Pharmacy Complete

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Hub and Spoke

Back to the Future

What next for community pharmacy?

This article I wrote for Pharmacy Magazine a couple of years ago explored what pharmacy might look like in the future. I speculated on two potential models which I called Nirvana and Amazonia. At the time I challenged the profession to create its own future and not be led by government and others to a place where we, and most patients, don’t want to go whilst being realistic when we operate in a healthcare ecosystem is changing at an increasingly rapid rate.

More recently, I played this back in one of our Viewpoint articles, Here and Now. With Amazon entering the pharmacy space in the United States with its recent acquisition of PillPack and some wholesalers, and rumours that it is in conversations with Pharmacy2U in the UK, it is very much here and now!

Doing the same thing and expecting a different outcome is not going to happen…

Hub and spoke – The reality?

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!

Putting community pharmacy at the heart of the NHS

The headline sounded great, however the underlying messages in the letter from NHS England and the Department of Health dated December 17 were not the clear vision for the future of the sector that the owners and employees of community pharmacies in England would have hoped for. What it was is a wake up call.

We understand that the NHS has financial, quality and access challenges and it was broadly accepted that the recent government spending review would have some impact on funding for the sector. However, many were unprepared for a £170 million cut (6% of the global sum) to be delivered in the 6 months from October 2016 (equivalent to a 12% cut in the period) and potential further cuts in the future.

How this will be delivered has yet to be negotiated, one can but assume it will come from fees and retained margin so difficult to predict the impact on individual pharmacies. In addition to the uncertainty that accompanies the lack of clarity, one big concern is the expectation that it will not impact quality or access to pharmaceutical services, something that the dedicated pharmacy workforce will always strive to maintain. We are already hearing plans to reduce investment in people, technology and premises at a time when access to healthcare services is already under enormous pressure.

The letter highlighted several other plans for the sector including a Pharmacy Access Scheme with an intent to reduce the number of contracts (the Minister stated between 1000 and 3000 less at a recent APPG meeting). How this will happen is apparently down to the sector itself based on viability in the new funding landscape that also includes the phasing out of the Establishment Payment currently worth around £25,000 per annum and meant to underpin some of the core running costs of a pharmacy.

The letter also refers to Hub and Spoke arrangements and large scale automated dispensing – we have yet to see any robust evidence of cost-efficiencies from such initiatives but should keep an open mind on the potential of remote assembly. Optimising prescription duration and online ordering of prescriptions with click-and-collect options are also mentioned. These may have some merit given the ever increasing volume related workload but will require a different funding model based on care including supply, not just supply activity. However, we should be concerned at the thinking around increasing home delivery. We must do nothing that reduces the opportunity for a face-to-face pharmacist-patient interaction and thus intervention to improve outcomes from the safe use of medicines; medicines are not commodities!

We must embrace technology and innovation; releasing the talent and time of pharmacy teams is highly desirable so that we can further increase and improve the delivery of pharmaceutical care, clinical services and healthy lifestyle interventions. However, these will need funding to appropriately incentivise and reward the value of such services.

Finally, it will be interesting to see the outcome objectives of a Pharmacy Integration Fund. I have always sought greater intra and inter-professional collaboration and the recent investment (£40+ million) for pharmacists in GP practices should be an opportunity both for patients and the profession as a whole, but this must operate within a culture and an enabled joined-up framework with all pharmacy sectors to succeed.

The pharmacy bodies, the sector and the profession have an important job on our hands to ensure that this potential burning platform is turned into a burning ambition and opportunity for community pharmacy teams to improve the health and wellbeing of their communities. We must create a compelling and relevant offer for a modern health and care system; one that meets the needs of the system and the population and delivers quality, value and a sustainable future.