In the United Kingdom, the contributions of community pharmacies to public health have not been clearly defined. As a consequence they are not routinely integrated into the work of the wider public health family. Whilst it is unclear why this should be, it has been acknowledged that they have the potential of playing a significant role in protecting and improving population health, identifying patterns of disease and providing health and social surveillance information to public health bodies (Department of Health 2005a; RPSGB 2003).
The role of the community pharmacy in public health remains to be fully exploited, even though they have been increasingly involved in health improvement activities such as services aimed at smoking cessation, sexual health and substance misuse services, etc, as laid out in the contractual framework for community pharmacies (DOH 2005b). An important area of public health where community pharmacies have been least involved is in health protection, and they have the potentials of complementing present efforts in surveillance of infectious diseases and providing support to affected population during an outbreak.
In Wales, health protection is one of the key responsibilities of the Public Health Wales (PHW) Health Protection unit and the Communicable Disease Surveillance Centre (CDSC) is the arm responsible for surveillance of infectious diseases, support for outbreak investigations and provision of health intelligence and applied research (NPHS Wales, 2007).
Presently, there are no initiatives or policies to formally engage the health protection unit of the Public Health Wales and community pharmacies to work together on health protection whereby routine intelligence and surveillance information are exchanged (NPHS Wales, 2007). These surveillances information could be in form of monitoring trends of over-the-counter (OTC) sales data (e.g anti-diarrhoeal, anti-fungal, cold and cough remedies, etc.) to detect outbreaks, and routinely providing community pharmacies with outbreaks and surveillance reports to enable them provide support to affected population.
Policy Framework Analysis: In order to achieve a successful policy change, a prospective policy analysis of the issue at hand (Analysis for policy), which is iterative and dynamic will be undertaken (Buse. 2005). The diagram below highlights the different aspects of the policy analysis and is explained in details under the policy headings - content, context, actors and process.
Need for change (Policy Content):
There is a need to evolve the roles of the health protection units and CDSC of PHW to include routine communication with community pharmacies in order to improve their effectiveness in surveillance and detection of infectious diseases outbreaks and protection of population health in Wales. This formal engagement of community pharmacies with the PHW Health Protection unit is important as a result of increasing knowledge and awareness of its potential benefits.
During the outbreak of E. Coli O157 in South Wales in September 2005 which affected about 150 people (with 1 death recorded), the pharmacy team of the then NPHS Wales noted anecdotal reports that community pharmacists had been consulted with regards to the sale of anti-diarrhoeal preparations (Walker 2009). Also during the outbreak of viral conjunctivitis in South Wales in August 2006, GPs and community pharmacies were advised against the use of ophthalmic chloramphenicol and there was evidence of public health protection by those pharmacies that acted on the advice (Hinchliffe and Walker 2008). These are pointers to the fact that community pharmacies can play a significant role in public health protection.
Policy Context;
Public or government policy has been described as a decision that a government decides or decides not to make (Dye 2001). In the current political context in Wales since devolution in 1999, the WAG has adopted the "citizens' model" of health service delivery where the public have rights and responsibilities in both receiving health services, and ensuring availability of the services to everyone (Welsh Assembly Government 2004; Beecham Report 2006).
Thus, the current policy environment in Wales can be said to be pluralist and the major contextual factors necessitating a need for change at this point in time are structural and endogenous in nature. These include the recognition by the UK Department of Health (2005a) that community pharmacies are untapped resources in protecting public health and the commitments of the Welsh Assembly Government in its One Wales a progressive agenda for the government of Wales, which aims to protect the health of the population with one of its health priorities of strengthening public health services (Welsh Assembly Government 2007).
Furthermore, improved electronic connectivity in community pharmacies (RPSGB, 2008) will allow for easy and quick transmission and receipt of data and information for surveillance activities. Lastly, increase in the knowledge that early detection and control of infectious diseases outbreaks in the population through an efficient surveillance system significantly reduces its burden on the health of the population and saves costs of treatment and hospital admission, hence improving public confidence in the government.
Policy Stakeholders (Actors):
This step involves identifying the policy actors and understanding their position and interests with respect to the issue of involving community pharmacies in PHW's health protection (Buse, 2005). This is important in order to achieve change and ensure its successful implementation and sustainability.
Welsh Assembly Government: Is a key stakeholder in making and implementing the policy by delivering the policy instrument in the form of an official statement and/or regulation. The following actors in the WAG include:
The Department of Health and Social Services: oversees all health related functions in Wales including "advising the Welsh Assembly Government in setting policies and strategies for health and social care in Wales"(Welsh Assembly Government, 2010a) and is key in decision-making with regards to approving the policy and delivering the policy instrument on behalf of the government.
The Department of Public Health and Health Professions (DPHHP): headed by the Chief Medical Officer for Wales, reports to the Department of Health and Social Services and has the objective of protecting the health of the peoples and being prepared for health emergencies (WAG 2010b).
Chief Health Professionals: including the chief medical officer, chief pharmaceutical adviser and others who provide expert knowledge in public health and related specialist areas to the WAG and other external bodies to protect and improve public health.
Public Health Wales (PHW): In October 2009, the new NHS trust established by the WAG became operational, incorporating the functions and services provided by the NPHS Wales, Wales Centre for Health (WCfH), WCISU and the Screening Services Wales. PHW is to provide resources, advice and information to the WAG, and all Wales NHS Trusts, Local Health boards, etc, enabling them to carry out their statutory public Health functions (Public Health Wales 2009). Its Health protection unit has as one of its strategic goals to reduce the impact of infectious diseases and emergencies in the population and delivers this through its Health Protection Teams and the Centre for Communicable Diseases Surveillance (CCDS) among others (NPHS Wales, 2007). The PHW is a key actor in achieving successful policy changes since they will be directly involved in the implementation of the policy.
Public Health Consultants in Wales: including Consultants in Communicable Diseases and Control would be part of the policy change process in obtaining experts inputs in their various specialised fields, and most especially pharmaceutical public health consultants would be main advocates and pioneers of the policy change.
Community Pharmacy Wales (CPW): is the local practice forum for Wales and is perhaps the most crucial stakeholder as community pharmacies are at the other end of the spectrum for implementation and the policy change affects them directly and the way they operate. CPW represents the interests of the over 700 community pharmacies in Wales and are recognized by the WAG as the negotiating body on behalf of pharmacy contractors, taking the role from the PSNC's Welsh committee following devolution (CPW, [no date]).
Nation-wide Chain Pharmacy Stores: These are particularly important stakeholders since their operations span across the different UK countries and are likely to have an integrated IT system for staff and data management. Their views are important since they represent a large chunk of community pharmacies, for example in Wales of the 714 community pharmacies, 91 are owned by Boots (Walker 2009).
Royal Pharmaceutical Society of Great Britain (RPSGB): is the regulatory and professional body for pharmacists and pharmacy technicians in the Britain with primary objectives "to lead, regulate, develop and represent the profession of pharmacy" (RPSGB, 2010a). Since more than half of the over 2300 pharmacists in Wales work in the community (RPSGB, 2010b), the RPSGB is an important actor in representing their interests and in ensuring that the policy is successfully made and implemented.
The Welsh Centre for Pharmacy Professional Education (WCPPE): is an operational unit of the Welsh School of pharmacy, Cardiff University and provides continuing professional development opportunities (CPD) for the pharmacy team in Wales (WCPPE, 2010). The WCPPE is important as a policy actor in devising and providing a CPD programme for community pharmacists in Wales as a part of the policy implementation process in ensuring its success and continuity/sustainability.
Faculty of Public Health (FPH): in the UK is the body that sets standards for public health specialists and aims to promote advancements in public health knowledge and maintain the highest level of professional standards (FPH, 2010). The FPH is a major advocate for public health in the UK and forging an effective partnership with it in pursing this policy change is crucial for setting the policy on the agenda and ensuring that it remains there up till its implementation and evaluation.
National Pharmacy Association (NPA): is the trade association for community pharmacies in the UK and aims to represent, support and protect their interests (NPA, 2010). The NPA is a potentially important actor in the policy process since their position can make or mar the implementation of the policy.
The Media: Is an excellent means of getting the issue on the agenda and in setting the ball rolling for discussions among different actors (Buse et al 2005). The proponents of the policy change may utilise a sponsored news documentary especially highlighting past consequences of outbreaks (including fatalities) and ways in which the community pharmacies could have provided important surveillance information to the PHW and the public and intervened to provide support to affected population.
Other Stakeholders will include:
Welsh Medicines Resource Centre (WeMeReC)
Local Health Boards in Wales
Board of Community Health Council in Wales
The Media
The Welsh Office of Research and Development for Heath and Social Care (WORD)
As a part of the policy analysis framework, after identifying the political actors, assessing their political powers and assessing their interests, positions and commitments (Buse et al, 2005), an abridged stakeholder analysis and summary of their power distribution is shown in Table 1 below.
Table 1: Stakeholder Analysis (Varvasovszky and Brugha, (2000):
Support
Against (Opposition)
Neutral
Welsh Assembly Government (WAG)
Community Pharmacy Wales (CPW)
Welsh Centre for Pharmacy Professional Education (WCPPE)
Public Health Wales (PHW)
National Pharmacy Association (NPA)
Media
Royal Pharmaceutical Society of Great Britain (RPSGB)
RPSGB
WeMeReC
Faculty of Public Health (FPH)
Nation-wide Pharmacy Stores, e.g. Boots Pharmacy
Board of Community Health Council in Wales
Consultants of Public Health in Wales
Local Health Boards in Wales
Media
Policy Process
Despite the pluralist nature of the political system in Wales, Luke's first dimension of power may not capture the full range of relationships that exists, while his second dimension of power may be useful in explaining the agenda setting process (Buse et al. 2005) since different policy actors all have varying powers to protect their interests. Policy change here would utilise the incrementalist approach which would involve "muddling through" the policy status quo which will include a new role for the Public Health Wales (i.e. routine communication of surveillance information with community pharmacies) and community pharmacies (i.e. providing OTC sales data to PHW).
The four-staged (linear) policy process - agenda setting, policy formulation, policy implementation and policy evaluation, provides a useful heuristic device (Stages Heuristics) which is useful in explaining the policy process, even though it is a cyclical process in reality (Hogwood and Gunn 1984).
Agenda Setting: Introducing this policy change onto the WAG agenda may not be achieved following the "politics-as-usual" approach where the WAG comes to determine and recognize that there is a major issue to be addressed (Buse et al. 2005). The Hall's model (1975) cited in Buse et al (2005) will be important in bringing the issue to the attention of the WAG since its legitimacy, feasibility and support can be deemed as high and pursued by the actors:
Legitimacy; Expanding the role of community pharmacies to complement current efforts at public health protection and involving them to provide support to affected population after an outbreak is a legitimate goal in terms of delivering the WAG objective of health protection. It is also underpinned by several reports (DOH 2005a, RPSGB 2003) advocating more involvement of community pharmacies in health protection.
Feasibility; Achieving the policy change will provide a platform at maximizing available resources for health protection as the policy change will not require any major additional financial and human resources in terms of opportunity costs. It involves expanding the responsibilities of the PHW health protection teams to routinely communicating with community pharmacies in their local authorities and analysing data obtained from them as part of surveillance. It is highly feasible, maximizes finite human and financial resources of government.
Support; A potential challenge in the policy process is getting adequate support especially from community pharmacies and their different bodies. Since its not part of the contractual framework of community pharmacies and no commercial rewards, community pharmacies may appear not cooperative. However, this challenge can be addressed by adequate advocacy and lobbying with the pharmacy groups (CPW, NPA, RPSGB) and ensuring that support is obtained. From the government perspective, support from the public health consultants and civil servants (minister, directors, etc.) would be sought after by the pharmaceutical public health consultants and partners advocating for the change.
Public Health Consultants in Wales, in particular pharmaceutical public health consultants would be the champion of the policy change by first accepting the need for change and propagating the message especially through the media. Health Protection Unit of the PHW who are a part of the policy implementers would be involved in this early stage to ensure their support, while other parts of the PHW including the Public Health Strategic Management Group would be carried along.
Community pharmacies on the other hand may prove difficult initially, but strong advocacy and use of political resources available especially through the RPSGB would ensure cooperation. Advocacy by pharmacists and consultants working within PHW to the RPSGB, CPW and NPA and the use of informal meetings and formal round table discussions between these stakeholders will ensure support. The support of the FPH would be required since it plays a significant role in advocacy for public health policy change (FPH, 2010).
Policy Formulation
Once the issue gets on the government agenda, a series of complex activities takes place within the policy network (process and actors), with the actors wielding their political powers and resources to pursue their interests in the policy.
The use of public consultation is a tool frequently used by the WAG (Strategic Policy Unit) in policy making processes, which would bring the policy network together to deliberate and provide technical information on the policy. At this stage and based on negotiations, the final details and adjustments of the policy change would be made before it is formulated. Policy formulation takes place by enactment of the policy through an appropriate policy instrument which in this case may be done through the issuance of an official policy statement/circular by the Minister of Health and Social Services.
This policy then flows down the hierarchy of the civil service and NHS to the PHW which then implements it. Community pharmacies either through the CPW, RPSGB and/or NPA will also issue policy statements to all its members to act as appropriate with the PHW.
Further reviews and discussions at a later time during and after evaluations have been carried out may then lead to further negotiation and decision on whether or not to include the policy in the community pharmacy contractual framework.
Policy Implementation
Implementation is the most important aspect of the policy process since it is where change is expected to occur. Using the "Bottom-Up" approach would involve the implementers; in this case the PHW Health Protection Unit and community pharmacies (CPW), to interact in the political process of implementation (Buse, 2005). Conflicts are bound to arise during implementation but it is important in identifying challenges and providing feedbacks for evaluation and for change of approach.
The "Top-Down" approach to policy implementation would be used to outline the administrative and managerial aspects including outlining goals and strategies, and assigning quantitative targets to ensure that the policy delivery can be monitored and evaluated to identify areas for improvement.
Implementation of the policy may only produce a marginal incremental change which is easy to monitor and requires very little human and financial resources. Successful implementation is an iterative process which and requires regular inputs and active participation of the members of the policy network. This can be achieved through a regular stakeholders' forum for discussions, suggestions and evaluations.
One other important aspect of the implementation is to include health protection as a Continuing Professional Development (CPD) programme for community pharmacies. This aspect would involve the RPSGB and WCPPE, ensuring sustainability of the change and can be achieved through active advocacy.
Policy Evaluation
Evaluation in a policy process is iterative and may be done at any stage of the policy process in order to appraise the levels of progress that has been made. Formative evaluation of the policy will be carried out during the policy agenda setting, formulation and implementation stages to modify and develop the final policy in order to accommodate the views of differing powerful actors. Summative evaluations on the other hand would be focussed to measure the level of impacts of early detection of infectious diseases outbreak achieved by the policy change over a period of time (Buse et al, 2005).
Evaluation of the policy may include the use of epidemiological studies such as ecological and case control studies to assess the effectiveness of detecting outbreaks of infectious diseases as a result of involving community pharmacies in surveillance in comparison with other areas of the UK. It involves the collection and use of qualitative and quantitative data to assess the effectiveness of the policy change. The use of the Donabedian's Structure-Process-Outcome Framework to conceptualize the policy evaluation is described in table 2 below.
Donabedian Framework for Policy Evaluation
Structure/Input:
Administrative/Managerial Components
Number of PHW Health Protection Teams and Community Pharmacies involved
Use of IT resources
Outcome
Early detection of outbreaks by community pharmacies leading to reduced burden of infectious diseases
Reduced burden/morbidity of infectious diseases in the population
Process/Activities:
Routine (Weekly or Monthly) communication and exchange of health protection reports and infection diseases surveillance data
Actions taken by community pharmacies to support affected population
Whether or not Continuing Professional Development (CPD) on health protection has been introduced to community pharmacies
Output
Amount of outbreaks detected through use of community pharmacies surveillance data
Amount of outbreak cases handled by community pharmacies (referrals and actions taken)
Number of community pharmacies taking the CPD on health protection
Summary
