The Covid pandemic is a chance for community pharmacy to finally persuade the government it is integral to the NHS, says Mark Koziol. The Pharmacists’ Defence Association chairman talks to Neil Trainis...
Mark Koziol is blunt, unflinching and persistent. The chairman of the Pharmacists’ Defence Association does not do things by half measures or say things half-heartedly, so when he suggests the entire community pharmacy sector in England can, and must, get involved in the Covid vaccination programme, he means it.
In January his organisation laid out an ambitious plan for all 13,500 community pharmacies to deliver the second dose of the AstraZeneca vaccine “as part of a collaborative and integrated NHS process.” Pharmacies collectively, it said, can administer almost two million second doses a week.
At first glance, the idea seemed fanciful. After all, community pharmacies across the country continue to work flat out to meet the needs of their local communities in unbearably difficult circumstances and if you believe National Pharmacy Association chairman Andrew Lane, some are struggling so much they are considering strike action.
“If you ask if it's realistic for community pharmacy to do this, you need to get down to the detail of what our proposal was because our proposals wasn't 'just give it to all the little community pharmacies and away we go,' it was a fundamentally different approach to how we do these vaccinations,” Mark says over a Teams meeting.
“Firstly, Covid vaccinations cannot be done in the same way as flu vaccinations. Flu vaccinations were opportunistic. Everybody who wanted a vaccination could get it, the vaccinations were provided on a one-pop vaccination, you get it once, somebody walks through the door, you take a vaccination out the fridge and give it to them and away they go.
“The highest number community pharmacy did in England at the height of last autumn's vaccination campaign was 73,000 vaccinations in one day. These are figures we got from PSNC. That was an average of 6.6 vaccinations per pharmacy. We've got to do more than that if we want to make a difference for the Covid vaccination.
“I know, because of the number of calls we got on our helplines, that our members were absolutely creaking at the seams and struggling to develop that high water mark of the flu vaccinations because they were dispensing and checking medicines, talking to patients, phoning doctors, consulting with healthcare professionals, supervising the pharmacy team and they were required to disappear into the consultation room to deliver an average of 6.6 vaccinations a day.”
Mark insists community pharmacies far and wide must draw on whatever resources they have at their disposal to allow them to deliver Covid vaccines and that includes bringing in a second pharmacist.
“The main components of our proposal is firstly, this is a second pharmacist's job. The only way you're going to be able to do eight, 10, 15, 30, 50 vaccinations in one day in a community pharmacy setting in your average community pharmacy in a suburb or somewhere else is if you get a second pharmacist in there to run a vaccination clinic.
“Look at what the GPs did. No GP said 'we'll run the surgery but I'll disappear into the vaccination room all day.' It was done in larger GP practice settings where they could take out the room the physiotherapist or chiropodist used to use and give it over to a different staff compliment who were mainly gathered from the primary care networks to come and use that particular surgery as a GP hub to deliver the vaccines while the rest of the GP practice was able to run in a normal way.”
It appears he is ignoring the reality many community pharmacies find themselves in. How can those contending with expensive overheads, not to mention swingeing cuts and government debt, afford to pay a second pharmacist?
The government hasn’t even paid them back for the costs they have laid out during the pandemic so far. “I think we have a solution to that,” Mark insists.
“GP practices didn't necessarily have the money to do it either. The staff were funded to come and do the vaccinations by the national vaccination programme. That's what we're talking about here.
“Our proposal says that depending on the location of a pharmacy, you're going to have a whole range of people interested in getting vaccinated in the community pharmacy.
"In some areas, the community pharmacy might be busy all day, every day delivering Covid vaccinations. In other areas, it might be a different location altogether. It might be in a much smaller town or village and you might only gather enough interest to run a vaccination clinic two afternoons a week.
“Here's another important difference between the flu vaccination and Covid vaccination. Because of the nature of the AstraZeneca vials, you can either get a minimum of eight vaccinations from the 4ml vial or 11 vaccinations from the 5ml vial. The vaccination minister was quite right, he doesn't want to see vaccinations lying around in pharmacies gathering dust.
“The bad news for us from an operational point of view is once you've punctured that vial for the first time, that vial only has a life of six hours then you have to throw it away. So you cannot run the Covid vaccination service in community pharmacy in the way that you do with the flu vaccination on an opportunistic basis and hope enough people walk through the door.”
As the PDA was putting together its proposals, Mark visited several vaccination hubs to see how they operate and the trips proved to be informative.
“People are given appointments and told to turn up at specific times. You can plan your vaccination clinics in community pharmacies by allowing patients to decide where they want to go for their second vaccination.
“If they select the pharmacy of their choice, you can then plan where you have and what times you have these vaccination clinics and in the quietest places, you can run a vaccination clinic and not have more than eight patients come in because you'll only have that one vial to deliver those eight vaccinations to those patients that you've got planned in.
“In other places that are more popular because of their geographical location, you can plan in 40 or 50 patients and you could run vaccination clinics the entire day and into the evening.”
During his visits to primary care network-run hubs, he noticed staff carrying Deliveroo curl bags around on their shoulders and that pricked his curiosity. He was told they were delivering vials to residential and care homes and just then, something clicked.
“What you've got is a situation where the local NHS-organised hubs can act as distribution centres for residential homes and care homes, why wouldn't it be possible for them to know that two vials are going to be needed in a certain community pharmacy on Wednesday, five vials are going to be needed every day in another community pharmacy?
“It’s entirely viable to distribute those vials in that way for the appointments that have already been made in the community pharmacies that are all organised during the existing booking system the NHS runs.
“The booking system gives you a choice of which vaccination hub you want to attend and there's no reason why they can't also add to that a list of community pharmacies in the locality that members of the public can then choose.
“And in choosing that, that pharmacy now knows how many patients it's going to get. If it knows it's going to get eight patients on a Thursday afternoon, it can aim to deliver those vaccinations or alternatively it books a locum to come in and cover the proprietor so the proprietor can deliver the vaccinations.”
Mark puts forward a very persuasive case. Perhaps the national community pharmacy network can, after all, pull this off. Not only is it achievable, he says, but necessary because “the nation can't afford to take out football stadiums, museums, Nightingale centres and conference centres to run mass vaccination programmes going forward forever.”
He says if pharmacies play a central role in the Covid vaccination programme, the government might be persuaded to ditch its erroneous and professionally offensive perception of many pharmacists as shopkeepers.
“I suggest we use that to springboard our way out of the malaise we've had in the last few years with all these cuts where clearly the sector hasn't been taken seriously by the government.”
It is pretty depressing to think it has taken the worst global pandemic in over a hundred years to get the government to take community pharmacy seriously. Yet for Mark, it runs much deeper than vaccines.
Pharmacists, he insists, can strike huge blow to the anti-vaxxer movement that is fuelling the fears of people, especially those in black and minority ethnic communities, about the Covid vaccine.
“We've got to find solutions to Covid-19 and community pharmacy is a massively important component of it because not only can it deliver the vaccines, it can go a very significant way to dispelling some of the anti-vaxxer sentiments, the question marks being raised in local communities, the stats that are starting to come out about the BAME community being less interested in the vaccination programme.
“SAGE said the antidote to that is to use local healthcare professionals and local scientists looking into their local communities. Well guess what? Community pharmacists are both of these things.”
Mark’s in-tray has filled quickly during the pandemic; personal protective equipment, vaccines for pharmacy staff, reporting of occupational infections, customer aggression towards workers, locum’s rates, Union recognition at LloydsPharmacy and, of course, the assessment.
He says the way the General Pharmaceutical Council handled it “exposed the fragility of the existing pre-reg system which was really fragile compared to how medics and nurses did it.” The issue caused a rumpus on social media.
“We advocated right at the start that a significant amount of care and attention should've been paid to the fact the prov-regs are on the front-line, right in the thick of the Covid crisis.
“I remember my first day qualifying as a pharmacist was the day I realised how much more I still had to learn. What I learned in my first year as a qualified pharmacist was probably more than all my previous education added together.
“More attention could've been paid to the fact there's been a very significant learning situation these guys have been involved in and the pre-reg assessment could've been of a different nature to the one that is being run now.
“There could've been more time spent looking at the experiences these pharmacists, or prov-regs, have been involved in during their prov-reg. You could've looked at what kind of circumstances they were working in, how much responsibility they were taking, how successful they were, did they manage to generate any testimonials from patients?
“Did they effectively manage to win some war medals as they went through their process? Those would've been positive, formative things to have looked at because had you done that, you would've encouraged that kind of experience all the way through the entire cohort.
“We said this should've been the way at the beginning but I recall the GPhC saying quite rightly at the time 'look, we don't know how long these guys are going to be out there. We don't know when the date of the exam is going to be. This might only last two months or four months.' With the benefit of hindsight, it's a hell of a lot easier.”
Nonetheless, many felt March's assessment was an unwanted distraction and should have been scrapped. According to the PDA, some pharmacy employers were allegedly cancelling prov-regs' study leave. Mark is asked why the PDA did not name those employers.
“We tackle it with the companies directly. There is a myth that says PDA likes to get a bit of tit-bit information and blow it up beyond all proportion and get it in the press as quickly as possible to cause maximum devastation and media interest. That's not the way intelligent unions work.
“Intelligent unions contact employers, they deal with specific individual cases. You'll be amazed at the proportion of cases that are overturned in this way and often people apologise and say there's been a misunderstanding.”
Three years after the PDA launched its Safer Pharmacies Charter in the Commons, Mark says many employers are still not meeting standards, something that has manifested itself in the treatment of prov-regs.
“A lot of prov-regs have had a really awful time. In some instances we've had to report employers to the regulator about how prov-regs have been abused in the workplace.
“To be put into what we sometimes euphemistically call a prescription factory that runs from eight in the morning till 11 o'clock at night, a 15-hour shift without a break with staff that need to be trained because they are all new, without the risk management exercises that are supposed to be done before you put a prov-reg in there, without the demonstration of the supervision that's supposed to be in place to supervise the prov-reg, is an absolute abrogation of what should be happening.
"And yet we're dealing with cases of prov-regs being put in those situations.”
Covid interrupted work on the Charter but Mark insists the PDA “intend to dramatically reinvigorate the programme as we pull out of this pandemic.”
And there is hope of progress.
“Our understanding is the GPhC have actually processed some owners of pharmacies in front of the statutory committee,” he says.
“We have seen figures to show owners of pharmacies are now going in front of the disciplinary machinery.”