Some refer to hub & spoke as dispensing hubs and others as centralised dispensing, but what we are really talking about is centralised or remote assembly. Dispensing includes supply to a patient which creates the opportunity for an intervention (pharmaceutical care) to support the safe and appropriate use of the medicine or provide advice on healthy lifestyles. This opportunity must be preserved at all cost for the benefit of patients, the health system and the profession.
Some of the larger multiples have been operating localised hub & spoke for many years to release capacity in some of their pharmacies, particularly for care home and MDS provision. However, this has now started to scale up for repeat prescriptions with Celesio/Lloyds, Boots and Day Lewis announcing plans. The current Human Medicines Regulations 2012 (HMR) prevent hub & spoke operating between different entities thus limiting the opportunity for independents.
Dr Keith Ridge (CPO for England) spoke at the RPS conference in September 2015 and stated that he wanted all community pharmacies to be legally allowed to embrace hub & spoke believing that it could deal with two-thirds of dispensing volume and thus release capacity to deliver patient care and improve safety. This is now nearing reality with The Letter in December 2015 outlining plans for community pharmacy reforms including changes to the HMR legislation and funding cuts.
The announcements have created a wave of mixed emotions, opinions and activity. Sue Sharpe (PSNC) said “It is folly, and a dangerous one at this time when the NHS is desperately casting around for cost savings, to leap to premature conclusions that large remote assembly or dispensing operations are a means to cost savings”. Rob Darracott (Pharmacy Voice) believes that utilising technology and lean practice to enable hub assembly will release capacity for more clinical services, improved safety, adherence, patient experience and outcomes and that the changes to legislation will level the playing field. The GPhC’s view is that this is an area for legitimate debate but there are some key questions to consider and it is a business decision how pharmacies organise themselves within the legal framework and professional standards.
The concern for many is that there are those who seek to replace the community pharmacy service with a remote supply operation which could send community pharmacy service development into reverse. This would be extremely detrimental in reducing the level of patient care leading to increased demand on GP and A&E services.
There are some examples of hub & spoke working in independents such as the Mayberry Pharmacy group with seven pharmacies in South Wales. Paul Mayberry began exploring lean principles in order to work smarter several years ago which helped the group cope with the impact of funding cuts in October 2012. Paul developed his skill mix with ACTs and installed a robot at one of his pharmacies (the hub) which required a big shift in mind-set to overcome resistance to change. They now use the hub for up to 60% of repeats and have reduced stockholding by 35% whilst releasing capacity to grow the business.
Celesio’s new Prescription Assembly Solutions unit in their Warrington warehouse has required significant investment. I have witnessed at first hand the impressive operation which employs the innovative use of new technologies under a nothing is impossible approach. They aim to support both the Lloydspharmacy group and their independent customers with this service to release time and talent in the pharmacy and reduces error rates.
This is a very complex scenario with many known unknowns and some unknown unknowns depending how funding, legislation, relationships, technologies and services develop. Many questions remain unanswered but this will evolve quickly once the legislation changes. Possibly the most important challenge will be leading the required change in culture, practice and behaviours of pharmacists and their teams to embrace change and utilise the released capacity effectively to enhance patient care and generate new service revenue.
So what does success look like? I would suggest that it is a sustainable community pharmacy sector performing and being appropriately funded for a greater role in improving the health and wellbeing of the communities they serve. One thing that is certain given everything else that is happening, is that embracing technological advances is a must, doing nothing is not an option!
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