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Vision is not enough — culture change needs strategy, action and investment

Speaking at the inaugural conference of the Independent PharmacyFederation in October 2008, Keith Ridge, Chief Pharmaceutical Officerfor England, called for culture change in pharmacy

By Graham Phillips and Michael Holden

Speaking at the inaugural conference of the Independent Pharmacy Federation in October 2008, Keith Ridge, Chief Pharmaceutical Officer for England, called for culture change in pharmacy (PJ, 18 October 2008, p433).

We agree. The Pharmacy in England White Paper (and equivalent strategies in Scotland and Wales) hold out the prospect that pharmacists could finally achieve their ambitions to do much more for patients and the public and, in the process, be recognised as patient-centred, medicines-focused healthcare professionals.

We applaud Dr Ridge’s achievements in creating these opportunities for the profession; driving forward the White Paper’s vision and tacking the radical and necessary (if sometimes controversial) reform of pharmacy’s professional support (the splitting of the regulatory and leadership roles of the current Royal Pharmaceutical Society).

Significant opportunities like these do not come along often but, when they do, they come with responsibilities. However, like devolution, culture change is a process not an event. A vision, however persuasive, is not, on its own, enough.

Realisation of that vision will only come with investment, strategic planning and, most importantly, targeted action. The garnering of pharmacists’ hearts and minds must be integral to it and, indeed, precede it.

Culture change requires the right environment. It needs stability, confidence, a road-map to a well defined destination and proper levels of support. All are crucial, yet, as far as pharmacy is concerned, few if any of these critical success factors are fully in place.

Contrast the image of the future that the White Paper paints with the reality for most community pharmacists for whom coping with their everyday workload brings with it significant stress.

The issues of workload and demoralisation have been highlighted by the PJ in a series of reports from the Pharmacists Defence Association (PJ, 13 September 2008, p286) and Oakley et al (PJ, 15 November 2008, p565; 22 November 2008, p598; 29 November 2008, p635; 6 December 2008, p672; and 13 December 2008, p696).

Add to this the intimidating regulatory environment, the fear of the consequences of making a dispensing error, the current global financial circumstances worsened by the indiscriminate fallout from Category M and the injustice and additional workload of the Prescription Pricing Authority’s capacity improvement programme changes, and factor in the lack of leadership and the disruption of the Society at a time when the support of a strong professional body would be key, and the result is that pharmacists are exhausted, punch-drunk and demoralised.

We believe that in community pharmacy we are mirroring the path general medical practice has taken in terms of the clinical and the quality agendas. No one could argue against the radical improvements in quality underpinning the growth in services offered by GPs over recent years.

But contrast the support and investment GPs have enjoyed during that period compared with government disinvestment in pharmacy over the same time. It is certainly not the right environment for culture change and we do not have the platform for it.

Nevertheless, we are where we are. The opportunity is now and our profession must seize it or risk losing it.

The way forward?

Vision without action is merely a dream. Action without vision just passes the time. Vision with action can change the world — Joel Barker

Pharmacy must step up to the mark and deliver the opportunities the White Paper has created. We can achieve this if we work together as a united profession but not in our current and increasingly discordant state.

There are some critical success factors that can enable this change:


Effective inter-professional relationships at the clinical level are a must. This requires mutual trust and confidence and will only happen if competence, communication and continuity are embedded in our everyday practice.

Practice-based commissioning

PBC must evolve from its current status of practice-“biased” commissioning to become true “patient”-based commissioning’. The Government must ensure that it is patients and the public, not the vested interests of any particular professional group, that are central.

In order for that to happen, primary care trusts must be obliged, empowered and supported to involve all the primary care team when commissioning — no more closed shop for GPs; no more externalisation of pharmacy.

PCT performance management must ensure this happens. If the Government’s World Class Commissioning principles were applied to pharmacy services, many of these issues would be resolved.

Strategic health authorities

SHAs have a crucial role. Some currently have wholly inadequate pharmacy input and this must change. SHAs must ensure that commissioning is patient-centred, equitable and transparent.


The Darzi strategy for reform must — as a principal, not merely as an entreaty — foster stability for community pharmacy. Primary care contractors, especially GPs and community pharmacists, must work synergistically in a new and different environment of competitive collaboration which benefits patients.


Government must reinvest more of the £1bn clawed back from community pharmacy to fund the opportunities outlined. This should achieve stability and a climate of confidence to encourage pharmacists to invest in the future believing that they will receive an appropriate return on their investments in premises and skill mix while the details of the White Paper are agreed and implemented.

Making it happen

It is not organisations that change, but people — Anonymous

Change requires the sort of engaging and compelling vision provided by the White Paper. But it also requires the profession to accept that we must re-engineer our practices and an honest acknowledgement from all sides that we will need proper support to do so.

For too long our profession has endured “sticking plaster syndrome”. It simply will not work this time.

Change also requires a different way of thinking, feeling and working. Organisations cannot change in isolation so we need to consider the key principles of change management in order to bring the grassroots of the profession with us. These key principles are:

  • Give people some time to adjust; listen to their concerns and feelings
  • Increase urgency; reduce complacency
  • Explain the reasons for change; consult and involve
  • Ask the pharmacy team for their ideas about making the change work
  • Answer their questions honestly and openly
  • Create sufficient trust for others to be open with us
  • Understand what the change would mean to the pharmacy team
  • Learn actively from the change experience
It is not the strongest species that survive, nor the most intelligent, but the ones most responsive to change — Charles Darwin

Are pharmacists responsive to change? They should ask themselves these questions:

  • On a scale of 1 to 10, how important is it for me to change?
  • Where will I be in five years’ time if I do not change?
  • Where will I be in five years’ time if I do change?
  • How will I re-engineer my processes to effect change?
  • Who will I need to bring with me?
  • What will I do first?
  • What might get in the way?
  • How will I get around that?
  • How will I delegate and empower?
  • What will make me more ready to change in the future?


There are many proponents in the field of change management. Professional effectiveness guru Stephen Covey would say that we should begin with the end in mind.

Leadership authority John Kotter would highlight the need to put the appropriate steps in place beginning with a sense of urgency and the establishment of a guiding team to create a clear vision and strategy which are effectively communicated to empower others to act.

Beyond this we should create some quick wins, not let up, and embed change in all that we do.

We are not convinced that these steps are yet in place. We call on the leading pharmacy bodies to work together (not compete nor duplicate their efforts) and we call for the broader profession to work together to seize this opportunity.

Let us set aside our differences, follow the vision for the profession and make it happen by walking the talk. The opportunity, once passed, may not come again.


The only constant is change — Heraclitus


Graham Phillips, of Manor Pharmacy Group, Hertfordshire, and Michael Holden, of balance consultancy

Citation: The Pharmaceutical Journal URI: 10043904

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  • Culture change needs a road-map to a well defined destination (Grio/

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