No going back: how the pandemic is changing community pharmacy
The coronavirus pandemic has been a huge challenge, but it has revolutionised pharmacy practice in some positive ways. In the third of a three-part series, we ask community pharmacists which changes they want to retain.
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The coronavirus pandemic has had a tremendous impact on community pharmacy, leading to changes in the working lives of pharmacists and their staff.
Pharmacists have seen a huge increase in demand for their services as patients struggle to access other healthcare providers, such as GPs, dentists and hospitals. In April 2020 — the first full month of lockdown — the number of accident and emergency visits more than halved compared with the same month in 2019, suggesting some people were unwilling to visit hospitals. Many others have had treatment for less urgent conditions delayed. Throughout this, community pharmacies have remained open, offering a vital service accessible to all.
Some of the adjustments pharmacies have made during the pandemic have been stressful, and pharmacists will be pleased to see the back of them. But there are other changes that have been more welcome, and which could be the start of a permanent shift in the way pharmacists and their teams work.
1. Improved collaboration with other healthcare professionals
Many community pharmacists have seen improved collaboration with other healthcare professionals and greater involvement with primary care networks (PCNs) during the lockdown, and would like these to continue.
I feel there is definitely more communication between community pharmacy and GPs
Laura Buckley, who works both as a pharmacist in primary care and as a locum community pharmacist in Hull and East Yorkshire, says: “I feel there is definitely more communication between community pharmacy and GPs.” Now people are accessing pharmacies first, “we have to talk to each other more”, she explains. “The surgeries seem to be more open to discussing [a patient’s medicines] with community pharmacy and have more time for us.”
Sunil Kochhar, a community pharmacist in Gravesend, picks out dentists as one profession with whom relationships have improved and deepened. With many dental surgeries shut, dentists often drop off private prescriptions for patients, talk to pharmacists and learn more about the range of dental products available through pharmacies, he explains.
PCNs are another area where engagement has been given a boost. Reena Barai, who runs an independent pharmacy in Sutton, London, says: “We have had a really good working relationship [with the local PCN] over the last three months.” Community pharmacy is part of the newly formed community response team set up in the PCN, she says, which also draws on GPs, the voluntary sector, and mental health and district nursing teams. It has regular meetings to discuss pressures on services and offer support where vulnerable patients are identified.
However, Dorset community pharmacist Mike Hewitson — who agrees engagement has improved — points out that pharmacists need to be recompensed for the time they spend on work for PCNs. “[GPs are] being paid to contribute to PCNs but pharmacists are expected to do it for the warm feeling it gives them,” he says (see Box).
Box: The funding gap needs to be addressed
Despite the extra workload community pharmacies have taken on during the coronavirus pandemic, there has been little in the way of extra funding. In England, the Pharmaceutical Services Negotiating Committee (PSNC) has negotiated £370m of advance funding for community pharmacies. However, it is expected that this will need to be reconciled in 2020/2021, although the PSNC is in ongoing discussions with the government to try to prevent contractors from having to repay it.
Advance payments have also been agreed for community pharmacies in Scotland and Wales, and in Scotland, additional funding of an initial £5.6m has been negotiated.
There has also been additional funding for new medicines delivery services for patients shielding during the pandemic, but some pharmacists say that this does not adequately cover the cost of the extra demand for deliveries to isolated older people.
Dorset community pharmacist Mike Hewitson warns that if the positive changes that have happened within community pharmacy during the pandemic are to remain, adequate funding must be negotiated. He describes pharmacy as “the easyJet of the healthcare world”, with costs already stripped back and no fat in the system to take on unfunded work. “If people want us to be high quality providers of care, then they need to find a way to bridge the funding gap,” he says.
2. A wider role in primary care
The lockdown period has highlighted the potential for pharmacies and pharmacists to take a wider role in primary care in the future. “We are the only part of primary care that has been open throughout,” says Hewitson. “Everyone else was told to shut up shop for their own safety — but we were told we had to stay open.”
He points out the “pharmacy first” message has been promoted for minor illnesses for many years, but has only really seemed to hit home during the coronavirus crisis: “In community pharmacy, we have spent years pushing for things to happen … suddenly the rest of the NHS decides it is what they want and it happens overnight!” This has led to more people coming to pharmacies with a broader range of problems; some that pharmacists have been able to resolve and others that have needed referral to a doctor or dentist.
We can be a bigger part of the system; we need to think how we embed our skills into it
Ade Williams, a superintendent pharmacist in Bristol, believes the pandemic has created an opportunity to reshape pharmacy’s role in primary care. Pharmacy has effectively been acting as a triage system for those who need to see a GP, as well as offering advice and treatment to others, he explains. Williams would like to see this new way of working embedded as a permanent shift, with pharmacy recognised as having a “gatekeeper” role, and potentially even referring directly into secondary care.
“We can be a bigger part of the system; we need to think how we embed our skills into it,” he says. This is likely to need a discussion about how extra work is funded and whether some pharmacists need to upskill to take it on, he adds.
3. More remote consultations
There has been a lot of media interest in doctors conducting patient consultations over the telephone during the pandemic, but pharmacists have also made more use of technology — whether it is just the telephone, or a webcam for virtual consultations. This has enabled them to reach patients who were shielding and could not leave home, for example, and has also reduced the need for face-to-face contact with others. Using remote consultations has given patients a choice about how they interact with pharmacists and allowed pharmacy teams to manage their workloads more effectively.
In England, some patients referred to the community pharmacist consultation service through NHS 111 have been dealt with over the phone, and pharmacies have still been able to claim the normal fee. Pharmacists have also been conducting the new medicine service via phone and can now do so via video too. Medicines use reviews can also now be provided by telephone or video consultation.
The Pharmaceutical Services Negotiating Committee (PSNC) is asking for additional investment for remote consultations as part of its funding negotiations with the government. It has also suggested that pharmacists could use video or telephone calls to consult with patients before this year’s flu vaccination, which would help to limit face-to-face contact.
A spokesperson for NHS England describes video and phone consultations as a “step change”, and says NHSX is providing it with advice about the technical capabilities that would be needed in community pharmacy. A change in regulations would be required to enable video to be used for advanced services commissioned through the community pharmacy contractual framework.
In Scotland, community pharmacies trialled the NHS Near Me video consultation service towards the start of the pandemic, and it has been available to all Scottish community pharmacies since mid-June 2020. A video consultation service was also trialled during July 2020 in community pharmacies in Wales, where it was used to provide advice for common ailments, smoking cessation and emergency contraception, as well as conducting discharge medicines reviews.
While some pharmacists are enthusiastic about doing more consultations in this way — Kochhar says he has done many without any issues — there is also a note of caution that they may not be right for all patients. “People do need that connection with someone they trust and a healthcare professional they know,” says Barai.
4. Better-connected IT
For many community pharmacists, a lack of connected IT is a huge problem. Kieran Eason, who runs an independent pharmacy in Tamworth, Staffordshire, says lack of intra-operability makes it more difficult to do relatively simple things, like sending prescription requests to GPs.
“Pharmacy IT is just a complete disaster,” he says, suggesting the COVID-19 crisis has highlighted flaws, such as the number of different systems pharmacists use.
Williams points out that, in the past, the arguments for better-integrated IT have tended to come from pharmacy rather than from general practice. However, some pharmacists believe the coronavirus pandemic has shifted the conversation, from pharmacists needing access to more information, towards everyone involved in care needing to know more about what is happening to patients.
Getting access to more information may be particularly important if patients continue to turn to pharmacies more than they have in the past. During the coronavirus pandemic, pharmacists have had access to “additional information”, such as significant past medical history and reasons for prescribed medicines, which have been included in summary care records by default. Although this change is temporary, no date has been set for it to end and NHS England says it will remain as long as the pandemic continues. A permanent change would require NHS Digital and NHSX to review the issue and consider information governance implications, according to a spokesperson for NHS England.
Having access similar to what I can access in general practice would make a big difference
Buckley says the gulf between information available within general practice and that within community pharmacy must not continue. “Having access similar to what I can access in general practice would make a big difference,” she says. With medicines use reviews, for example, this additional information might enable pharmacists to be confident in suggesting more changes, she adds.
One area where IT has enabled more connected working during the pandemic is in the use of electronic prescriptions and electronic repeat dispensing. These processes have been around for years, but lockdown has given an impetus for GPs and patients to use them, with data from NHS Digital showing that the proportion of prescriptions issued electronically increased from 75.0% in February 2020 to 86.5% in April 2020.
Anecdotally, some pharmacists say that GPs have been more willing to set up electronic repeat dispensing (eRD) during the pandemic, although national figures show that the proportion of prescriptions dispensed via eRD has remained largely similar at around 14%. Use of eRD reduces workload for both GPs and pharmacists, and can also reduce footfall into pharmacies — which will be vital if the need to socially distance continues.
5. Flexible opening times
It has given us the time to plan ahead and think things through a bit
One of the freedoms given to pharmacies during the crisis was permission to close for 2.5 hours per day during their normal opening hours. While pharmacies still had to open during certain core hours, this gave some flexibility. “It has given us the time to plan ahead and think things through a bit,” says Eason.
Pharmacies often opened later and shut earlier, giving them a chance to catch up and brief teams for the day ahead. The extra time helped pharmacists to find time for complex queries, plan and manage workflow, and for the pharmacy to be cleaned. A proper lunch break was also important for staff and pharmacists, leaving them feeling less stressed.
However, NHS England and NHS Improvement removed these flexibilities from the standard operating procedure that permitted them on 11 August 2020. Pharmacies have also been able to temporarily alter opening hours — or even close completely — under emergency regulations, but these are due to expire on 30 November 2020.
Many pharmacists would like to see such flexibilities continue, but this may be challenging. There is a lot of societal pressure for long opening hours; pharmacies within supermarkets, for example, may face pressure to match the store’s hours. Kochhar also acknowledges that, as people return to work, lunchtime closures could become problematic since this is when people are able to pick up their prescriptions. Any change to opening hours would have to be carefully managed.
6. More involvement in vaccination services
Demand for the influenza vaccine is expected to be high this year, with the groups eligible for free vaccinations being expanded to include people aged between 50 and 64 years, as well as people on the shielded list and those in their households. Both GP practices and pharmacies have been encouraged to order sufficient supplies and to try to complete the programme of vaccinations as soon as possible.
There will be many more vaccines to be administered, and both professions will be needed to deliver
Barai points out that improved relationships with PCNs during the pandemic has led to a greater understanding of each other’s roles, which should help closer working when it comes to providing flu vaccinations.
Kochhar, too, is hopeful that there will be collaboration, rather than competition, between GPs and pharmacists over vaccinations. “There will be many more vaccines to be administered, and both professions will be needed to deliver,” he says.
If, and when, a COVID-19 vaccine comes on stream, there is likely to be huge demand, which GP practices may struggle to meet. The government is consulting on whether to allow more people, including pharmacy technicians, to administer COVID-19 or flu vaccines as part of wider plans to support the roll-out of COVID-19 vaccinations.
Pharmacists believe they can contribute more, both for this year’s flu vaccinations and potentially for any future COVID-19 vaccine. This will mean different ways of working: the PSNC has negotiated that pharmacists can deliver flu vaccinations within the pharmacy but outside the consultation room, as well as “off-site”, to manage infection control during the coronavirus pandemic. Off-site locations could include community halls, places of worship, car parks and sports facilities. Pharmacists will also be able to vaccinate care home staff at their place of work.
7. Better recognition for the profession
When the coronavirus pandemic began, it was initially unclear whether pharmacy staff would be treated as key workers — allowing them to send their children to school (and therefore continue to work) during lockdown. This was a rocky start in terms of recognition of the role community pharmacy could play; however, things improved as the lockdown continued.
Community pharmacy staff were added to the key worker list and included in the government scheme to pay £60,000 to the relatives of NHS and social care workers who died from COVID-19 contracted in the course of their work. They were also included in NHS worker shopping hours at supermarkets. And overseas pharmacists were listed as eligible to apply for a new fast-track scheme for health and care visas, announced on 14 July 2020.
Those in high places have realised how the sector has stepped up and what it could be capable of
Community pharmacists received regular mentions from health secretary Matt Hancock and prime minister Boris Johnson during the daily coronavirus press briefings and, according to Sandra Gidley, president of the Royal Pharmaceutical Society, community pharmacy has been involved in discussions at the highest level. “Those in high places have realised how the sector has stepped up and what it could be capable of,” she says. “I think the profile of pharmacy has been raised and that is very helpful.” This realisation among those in power bodes well for the future, she adds.
It is not just government that has recognised the role pharmacists are playing; awareness of community pharmacy among members of the public has also increased. A survey of more than 2,000 adults by the Proprietary Association of Great Britain found that almost one in three people (31%) who would not have visited a pharmacy for advice before seeking help elsewhere said they were more likely to do so following the pandemic.
Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2020.20208309
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