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PJ Online | Broad Spectrum (Has community pharmacy a role in dealing with health inequalities?)

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The Pharmaceutical Journal Vol 267 No 7179 p880
22-29 December 2001

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Has community pharmacy a role in dealing with health inequalities?

By Paul Bissell, Claire Anderson and Alison Blenkinsopp

The Labour Government continues to place emphasis on the reduction of inequalities in health in the United Kingdom, in response to growing evidence of a widening gulf in life expectancy between the richest and the poorest sections of society. Indeed, government responses to the health inequalities agenda include numerous initiatives such as the appointment of a Minister for Public Health, the creation of Health Action Zones, the promotion of "joined-up" government and "partnership" working for the National Health Service, and the setting of specific targets for reducing inequalities in health. These initiatives indicate that inequalities in health are at the top of the policy agenda.

But where is pharmacy in this? How is it responding to this agenda? The recent publication by the Royal Pharmaceutical Society and the Pharmacy Healthcare Scheme (PHS) of research evidence relating to the involvement of pharmacy in health development represents an important initial step in pharmacy's response to this agenda.1 The report sets out the findings from a detailed review of the UK and international literature to demonstrate that there exists sufficiently robust research evidence of the effectiveness and public acceptability of certain pharmacy services for them to be recommended for more widespread implementation. The report refers specifically to smoking cessation, lipid management, immunisation and supply of emergency contraception as services which meet the criteria for acceptability and effectiveness.

The launch of the Society/PSH document at the 2001 British Pharmaceutical Conference was preceded by a debate focusing on pharmacy and public health. This provoked considerable interest and argument among participants about the nature of pharmacy's engagement with public health. As researchers working in this area, we feel it is important to retain a distinction between general health services provided by pharmacists and those aimed at improving public health or reducing health inequalities. For example, provision of treatment of minor ailments free of charge to patients exempt from prescription charges can address the inequality relating to low income groups and their access to over-the-counter medicines. It can also be argued that making better use of pharmacy services for this group will free GP and nurse time in deprived areas enabling more time to be spent on the treatment of serious and chronic illness. Nevertheless, it is difficult to view the transfer of minor ailments to pharmacy as having a similar public health impact as compared to, say, widening access to emergency hormonal contraception or improving services for drug misusers.

But what about pharmacy's role in relation to the fundamental causes of inequalities in health? What can be done there? The academic and policy consensus is that inequalities in health are rooted in differences in the material conditions of life. Pharmacy commentators acknowledge the need to address "the wider determinants of health status, such as poverty, pollution, housing and education".2 Researchers can be forgiven for thinking that there may be little scope for pharmacy to make an impact here. However, we want to suggest that pharmacy may be able to play an important mediating role in reducing health inequalities through fostering social capital in local communities.

Social cohesion

Social capital refers to the institutions, relationships and norms that shape the quality and quantity of a society's social interactions. As McKinlay argues: "Social system influences ... may account for as much (if not more) of the variation in health and/or illness statistics as do environmental influences or even the attributes and lifestyles of individuals."3 It is increasingly suggested that higher levels of social capital foster health maintenance through improving social connectivity and levels of social cohesion. For example, research shows that the lower the trust among citizens, the higher the average mortality rate. Within health promotion there is a long tradition of developing relational ties and networks, which are seen to build problem-solving capacities and to impact on health. These literatures emphasise the influence of "place" on health, and there are now calls for more place-related initiatives to address health inequalities through developing social capital.4 The social capital agenda is already an important undercurrent in public policy, earning Robert Puttnam, an early proselytiser of the idea, an audience with Bill Clinton, and latterly with Tony Blair.

How might pharmacy develop a research agenda in this area? We believe there is an urgent need for descriptive research. For example, there is anecdotal evidence that community pharmacy plays an important role in the maintenance of social cohesion, providing a space for individuals to develop networks of trust and support. One example might be the development of CHAT centres by Lloyds Pharmacy. Another is Croydon Health Authority's scheme to provide advice, information and referrals to social services from community pharmacies. Furthermore, there is limited evidence that some pharmacists provide what might be called pastoral care, which encompasses a supportive or compassionate approach to relationships with clients that goes far beyond the provision of advice about medication. It is possible that this aspect of the work of community pharmacists promotes well-being, social cohesion and the capacity to maintain health. However, it is an activity (or set of activities) that is currently under-researched and accorded a relatively low status in the eyes of the profession. Indeed, pharmacy has been (perhaps rightly and, certainly, not surprisingly) concerned to develop its role as a provider of discrete and specific health services, rather than explore the wider aspects of its role in terms of health development.

However, as is now increasingly acknowledged, the organisation and functioning of the social system, and the place of the individual within his or her community of relationships is an important influence on health. It is pharmacy's location at the centre of many communities which may allow it to make a unique contribution to enhancing social capital. We believe that pharmacy practice researchers now need to engage with this agenda to explore the contribution pharmacy makes to local community health networks. In so doing, pharmacy is likely to become increasingly important in the debate about health inequalities.

References

1. Royal Pharmaceutical Society/ Pharmacy Healthcare Scheme. The evidence relating to pharmacy involvement in health development: report 1. A critical review of the literature 1990-2001. Executive Briefing Paper. London: The Society; 2001.

2. Boorman G, Kalsi S, Khan I, Patel H. Developing public health pharmacy. Pharm J 2001;266:572.

3. McKinlay JB. Bringing the social system back in: an essay on the epidemiological imagination. Boston: New England Research Institute; 1995.

4. Popay J, Williams G, Thomas C, Gatrell A. Theorising inequalities in health: the place of lay knowledge. In: M Bartley, D Bartley, D Blane & G. Davey Smith (editors). The sociology of health inequalities. Oxford: Blackwell; 1998.

Mr Bissell and Dr Anderson are from the school of pharmacy at University of Nottingham. Professor Blenkinsopp is from the department of medicines management at Keele University

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