In chapter, there are the literature review follow by suggestion which was mentioned earlier from the reliable source such as book , journals from database such as Medline and International Pharmaceutical Abstracts , the Department of Health, the National Health Services and Royal Pharmaceutical Society. The consumer behaviour of healthcare services , attitude toward quality of healthcare service, the theoretical of measuring the quality of health care also provide to help the find the answer the aims and objective of this entire research.
Term of attitude is used widely, according to Solomon (2009) state that an attitude refers to general evaluation of people, advertisements, objects or issue. According to Peter et al. (2002) state that attitude is "a person’s overall evaluation of a concept". However, Fishbein (1975) defines attitude as a person’s favourable or unfavourable feelings toward an object. According to Brehm et al. (2002) state that attitude is a mixed reaction positive, or negative to a person, object, or idea. An attitude is lasting because it tends to endure over time (Solomon, 2009). It is general because it applies to more than a momentary event. Attitudes help to determine whom you choose to date , what music you listen to. Two people can each have an attitude toward some object for very different reasons. As a result, it can be helpful for a marketer to know why an attitude is held before attempting to change it.
The functional theory of attitude facilitates social behaviour was developed by psychologist, Daniel Katz, are utilitarian function, value-expressive function, ego-defensive function , and knowledge function. Utilitarian function which describes the basic principles of beneficence and punishment. Value-expressive function which the attitude was formed because of what the product says about him as a person , not because of its objective benefit and high relevance to the lifestyle. Ego-defensive function which is formed to protect the person from internal feelings and external threats. Knowledge function which is formed because of the need for structure, order or meaning such as congruent with new product. Normally, an attitude will be dominated by a particular one function , but in some cases more than one function can be served (Solomon, 2009).
There are many theories which explain and define the meaning and how to measure the attitude. The ABC model is one of attitude theories which consist of three components: affect, behaviour, and cognition. Firstly, affect is how an individual feels about regarding the object. Secondly, behaviour mentions to person's intentions to take action. Thirdly, cognition is knowledge and individual’s belief about the attitude object. All these components of an attitude seem to be important, but depending on a level of consumer motivation to relate to the attitude object to define their relative importance, whether they are main or minor users, and so on (Solomon, 2009).
Attitudes are not formed in the same way, It is important to differentiate among types of attitudes. For instance consumers who have a highly brand-loyalty that completely held confident attitudes toward an object, and it would be difficult to reduce the strength of this involvement. While another person may have a lightly positive attitude toward a product but be truly willing to leave it when the good things comes along(Solomon, 2009).
Consumers vary in their degree of commitment to an attitude relates to their level of involvement which is three levels : compliance, identification and internalization. First, compliances apply to form of persons’ attitude because it helps in gaining benefit or avoiding penalty from others. This attitude is very apparent and probably to be changed. Second, identification refers to an identification process occurs when an attitude forms of behaviour in accordance with the group’s or another person’s expectations. Third, internalisation is a high involvement level and it is very hard to change because consumer internalizes attitudes is seated deeply and become their value system’s path(Solomon, 2009).
Attitudes are so complex because there are several factors that influence their attitude and behaviour such as some people will action by concern about their friends or family would approve that action. The attitude models will help the marketing researcher to evaluate and specify the different elements that may influence people’s attitude objects(Solomon, 2009).
The multiple attitude models assume that the beliefs involve a consumer’s attitude toward the objective. The specific beliefs can identify and combine to derive a measure of the consumers’ overall attitude. There are three elements specify this model: attributes, beliefs , and importance weights. Attributes refer to the characteristics of the attitude object. Beliefs refer to acknowledgment about the particular attitude objective and can measure to extent which the perceives of a consumer that the brand obtain a particular attribute. The weights of importance indicate to the relative a priority attribute to the consumer. People will be weighted on one attribute differently.Some are more likely to important than another(Solomon, 2009).
The Fishbein Model is the most influential multiattribute model. The attitudes are measured by three components: Firstly, salient belief which refers to an attitude of person during evaluation. Secondly, object-attribute linkages or a likeliness that a particular object has an important attribute. Thirdly, evaluation of each important attribute. The attitude toward objective are computed by combining these three elements. By summing score on each attribute, which customer rating, will be computed an overall attitude score for each belief. The most total attitude score will be the most favourable attitude toward the object (Solomon, 2009). Moreover, the Fishbein model may enhance by the past and predicted behaviour of consumers. (Smith, Terry, Manstead, &Louis, 2008)
In order to measure the attitude, the Self-report measures can use to measure people attitude which is used in this research. This type of research measure the attitude by using the questionnaire which is can be either close or open question. The question will ask the respondent the same construct of a questions’ series. The respondents will be read and do the questionnaire without the researcher interfere. Likert or Likert-like scale are also used to usually using in self-report measure. Likewise, this study of measuring the consumer attitude toward quality of community pharmacy services by asking a participant that how important of these statements that they feel about each statement. For example in this research the respondents will decide strongly agree, agree, not decided, disagree and strongly disagree about the feeling of a particular statement in community pharmacy services
2.3 CONSUMER BEHAVIOUR
Understanding of the consumer behaviour is the most important factor for increasing the ability of the organisation to compete with the rival in the market place which is growing continuously. According to the NHS information Centre, General Pharmaceutical Service in England (2011) state that in last five years there were more than 1,200 new pharmacies has been established since 2005. An increasing of community pharmacy is offering and options allow the customer to have more chance or opportunity to switch to a rival. Additional, the economic crisis has recently in the UK and all the European countries, the business which offer the lowest price of product are greater demand for consumers. The research on consumer behaviour concentrates on how individual consumer makes the decision to purchase a product or service which satisfies their need. (Well & Prensky, 2003 ; Schiffman & Kanuk, 2004).
According to Kim, Ferrin, &Rao (2009) claim that there are three phases of the consumers behaviour process which is pre-purchase , purchase and post-purchase (post-consumption). A repurchase phase is possible to occur after this cycle if consumers would like to repeat the business. The study of consumers behaviour process helps the provider to understand how attitudes of consumers are formed and impact each phase differently. For an instant, in pre and post purchase phases beliefs and developing attitudes occur when the consumers’ expectations are violated or confirmed and also realigned for the future purchases. Furthermore, trust which occurs in pre-purchase phase later than post-purchase, play a role in making the decision and formatting intentions. The difference between pre and post purchase phases is that in the post-purchase allow the consumers to confirm pre-purchase standard on service’s satisfaction , product’s performance from the actual and direct experience (Kim et al., 2009). On the purchase stage, it is critical to appraise the change from consumers' behaviour intention to a substantial transaction decision for the consumers’s purpose are a predictor for behaviours (Ranganathan&Fanapathy, 2002 ; Kim et al., 2009).
According to Lamb et al., 2012 argue that there are five steps of the consumer decision making process: problem recognition , information search , and evaluation of alternatives, purchase , and post-purchase evaluation that consumers go through in order to buy services or products.
2.3.1 Problem recognition
Consumers recognize that their needs in several ways such as when a current product does not work properly or about to finish (Lamb et al., 2012 ; Hoyer & MacInnis., 2007). The providers use advertising , packaging and sales personnel to stimulate the consumer awareness and recognize the problem.
2.3.2 Information search
When consumers realise that there are problem occur, they will look for information or the way to solve their problems. The information is divided into two different groups. First, an internal search which is the information from previous experience that satisfied their need (Hawkins et al., 2001). Second, an external search which consumers can find extra information from other people, media, independent sources and retailers (Hoyer and MacInnis , 2007).
2.3.3 Evaluation of Alternatives
In this process, consumers evaluate of choices or options which consumers compare the available information and option that has been searching through the searching process that most likely resemble more problem solving (McCall et. al., 2002). Typically, the consumers will use two methods to evaluate alternative which is the option that requires the consumers’ knowledge to compare of each available alternative attribute which are named as attribute-based choice. The other method is occurring when consumers evaluate by using their emotion. For example, impression and attitude. This is also called attitude-based choice (Hawkins et al., 2001).
In this process, there are several factors which affect the purchasing of consumers. For example the image of store including store atmosphere, service, convenience, merchandise, physical facilities and promotion. The consumer purchasing decision also influences by the operating in the store such as consumer intent to buy a particular brand but they buy alternative brand or additional products (Hawkins et al., 2001).
In this process, consumers evaluate the level of satisfaction of the products’ and services’ performance that their purchase meets their expectations (Hoyer & MacInnis, 2007). According to Lamb et al (2012) state that the price of products and services is also affecting the level of satisfaction and expectation. The consumers can experience of unsure of the correct decision or dissonance. The business providers can help to reduce this effect by advertising in the magazines or media and deliver additional information by experts (Hoyer & MacInnis, 2007). This information will make the consumers confidence that they purchase the correctness of the products or services (Hawkins et al., 2001). The thank you letters and emails are also helping to reduce dissonance.
Southerland (2008) suggests that the decision making of consumers is a process that occur step by step, each process can take vary from a second, a day , months or even a year.
There is some problem in healthcare consumer that they have no choice to choose the health care service because it has controlled by insurers , employers and the government (Herzlinger, 2002 and Spiers, 2003). There are many writers stat that the consumer has no place in healthcare (Clarke et al , 2007 , Le Grand, 2007 and Needham, 2007). Customers have not often been very apparent in healthcare, regardless of whether particular commentators regard it as a good thing or not (Herzlinger , 2002).
The NHS consumers have rarely challenged to make a decision on the healthcare service (Powell and greener , 2009). According to Coulter (2002) and Smee (2005) agreed that The doctors knew what was the best for treatment, so no need to know the patient’s views. In addition, Spiers (2003) state that the government abolished the individual consumer when the NHS founded in 1948.
According to the DH (2006) , the NHS ensures that people have real choice, by offering the convenient appointment and opening time which respond to the needs of the patient. From the NHS operating framework for 2008-9 state that their the NHS strategy is responding and listening to what matters to our public , patient and staff. Choice is an important way of building public confidence in the NHS (DH, 2007). It will not be the NHS of the passive patient (Brown, 2008).
2.4 CONSUMERS’ ATTITUDES IN COMMUNITY PHARMACY.
There are several of research studies of consumers’ satisfaction in community pharmacy. According to the research " Public health in community pharmacy: A systematic review of pharmacist and consumer views which was conducted by Eades, Ferguson and Carroll in 2011 found that most of pharmacy consumer did not expect to be offered and had never been offering public health service by a local pharmacist. In consumer point of views, pharmacists are an appropriate professional of public health advice but some consumer unsure about the pharmacists’ ability.
A survey in Australia of pharmacy consumers found that about 88.2 percent of consumers had never received advice on diet and exercise , 65 percent in preventing health problems and nearly 60 per cent in smoking advise from a pharmacist (Sunderland et al, 2006).
The survey study in Sweden found that customers expected to receive information from community pharmacy about 80 per cent, while around 36 per cent of general health issues , 24 per cent on diet and around 21 per cent on disease or illness and smoking advise (Larsson et al, 2008).
In Nigeria, the community pharmacy survey found that the customers’ satisfaction was very low if compare with other public health service (Oparah and Kikanme, 2006). The survey of nicotine replacement therapy in the USA found that the discussion of medicine related smoking cessation such as a side effect of smoking medication with the pharmacist is useless (Hudmon et al, 2003).
However, there are a lot of consumers who do not receive or expect to get advice from pharmacists on the topic of public health, the satisfaction of consumers who has the experience of advising services from the pharmacist is high (Eades, Ferguson and Carroll, 2011).
According to Teh,Chen and Krass(2001), conduct the survey in Austreria found that the consumer who has experienced of health screening or promotion have more positive attitude than people who did not.
In the USA , the survey of experiences consumer of community pharmacy based smoking cessation service also found very positive in satisfaction (Kennedy et al, 2002).
Pharmacies in Estonia were easy to access and convenient but some experiences of discomfortable when there are other consumers (Vorobjov et al , 2009).
On the pharmacist's ability of consuming aspect, the survey in the UK reported that around one third of consumers were unsure if the pharmacist was qualified and had experience to give them the advise on sexual health issues (Wood and James, 2010) and there are patients who has negative attitudes toward pharmacist training in providing smoking service advising approximately three quarters (Couchenour, Carson and Segal, 2002).
Hence, the survey of nicotine replacement therapy in the USA found that knowledge of pharmacist in smoking cessation relation to prescription medicine as high on average 8 out of 10. On the other hand, the knowledge relating to non-drug therapy is low as 4 out of 10 (Hudmon et al, 2003). In Arab Emirates study in diabetes patient showed that pharmacist advise can help them to reduce blood sugar (Abduelkarem et al, 2004).
2.5 PATIENT SATISFACTION IN HEALTHCARE SERVICES
Understanding patient satisfaction and service quality in healthcare service have known as critical to underdeveloped service improvement strategies. (Gill and White, 2009). Heidegger et al., 2006 state that concept of satisfaction is complicated. Furthermore, Hawthorne, 2006 agree that satisfaction is a multidimensional concept; not yet specific defined; and part of an obviously yet to be determined complex model. While there are several patient satisfaction studies issued in peer reviewed journals, there is a smaller body of critical literature reviews and analyses the use and its construct. Since the 1970s there are agreements that patient satisfaction suffers from the construct’s inadequate conceptualisation, no significantly changed in a situation, and no agreement on the definition (Hawthorne, 2006). Crowe et al. (2002) also found that there are 37 studies issues in investigate of methodological and 138 studies of investigating the satisfaction’s determinants. The study showed that there is no achieving definitively agreement of satisfaction conceptualisation with health care and still not answered why patient become dissatisfied or satisfied. The satisfaction has not only indicated adequate service but also is a relative concept. Moreover, both Urden (2002) and Crowe et al. (2002) comment that patient satisfaction is a service cognitive evaluation that is emotionally affected, and it is therefore a perception of individual subjective. Crowe et al. (2002) also agree that the most vital judgement of satisfaction is the interpersonal connections and their connected aspects of care. What is concurred is that satisfaction has come to be an endpoint in outcomes research and the services benchmarking. Patient satisfaction has come to be perceived as a part of health quality of outcome that additionally encompasses the clinical results, health related quality of life and economic measures. (Heidegger et al., 2006).
In the 1980s , the main patient satisfaction theories were published alongside more recent theories being mainly "restatements" of those theories (Hawthorne, 2006). Five key theories can be identified. For example, Discrepancy and transgression theories which defined by Fox and Storms in 1981, In 1982, Linder-Pelz established the Expectancy-value theory , Ware et al. highlight the Determinants and component theory in 1983 , Fitzpatrick and Hopkins proposed the Multiple model theory in (1983) and in 1980 the Healthcare quality theory of Donabedian defined that satisfaction was the main outcome of the interpersonal process of care. He argued that the expression of satisfaction or dissatisfaction is the patient’s determinants of the quality in all aspects of care, especially, in relation to the interpersonal of the care component. In this study which I mention earlier before that follow the conceptual framework of quality health care by The Donabedian Theory.
The satisfaction measurement varies reliant on the assumptions that are created as to what satisfaction means (Gilbert et al., 2004) and a number of approaches that the research would like to measurement can be identified such as performance only , expectancy- disconfirmation , technical-functional split, satisfaction versus attribute importance and service quality (Gilbert and Veloutsou, 2006). Cronin et al.( 2000 ) reported that there is more extensive review of patient satisfaction measures recently published on patient satisfaction over 38,000 articles using the Pub Med or Medline database.Moreover,there are internet based search over 10,000 websites. (Hawthorne, 2006).
2.6 THE QUALITY OF HEALTH CARE
The quality of health care in this research will be follow the theory of Avedis Donabedian which explain that there are three elements of quality health care : Health , subjects of care and provider of care (Burns and Grove, 2006). According to Loegering, Reiter, and Gambone (1994) suggest that there is another dimension of the provision of care such as access to care. He also modified Donabedian’s levels to include the family, community and patient as recipients of care as well as providers of care.
This research study aims to examine all three concepts of the quality of community pharmacy services which follow by Donabedian (1987) identification that there are three objects of evaluation of quality: structure, process, and outcome. (Burns and Grove, 2006). See Figure 2.1
Figure 2.1 The health services system
Source: From Vivier, P. M., Bernier, J. A., & Starfield, B. . Current approaches to measuring health outcomes in paediatric research. Current Opinions in Pediatrics, 6 , 531. ( (Burns and Grove, 2006).
2.6.1 Evaluating Structure
Structures of care are the administration’s and the organization’s elements that lead the processes of care. In evaluating structure, the first step is to describe and identify the elements of the structure. There are several administration and management theories might be used such as leadership, tolerance of innovativeness , decision-making processes, organizational hierarchy, distribution of power and financial management. To evaluate the impact of various structural elements are the second step. Structures of care also include personal, facility and equipment.
In this research the question that the researcher ask the participant about structure are as follows:
A specialized pharmacist is present at the pharmacy
Sufficient staffs are available
The waiting areas are comfortable and convenience of the services
Consultation room is provided for private discussion
The pharmacy is clean
The pharmacy layout is clear and well organized
The medicines or appliances are in stock
Many choices of health product such as a nutritional supplement, milk powder, medical supply, etc. are available
2.6.2 Evaluating Process
There are three components of the process which are defined by Donabedian are standards of care, practice styles, and costs of care. The process of clinical management may use for most health care professional rather than science.
In this research the question about evaluating process that the researcher asks participant was guided by the structure of the new contract for community pharmacy which divides the community pharmacy service into three types : essential , advanced and enhanced as follows
About services of pharmacist
Polite and take the time to listen to what you want.
Answer any queries you may have.
Provide advice on a current health the problem or a long-term health condition.
Provide general advice on healthy lifestyles.
Keep patient medication records effectively.
Offer services such as blood pressure measurement or cholesterol testing, etc.
Offer complementary health service such as acupuncture ,needle exchange schemes , influenza vaccination ,etc.
Provide clear label of the medicine.
Dispose of the medicines that the patient no longer needs.
2.6.3 Evaluating Outcomes
Donabedian define that the goal of outcome evaluation is not as simplistic as it might immediately appear .The Donabedian’s theory requires that the outcomes be linked with the process. The outcomes also must be relevant to the health care system and the aims of the health care professionals.
Furthermore, Outcomes are time dependent and temporary or permanent. Some outcomes may be apparent immediately whist may be apparent for a long period.
In this research the question statement of evaluating outcomes that researcher asks respondents are as the follows:
Increase benefit of the medication use.
Reduce the risk of safety to medication use.
Improve your understanding about medicine.
Improve your quality of life.
Provide medicines with the reasonable price.
Provide an efficient service.
Provide a satisfactory service.
2.7 SOCIO-DEMOGRAPHIC FACTORS
There are several studies were reviewed to examine the relation between socio- demographic characteristic factors and reported of attitude or satisfaction with healthcare.
Socio-demographic characteristic factors consisted of age , sex , occupation , education , income and ethnic origin.
Age: People in different age groups certainly have different wants and needs (Solomon, 2009). In a study of Javed (2005) found that the old group of people were more satisfied in services rather than younger .Moreover, the older people have more and different needs for health services than other age group (Tootelian et al, 2012).
Gender: Differentiating by gender start at an early age for example the colour of diapers are sold in blue for boys and pink for girls ( Solomon, 2009). In the study in Pakistan, female were more satisfied in out patient department service more than male (Javed, 2005).
Ethnic origin: The implications of changing ethnic composition in London are quite pronounced (Tootelian et al , 2012). According to London poverty’s profile (2012) reported that London is the most changing ethnic cities of the UK. Approximately 40% of population outer London are from another ethnic group and around 50% of population in inner London are not White British.
Education: In a study of Javed (2005) in the context of education level found that people who had an education level of primary and lower had the highest proportion of satisfaction more than people who have an education level higher than secondary school.
Occupation: The result of occupation in the study of Javed defined that people who were the government employees had the highest proportion of satisfaction.
Income. According to Smith (2005) state that people who have higher income may concern about the value and quality more than people who have less income.
2.8 THE OVERVIEW OF LONDON
London is the capital city of England and the biggest city in the Europe. British people refer to people who live in the UK , which includes England ,Scotland , Wales and Ireland.Total area of London is 1,570 sq km .In 2011, London population about 8.2 million with approximate 3.2 million people lived inner London and 4.9 million were remaining in outer London ( Office for National Statistics (ONS), 2011).
The climate in London is difficult to forecast in advance.Thus, It is changing from day to day. Furthermore, London is the most changing races cities of the UK. Approximately 40% of population outer London are from another ethnic group and around 50% of population in inner London are not White British( London poverty’s profile , 2012).
2.9 HEALTHCARE SYSTEM IN ENGLAND
The Department of Health (DH) driven the healthcare system in England and responsible for planning , policy , inspection and regulation. The healthcare services in England are provided free healthcare for all the residents of the UK by The National Health Service ( NHS) .
2.9.1 THE NATIONAL HEALTH SERVICE ( NHS )
188.8.131.52 History of NHS
The NHS is publicity-fund systems which was born on 5th July 1948. Aneurin Bevan , The health secretary, opens Park Hospital in Manchester. Originally, the services are free. Doctors , pharmacist , nurses, dentists, opticians and hospital are brought together under on the organisation. Funding the NHS is a strong egalitarian element of general taxation which redistribution between poor and rich (Greener, 2009).The industry of pharmaceutical was created a several of new drugs such as cortisone ,better anaesthetic agents,antibiotics, mental illness drug,antihistamine and diuretics drug all became available. (Rivelt , 1998)
In 1952, The charges of prescriptions are introduced until 1965.The free-charges of prescriptions are remained until 1968.
Figure 2.2 Structure of the NHS at 1984
Source: Ahmed and Cadenhead, (1998)
According to Talbot-Smith and Pollock (2006) state that the original NHS is described as based on command and control. The department of Health (DH) issued the instruction for local service organization. The structure of the NHS was related to the type of services such as primary, secondary , tertiary and preventive care. The department of Health , the NHS Supervisor and Management Board were responsible for implementing policy and developing strategy. They are also responsible for performance of nationwide function such as managing the NHS’s estates, workforce planning , IT and data collecting. Regional health authorities were responsible for overseeing and planning the provision of tertiary care their areas. District health authorities were responsible for providing planning and secondary care services such as hospital and primary care in their local community. General practices (GP) were independent contractors which not directly employed by the NHS ( see Figure 2.2 ).
2.9.2 Structure of NHS at present
The NHS was restructured radically by the government from time to time.
The NHS plan was established in 2000, providing the patient much more choice of service providers.
The prime determinant, Parliaments, is staring at the top. The Department of Health has mainly remained strategic role, to set " nation tariff" by set the prices of each Healthcare service. The local Strategic Health Authority (SHA) responsible for monitors the input from the Healthcare Commission and serve the local population. Primary Care Trusts (PCTs ) represent the local primary care community such as GPs , opticians , pharmacies , dentists. The secondary care such as hospitals are also commission of PCTs (Talbot-Smith and Pollock , 2006) See Figure 2.3.
Figure 2.3 The NHS structure at present
Source: Talbot-Smith and Pollock , 2006
Primary care refers to health care services provided outside the hospital setting such as General practice (GPs), community pharmacy, dentistry practices, optical practices. There are over 300 million patient contacts primary care each year. It accounts for 81 per cent of daily patient contact with the NHS. (Talbot-Smith and Pollock , 2006)
2.9.3 General practice (GPs)
The first point of people to contact with the NHS are GPs. Generally, they provide services for people who registered with their practices and live in the local area. GPs and the primary care team provide general medical services’ (GMS) , managing the patient’s care with chronic conditions such as respiratory disease, treating people who seek medical attention and providing preventative services such as young babies and mothers health checking. GPs also role as gatekeeper’s by controlling the access to secondary care services. GPs operate as small businesses unlike the rest of the NHS. They are independent practitioners which are under contract with their local PCT. The budget that they receive known as the global sum to cover their running costs including staff salaries , GP’s incomes and cost of services. (Talbot-Smith and Pollock , 2006)
2.9.4 NHS Walk-In Centres
In April 1999, The Primary care walk-in centres were established. There were 65 NHS Walk-in Centres in the UK by the end of 2004.Staff employed and organization run by PCTs. They provide open access to services , advise and treatment for primary care services such as minor injuries and ailments. They can be used by everyone and an appointment is not necessary. They are open every day from early morning to late evening, 365 days a year. In 2004, there are over 1.5 million patients receives healthcare service. (Talbot-Smith and Pollock , 2006)
2.9.5 NHS direct
NHS direct provide 24-hour private telephone helpline service, online consultancy and an interactive digital TV health advice programme, which is intended to provide patient with faster and easier information and advice about health conditions , improve the accessibility and responsiveness of services. In 2003 , there are 6.4 million calls and 6.5 million visits to NHS direct service with 2,000 staffs. The cost of operation around 163 million pounds by 2005-6 (Talbot-Smith and Pollock , 2006).
2.9.6 NHS dentistry
The treatment of oral health is not free at the point of delivery. Some groups of people are exempt from fees such as pregnant women and children. Dentist operates as independent practitioners and able to choose to provide NHS services. The budget for providing dental services are held by PCTs, at an estimated cost of 1.6 billion pounds in 2005-6 (Talbot-Smith and Pollock , 2006).
2.9.7 NHS ophthalmic services
For children and people over 60 are able to do free sight tests which are provided by the NHS including people who have certain eye condition or in receipt of benefits such as income support. There are over 6,000 operating ophthalmic service providers in 2004.The general ophthalmic service expenditure was 322 million pounds in 2003-4 ,9.8 million NHS sight tests and 3.5 million pairs of glasses (Talbot-Smith and Pollock , 2006).
2.9.8 NHS pharmaceutical services
NHS pharmaceutical service is one of the primary care elements consist of the the dispensing of prescription of medicines , drugs, and appliances such as devices to monitor blood glucose levels or syringes. Community pharmacists are responsible for dispensing of prescriptions which written by GPs and dentists. The qualifying nurses and pharmacist are also able to prescribe a limited range of prescription-only medications since 2003 (Talbot-Smith and Pollock , 2006).
There are 10,000 pharmacies have contacts to dispense NHS prescriptions including large corporations such as Boots as well as smaller independent pharmacists. The are community pharmacy within 300 meters nearby GP surgeries around 75 per cent. There are 668 million prescriptions were dispensed in the year to June 2004 which cost 7.8 billion pounds ( only the drugs themselves). The prescriptions are increasing 24 per cent and 41 per cent of drug costs since the NHS Plan was published in the year 2000 (Talbot-Smith and Pollock , 2006).
Pharmacies play a key role in ensuring the safety use and supply of medicines , providing quality healthcare to patients. The pharmacist is working in the primary care such as community pharmacies and hospitals. They also offer advice on common problems such as pains, colds, coughs , aches , stopping smoking and healthy eating. A pharmacist can help patient decide where they need to see a doctor. The appointment does not necessarily if the patient would like to talk in person. Typically, the private consultation area provides in pharmacy which patient can discuss without being overheard by another member of staff and the public (the NHS website , 2013).
The community pharmacies or local pharmacy may provide services such as Emergency contraception , Incontinence supplies, Pregnancy testing , Weight management , New Medicine Service , Stop smoking services , Needle exchange and supervised drug administration , Chlamydia screening and treatment , Medicines Use Reviews and Truss fittings. They also provide minor ailments advise including Children's problems , Aches and pains, Skin conditions, Tummy troubles , Allergies , Minor injuries , Women's health and Bugs and viruses (The NHS website , 2013).
2.9.9 The NSH structure from April 2013
The 152 Primary care trusts (PCTs) which is responsible for controlling local spending on primary and secondary care will be replaced by Clinical Commissioning Groups (CCGs) which is more than 200 organisations of GP-led from April 2013 ( www.ewin.northwest.nhs.uk/) (see Figure 2.4 ). CCGs will be responsible by closing the NHS budget to 60% and more efficient for improving the quality of care. The SHA will not be longer exist from 2013 .
Figure 2.4 The NHS structure from April 2013
Source: adapted by Winit-Watjana (2012) from :www.psnc.org.uk/liberatingthenhs
2.9.10 The benefits of the NHS reform
Firstly, the Local clinicians , the commissioning of health services, will focus much more on patient care outcomes and the service’s quality so the quality of life and patient care outcomes will be improved. Secondly, Improve the efficiency of financial management by providing utilized resource for the most effective care and treatment available. This arrangement aims to reduce waste and drive the system efficiency.
The risk of changing the new structure is also occurring if it is not managed in a proper way and the huge cutting of funds that the government will save around £20m over the coming years will can meet the needs of the population which is increasing. ( www.ewin.northwest.nhs.uk/)
2.9.11 Private Healthcare
The UK has a moderately forceful private healthcare sector, that is funded mainly by private insurance contributions, but it is used merely by a manipulated percentage of people , frequently as a top up to the fundamental state health care Contributions to private funds vary from person to person and are dependant on general health, age, the existence of previously diagnosed diseases, and the level of care required by each person. Many firms offer the private health insurance as a benefit of the job for their employees and their dependants’. There are the leading private hospital operators in the UK such as BUPA and Nuffield Hospitals ( The NHS website, 2013).
There are only 9 percent of revenue from outpatient , inpatient and day-case was funded by the NHS, 67 per cent was funded by private medical insurance and the remainder by self-paying UK and overseas patients in 2003-4. (Talbot-Smith and Pollock , 2006).
2.10 COMMUNITY PHARMACY
Community pharmacy is "a unique hybrid of professionalism and business. In addition to dispensing pharmaceuticals, pharmacist in the community (retail) pharmacies answers questions about prescription and over the counter (OTC) drugs and give advise about home health care supplies and durable medical equipments" and "include all of those establishments that are privately owned and whose function, in varying degree, is to serve societies need for both drug products and the pharmaceutical services"( Saini and Rai, 2012)
Community pharmacies are independent contractors and divided into several different types and size such as large chains or sometime call multiples pharmacy company. The multiple community pharmacies are typically located on High Streets or supermarket. Hence, the small individually owned pharmacies in the suburbs or small community or deprived areas. (The PSNC website)
2.10.1 SWOT analysis of community pharmacy in the UK
Community pharmacy is respected as a professional and a well-liked by the general public.
Pharmacists and staffs who are working in community pharmacy tend to accommodate to the needs of the community easily.
With the pressure on the NHS and secondary care are increasing , the demand of primary care may raise as well.
The public can access to community pharmacy easily without making an appointment.
Pharmacists always incline to undervalue their services for instant they try to supply and delivery of monitored dosage boxes at no supplementary cost.
In order to beat rival community pharmacies tend to open for longer hours.
The majority revenues of community pharmacies rely on the NHS dispensing.
The nature of pharmacist is always compromise on the business skill.
Increasing of pharmacist prescribing if people need to wait at GP for a long time.
The pharmacists should be flexible and always ready for relocation into GP.
The government will provide the provision fees for local community pharmacy that willing to undertake extended roles.
The reclassification of increasing the number of pharmacy-only medicine would be a good opportunity for community pharmacy.
A downturn and recession of economics in the UK may be a threat.
The changing health and safety regulations and employment may increase bureaucratic burdens on the business.
Increasing of the number of competitions especially the supermarkets.
The control of the NHS contracts relaxes for new entrants to the market.
2.10.2 PEST analysis of community pharmacy in the UK
As a result of the NHS policy intend to bring community pharmacy into the full member of the healthcare team, involvement in care delivery will extend markedly. The government intends to create equal opportunity for the public by increasing the availability of healthcare.
The mandatory price cuts of generic drug in order to reduce medicine cost and revenues for community pharmacy.
The government regulation on planning , VAT , taxes , employment , and health& safety ,thus the EU regulation are factors that affect every business.
The exchange rate , interest rate , GDP, economic cycles and money supply are the factors that affect both the disposable income of the public and the stock market.
As a result of higher Inflation , cost of wage bill is higher as well.
The majority revenues of community pharmacy are the prescription drug which payment under the NHS contract.The NHS plan to cut the budgets in community pharmacy will affect the income of community pharmacy.
Increasing competition in the market shares such as supermarkets may affect the community pharmacy business.
Due to a huge changing of public demographic in the UK, there are some changes of customer behaviour trend in purchasing of medicines.
A supermarket may offer a various OTC medicine in the cheaper price and long hours which convenience for the general public.
Electronic Prescription Services that the prescription data are transmitted to a community pharmacy directly will be used in dispensing.
The electronic order online will help the patients to get medicines without going out to the local community pharmacy.
Community pharmacies in England are involved with several national organisations. For example:
The General Pharmaceutical Council (GPhC) organises an independent body.
The Royal Pharmaceutical Society of Great Britain (RPSGB) has recently formed all functions of the professional regulator.
The Pharmaceutical Services Negotiating Committee (PSNC) provides aid to the network of Local Pharmaceutical Committees (LPCs) and work as the representative body for community pharmacies in order to negotiate with the national NHS contractual terms.
The National Pharmacy Association is the trade association for the owner of community pharmacy and provides a various range of aid to help their businesses run successfully, including the insurance services supporting (The community pharmacy- a guide for general practitioners and practice staff, 2010).
The community pharmacy which is conducted by the local Primary Care Trust (PCTs), need to follow the conceptual framework which is negotiated by the Pharmaceutical Services Negotiating Committee (PSNC) , the NHS Confederation and the Department of Health (DH). There are four main areas for the patient which the new contract purpose to enable the community pharmacies to contribute to patients; self-care , public health , management of long-term conditions, and improving access to services (Waterfield, 2008).
The structure of the new contract for community pharmacy which divides the community pharmacy service into three types : essential , advanced and enhanced (see Figure 2.5 )
Figure 2.5 Contractual framework for community pharmacists in England and Wales.
Source; Waterfield, (2008).
2.10.3 Essential services
All community pharmacies or contractors have to provide essential services as follows;
Dispensing of medicines: the pharmacy must ensure that the dispensing of medicines is safe by checking the clinical and accuracy, appropriateness , legal when a prescription is presented and ensure that the patient understands how to use the medicines or dispensing items including potential side-effect and drug interaction.
Repeat dispensing of medication, which is forced by the NHS regulations since 2004, is limited to a particular group of patients such as patients with long-term conditions and the symptoms is stable.
Disposal of waste or unwanted medicines: the aim of this service to reduce the risk of accidental poisoning or exposure to the medicine of the people at home. Furthermore, to decrease environment by an appropriate disposal process.
Promotion of healthy lifestyles in Public Health consists of two separate areas: prescription-linked intervention and involvement in public health campaigns.
Signposting staff at the pharmacy will advise or inform the patient or client if they need social need and extra support and write a referral note in some cases.
Support for self-care pharmacist suppose to give information and advise on both long-term condition and minor illness, interventions of a healthy lifestyle and nonprescription medicines.
Clinical governance requirement the community pharmacy needs to improve their quality of services continuously by conducting the survey once a year asking the public and patient about their quality of service, facility and staff. In this research the researcher also asks the participant which including these clinical governance services such as there are enough staff.
2.10.2 Advance services
In advanced services both the pharmacist and the pharmacy were required the document to be accredited including prescription intervention (PI) service, a medicines use review (MUR) and issues which support MUR service (Waterfield, 2008).
2.10.4 Enhanced services
Enhanced services which are controlled by the primary care trusts (PCTs) and only for England and Wale. The service which the enhanced service in the community pharmacy is free of charge. For example, supervised administration of medicines, stop-smoking support service, supply of medicines via patient group directions and minor ailments schemes. (Pharm J, 2006; 277: 628).
2.10.5 Funding for community pharmacies
Table 2.1, around 94 per cent of income of community pharmacy from the prescriptions dispensed as shown in Table 2.5 , Over the counter (OTC) around 4 per cent and the rest from Local NHS services and Private service. (The community pharmacy- a guide for general practitioners and practice staff, 2010).
Table 2.1 Percentage of annual income of community pharmacy.
Source: The community pharmacy- a guide for general practitioners and practice staff , 2010.
2.10.6 Funding for the national pharmacy contract
Funding of community pharmacy in the England follows in the Drug Tariff which provide the details of community pharmacy remuneration for essential and advanced services.
The total funding of national agreed is distributed through allowances, a combination of fees and purchasing margin.
For instance pharmacy provider receive a professional fee for all prescription items, fees for extemporaneous dispensing , some additional fees, measuring and fitting trusses and hosiery, and controlled drugs dispensing.
In addition , an established payment may support providers who exceed a specified volume threshold which depend on the volume of prescription items submitted in a month. Practice payments are one of the fund that all pharmacy providers are eligible to receive as well such as providing the provision of auxiliary support for people under the Disability Discrimination Acts (DDA) 1995 and 2005. Pharmacies will receive a payment every month for the spine connectivity (N3) service charge if they are using a compliant Electronic Prescription Service (EPS) system (The community pharmacy- a guide for general practitioners and practice staff, 2010).
The reflecting of long-term pressure and financial crisis on the NHS expenditure is in the public. In spite of spending on health care will not suffer as much on the national budget, the growth rate is expected to slow down continuously in the following years which is one percent of growth rate in 2013.On the other hand, there is one in six people in the UK or 10 million people are age 65 or older and in 2015 (Anscombe , Plimley and Thomas, 2012)