There is a ¯oor to ceiling glass partition betweenthe sta� and the customers which is totally enclosed

apart from a small hatch at eye level. Because ofthe layout of the place it is very di�cult to see theclients in the waiting area. This is because the glass

partition has shelves full of products on it. Theglass partition extends from the ¯oor to the ceiling''.

A sign on the bullet-proof glass read: ``Don'tlet `you've been framed' turn into `you've beencaught': video camera operating here''. Theotherwise extraordinary fortress arrangements

were normalised but viewed by the sta� as an in-adequate response to the degree of potential risk.For example, during the observation period whenthe owner visited the premises, the main discus-sion centred around the adequacy of the newiron bars ®tted to the windows. This hostile en-vironment and layout set the context and par-ameters of the relationships between sta� andcustomers.

In this pharmacy few people paid for their pre-scriptions re¯ecting the low incomes of many ofthe local population. Counter sta� estimated thatonly two to four people paid for their prescrip-tions everyday. The pharmacy was busy, dispen-sing some 5000 prescriptions items per month.This compared with a range of 1000 to 4000 inthe other nine pharmacies. Referrals to the GPwere among the lowest. Proximity to the healthcentre and the use local people made of the GPas their ®rst resource goes some way to explain-ing this. In relation to pharmacies in the other lo-cations studied this pharmacy also had thelargest sta�/customer ratio.

Much of the activity in the pharmacy wasshaped by the focused service provided for thehealth centre next door, and the poor andsocially disorganised locality, where there werefew other retail outlets. There was an almostexclusive reliance on the dispensing of prescrip-tion medicines, including very high rates ofmethadone. Activity varied according to theopening hours of the health centre, with mosttaking place during surgery hours. In comparisonto the other pharmacies large numbers of peoplewere waiting at any one time. The predominanceof prescription tra�c, including the routine dis-pensing of methadone, added to the feel of thispharmacy as a dispensary rather than a retailoutlet. Advice was generally limited to the bestway to use a product (e.g. putting in eye drops).While health advice about minor ailments was aminority aspect of pharmacy sta�±customer in-teractions across most of the pharmacies in thestudy, it was virtually absent at this site.

Internally the fortress-like conditions set up avirtually impenetrable barrier between the sta�and clients. As indicated in the researcher's ®eldnotes, visual contact was limited and the type ofcommunication allowed by such physicalarrangements restricted verbal interaction:

``Clients tapping on glass of `shop area'. I moveback into dispensary as it is impossible to see theirfaces from the `shop area'. It is also extremely di�-

cult to hear what they are saying because they haveto speak through the little hatch and unless you areright next to the hatch you can't hear''.

The type of communication allowed by theseinternal spatial arrangements at times set up the


368

conditions for con¯ict and frustration on the partof the `customers' as illustrated by the descrip-tion of a young Afro-Caribbean woman attempt-ing to communicate across the barriers:

`` . . .seems to be getting rather agitated that there isno-one at the hatch to serve her. Starts knockingon the glass, peering pointedly into the `shop

area' . . . There is really hardly any customer contactapart from the dialogue spoken directly through thehatch when being served''.

The possibilities of providing àdvice' in thiscontext were circumscribed. The minimal inter-action between sta� and `customers' meant therewas little exchange of information or asking ofquestions. Because of the hatch arrangementsand the bullet-proof barrier, interactions wereshort and to the point. A typical interaction inthis regard is illustrated by the following requestfor a product from a young man:

Man: Calpol and paracetamol pleaseCounter assistant: Is it for babyMan: YesCounter assistant: What ageMan: OneCounter assistant: What is it forÐa cough?Man: No it's for the ¯uCounter assistant: WhatÐjust to keep the

temperature down?Man: GruntCounter assistant: Not having anything else is he?Man: No.

What little communication there was generallyabout money. Usually this related to whetherpayment for prescriptions was required. The fol-lowing exchange between a young woman and acounter assistant, in relation to the dispensing ofa prescription, was typical of the concern overcost:

Counter assistant: Are you pregnant?Woman: No, but the doctor told me they were

freeCounter assistant: If you're on income support you just

sign the back of your prescription andeverything is free

Woman: Not on income supportCounter assistant: Well it would be cheaper to buy them.

They are 95p for 20 (iron tablets)Woman: I'll leave it then.

Whilst at times the di�culties with communi-cation were acknowledged by sta�, the dangerswere always seen to outweigh any bene®ts thatless stringent measures might bring. As one mem-ber of sta� explained: ``The di�culty is that inorder to hear the customers you have to put yourhead fairly near the hatch and you never knowwhen one might strike''.

In most respects the arrangements in this phar-macy militated against a consumer-orientedapproach to information and advice giving, andthe notion of customerÐthe traditional way in

which pharmacy users are consideredÐwassomething of a misnomer. However, the arrange-ments at the pharmacy did meet the needs of agroup of methadone users who were more mar-ginalised or excluded in the other pharmacy lo-cations. Here, special arrangements were in place,for example the setting aside of the pharmacycounselling room, to meet the needs of a groupof clients who were actually a signi®cant pro-portion of visitors to the pharmacy. Normallysuch rooms are set aside for the provision ofadvice for a range of minor ailments. By con-trast, in this pharmacy the counselling room wasused almost exclusively in relation to the dispen-sing and activities associated with drug misuse.In this regard the internal organisation and useof space within the pharmacy is in¯uenced by thenature of local demand and attempts made tomeet and manage it. The inner city pharmacycounselling room, stocked with syringes, con-doms and needles was set up in response topeople coming in and asking to buy syringes,which according to the pharmacist, was `di�cult'to manage within the previously existing arrange-ments. Thus, in some respects this may be viewedas a positive way of meeting the needs of the cli-ent group using the pharmacy. Rather than beinga marginalised group who were hurried out ofthe shop as soon as possible, as in the otherpharmacies observed, this pharmacy dealt withmethadone clients in a more caring way. Despitean acknowledgement of the business of the phar-macy and the `di�cult' people who used it, custo-mer interviews also suggested that the pharmacyacted as a valued communal resource and pro-vided a focus of collective identity, as indicatedby the comment from this middle-aged woman:

`Ìt is very busy in that area, very busy, and itsmostly coloured (sic) people. So we all sort of know

one another, so we all sort of say òh I'm going tothe chemist', and everybody seems to centre on thatpoint''.

The importance of keeping open the only phar-macy that people had access to was stressed toresearchers by this woman who was initially reti-cent about being interviewed:

``So it's nothing to do with them wanting to closethem up and combine them in one place, because Imean it is very, very essential where it is for us, youknow''.

The small town multipleÐthe Èmporium'

The small town pharmacy belonged to the samemultiple group as the inner city pharmacy.However, there were few similarities in either thetrade or the way in which the business operated,despite both operating in areas of high social


369

deprivation. This pharmacy was dominated bythe sale of non-health products and not situatednear any local health centre. A description of thelocation is provided in the ®eld notes, viz:

``The pharmacy is located in a busy shopping centre

in the centre of a small town. It is sandwichedbetween a shoe shop and a building society. Within20 metres there are two large well known multiplepharmacies. There are approximately 25 shops in

the shopping centre as a wholeÐso to have threechemists very near together means that competitionis sti�. Despite this, the pharmacy is extremely busy

as it seems to do a roaring trade in cut price toile-tries, many people buying several items at a time''.

At one point during the week-long ®eld workthe observation was made of a long queue ofpeople stretching down the shop buying facecream, moisturising lotion, toilet rolls, paperhandkerchiefs, lipsticks, shampoo and Christmasgifts at bargain prices. The di�erence in the lay-out and operation of this pharmacy compared tothe inner city one is illustrated by the descriptionof the pharmacy as a thriving shop:

``There are always a lot of people browsing in theshop which has a very open arrangement. Theshopping centre gives out free supermarket-type

trolleys and some customers bring those into theshop''.

Peoples' expectations di�ered too in so far asthey frequently centred on the `non health'aspects of buying products at the pharmacy. Atanother point in the week's observation theresearcher notes that the pharmacy acts as asocial venue for people. Elderly people in particu-lar are noted chatting over the hair products.The main attraction of the shop is the pen-sioners' `discount day' when there is 10% o� allproducts, usually accompanied by a consequentrapid emptying of shelves. The buying of cheapproducts was the main business of the pharmacy.The purchasing or use of the pharmacy forOTCs, and the cashing of prescriptions in par-ticular, was of relatively less salience than inother pharmacies. This pharmacy had less thanhalf the prescription volume of the inner citypharmacy. The number of customers using theshop each day was estimated at 400. The peopleusing the pharmacy acted as and were dealt withas customers or shoppers, as the description of adiscount day observed by the researcher illus-trates:

``The shop is almost full of pensioners browsing,buying toiletries, chatting both inside and just out-

side the shop where there is a rotunda with faketrees. This seems to be a favourite gathering placefor pensioners. The pensioners enter in droves,scoop up armfuls of products, stand waiting for

ages in the queue, chatting and depart with largecarriers bags. There is a distinct gender imbal-

anceÐprobably four times as many women pen-sioners as men''.

Cotton wool, baby, hair and shaving productswere the most common purchases. The display ofgoods was a frequent focus of attention of thepharmacy sta�. Like the inner-city pharmacythere was evidence of forti®cation against `unde-sirable' elements. However, rather than beinginside the shop, the forti®cations against the mar-ginalised and the `underclass' took place at theinterface between the private space of the shopand the more public space of the shopping pre-cinct where loitering is forbidden. The latter ispoliced by security guards.

As with the inner city pharmacy the most com-mon communication between customers and sta�in the pharmacy was the cost of products re¯ect-ing the material circumstances of the local peopleusing the pharmacy. However, communicationsdi�ered in so far as in the inner-city pharmacythe discourse was about the payment of prescrip-tions, whereas here it was about the cost of non-prescription products. The following exchangewith a woman of about 65 years is illustrative ofthis sort of interaction:

Woman: Can you tell me how much Sanatogencod liver oil is?

Counter Assistant: LiquidWoman: YesCounter Assistant: £2.65 and then there's a larger oneWoman: How much would that be?Counter Assistant: Why don't you come tomorrow, it will

be cheaper then?Woman: I'll get 20p o� tomorrow, won't I? Yes,

right then.

The type of communication between sta� andcustomers also re¯ected the shop-like nature ofthe pharmacy. Customers were more assertive intheir communications with sta� than in theinner-city pharmacy. Customers frequently askedfor a product they wanted and might be loath totake the pharmacist's advice. In line with actingas consumers in any other shops, most requestswere for named products, as illustrated by thisrequest:

Woman: NytolCounter assistant: Have you had it before?Woman: NoCounter assistant: Are you on any other medicines?Woman: NoCounter assistant: <reading packet> Take two tablets

before going to bed. It is just for shortterm use you know

Woman: <impatiently> Yes.

However, consumer choice was more limitedthan in community pharmacies in the more a�u-ent areas, the range of products stocked was lessand there was a frequent shortage of mainstreampharmacy items. As with the inner city pharmacy


370

referral rates to the GP were low in this phar-macy. Unlike the inner city store however, refer-rals were rare because of the product demand-ledservice operating in the pharmacy. With custo-mers acting in such a determined way about theirself-care and self-medication needs, the pharma-cist has little oportunity to refer. This type of(demand led) customer activity was not alwaysappreciated by the locum pharmacist who viewedthis form of behaviour as counteracting her roleas a professional. The locum pharmacist com-mented to the researcher that she has to dealwith `stroppy' people all day and that people arefrequently rude to her and `not respectful'.Unlike the inner city pharmacy local peopleusing this multiple were seen as a nuisance ratherthan a threat.

This pharmacy also serves methadone usersÐthough the numbers are less than the inner-citypharmacy. Rather than separating o� an area formethadone customers, they are dealt with withinthe main area of the shop. In the absence of asegregated area, a strategy is adopted wherebythe time spent in the shop is very short. Thelength of stay in the shop of those attending fora methadone prescription was recorded as beingabout two or three minutes. Information fromthe pharmacists suggests that this is a deliberatepolicy, with methadone prescriptions dispensedwell in advance so that the person requiring it isgiven it straight away. According to accountsfrom sta� this strategy is designed to cut downon potential aggravation, annoyance to othercustomers and the possibilities of shoplifting.

Rural pharmaciesÐa `haven in a heartlessworld'

Things were very di�erent at the rural pharma-cies located in picturesque and a�uent villages.In one of the pharmacies the dispensary isdescribed as being small and old fashioned in the®eld notes:

``The shop is an extremely small room, holdingabout four customers at one time. The dispensary isvery tiny and a long thin shape. There is a little

passage between the actual shop and the dispensaryarea. The pharmacist cannot see the shop area fromwhere she sits''.

The absence of surveillance is therefore inmarked contrast to the two other pharmacy set-tings. At about 1000 per month, the rate of pre-scribing is about a 1/5th the rate of the inner citypharmacy. One of the rural pharmacies providesa medicine dispensing and delivery service to tworesidential homes and a children's home. Activitywithin the pharmacies were inextricably tied tothe surgery times of the local GP practices.

During periods where there were no surgeries theshops were described as `extremely quiet'. Theboundaries between work and non-work environ-ment were blurred. In one of the pharmacies theowner's cats were free to walk about the dispen-sary. Relationships between sta� were di�erenttoo, with the counter sta� in one of the ruralshops noted as `bossing' the pharmacist about,(e.g. by giving him directions about where heshould work in the dispensary). The rules govern-ing work practices and roles were evidently morerelaxed, with, for example, one of the counter as-sistants doing her homework for a course whenthe shop is quiet. The division of labour betweenpharmacy sta� involved a blurring of roles. Thepharmacist at one point is noted ®xing the lightsin the window, whilst the counter assistant ordersantibiotics over the phone. A paternalism thatarises out of familiarity and obligation is alsoidenti®able in the rural settings. For example, thepharmacist notes that they are oversta�ed but isunable to ask the counter assistant to do lessthan whole days as she lives too far away andthe bus service is not good. The Gemeinschaftfeatures are also carried by the pharmacist's per-sonal biography and relationship to the area asdescribed in these ®eld notes:

``P has only been in this pharmacy two years as amanager. Before that he had his own shop, left tohim by his father which was originally run by his

grandfather. The shop was unique in that it func-tioned as a high street pharmacy but they had allthe ingredients for making up their own remedies.

It also had all the Victorian ®ttings in oak paneldrawers from ¯oor to ceiling and was quite amuseum piece. P's job there involved not only shop

work, making up their own medicines but also hav-ing two outside dispensaries at the cattle market''.

The continuity of these practices was evidentin his contemporary dispensing practices. Thepharmacy makes up its own cough mixture andlocal knowledge means that customers wereobserved asking for preparations which the phar-macist made several years ago. In the rural mul-tiple the discourse between sta� and customerswas also of a di�erent order. Advice giving as anactivity was more substantive than at the othertwo locations. For example the pharmacist regu-larly referred to the `MIMS' (Monthly Index ofMedical Specialities) to look up side e�ects ofmedications for individual purchases of medi-cations. Customers asked for a wide range ofitems and assistance not as noticeable in theother pharmacies. In addition to advice beingmore substantive, individually tailored supportwas given. This included observation of events,in which an elderly women asks for an ordinarytop on the bottle as she couldn't manage to take


371

o� the child-proof one. Also a scalp ointmentwas made up especially on the premises for alocal man.

The boundaries between the formal and infor-mal were blurred in sta�±customer interactionswith conversations extending beyond informationabout products to discussions about everydaylife. For example, a middle-aged woma?n had along conversation with the counter assistantabout how her horse required grazing in the win-ter. Another customer talks to the counter assist-ant about a neighbour in a village who's movinghouse. Humour and laughter is also a feature ofinteractions at this pharmacy, which appear toarise out of more intimate relationships.

The informal relationships between sta� andcustomers involved a crossing of spatial bound-aries within the pharmacy. Customers were some-times invited into the dispensing area of the shopby sta�. Advice-giving was also more extensivethan in the two pharmacies in the poor areas inthat it extended to ailments rather than simplyproducts dispensed or purchased. Customerswere more likely to present health problems tothe pharmacist. In the following incident invol-ving a 50-year-old man, the preference is for thepharmacist, who the customer implicitly views ascompetent, to deal with the complaint withoutrecourse to the GP:

Man: Have you anything for that? <showsdamaged hand>

Counter assistant: Have you burned it?Man: I can't remember burning it<Counter assistantto pharmacist>:

Have you got a minute <P's Christianname>?

Pharmacist: Put your hand out straightMan: The cuts seem to be moving aboutPharmacist: It may be eczema. I have got the HC

cream, Fucidin H, but I would go tothe doctors with that.

Man: I would do if you could walk straightin

Pharmacist: Have you been mixing chemicals?Man: NoPharmacist: Have you used ®breglass?Man: No. I've always used Lux soap and then

I went on to Imperial Leather. Do youthink I'm allergic to it?

Pharmacist: Hmm. Is it painful?Man: It is if it's put in cold water. Will TCP

help?Pharmacist: No not really. The HC45 says not to

use it on broken skin <looking atpack> and it is isn't it

Counter Assistant: You'd better call at the doctor'sMan: Oh, well I want some plasters, 35

assorted onesCounter Assistant: Right £2.05 pleasePharmacist: What year is your Jaguar?Man: It's 35 years old.

Conclusion

The study reported here suggests that locality in-¯uences and shapes the activities within commu-

nity pharmacies. The di�erences in service andadvice-giving in the di�erent pharmacy settingsrelated in part to the socio±economic status ofpopulations using the pharmacy and the compo-sitional e�ectsÐwhat else was in the area inwhich the pharmacy was located. The pharmaciesalso operated the way that they did in responseto contextual featuresÐthe reputations of theareas and populations being served. Locality fea-tures were linked to internal spatial arrange-ments, in so far as the latter tended to act as anextension of the external environment. In theinner city pharmacy, where social threat washigh, the pre-occupation with security militatedagainst the delivery of a customer-oriented ser-vice evident in other settings, except for the ser-vices to drug misusers. The absence of healthadvice in this setting also related to the closeproximity of a health centre and the predomi-nance of prescription tra�c. Things were di�er-ent in the pharmacy located in the busy shoppingarcade despite also being in an area with highunemployment; people using this pharmacyacted, and were dealt with, as customers. Herenon-health activities and the purchase of non-medicinal products predominated. Thus, in com-mon with ®ndings from other social research,there was evidence of variations in settings withotherwise similar socio±demographic character-istics (Evans et al., 1995). In this regard thesocial disorganisation of the inner city contrastedwith that of the smaller town with its more stableand mature community. Whilst there were di�er-ences and similarities in the two pharmacieslocated in poor areas the biggest di�erences werebetween these two and the pharmacy in the rurallocations. In the latter, the nature and context ofinteraction was more informal and the use madeof the pharmacy as a health and social resourcegreater. The pharmacies were better resourcedand the service more individually tailored to therequirements of individuals. The way in which in-dividuals used this service also di�ered.

The di�erences that setting and organisationappears to makes to community pharmacy mayact to reinforce the inequalities in health statusand health care operating within a locality. Therichness and extent of advice provided in therural area pharmacies contrasted starkly withthat provided in run down and deprived areasand in the pharmacy where non-health matterswere the main focus of pharmacy activities. Theethnographic type method used in this studysuggests that inequalities may not simply relateto the use of services but to the more subtle andless tangible aspects related to the type of serviceprovided. Health policy and professional guide-lines relating to primary care and communitypharmacy are based on the assumption of a simi-lar advisory service being provided to local popu-


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lations. This study suggests that an inverse carelaw may be operating in relation to the use ofcommunity pharmacy, with people in areas withthe greatest health need seemingly receiving apoorer quality service than those using pharma-cies in more a�uent areas. Aspects of the inversecare law reported here relate not so much to thefact that disadvantaged groups make less use ofpharmacies, (though this was clearly evident inrelation to the purchasing of OTC medications),or to the accessibility of the service, but to thequality of the service and attention that peoplereceive and particularly to the environmentwithin which these services are delivered.

In conclusion then, structural and material fac-tors are important considerations in understand-ing the provision of pharmacy services to thegeneral public. Currently health authorities areproviding ®nancial incentives and rewards for thedevelopment of the extended role of the pharma-cist. Attention needs to be paid to locality e�ectsand the context within which advice is given. Inparticular the health and advice needs of particu-lar populations needs to be taken into consider-ation in prioritising areas for development anddiverting resources to pharmacies serving areaswith the greatest health need.

AcknowledgementsThis study was funded within the core programme of theNational Primary Care Research and Development Centre bythe Department of Health.

Notes1`Structuration' refers to the in¯uence of social agents andagencies on outcomes in a locality.

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Advice-giving in community pharmacy: variations between pharmacies in different locations

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