The reforms of pharmacy in England are novations and replacements
Over the years, the Government has pledged to reform the operation ofcommunity pharmacies in England. Darrin Baines looks at how some ofthese changes may not be innovations for community pharmacies, butrather novations or replacements, based on the existing model ofpractice
Over the years, the Government has pledged to reform the operation of community pharmacies in England. Darrin Baines looks at how some of these changes may not be innovations for community pharmacies, but rather novations or replacements, based on the existing model of practice
Since the publication of “Pharmacy in the future” in 2000,1 the Government has repeatedly pledged to reform the operation of community pharmacies in England. Based on the work of the Royal Pharmaceutical Society and other pharmacy bodies, this reform agenda has significantly changed since its inception.
In the beginning, the programme was aimed at modernising the existing service by updating the national pharmacy contract and reprofessionalising the pharmacy workforce. At present, the Government’s agenda has moved away from the directives of national planning and now focuses on local commissioning.
Against the background of evolving policy, an underlying theme has consistently been that of innovation. In response, the Society funded an in-depth study in 2003, led by Jennifer Tann and Alison Blenkinsopp, which outlined a framework for understanding innovation in community pharmacy.2
Although this work sketched a clear path for modernisation, little seems to have fundamentally changed when one enters most pharmacy premises today. To help understand the perception that fundamental change is absent, this article argues that what may be classified as innovation by some, may instead be defined as either novation or replacement.
Although the word “innovation” is in constant use, the related term “novation” is rarely used outside legal circles. Based on Roman law, the concept means substituting a new legal obligation for an old one. For example, when contracts change parties but obligations remain the same.
It may be argued that the term “innovation” is sufficient, however, the word “novation” is useful in describing forms of substitution, not as fundamental as innovation. For instance, the introduction of repeat dispensing as an essential service constituted a novation rather than an innovation in pharmacy practice.
Similarly, changes such as the compulsory inclusion of patient information leaflets in all prescriptions are not innovations but replacements in operational behaviour.
By differentiating between innovation, novation and replacement, it can be suggested that the reform agenda was not primarily aimed at fundamentally changing English community pharmacy. On the contrary, the programme introduced by “Pharmacy in the future” had as much to do with protecting the existing model of practice as creating a radically new world.
Indeed, pharmacy reforms have concentrated as much on protection as innovation, with the exception of medicines management, which may eventually pave the way for robotic dispensing of NHS prescriptions. Widespread innovation will not occur until pharmacy practice is based around technician-managed, automated dispensing.
However, for this outcome to be achieved, the national contract will need to be abolished, control of entry relaxed and local commissioning of pharmaceutical services introduced.
Degrees of innovation
Academic and business research on the subject of innovation is large and ongoing. Therefore, no single conclusion can be drawn about the precise nature of this form of change.
However, among the competing perspectives in the field, there is a common theme that innovation often represents beneficial newness. While the starting point of the mainstream literature is often the product life-cycle, this article focuses on the less discussed issues of what degree of change actually constitutes innovation.
For instance, futurist and strategist Peter Ellyard suggests that there are two types of innovation: “repairing the old” and “creating the new”.3
However, changes in behaviour should not be classed as innovation unless they are, in some way, fundamental.
Given that innovation is often stereotyped as always being positive, there is a common misconception that, not only are all changes innovation, but that all innovation is good.
For the past decade, this line of fallacious reasoning has been widespread in NHS policy circles. For example, it is commonly argued that community pharmacy must change because change is innovation and innovation is good.
While this argument is logically valid, the conclusion is empirically unsound because the premises are not necessarily true — change should not always be classed as innovation.
Innovation, novation and replacement
Although literature often equates innovation and change, it is argued that the following hierarchy of change exists:
- Innovation — fundamental shift to a token of a different type
- Novation — substitution with a different token of the same type
- Replacement — replacement with a similar token of the same type
According to the philosopher C. S. Peirce, “types” are usually abstract and unique, while “tokens” are their concrete particulars.4 For instance, the conceptual category of manual writing instruments could contain the concrete examples of pens and pencils.
Using Peirce’s distinction, an object is said to be replaced if it is changed with one that is the same in its concrete features. For example, an HB pencil is replaced with another HB pencil.
Novation occurs if an object is replaced by an object of the same type but not necessarily the same token. A pencil could be replaced with a pen because they are both manual writing instruments, but different tokens of that type. Finally, innovation occurs when the pen is replaced with the typewriter because the type and token have been swapped.
Under this classification system, innovation is not simply change. At the lowest level, replacement can involve change. For example, if the means of manufacturing HB pencils evolves so their leads become less toxic, then they would still be classed as the same token, even though their construction has been altered.
Similarly, novation can lead to change that is not classified as innovation. If we swap a pencil for a pen, then we have changed our use of tokens but not the types we employ. Under the hierarchy, change can occur at all levels, but innovation only happens when we swap types.
In relation to pharmacy, this system of classification suggests the ways in which pharmacists’ work can be changed both in terms of replacement and novation, without innovation occurring.
Dispensing all medicines with a patient information leaflet can be seen as replacement. This is because the act of dispensing (the token) has not fundamentally changed but an alteration has occurred.
In other words, the observable characteristics of what is being done do not look substantially different. As a result, a widespread programme of changes based on replacements in pharmacy practice is unlikely to be noticed by patients.
In the current context, if we accept that there is a class of acts called “manual dispensing”, then we could argue repeat dispensing, as an essential service, is a novation in pharmacy practice. This is because the basic type has not changed, although the characteristics of the act have, on the surface, altered.
There is no difference in type between traditional repeat dispensing and the contract version of issuing repeats because they both go about fulfilling prescriptions manually.
However, we can say innovation has occurred in pharmacy when there is a change in the types of activities performed. The switch from manual dispensing to robotic dispensing would be classed as innovation because we have switched between conceptual categories, similar to the innovative switch between pen and typewriter.
Therefore, innovation is not simply change but requires an alteration in type in order to be classed as fundamental.
Creation of classes
The hierarchy of change attempts to differentiate between replacement, novation and innovation by referring to types and tokens. Although this approach tries to be logically sound, problems can occur in its application. For example, some readers may argue that the pen was an innovation over the pencil.
In everyday terms, this argument may be sound. However, once we classify them both as manual writing instruments, they cannot be innovations for each other because they represent tokens of the same type.
How we view replacement, novation and innovation depends primarily on how we construct our types. If we construct two categories of pharmacy practice, such as manual dispensing and medicines management, then tokens, such as medicines use reviews, can be seen as innovative. If we do not have an alternative category, then innovation cannot occur.
But how we define innovation and other changes depends on how we construct our categories. Although this may sound theoretically abstract, this issue is essential to our understanding of how community pharmacy should be reformed, because categories create knowledge and knowledge informs action.5
In his review of the success of recent pharmacy policy, Marcus Longley stated that, during the mid-1990s, pharmacy had “a bit of an image problem” because “many non-pharmacists thought of the profession as being somewhat locked in the past, trying to preserve its privileges against competition, not being committed to the health agenda, and condoning poor performance”.6
In response, pharmacy leaders created an attractive vision of the future, in which the status quo was not an option. However, the profession was not guaranteed that its vision would be the way forward chosen by the Government.
When “Pharmacy in the future” was published, some commentators argued that, on the surface, the Government paid lip service to the profession’s vision.
However, the agenda hidden behind the rhetoric was to introduce the operating procedures of hospital pharmacy into the community. Manual dispensing would eventually disappear and robotic supply processes, staffed by technicians, would be introduced instead.
Although the Government supposedly held this long-term goal, initial reforms were not aimed at fundamentally changing community pharmacy in England.
If we reanalyse the reform agenda since 2000, evidence suggests that the Government has had both short- and long- term goals for community pharmacy. In the short-term, the emphasis has been placed on promoting replacements and novations in pharmacy practice.
However, one main innovation, medicines management, has occurred probably as a means of bridging the gap to the Government’s longer-term agenda. In the future, if changes in policy make robotic dispensing the norm in the community, most patients will not have automatic access to a pharmacist.
To compensate for this, NHS technicians, nurses and doctors will be able to request a medicines use review on behalf of a patient, therefore, allowing the patient to have access to a pharmacist. Therefore, medicines management is a vital innovation that paves the way for fundamental changes ahead.
In recent years, many within pharmacy have accepted the ideological belief that innovation is automatically good. Against this modern notion, it is useful to reflect the word has not always had the same positive meaning.
For instance, in the Byzantine world, innovation meant “to injure” because it was believed that the teachings of God were ideal and should not be altered.7
In relation to pharmacy, there is currently a widespread belief that the future lies with change. However, just because the profession is historically constrained, it does not mean that innovation is automatically good.
On the contrary, if a continuation of the current reform agenda results in widespread pharmacy closures or a reduction in patient access to pharmacists, perhaps history will judge that pharmacy, as a profession, has spent the past 10 years absorbed in innovatory self-harm.
1. Department of Health. Pharmacy in the future: implementing the NHS Plan. London: Stationery Office; 2000.
2. Tann J, Blenkinsopp A. Understanding innovation in community pharmacy. London: Royal Pharmaceutical Society; 2003.
3. Ellyard P. Imagining the future and getting to it first. In: Australian Institute of Management (editors). Innovation and imagination at work. Sydney: AIM; 2001.
4. Peirce CS. Collected papers of Charles Sanders Peirce. Hartshorne and Weiss (editors). Cambridge, MA: Harvard University Press; 1931-58.
5. Lakoff G. Women, fire and dangerous things. University of Chicago Press; 1990.
6. Longley M. Pharmacy in a new age: start of a new era? The Pharmaceutical Journal 2006;277:256–7.
7. Byzantium Empire. National Geographic 1983 164;6.
Citation: The Pharmaceutical JournalURI: 10040587
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