Pharmacy experts from the University of Reading set out how community pharmacies have adapted to the coronavirus pandemic and ensure that patients still receive outstanding patient care…
Pharmacists and their teams deliver key services to a multitude of patients within the community setting. Community pharmacy is a vital part of the health workforce. Yet, as the coronavirus epidemic has taken hold in the UK, many in the profession have been questioning why community pharmacists are left to fend for themselves in these tough times.
There have been numerous disparities in the way that community pharmacy teams are being supported compared to other health professions during the pandemic, exposing apparent injustices. For example, community pharmacies’ open-door policy and availability to the public was maintained, while GPs, dentists and optometrists closed their doors.
Removing primary care support and its inevitable impact on the one remaining healthcare setting was not considered when these decisions were made, resulting in pharmacies being inundated with angry, upset and frightened people confused about how to access healthcare or unable to access their usual health provision.
Community pharmacies therefore had to deal with many of the minor illness consultations normally fielded by GPs, dental problems usually seen by dentists and more serious conditions and injuries that would normally be dealt with by A&E.
This health-seeking behaviour and stockpiling compulsions drove additional people into pharmacies at the start of the pandemic, increasing the risk of virus transmission, while the stockpiling intensified existing prescription-medicine and over-the-counter item shortages in many pharmacies.
Prescription-medicine shortages continue, and recent announcements about face coverings being mandatory on public transport have fuelled panic buying of masks and face coverings. Within the confined spaces of most practices, there is a need for pharmacy staff to use Personal Protective Equipment (PPE) which is not easy to obtain. The NHS PPE stockpile is still unavailable to community pharmacies, although some of the stockpile has been made available to pharmaceutical wholesalers for pharmacies to purchase.
Many pharmacies have installed Perspex screens as an interim measure with a £300 oneoff payment per pharmacy, yet anecdotally, many pharmacies have spent hugely in excess of this on barriers and screens.
Additional funding for community pharmacy is particularly needed at this time but other funding announcements so far have related to advance payments rather than additional monies. A total of £350 million has been agreed to help fund extra costs for PPE and other cashflow pressures but at some point in the future this will be clawed back from pharmacy finances, causing further hardship.
Test and trace
Staff must self-isolate following coronavirus symptoms which has left some community pharmacy teams too short-staffed to operate. With the NHS test and trace system now operating, a further threat to the pharmacy workforce has arisen—entire teams may be required to self-isolate for two weeks if a work colleague tests positive for Covid-19.
The current NHS advice for pharmacy teams is to only wear PPE if less than two metres from the public, yet most teams cannot achieve two metres social distancing from their work colleagues in crowded dispensaries. If wearing PPE, healthcare workers identified as close contacts to an infected co-worker may be exempt from self-isolation, subject to a risk assessment by the tracing teams. So should all pharmacy staff be wearing masks 100 per cent of the time to protect the workforce?
Further guidance on this issue should be forthcoming very soon. If so, who is going to pay for this PPE? Another solution is for traced pharmacy staff to be eligible for viral testing without displaying symptoms — if the test is negative, they can return to work.
But we are also hopeful. Pharmacies were given permission to close for up to two-and a half hours per day in recognition of the increased workloads. New guidance to help pharmacies manage for short periods without a pharmacist was released.
We welcome the promise of government funding to mitigate some of the impact of coronavirus on community pharmacy. We thank the thousands of volunteers who have helped us and we thank those who recognize the value of community pharmacy in these exceptional times.
We call on manufacturers to reconsider the quotas imposed on community pharmacies to help deal with local drug shortages. And we thank GPs for working with us, initiating electronic repeat dispensing and finally clarifying to patients how they can access their services. As well as this, we are reassured that pharmacy teams and their households are eligible for coronavirus tests and we acknowledge the promise that pharmacists could soon order PPE from the NHS.
Input into future
But ultimately, we voice what has been said by others, that pharmacists want input into future policy changes before they are finalised so that these can reflect capacity and preparedness on the ground, these policy changes need to be cascaded quickly so that we can prepare and implement in sufficient time, and we highlight the need for new policy to be publicised more accurately in the media for the benefit of all.
For example, GPs wrote 84-day prescriptions in March to ensure sufficient supplies for patients during the impending lockdown. For pharmacies, this contributed to severe stock shortages but also a vast increase in the cost of medication for that month. This created a significant problem; as pharmacies receive reimbursement three months in arrears, the resulting cashflow crisis left many unable to purchase new medicines.
Many now worry that this may be repeated with a second wave of cashflow difficulty. Another example relates to the reimbursements offered for deliveries to shielded patients. To claim the delivery payment, pharmacies wasted a lot of time checking Summary Care Records or speaking with patients to determine their shielding status — many have wondered why the NHS did not send the list of shielded patients directly, similar to council workers and supermarkets, so that this service could run efficiently and be available to those that needed it right from the start.
In reality, many more patients than the official shielded group are vulnerable and initial national communications led all vulnerable groups, such as people over 70, to expect pharmacies to deliver their medication. To help these patients, community pharmacies have been hiring extra drivers at their own expense or using volunteers, who in turn require training to ensure patient safety. These additional deliveries are currently free-of-charge, but the timing was not ideal for some pharmacies which were just beginning to charge for deliveries as lockdown hit.
These challenges are taking a heavy toll on pharmacy teams. The huge mental health burden of the pandemic on the general public is only now being recognised and addressed. In community pharmacy, many staff have had to deal with abuse from members of the public, with additional burden of work as other health professions closed their doors, with coworkers choosing to leave the sector or change profession altogether, or with uncertainty as their work premises were sold on by corporate chains. Pharmacies were also caught unawares by the decision to mandate their opening on the Easter Bank Holiday even though teams were exhausted and needed a break.
With hindsight the inclusion of pharmacy at the heart of policy changes might at least have boosted the morale of staff, who were left out of the original Clap for Carers Campaign, had to seek clarity on whether and who was included in the death in service payment, and prove their status as NHS workers to gain access to protected time in supermarkets.
There are some reports of pharmacies rewarding staff who have worked during the pandemic, which is to be applauded. And it’s also welcome news that dentists will return to their businesses. For pharmacy, this means that patients can receive urgent prescriptions in person, removing the need for pharmacists to feel obliged to accept emailed prescriptions- dentists’ lack of access to electronic prescribing has created dilemmas on whether to accept urgent prescriptions by email, a legal grey area. But the challenges for pharmacy continue.
In early June, there was an announcement that coronavirus antibody tests would be rolled out with community pharmacy involvement. But it was unclear how pharmacy might take part as a venous blood sample is required, which most pharmacies do not offer. There are other, more routine obstacles for community pharmacy too.
Take the New Medicines Service (NMS), a service that can be conducted over the telephone, in keeping with social distancing rules. Unfortunately, NHS England still insists that a written signature of consent is needed before the service can commence, which requires the patient’s physical presence and contamination of pens and paper in the pharmacy.
Similarly, written consent is still required for Medicines Use Reviews (MURs) and MURs are still prohibited via telephone unless an NHS form is completed to assess the case for individual patients. This has created barriers to service provision, necessitating the use of pharmacy consultation rooms, some of which do not afford space for social distancing and have been mothballed for safety.
As a result, the NMS and MUR services, important for promoting adherence and identifying medication difficulties, have ceased in some instances. This difficulty in providing NHS Advanced and Locally Commissioned services, and also private clinical services due to the suspension of services in consultation rooms, diminishes our community role; it also has a huge impact on the finances of a profession that has recently been restructured to obtain its profit from clinical service delivery rather than dispensing via the Community Pharmacy Contractual Framework (CPCF).
Many pharmacies are now conducting risk assessments to consider how to open up their consultation rooms with strict disinfection protocols and appropriate PPE so that some of these clinical services can resume, or face financial ruin.
Some services must be resumed, for example, the flu vaccination season will start in September.
Community pharmacists conducted upwards of 1.5 million NHS flu vaccinations last year and now await the service specification (which, it seems, GPs have already received) that will help them plan to deliver this service safely and effectively.
Close contact with patients on this scale poses a risk to pharmacists, and safety measures in addition to PPE are currently being considered to mitigate this risk.
Another service that has already restarted is the acceptance of patient-returned medicines for disposal. This service was paused by many pharmacies at the height of the pandemic because of fears about virus transmission – but has begun again following very welcome guidance issued by the PSNC, which will enable drug misuse services, care homes and members of the public to deal with unwanted medicines safely.
But as pharmacy begins to resume services, new challenges arise such as the need to prepare pharmacy teams for the difficulties of the next flu season, safely managing patients through procedures and training, but also dealing with the mental health toll of day-to-day potential staff exposure to coronavirus, the looming prospect of whole teams being wiped out by the test and trace service, or the possibility of having to persuade entire pharmacy teams to wear face masks for the whole day, every day, and find funding for their purchase.
We have no doubt that as the going has got tough for pharmacy, ‘the tough have got going’. The pharmacy profession is supported by a range of professional bodies that have also risen to the challenge and provided speedy guidance and support but also sought to champion the cause of pharmacy.
These bodies are beginning to make an impact and change policy, raising the profile of pharmacy. Supportive patients who have brought in cards, cakes and other gifts at this difficult time or sent kind messages and praise for our pharmacy staff have kept a whole profession going.
Many pharmacists have taken the opportunity to enhance their knowledge too in these tough times, accessing webinars and online packages so that they can work at their best and look to a time when the pandemic is over and business can begin to get back to normal. Rising to the challenge? We think pharmacy is doing so, and may it long continue.
Gurinder Singh Purewal, Caroline Parkhurst and Parastou Donyai jointly wrote this article. Purewal and Parkhurst are teacher-practitioner pharmacists and Donyai is a professor at the University of Reading.