We have previously speculated how the concept of McDonaldisation,1 with its rationalised policies and practices for predictable, routinised food production and delivery, might be applied to community pharmacy, resulting ultimately in the advent of the McPharmacy.2
Evidence of McDonaldisation abounds. Independent pharmacies are increasingly supplanted by large multiple chain and supermarket pharmacies, whose products and services are standardised, whose tasks are ?routinised?, whose client-staff interactions are regulated and where there is an increasing dependency on technology. If it is not already there, a McPharmacy is coming to your neighbourhood soon!
This trend, we believe, is intimately associated with a sea change in the public?s perception of and relationship with medicines. Historically, the relationship was characterised by wholesale acceptance that medicines, having an inherent power to heal, possessed such exceptional symbolic value they could and should only be accessed from a doctor?s surgery or a pharmacy. The knowledge and ability to exploit these properties were primarily the domain of science-based health professionals. To the public who sought to consume medicines, their effects were largely esoteric - ?I don?t understand how they work. They just do.?
Health professionals have long claimed that medicines? power to heal sets them apart and that consequently they should be subject to regulatory control to prevent their inappropriate use (and misuse). Restricting their availability also served to reinforce the view that medicines are indeed powerful and valuable.3 Not surprisingly then, controlling access to medicines carries with it considerable powers and prestige, long cherished by both the medical and pharmaceutical professions.
However, the public?s relationship with medicines is becoming increasingly prosaic. Anecdotal evidence (substantiated by the Department of Health?s recent efforts to ?educate? patients not to request antibiotics from their GP for viral infections) indicated that the public increasingly regards medicines as ?matter of fact? rather than special. It is in this climate that McPharmacies are set to proliferate.
Public access to medicines has been the subject of recent reform as increasingly potent drugs become openly available - a trend that is likely to continue. Accessing medicines over the counter ?empowers? the public to take greater responsibility for their own health while undermining the hegemony of the medical and pharmaceutical professions to promote medicines as essentially quixotic or esoteric.3 However, deregulating medicines alters both the public?s and the professional?s relationships with them. GPs thus exhort those not exempt from prescription charges, where appropriate, to ?buy? medicines rather than access them via prescription - demystifying and potentially devaluing them in the process. Pharmacists themselves ?sell? an ever increasing range of pharmaceuticals not as ?medicines? but as commodities undifferentiated from other products.
McPharmacies, with their corporate ethos, advertising campaigns and routinised sales techniques, encourage the public to regard medicines as standardised consumables accessed in the same way as others. As such, the symbolic quality of medicines becomes rendered down to that of a mere demystified brand or ?own-label? product accessed from a site with a distinctive corporate identity, ie, a McMedicine becomes a commodity like any other. Add to this the combination of proliferating OTC medicines and the likely demise of resale price maintenance and the public are given a clear signal that medicines have become mere products.
The ?commodification? process is not restricted to medicines; it is evident across a wide range of health-related enterprises, most notably in the burgeoning membership of health clubs promising fitness for a fee. However, its application to medicines raises specific issues. For example, does it matter that the majority of analgesics are now purchased from non-pharmacy outlets? How can ?excessive? sales of a ?commodity? such as paracetamol be restricted by the Government when the public is derisively unconvinced of the necessity? Should the consumer be king, with ?stronger? branded medicines (promoted by advertising) being demanded for common ailments previously adequately treated with simpler, cheaper alternatives? Particularly noteworthy is the danger of complacency engendered by ?commodification?, highlighted by recent concerns regarding the OTC sale of phenylpropanolamine.
As medicines transform into commodities, they can nevertheless retain a high, non-pecuniary value. For instance, as a tradeable commodity, two paracetamol tablets may be valued in pennies, yet as a remedy for an individual?s acute headache they have a high value. The clinical knowledge and skills of pharmacists, appropriately applied, can imbue a pharmaceutical product with this enhanced use-value, thereby resisting ?commodification?. Although in many respects medicines are undoubtedly viewed by the public as commodities, pharmacists through their relationship with OTC medicines, in particular pharmacy medicines, can resist this process. A case in point might be the current debate concerning the supply of emergency hormonal contraception from pharmacies. The nature of pharmacists? input at the point of sale, the context of the interaction and client expectations will determine whether or not EHC is perceived as yet another commodity.
Accessing medicines from a specialist rather than a generalist source (in which medicines are just one of a variety of commodities) is akin to buying a plant from a nursery. Such a plant has a perceived symbolic value in terms of quality. It is seen as a ?proper? plant, having been selected purposefully from an extensive range by the nurseryman rather than from a DIY store, where the cost of the plant - which is self-selected - is the prime consideration. This illustrates the other side of the coin for the public: the responsibility for selection is frequently, and through self-selection merchandising encouraged to be, that of the individual rather than a third party. From the consumer?s perspective, accessing medicines from the McPharmacy is an undifferentiated experience among other consumer experiences. Even when the selection of the product is assisted by a third party, in the case of the McPharmacy, interactions between client and employee are ?routinised? and standardised to an extent that products are not imbued with the added symbolic value, which pertains when a specific remedy is selected by an expert for an individual?s requirements.4 If the trend towards increasingly undifferentiated medicines usage continues and the McDonaldisation of pharmacy encourages it, not only will this mark the demise of the symbolic mysticism associated by the public with medicines, it will signal the very apotheosis of health as a consumerist issue.
Geoffrey Harding is senior lecturer at the department of general practice and primary care, St Bartholomew?s and the Royal London school of medicine and dentistry. Kevin Taylor is senior lecturer at the School of Pharmacy, University of London
|1.||Ritzer G. The McDonaldisation of society (2nd ed). Thousand Oaks, California: Forge Press; 2000.|
|2.||Harding G, Taylor K. The McDonaldisation of pharmacy. Pharm J 2000;265:602.|
|3.||van der Geest S, Whyte SR. The charm of medicines and metaphors. Med Anthropol Quarterly 1989;3: 345-67.|
|4.||Harding G, Taylor KMG. Responding to change: the case of community pharmacy in Britain. Sociol Health Illness 1997;19:521-34|
Citation: The Pharmaceutical JournalURI: 20003997
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