The labels ‘public’ and ‘private’ mask complex realities. Take, for instance, the UK government’s classification of community pharmacy as private sector. On the surface, it seems straightforward.
Pharmacies are businesses, after all, operating within a market economy. Yet, a deeper philosophical examination, coupled with sociological insights, reveals nuances with significant implications for pharmacists and wider healthcare.
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‘What is private, truly?’ is a question that Socrates might have liked, but continued, ‘Is there a better question?’
This is more than an abstract debate about the NHS. It touches upon the very essence of what it means to provide care. Consider also NHS GP surgeries. They are private businesses.
The lines blur. And what of NHS hospital consultants? Many are also permitted to dedicate a portion of their time to private patients. Public and private are mingled and complicated.
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Private sector managers often cite market pressures, competition, and the need for profitability as primary drivers in their decision-making. Public sector managers, while not immune to financial realities, tend to emphasise patient needs, equitable access and the broader social mission of healthcare.
Public and private reflect fundamental differences in how society perceives those sectors. The private label, while acknowledging the business aspect of pharmacy, risks overshadowing its crucial function as a vital component of the healthcare system.
Are pharmacists at root entrepreneurs, or healthcare professionals with ethical and social responsibilities? We know they are both, but the balance between these two roles is ever and again being negotiated.
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A recent illustration is the deluge of advertisements in pharmacy windows and online for Semaglutide (Wegovy), a glucagon-like peptide-1 receptor agonist (GLP-1 RA) subcutaneous injection. Sometimes online consultations with pharmacist independent prescribers (IPs) were extremely short.
The General Pharmaceutical Council (GPhC) felt it necessary to add extra requirements for independent verification of the information provided by the patient, such as direct observation. A proper consultation might last 20 minutes. Questionnaire-style prescribing, alone, is insufficient.
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Jack Cohen, the founder of Tesco, said “pile it high and sell it cheap”: a business model of high volumes and low prices attract customers. However, after the GPhC edict, pharmacists had to spend more time selling: labour costs increased. That presumably reduced profits.
That seems a stark illustration of public service being more in the public than private interest. Users are more obviously patients rather than customers.
Taxes, including from private organisations and employees, some poorly paid, pay for the British public (notably hospital) pharmacists. But public services are an investment in a healthier, wealthier population and nation.
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We must also acknowledge the contributions of other healthcare professionals and other healers and carers, some without formal qualifications. The landscape of care is like a harvest grown from the varied seeds of paid professionals such as medical practitioners, pharmacists, and nurses, to the nurturing yield of unpaid family and community volunteers.
Collaboration and interprofessional working are crucial for effective healthcare delivery. The pharmacist, situated at the intersection of clinical knowledge and community access, plays a pivotal role in this network of care.
The government’s ‘private sector’ classification raises concerns about the potential for market forces to dictate healthcare decisions.
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Will the pursuit of profit overshadow the needs of vulnerable populations such as the worried well, who are desperate for that envious lithe image on social media or someone suffering from anorexia nervosa?
Will cost-cutting measures compromise the quality of care? The recent illustration of Wegovy suggests an all-to-real problem. Other easy-to-sell profitable treatments (including new GLP-1 RAs) may well arrive shortly, bringing new moral challenges.
Funding and resource pressures impact all healthcare areas, including community pharmacy.
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Sociologically, in purely market-driven healthcare systems, access to care can become stratified. Those who can afford it receive preferential treatment. Put brutally, money buys better healthcare. That seems neither fair nor just.
Should only those who can afford medicines and services receive them? On the one hand, pharmacists should be astute business managers, ensuring the financial viability of their pharmacies. On the other hand, they must also be compassionate ethical caregivers.
That requires a delicate balancing act: virtuoso juggling.
Dr Malcolm E. Brown is a retired community, hospital and industrial pharmacist, and is a sociologist and honorary careers mentor at the University of East Anglia.