Compliance aids: who is the tray really for?

A few weeks ago, I spoke to a pharmacy that fills compliance aids for 400 patients a week.

It is an impressive operation and they have invested seriously in it, robotics included. The people running it are experienced, conscientious pharmacy staff doing their best by their patients.

However, I realised a few things that I think are worth talking about.

Firstly, they do not know which of those 400 patients benefit from the compliance aid and which do not. There is no assessment of patients.

Secondly, the addition of a robot has not freed anybody up in the team. The time it saves in the dispensary goes straight back into loading it, servicing it and keeping it running. In fact, having made the investment, they said they now feel obliged to fill as many trays as possible to justify it.

They also suspect, without being able to prove it, that they are losing money on the whole enterprise.

So: four hundred patients a week, a serious capital investment, no clear idea of who benefits, and a strong suspicion of a loss. All of this was entered into in good faith of course.

I am not holding up pharmacies such as this as an example of poor practice. We have all filled or checked our fair share of trays.

This reflects current practice, albeit at scale, and similar issues exist in community pharmacies across the UK.

This brings me to the question that I would like to put to the profession: Why are we doing this?

We are not even paid for it, and it is costing us money

The familiar complaint is that compliance aids are unfunded. Community Pharmacy England’s position is more precise: there is no additional fee, but an amount for their provision sits inside the single activity fee. So strictly speaking, we are paid.

The ‘practical’ version is this? The single activity fee is £1.52. We receive £1.52 for a tray that takes 20 minutes to fill and check or £1.52 per item for original packs that will take two minutes.

What does a tray actually cost us? Remarkably, there doesn’t seem to be a UK published a figure. The closest is a NICE quality and productivity case study from Taunton and Somerset NHS Foundation Trust, which costed a single monitored dosage system at £12.52 (25 minutes of technician time at £7.69); 10 minutes of pharmacist checking at £4.39; and 45p for the device itself. Those are hospital pay bands and do not include employer costs and from 2015, but we can use this as a benchmark.

Take a patient on eight items, moved from monthly original packs to weekly trays. That is four trays a month, or roughly £50 of costs. The switch to weekly prescribing takes the same patient from eight items a month to 32, which is about £36 of additional fee income. We have spent £50 to earn £36. And the £36 came out of the same national pot that funds every other pharmacy in the country.

Multiply that by 400 patients and the shortfall runs into tens of thousands of pounds a year. The pharmacy I visited suspected that it was losing money on compliance aids, and on this arithmetic, it almost certainly is.

So why do we do it?

We do this partly because everyone around us expects us to. Care providers, carers, families and prescribers all ask for trays, on the basis of their own assumptions about what a patient needs. Very few of them know that there are over 30 different interventions available to support someone who is struggling to take their medicines, and that a plastic tray is only one of them and is suitable for only some.

And we do it because of competition. If the pharmacy down the road offers trays and we do not, those patients walk, and they take their repeat prescriptions with them. Pharmacy valuations track turnover, turnover tracks prescription volume, so we do whatever it takes to hold on to volume.

The compliance aid has quietly become a customer retention device that we pay for ourselves.

In England there is a further twist that ought to trouble anyone who has argued for better funding. Our contract is a negotiated envelope, £3.636bn for 2026/27, and it does not swell every time we dispense more. Seven-day prescribing multiplies item counts, and the pharmacy doing more of it captures a slightly larger slice, but the pot does not grow to meet it. Collectively, we are dividing the same money into smaller pieces and paying for the privilege in staff time.

It is a remarkably efficient way of robbing Peter to pay Paul.

Someone will object that rising volume is exactly the evidence we need for a better settlement. I would gently suggest that activity nobody has assessed the need for is the weakest possible foundation for a funding claim.

“But we are legally required to”

The reasonable adjustments duty under the Equality Act is mentioned to me frequently, and rightly so. It is a real obligation and it is not going away.

But look closely at what the duty requires. It aims at situations where there is a disability-related need. Identifying that need is an assessment. The law presumes a piece of clinical work that, for the most part, the sector is neither doing nor is funded to do.

Where we have assessed a patient, established a genuine need and supplied a compliance aid, we should do it with confidence and be proud of it.

Where we have assessed nobody at all, we are not discharging a legal duty. We are guessing, and hoping the patient benefits.

This is exactly where pharmacy should be leading

If the law presumes an assessment, the obvious question is who ought to be doing it. Community pharmacy sees these patients every week, often for years. Nobody is better placed to judge whether someone can manage their medicines, and nobody has a stronger claim to lead on the supply of medicines and the support people need to take them.

We have not led on this, because the tools have not been good enough. The paper and PDF assessments in circulation carry no real pharmacist accountability, no properly informed patient consent, no sight of how the patient actually manages at home, and no data behind the decision either way. An assessment that records none of those things is simply not helpful. It’s just a form.

The assessment is important. And it’s a fixable problem, and fixing it is where I would put the profession’s effort because if we can get that bit right, everybody wins.

It is not a good deal for commissioners either

None of this serves the NHS well. Trays make medicines harder to review and considerably harder to stop, so problematic polypharmacy is supported by this plastic. Dispensing errors gain a new route in, both in terms of frequency and severity. Seven-day cycles generate waste every time a medicine changes. Prescribing volume rises, and the cost follows it. Commissioners are paying more due to the use of an intervention with a very thin evidence base.

This is a pharmacy market failure

I should declare an interest. I am Director at Northern Informatics Ltd where we are working on medication assessment, so I have a stake in this being taken seriously.

I also spent a long time in community pharmacy filling trays without asking any of these questions, which is my reason for doing this work.

Every individual decision made is rational: keep the patients; match the competitor; buy the robot. Add together several thousand of these rational decisions and the sector loses millions of pounds each year. Tens of thousands of patients receive an intervention they may not benefit from, and people who genuinely struggle to take their medicines get a plastic tray instead of the solution they need. This is a textbook market failure in my mind.

Do you believe this is a problem that needs fixing? If you do, it needs an intervention.

I think there are three things that would improve this: 1) a funded adherence assessment, so that no compliance aid is supplied without someone establishing that it is the right intervention for that patient; 2) a nationally recognised evidence-based assessment and 3) the GPhC ensuring minimum standards around the supply of compliance aids by community pharmacies.

None of the above can happen without pharmacy, regulatory and NHS leadership choosing to act. If you are a pharmacy or NHS leader who thinks this is worth a conversation, I would be glad to hear from you.