A digital revolution is under way to integrate of all parts of the health and social care systems, as Steve Titmarsh explains…

A move to more digitally based health services is hoped to improve productivity and efficiency and help people access the best care, as well as drive research and transform services through insights gained from the data collected.¹

The Covid pandemic was, in some ways, a driver of change towards a greater use of digital services such as video and telephone consultations.²

In Wales, the vision is that “making better use of digital, data, and technology is helping to raise the quality and value of health and social care services … changing the way care is delivered and bringing it closer to home,” the clinical lead for pharmacy, Cheryl Way, has been reported as saying.³

For community pharmacists, key areas are the EPS system and the development of hub-and-spoke methods of operating. These developments sit alongside communications (including messaging, referrals and appointments), and patient information in the form of websites, apps and some of the wearable devices being developed to monitor health status.

These are reflected in the five main workstreams of the Community Pharmacy IT Group (CP ITG):⁴

• Interoperability and security: Ensuring information about people’s health and care can be safely and securely accessed, wherever it is needed.
• Reducing burden: Use of digital to reduce the burden on pharmacy teams, so they can focus on patients, and appropriate infrastructure for the task.
• Good use of digital: Support the use of digital within pharmacy to improve health and care productivity, improve patient safety outcomes and improve cooperation between pharmacy teams and the health and care system.
• Patient and pharmacy tools: Support enabling patients to be able to choose digital tools to access medicines information and pharmacy services directly, so they can receive the best outcomes, recognising the need to also remain inclusive for all patients.
• Set out roadmap priorities: Development and promotion of a wider community pharmacy digital roadmap/vision.

Helping computers talk to each other

Interoperability will be a key aspect of the digital revolution, necessary if the diverse parts of the health (and social) care system are to integrate effectively. For integration to work IT systems need to be able to “communicate with each other to ensure real-time information is available for the practitioners involved in a patient’s care. This is essential for safety and providing quality care as well as improving the patient’s experience”, explains the National Association of Primary Care’s report Primary care home: community pharmacy integration and innovation.⁵

Mark Merry, product strategy lead at Positive Solutions, agrees. “Consuming and sending standard messages from NHS 111, recording consultations, updating GP systems and claiming payment all require data to be received and transacted accurately to reduce the risk of errors or administrative mistakes. After a clinical event, accurate patient health record can be shared wider across the NHS using the same set of standards, improving the communication and value that community pharmacists offer the care network.”

The Professional Records Standards Body (PRSB) is working to ensure that the clinical record standards being developed to support electronic interoperability are consensus based and meet the needs of clinicians and patients. This will help with interoperability and enable the right data to be exchanged between organisations.⁶

The CP ITG says that the PRSB’s work on the Shared Care Records Core info standard (otherwise known as ‘ShCR) should be expanded and coded. PRSB also worked on the community pharmacy info flow standard for notifications from pharmacy IT systems to GP systems (eg. community pharmacy confirms to GP system the pharmacy has delivered NHS flu vaccination to patient). This standard should be expanded for pharmacy to send or receive other types of referrals.

However, PRSB standards for medication dose and timings are not yet used within prescribing and dispensing systems.

NHS services delivered to or by community pharmacy should only be delivered after the appropriate technical standards have been set out, as with the NHSBSA Manage Your Service (MYS) API.⁷

Views on hub-and-spoke

Although innovation and efficiency improvements are generally welcomed, the government’s recent consultation on expanding hub-and-spoke dispensing beyond single legal entities⁸ has come in for some criticism.

The NPA “remains concerned that hub-and-spoke will not deliver benefits to many independent pharmacies and could have unintended adverse consequences for the sector”.⁹

A recurring theme is the potential risks to patients and where responsibility lies for the dispensed medicines. The Pharmacists’ Defence Association (PDA) says: “Both of the proposed hub-and-spoke models have the potential to undermine patient contact with pharmacies and pharmacists if not introduced properly and with a broader assessment of the risks and benefits.”

It adds: “The arrangements must specify each step of the end-to-end process and who is responsible and accountable for each specific part within that process. There should be no ambiguity around which party does what and when.”¹⁰

The General Pharmaceutical Council agrees, saying the proposed changes “raise issues of responsibility, accountability, liability, and the interconnectivity of IT systems. With regards to patient safety, we believe the largest risk with hub-and-spoke arrangements is a lack of understanding around roles, responsibilities, and accountabilities”.

The GPhC goes on to say the arrangements should set out “responsibilities, accountabilities, and liabilities for each step within the supply process”.¹¹

Community Pharmacy Wales says that the proposed changes to hub-and-spoke arrangements go against its strategy to place pharmacy services at the heart of the community. That is the reason the Welsh Government has resisted the establishment of internet or distance selling pharmacies (DSPs) in Wales.

Indeed, CPW “believes that, for a change as important as this one, a consultation should have been held in each country, so that the views of the Government, NHS and the pharmacy network in each country could be properly established as a first step.”¹²

Pharmacy Forum NI speaks for many in its opposition for a hub-to-patient model, which it believes “will significantly undermine the relationship between the pharmacy and the patient and create uncertainty about accountability. The model cannot match local pharmacies for service, advice and care”.

The Forum adds: “These legislative proposals appear to be driven by an English-centric model. Northern Ireland differs significantly from the rest of the UK in that it has a much smaller population in a typically more rural situation. The thrust of this proposal seems to be to respond to drive efficiencies from the 2015 Spending Review.”¹³

The PDA challenges the idea that the hub-and-spoke arrangements will free up pharmacist time for activities such as patient consultations. “The evidence from the HEE surveys shows that pharmacy owners are cutting back on staffing (and even more worryingly trainee staff) and these owners are increasingly relying on pharmacists to work singlehandedly. Far from being freed up, pharmacists are becoming increasingly bogged down into checking off deliveries and such like.”

That raises a related issue, which could again be to the detriment of patients: “As pharmacy operators continue to cut their costs, the option to deliver directly to patients from the hubs will ultimately lead to an increase in this, whether patients choose this option or not … The patient would have had no contact with a pharmacy or a pharmacist and the opportunity for counselling or advise will be lost.”¹⁰

The Association of Independent Multiple Pharmacies (AIM) says the number of patients per pharmacist at all hubs, including DSPs, needs to be limited and regulated by the GPhC. This is because there can be a clear commercial advantage for a hub operating to say 100,000 patients per pharmacist versus a hub operating to 10,000 patients per pharmacist. Any lack of regulation on this might lead to a race to the bottom on pharmacists’ costs.¹⁴

The PSNC says: “There are virtually no financial efficiencies envisaged by these hub- and-spoke dispensing proposals, and, if used, are more likely to add cost to the community pharmacy sector.”¹⁵

Company Chemists’ Association) CEO Malcolm Harrison, says: “It is vital that any changes made on the back of this consultation are based on robust data and the lived experience of pharmacy businesses. I am concerned that the promises in the current five-year funding deal of improved capacity and cost-savings, are unlikely to be realised at all.

“The impact assessment also makes predictions on a yet unborn market, stretching 10 years into the future. Hub-and-spoke technologies do have the potential to enable new dispensing models in the future if new commissioning can support a change in operations. I would caution against firm predictions about likely benefits without stronger commitments to enablers of change.

“The CCA is also aware of claims that only the large businesses, which currently operate automated facilities would stand to benefit from the changes in legislation governing dispensing between legal entities. We think it is worth clarifying that neither the CCA nor any of its members have ever called for this change. This direction of travel by the Department of Health was initiated by parties from outside of the CCA.”¹⁶

References

1. https://digital.nhs.uk; accessed July 2022.
2. https://www.gov.uk/government/publications/nhs-covid-19-app-user-guide/nhs-covid-19-app-what-the-app-does; accessed July 2022.
3. https://dhcw.nhs.wales/news/in-depth/how-digital-technology-is-paving-the-way-for-change-in-community-pharmacy-in-wales; accessed August 2022.
4. https://psnc.org.uk/digital-and-technology/community-pharmacy-it-group-cpitg/cp-itg-representatives-workstream-update; accessed July 2022.
5. https://napc.co.uk/wp-content/uploads/2018/05/Community-pharmacy.pdf; accessed August 2022.
6. https://informatics.bmj.com/content/26/1/e100016#ref-31; accessed August 2022.
7. https://committees.parliament.uk/writtenevidence/109087/pdf; accessed August 2022.
8. www.gov.uk/government/consultations/hub-and-spoke-dispensing; accessed August 2022.
9. www.npa.co.uk/representing-you/campaigns/npa-leads-the-debate-on-hub-and-spoke; accessed August 2022.
10. www.the-pda.org/pda-responds-to-the-department-of-health-and-social-care-consultation-hub-and-spoke-dispensing; accessed 8 August 2022.
11. www.pharmacyregulation.org/sites/default/files/document/gphc-response-to-dhsc-hub-and-spoke-consultation-june-2022.pdf; accessed 8 August 2022.
12. www.cpwales.org.uk/CPW-s-work/About/Consultations-and-Responses/Consultation-Responses/20160516-CPW-response-to-hub-and-spoke-consultatio.aspx; accessed 8 August 2022.
13. www.pfni.org.uk/wp-content/uploads/2022/06/PFNI-ConsultResponse-HubSpoke-9.6.22-vf.pdf; accessed 8 August 2022.
14. www.aimp.co.uk/ProjectWebApp/Default/Uploads/aimp/AIMpDHSCConsulationHubAndSpoke.pdf; accessed August 2022.
15. https://psnc.org.uk/wp-content/uploads/2022/06/PSNC-response-to-DHSC-hub-and-spoke-consultation-June-2022.pdf; accessed 8 August 2022.
16. https://thecca.org.uk/cca-calls-for-evidence-based-approach-to-hub-and-spoke-dispensing-proposals; accessed August 2022.