Is hub and spoke dispensing good for community pharmacy?


Community pharmacy is changing with the times. New technologies are being introduced, focuses are shifting and new ways of working are developing before our eyes.


And one of the biggest moves over the past half-decade has been the rise of hub-and-spoke dispensing.


Since 2015, most large multiples – the likes of Boots, Rowlands, and LloydsPharmacy – have looked to achieve efficiency savings using hubs that centralise the dispensing process, delivering pre-made medication bags to branches across the country, which are then collected by patients.


Rowlands, for example, announced the opening of a new hub in Cheshire last year, which uses MediPAC technology and has the capacity to dispense 16 million prescriptions a year to branches across England, Scotland, and Wales. Boots Chief Pharmacist Marc Donovan has referred to hub-and-spoke as the “future” and praised the technology’s capacity to reduce mix-ups in product selection. LloydsPharmacy, meanwhile, has three separate hubs – in Warrington, Ruislip, and Bristol – that were set up within existing depots belonging to wholesalers AAH.


These hubs improve safety and, by reducing the time pharmacists spend processing prescriptions, increase efficiency.


Yet the biggest impact of the new system has perhaps been on the activities of pharmacists in the community.


Pharmacists still need to assemble fridge items and controlled drugs manually along with clinician checks, but the fact that so many items are dispensed remotely frees up time. Consequently, these companies’ in-store pharmacists can focus on providing services.


That has meant an increased capacity to push things like the in-store Covid swab test that was introduced by Boots in October, at a cost of £120. In the last week, Well and LloydsPharmacy has also announced that in-store Covid tests will be available to people showing no symptoms of the disease in some of their branches at the same cost as the Boots test.


These tests are in addition to the many other services all three multiples offer. And given those services often provide better margins than dispensing NHS prescriptions, that time is being well used.


Yet for many independent community pharmacies little will have shifted in the last five years. Current legislation dictates that two legally separate pharmacy businesses cannot share dispensing services and whilst some independents have their own dispensing robots, for those with neither the budget nor space for such a machine, that restriction means that all dispensing must still be done manually. For independents who want to conduct extra services, it is often necessary to have two pharmacists in-store, which comes at a cost.


Yet that could soon change. Legislation that is currently going through the House of Lords (namely the Medicines and Medical Devices Bill 2019-21) is set to allow separate pharmacies to share hub services and smaller pharmacies to take advantage of hub services offered by bigger groups or by companies such as HubRx, a new automated dispensing service set up specifically to cater to independents.


Like it has for the big multiples, this will have knock-on effects for the community independents that choose to avail themselves of remote dispensing services. It should increase efficiency and accuracy and may reduce costs. Most importantly, though, it will free up time that can be used to other ends.


Even before the introduction of hub dispensing though, there are things independent pharmacists can do to save time. Velresco, a company that specialises in maximising efficiency across various kinds of organisations, carried out a study over 150 dispensary sites and found that by delegating to their dispensary team, including the delegation of accuracy checking to an ACT, the average pharmacist could save 50% of their working hours.


If a pharmacy is open 50 hours a week, that is a potential saving of 25 working hours. Translating that into financial terms, assuming an hourly rate £21, that is £525 per week that could be economised through introducing leaner processes. Given that time could be used to provide valuable clinical services instead, streamlining could add even greater value.


And even after the introduction of hub dispensing for independent pharmacies, advice such as that provided by Velresco will remain useful. As previously alluded to, there will still be some dispensing work to be done in-store (refrigerating items, dispensing controlled drugs and doing final checks) so delegating workload and implementing more efficient processes will still save time.


Additionally, the increasing integration between Patient Medical Record (PMR) systems and dispensing could be a further boost to pharmacists looking to free themselves up to be more hands-on with patients. A perfect example of this is the Golden Tote, an automated repeat prescription process accessible through EMIS’s existing PMR system, that was introduced by Rowland’s parent company PHOENIX last year.


Golden Tote sends stock to pharmacies based on the prescriptions they have; it allows pharmacies to scan medication items and match them to prescriptions, saving time spent putting stock away and taking it off shelves because you know which delivery boxes match which prescriptions.


If utilised fully, the combination of all these new, time-saving technologies and processes will mean that local pharmacists will be freed up to spend more time providing the sort of face-to-face services mentioned above and upsell over-the-counter products.


Following the funding reductions of the last few years, many pharmacies have already started this shift to a service-based model, often providing flu jabs or travel clinics. But with more time available, it will be possible to expand that offering with innovative new options. These can include sexual health clinics, warfarin monitoring clinics, sore throat tests, drug misuse services, medicine use reviews and needle exchange. With margins on dispensing NHS prescriptions so slim, that could be positive news.


As was laid out in the Community Pharmacy Contractual Framework, community pharmacies are being more tightly integrated into Primary Care Networks and will become the first port of call for preventative services and minor illnesses.


Pharmacists have multiple clinical skills and with these developments, they will have more opportunity to use them.



Numerous potential risks and barriers with hub and spoke


The National Pharmacy Association has published an account of an expert discussion on hub and spoke dispensing, held at the King’s Fund earlier this year.


Organised by the NPA and chaired by King’s Fund chief executive Richard Murray, the participants included representatives from community pharmacy, the pharmaceutical industry, wholesalers, the NHS, government and regulators.


The meeting concluded that hub and spoke has some potential to release capacity at pharmacies and improve patient safety, but that there are significant risks and barriers to overcome.  It was also a key theme that other capacity-releasing measures could achieve similar aims without the same risks.


All participants at the roundtable in February had access to a NPA report published that same month, which highlighted that large scale automated dispensing remains very limited globally, despite the technology being established for many years.


NPA chief executive, Mark Lyonette, said:


“This meeting was unique in terms of the broad range of stakeholders it brought together in one place to discuss this important issue. The NPA remains very sceptical about some of the grander claims made for hub and spoke dispensing. No studies of the impact on patient safety of the full end-to-end process have yet been conducted. But we see it as our duty to seek solutions that mitigate risk for our members and patients, to engage fully in debates about automation and service re-modelling and to ensure proper scrutiny of the assumptions on which claims for hub and spoke are built.”


King’s Fund chief executive, Richard Murray, said:


“I was pleased to be invited by the NPA to chair this event, as someone with an abiding interest in the success of community pharmacy. Hub and spoke is a contentious matter within the pharmacy sector, but this roundtable discussion was a serious, balanced exploration into safety, efficiency, regulation and feasibility.”


The write-up of this roundtable meeting (which took place on 25 February) was delayed by the onset of coronavirus and the need to reprioritise workstreams.


Its publication this month coincides with ongoing consideration of the Medicines and Medical Devices Bill in parliament, which will pave the way for regulations to legalise ‘inter-company’ hub and spoke dispensing, where a pharmacy can outsource elements of its dispensing to a third party.


You can read the write up of the round table discussion by clicking here. 



NPA make formal submission to MPs on medicine supply regulations


In a formal submission to MPs, the National Pharmacy Association argues that changes to regulations on medicines supply should be subject to parliamentary scrutiny, including rules about hub and spoke dispensing.


The Medicines and Medical Devices Bill, currently being examined by the Public Bill Committee, will confer power to ministers to amend or supplement medicines law, without the need for primary legislation.


A bill of this kind is seen as necessary to facilitate the uninterrupted business of government following the UK’s exit from the European Union.


However, it also opens up the possibility of important changes to the rules around medicines supply taking place without sufficient parliamentary scrutiny and democratic accountability.


This includes regulatory changes to allow inter-company hub and spoke dispensing, where a pharmacy outsources elements of its dispensing to a third party.  The NPA has consistently warned that official claims about the benefits of inter-company hub & spoke are overblown and that it risks diminishing competition and choice in the pharmaceutical wholesale market without a level playing field. Other unintended consequences could be less resilience of the medicines supply system and rises in medicines prices.


NPA chief executive Mark Lyonette said:


“The changes relating to the safe supply of medicines that could be implemented using secondary legislation empowered under this Bill are significant. Big changes to the way that medicines are supplied to the public could be enacted without the need for further primary legislation.


“What matters to the people of this country should matter to our politicians – and people do care about the safe supply of medicines.  We want the provisions of this Bill to require both full consultations with stakeholders and sufficient parliamentary scrutiny.”


The Medicines and Medical Devices Bill will confer power to amend or supplement the law relating to human medicines, veterinary medicines and medical devices; and make provision about the enforcement of regulations. The Bill passed at second reading on the 2nd March 2020 and is now with the Public Bill Committee.


Following representations by the NPA, an amendment to the bill was laid last week, which if adopted would limit the power of ministers to amend or repeal provisions in an Act of Parliament using secondary legislation to two years, before requiring Parliamentary approval to extend them.