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Spoke & Hub Pharmacy

The title of this article is deliberately reversed from the traditional Hub and Spoke descriptive as this potential efficiency solution should centre on the spoke, i.e., the community pharmacy, their team and their patients.

The Government have now announced the draft regulation and legislation changes required to enable remote prescription assembly across different business entities from the planned date of January 2025. Under the proposals, the Medicines Act 1968 will be amended and there will also be changes to the Human Medicines Regulations to ensure patient safety, governance and accountability.

The proposals enable two models:

Model 1 (spoke-hub-spoke) will allow a spoke pharmacy to send a patient’s unassembled prescription or part-assembled prescription to a hub. The hub will complete the assembly of the prescription and return it to the spoke (‘deemed retail sale’).  The spoke will supply the prescription to the patient along with providing advice on the medicine.

Initial reflections:

  • This models allows the spoke pharmacy to retain the patient relationship and the patient interaction/intervention/service opportunity. 
  • Potential trust issue between spoke and the hub on data protection/patient retention?
  • Clinical governance challenges (perceived or real) for the spoke who has not assembled the prescription; i.e.:
    • potential of professional confidence/trust issues for Responsible Pharmacist?
    • who is accountable/responsible and will they be tempted to recheck the item to ensure fully complete and accurate before handing out and discussing with patient? 
    • this may lose elements of efficiency gain and released capacity.

Model 2 (spoke-hub-patient), a spoke will send a patient’s unassembled prescription or part-assembled prescription to a hub, which will complete the assembly and dispense the order directly to the patient (‘retail sale’). The spoke pharmacy may supply some part of the prescription direct to the patient under a ‘parallel retail sale’.

This model had little support in the consultation responses and is more akin to a distance selling pharmacy (DSP) model. However, it may give an independent the opportunity to match a DSP offer. There are additional challenges with this model:

  • Risk of partial or total loss of relationship between spoke pharmacy and patient given most prescriptions generated are sent through EPS.
  • Loss of footfall into pharmacy and thus opportunistic service recruitment and/or OTC treatment sales.
  • Potential trust issue between spoke and the hub on data protection/patient retention.
  • How and who will communicate with patients with an expected delivery date and any out of stock items, and how these will be managed?
  • How will recruitment into the New Medicine or Discharge Medicines services work?

Key points:

  • Both the hub and the spoke must be registered pharmacies and hence regulated by the GPhC.
  • In both models, NHS fees and reimbursement will be paid to the spoke pharmacy and hence the spoke pharmacy will have to reimburse the hub for the medicines supplied and a fee for the assembly and distribution costs. How will that work and against what tariff/cost?
  • Spoke pharmacies have to display a sign informing their patients that they utilise hub and spoke and require formal arrangements between spoke and hub.
  • Hubs will not have to meet good distribution practice (GDP) nor require a wholesaler dealers licence. 
  • Dispensing Doctors also considered as a spoke under the proposals.
  • The proposals include alignment with planned original pack dispensing changes.

Some broader unanswered questions:

Big questions remain on the financial viability of the models for both the hub and the spoke given the current dispensing fee (single activity fee) and reimbursement system with retained margin under Cat M. The average net income per item is around £2.20 for a pharmacy doing 7000 items/month and £2.12 for a pharmacy doing 20,000 items/month. Pharmacy2U are in the process of taking over LloydsDirect resulting in a DSP doing over 2.7 million prescriptions per month. However, it would seem that they have yet to make a profit out of its existing NHS dispensing model, so the idea of splitting a pharmacy’s net income under current contractual arrangements is, at the very least, questionable as a business model.

  • Given the spoke is reimbursed for medicines but does not hold it, how will CatM and drug tariff discount scales operate for both entities?
  • How will this impact wholesaler discount thresholds?
  • How will this impact relationships between pharmacies and wholesalers and manufacturers?
  • How will this impact patient perceptions of service experience given likely additional lead times?
  • What happens with out-of-stock/owing items?
  • What is the pharmacy name on the item label?
  • How does a spoke pharmacy track where the completed prescription is on its journey back to the pharmacy or to the patient?
  • Who will liaise with the patient’s surgery to request changes for medium/long-term supply chain issues?
  • What are the implications for the already challenging medicines supply chain?

At this time, the GPhC have yet to opine publicly on the proposals as part of their wider review of inspections, and pharmacy organisations have been relatively quiet although generally welcoming the level playing field, but with the caveat that the core funding needs fixing first.

Should a pharmacy adopt a model it would need to utilise any released capacity to generate profitable revenue to replace that given to the hub. Whatever the decision, it will need to be part of a transformative business plan.

A new year, a new Government, a new NHS… what’s new for community pharmacy?

The Secretary of State for Health and Social Care, Matt Hancock, recently gave a speech on the newly elected Government’s priorities for the NHS:

  • Prevention: because prevention is better than cure
  • People: because we need more people working smarter
  • Technology: because patients and clinicians demand better
  • Infrastructure: because buildings matter too.

The following extract from the speech relates to Community Pharmacy and the prevention priority building on the Healthy Living Pharmacy foundations:

And we will also “unleash the potential” of our pharmacies because there really is so much more they are capable of doing.

Over the next 5 years, they will become the first port of call for patients with minor illnesses. More than 10,000 pharmacies are ready to receive referrals from other parts of the health service – and that number will grow.

The prevention agenda is incredibly important because prevention is better than cure. We also know the challenges the NHS faces: demand is rising faster than at any point in history. Baby-boomers are reaching the age where they need more and more healthcare.

So, as well as investing in infrastructure, we need to make the 2020s a decade of prevention of ill health:

  • Support everyone to take more care of their own health. I don’t believe in the worried well – I want healthy people to be concerned about their own health so they stay healthy.
  • Vaccinate against preventable diseases.
  • Redouble our efforts to be smoke-free, redouble our efforts on obesity, and embed a more proactive, predictive and personalised approach across the NHS.

So what does this mean for community pharmacy? Whatever the colour of your politics, the fact that there is continued mention of the role that community pharmacy can play within an integrated NHS must be a positive. That focus has carried over from the NHS Plan, the Prevention Green Paper and the new CPCF into the newly elected Government’s plans for the next 5-years.

At a national level, building on the platform that the new CPCF provides, the first step is to deliver what is now in place whilst continuing negotiations to embed new services. This would mean that the currently unallocated funding (around £250 million) is accessible to all contractors and we must sort out the reimbursement mechanism following the recent consultation to make it more equitable for all.

At a local level, contractors, supported by their LPC, must engage more than ever before – firstly with each other and then with PCNs to ensure that they understand their needs and priorities. PCN Clinical Directors and all other health and care providers must also understand what pharmacy could offer to address their needs, particularly their real pain points. The skills of the identified PCN Community Pharmacy Leads will be crucial. This is why we created our award-winning portfolio of HLP support and launched our new Effective Engagement and Communication leadership programme which a number of LPCs have already embraced.

Apologies for plagiarising an over-used political phrase – Let’s get it done!

New Community Pharmacy Contractual Framework 2019-2024

The English community pharmacy funding settlement for the next five years has been announced the first time that we have agreed a multi-year settlement. The agreement, set out in the new Community Pharmacy Contractual Framework (CPCF) which commences on 1st October 2019, aims to build on the clinical skills of community pharmacists and their teams which must be seen as a positive step.

The Headlines

Funding:

  • The contract sum will remain unchanged at £2.592 billion until the end of 2023/24, £1.792bn for fees and £800m in retained margin.
  • The Single Activity Fee (SAF) will be £1.27 from August 2019 (currently £1.26).
  • Category M prices will increase by £15m a month from August 2019 to recognise that there was predicted to be a shortfall in margin in the current year.
  • Pharmacies will receive monthly transitional payments in the second half of 2019/20 and in 2020/21 to meet costs associated with changes such as integration into Primary Care Networks (PCNs), preparation for Serious Shortage Protocols (SSPs) and implementation of the Falsified Medicines Directive (FMD).
  • Establishment Payments will be phased out by 2020/21.
  • The Pharmacy Access Scheme (PhAS) remains at £24m a year.

Services:

  • A new NHS Community Pharmacist Consultation Service (CPCS) is introduced nationally as an Advanced service in October 2019. This will replace the current NHS Urgent Medicine Supply Advanced Service (NUMSAS) and local pilots of the Digital Minor Illness Referral Service (DMIRS). The new service will operate with a fee of £14 per consultation. Initially using referrals from NHS111, but piloting referrals from GP practices with an intent to implement nationally in 2020/21.
  • Medicines Use Reviews (MURs) will be phased out over the next two years with pharmacists working in PCNs undertaking Structured Medication Reviews (SMRs). Contractors will be able to deliver 250 MURs in 2019/20 and 100 in 2020/21.
  • New Medicine Service is retained with potential extension of therapeutic areas and funding.
  • Medicines reconciliation service as part of transfer of care.
  • Being a Healthy Living Pharmacy will become an essential requirement within the new framework from April 2020 to support the prevention agenda and will include:
    • Mandatory health campaigns aligned with equivalent campaigns in general practice under an integrated programme
    • Hepatitis C testing for people using needle exchange services
    • A testbed programme for:
      • detection of undiagnosed cardiovascular disease (hypertension, atrial fibrillation)
      • stop smoking support from secondary care referrals
      • point of care testing for minor illnesses to support AMR
      • vaccination and immunisation services
      • routine monitoring of patients, e.g. those taking oral contraception
      • activity complementing future PCN service specifications, e.g. early cancer diagnosis and health inequalities.

Pharmacy Quality Scheme (PQS) 

  • This replaces the Quality Payments Scheme (QPS) and pharmacies can earn additional payments for meeting quality criteria. Funding for the scheme will continue at £75m a year.
  • Some elements of the former QPS will become Terms of Service requirements from April 2020, e.g. Healthy Living Pharmacy.
  • The criteria include:
    • A collaborative approach to engage with PCNs
    • Activity complementing the GP QOF Quality Improvement module on safe prescribing, e.g. lithium safety audit, valproate in pregnancy, NSAIDs
    • Checking whether patients with diabetes have had their annual foot and eye checks with appropriate referrals
    • Reduction in sales of sugar sweetened beverages (SSB)
    • Training and assessment of look-alike, sound-alike (LASA) medicines with evidenced safety reporting action
    • Update previous risk review with recorded mitigations
    • Sepsis training with risk mitigation
    • All patient-facing staff are Dementia Friends and a Dementia Friendly environment standards checklist completed.
  • The 2020/21 PQS may include:
    • Suicide prevention training
    • Inhaler technique audit
    • Anticoagulation audit.

Transformation and Technology:

  • A range of reviews with the aim to free up capacity:
    • Legislation to permit wider hub and spoke dispensing
    • Original pack dispensing review
    • Better use of skill-mix
    • Different terms of service for online pharmacies.

The Commentary

Firstly, we should recognise that this will undoubtedly been a big task for PSNC to achieve and remains so as negotiations are ongoing.

It should be no surprise, but will be disappointing to contractors that the contract sum has been fixed at the current level for the five year deal which is less than in previous years against a backdrop of rising operating costs. With prescription numbers set to fall due to various deprescribing initiatives, the proportion of income associated with dispensing will also drop. Hence, those relying on volume alone and not adapting to a service-led contract will struggle to survive. One can only hope that new and sustainable funding will come through on the back of some of conceptual and testbed service opportunities and that the sector is ready, willing and able to deliver.

Unfortunately, the continued use of retained margin to deliver around 30% of funding will perpetuate an unfair averaging system where not all contractors can realise their full funding, and, in some cases, drive the wrong focus and behaviours. In addition, a consultation on a review of reimbursement was announced by DHSC which will impact on this.

The eventual loss of MURs is also disappointing. Yes, they needed reform (Murray Review), but a good consultation on safe medicines use adds enormous value to patients (see our previous Viewpoint article). Not to acknowledge and fund this provision of pharmaceutical care as an adjunct to medicine supply and support medicines optimisation is a lost opportunity for patients, the NHS and pharmacy. Structured Medication Reviews by pharmacists working in a PCN will add value, but will only reach a proportion of patients and misses the opportunistic interventions on adherence and healthy lifestyles which can improve patient outcomes. On a positive note, the New Medicine Service, that also adds value to patients and the health system, is retained and a medicines reconciliation service is to be added to support transfer of care.

The arrival of a national minor illness consultation service (CPCS) should be welcomed and quickly embraced, particularly when GP referrals are included; certainly all GPs we know welcome its coming. This is likely to be a big stream of work and funding in the future and pharmacy teams will need to be ready to deliver against expectations.

Embedding HLP in the contractual framework, rather than just in the quality scheme, should  be celebrated. Many contractors have fully adopted the organisational development, health promoting ethos and criteria which are the foundation of HLP; however, some have undoubtedly just ticked the box. The opportunity to develop the right knowledge and skills within the pharmacy team and deliver a healthy living environment and enhanced customer experience will pay dividends. There will also be new services to build on these foundations. Given the launch of the Prevention Green Paper with which the pharmacy contract is aligned, the opportunities for community pharmacy to be at the forefront of prevention are significant.

One comment I saw on Twitter called it a Curate’s egg, good in parts, less so in others. Undoubtedly true, but it’s what we’ve got and we will have to make the most of it whilst building relationships with PCNs to tap into the funding that will flow through there. Contractors will also need to develop their own business plan around non-NHS services to meet local needs.

We have developed a short animation which illustrates what the new contract means through the eyes of patients that use community pharmacy.

Pharmacy Complete is here to support contractors in ensuring they meet the HLP criteria and optimise the benefits that brings. We are also here to support the engagement with PCNs and development of a business plan for a sustainable future.

Helping you to help others

Digital Healthcare

I recently listened to a presentation on the NHS’s plans for Digital Healthcare. They are huge, comprehensive and integrated around a new NHS App. They will eventually touch everyone who is either a provider or user of healthcare services. Worryingly, when I asked the speaker about community pharmacy’s place in that integrated system, she went blank then said “…not sure community pharmacy is my thing.”

Community pharmacy and digital healthcare is very much the focus of this year’s Pharmacy Business Conference and will be referenced in my business planning talk at the Pharmacy Show and by others I am sure – pharmacy owners need to listen and act.

The majority of community pharmacies have yet to embrace advances in technology and digital channels to promote what they do. Indeed many have only recently signed up to NHSmail and some remain dependent on fax transmissions as a means of being reached. PMR system suppliers are only now waking up to the need to create a fully integrated clinical patient management system rather than a PMR system that has barely evolved in a decade and some are still largely a labelling and ordering system that happens to interface with EPS, SCR.

New technologies including cloud-based patient-owned data, smartphone apps, smartspeakers, wearable devices, point-of-care diagnostics, robotics and artificial intelligence are coming to market at an increasing rate and this will only accelerate. This will enable a greater population reach and impact for any provider who appropriately adapts and adopts innovations within this important and developing market.

I also read a fascinating insight into Google’s (Alphabet) plans for healthcare – link this to activity and plans by Amazon, Microsoft and Apple then the healthcare landscape really gets disrupted. Imagine this scenario: you ask Dr Alexa for an appointment which is video streamed on your smartphone, prescription sent electronically to Amazon Pharmacy with an adherence and lifestyle support consultation through your phone and medicines delivered same day to your place of work, a collection box or home. All this fed into your patient health record which you, and anyone you consent to, can access through an App.

If community pharmacy fails to engage with this rapidly changing digital ecosystem it will be left behind and, at best, be outside the integrated system. We must not let that happen.

Saving lives

A patient came into the pharmacy to thank me. Nothing unusual in that although infrequent, our customers are generally very grateful for the support we give them across a range of issues – their medicines, general health and wellbeing. On this occasion though, the thank you will be remembered for the rest of my career. The gentleman came in specifically to thank me for saving his father’s life.

I remembered him clearly – he had come in on a Saturday morning wanting to speak to the pharmacist. He was in a quandary – he was concerned about his 84 year old father, who had developed cellulitis and despite being on antibiotics, wan’t improving. An hour and a half away, the son was managing the issue remotely and was being fobbed off by his dad who didn’t want to leave his caring role for his wife with dementia. A familiar story. Many questions later, I was concerned. This could likely deteriorate into either a sepsis or acute kidney injury. I advised strongly for him to call 111, not to leave it, not to feel ’embarrassed’ about ‘making a fuss’ (his words) and get to see his dad as soon as he could. He committed to this action and left.

So what happened? He came in to tell me that he followed my direction; 111 immediately called out an ambulance and his dad was admitted into hospital. Despite IV antibiotics he developed a sepsis three days later and was put into intensive care. They almost lost him but I’m pleased to say he survived and at the point of discussion, was in a ward and eager to get home and back to his wife.

What made me have this insight? The same situation played out with my late mother several years earlier. I had recently undertaken some CPD on Sepsis and I’m passionate about reducing the risk of AKI. More so, I asked questions. And listened. Aside from the intellectual assessment, I followed my instinct.

Stories like this will be happening up and down the Country. Community pharmacists and their teams make a real difference. And sometimes we save lives.