Dr Dai Lloyd MS
Chair, Health, Social Care and Sport Committee
Welsh Parliament
Cardiff Bay
Cardiff
CF99 1SN
19 May 2020
Dear Dr Lloyd
Response by the Royal Pharmaceutical Society in Wales to the Welsh Parliament Health, Social Care and Sport Committee’s Inquiry into the impact of the Covid-19 outbreak, and its management, on health and social care in Wales
Thank you for the recent opportunity of contributing verbal evidence to the Committee’s inquiry into the COVID-19 outbreak. As the professional body representing pharmacists across all health care sectors, we are pleased to follow this up with supportive written evidence. In this submission we reflect on pharmacy’s experience of dealing with the COVID-19 pandemic to date and importantly highlight key learning points and recommendations for future action by the Welsh Government and NHS Wales.
Key points:
The COVID-19 pandemic has reinforced the need for:
· Recognition that the pharmacy profession is essential and fundamental across all sectors of health and social care in national contingency planning from the outset and throughout all transitionary phases during any public health crisis
· Urgent digitisation in pharmacy services including the need for read and write access to shared patient records and the development of a robust electronic prescribing solution across Wales.
· Enabling pharmacists to manage shortages in medicines through legislative change that allow pharmacists to use their professional judgement to make minor amendments to prescriptions in the event of a medicine being out of stock.
· Ongoing routine access to services and resources to support the mental health and wellbeing of all pharmacy teams in line with other health professional groups. There should be equity across all health care professionals.
Pharmacy’s commitment to patient care during the COVID-19 outbreak
1. We are proud of the resolute commitment of the pharmacy profession across all sectors to maintaining the delivery of care and the supply of medicines during the pandemic. The profession has risen to the challenge of increasing workloads and innovative approaches to service design have been quickly found and implemented to ensure continuity of care. Collaboration among pharmacy teams across different localities and with other professional groups has also been inspiring.
2. As a membership body representing all sectors of pharmacy, the RPS took a strategic decision at an early stage in the pandemic to mobilise all financial and human resources to support the profession across Great Britain to cope with the unprecedented challenges of dealing with this pandemic.
Government recognition of pharmacy teams
3. We recognise the significant challenge faced by the Welsh Government in leading and coordinating the approach to COVID-19 across health and social care sectors. To date, we have welcomed the actions taken by the Welsh Government to support pharmacy teams. The ability to introduce flexible opening hours has, for example, been particularly welcomed in community pharmacy. This has ensured the time needed for a critical break from immediate patient facing pressures, to undertake clinical work without interruption and to prioritise the most vulnerable patients. The relaxation of contractual obligations has been very much welcomed by community pharmacy in coping with the increase in demand.
4. A great deal of work has been undertaken across the NHS by pharmacy professionals in response to the COVID-19 Pandemic which needs to be recognised. This includes:
o Maintaining access to vital medicines in all sectors by re-designing supply processes, working with medical colleagues to change patients to alternative products which require less frequent administration, and implementing delivery initiatives to vulnerable people from community and hospitals.
o Planning and managing the supply of critical and end of life care medicines as the demands have significantly increased and the supplies have decreased: Developing new service models, frameworks to support ethical professional decision making for individual patient care, and maintaining governance and advice to support alternative choices of medicines which can be unfamiliar to clinicians.
o Developing local protocols to promote and enable access to medicines via clinical trials for COVID-19. Some medicines have only been available via trials and evidence is vital to inform on-going treatment choices.
o Advising on oxygen supplies and providing quality control to enable the oxygen pipe infrastructures to be expanded in acute care.
o Maintaining clinical pharmacy services to acute care patients with provision of training to grow ICU pharmacist numbers and continuing to support non- COVID services.
o Installing and running new pharmacies and services to new field hospitals using novel service models.
o Advising on treatment options using the limited evidence available and ensuring good governance is maintained.
o Aseptic preparation of medicines in ready to use forms for acute care, saving nursing colleagues’ time and the difficulty of undertaking this task while in full PPE.
5. It has been disappointing that, some headline policies have been announced by the Welsh Government without the necessary detail and limited information on implementation. The announcement of the Welsh Government’s Death in Service Scheme is one such example. The announcement of this scheme initially left pharmacists and others across the health service looking for clarity on if and how the scheme applied to them. While the Minister for Health and Social Care confirmed the scheme would apply to community pharmacy following its announcement, we have yet to see or fully understand the details of the scheme.
6. We have heard from our community pharmacy and primary care members about difficulties associated with lack of recognition as NHS key workers. While we recognise this is unintended, and Welsh Government do quite rightly include pharmacists and their teams as key workers, not having official NHS ID has meant that pharmacy team members have not been able to routinely benefit from positive initiatives, such as priority access for NHS frontline staff to supermarkets and free public transport.
7. We were pleased that the Welsh Government took action to introduce ID Cards for colleagues working in social care to address the very same issue. A similar scheme for community pharmacy and primary care staff would help them to access services. This would also solidify the place of community pharmacy teams in the NHS family.
8. While we appreciate the pace of change of coping with this public health crisis, we believe that more could be gained from further engagement between Welsh Government officials and professional bodies. We are pleased that we have benefited from regular discussion with the Chief Pharmaceutical Officer and Head of Pharmacy and Prescribing. This enables us to keep our members better informed and reassured with appropriate support and professional guidance. We welcome all further opportunities to work closely with the Welsh Government to provide a wide pool of expert opinion to input into and provide constructive challenge to policy-making.
Recommendation 1: Plans for front line staff delivering NHS services must include consideration of all pharmacy teams, including community pharmacy from the very outset.
Recommendation 2:Key worker status for pharmacy professionals working in community pharmacy and primary care should be assured.
Protecting pharmacy teams
Personal Protective Equipment
9. Ensuring pharmacy teams in all settings can deliver services without any compromise to their safety has been, and remains, our paramount concern in managing the coronavirus outbreak.
10. While there has been a variance in government responses to the distribution and provision of PPE across the UK, we have welcomed and congratulated the Welsh Government for its response in ensuring PPE equipment was supplied to pharmacy teams at an early stage. We were pleased that PPE was distributed rapidly to all 715 community pharmacies in Wales. Feedback from our members suggests that, generally, the standard of PPE and the speed of its distribution to pharmacy teams has met need.
11. We were pleased that the Welsh Government led the way among UK nations by introducing regulations on social distancing in the workplace. This was a welcome step. Unfortunately, the accompanying guidance caused some initial confusion among our membership regarding the use of PPE when 2 metre distances could not be maintained. This was concerning as one of our recent surveys revealed that 94% of respondents could not maintain social distancing of two metres from other staff in their pharmacy. We were also aware of cases where pharmacists and their teams contracted COVID-19, disrupting the supply of local services.
12. We support all efforts by the Welsh Government to continue to proactively source PPE internationally, as well as supporting Welsh businesses to manufacture stocks. It is reassuring to hear the Health Minister confirming the sourcing PPE as his number one priority.
13. At the point when lockdown measures can be gradually relaxed in Wales, it can be expected that footfall within community pharmacies will grow, increasing the risks of viral transmission and ensuring the continuing need for PPE. The needs of hospital-based pharmacy teams should also be understood and supported during the transition to routine hospital services. Supply must continue to meet demand at this time.
Priority COVID-19 testing for pharmacists and their staff:
14. Early testing of pharmacists and their staff has been a consistent feature in discussions with our members. We fully support early testing as a crucial step in facilitating an early return to work following self-isolation.
15. We have been pleased to hear reports from our members that access to testing for pharmacists and teams has generally been efficiently managed by Health Boards across Wales. However, we have been made aware of some variation in the time that pharmacists are waiting to get their results - sometimes up to 5 days after the test - resulting in a prolonged absence from work.
A Strong Stance on Abuse
16. Community pharmacies have been one of the few healthcare settings that has remained physically open to the public during the pandemic. It is therefore disappointing that community pharmacy teams have had to deal with incidents of aggression and, in some cases, violence from the public.
17. We escalated our concerns about the risks of abusive and violent behaviour towards community pharmacy staff to the police forces in Wales. We were very pleased with the quick and decisive response from the police and their commitment to increasing assurance visits to community pharmacies across Wales at this challenging time.
18. It was also reassuring to hear robust public messaging by the Welsh Government when reports of abuse and violence towards pharmacy teams emerged. This included public calls for patience and respect towards pharmacy teams by the First Minister, the Health and Social Care Minister and the Chief Pharmaceutical Officer. We know that pharmacy teams have also appreciated the strong public stances taken from other MSs to encourage respectful behaviour at community pharmacies.
19. We are proud that during the pandemic, community pharmacy also committed to supporting victims of domestic abuse. Along with a number of pharmacies across the UK, we have supported the Safe Spaces scheme as part of the UK Says No More campaign[1]. We have also been pleased to advise on the potential roll out of the Welsh Government’s Live Fear Free[2] initiative using community pharmacies to signpost victims of abuse to appropriate support.
Medicines Delivery Services
20. On 5 May, we welcomed the launch by the Welsh Government of the new volunteer prescription delivery scheme to support those shielding. We appreciate the hard work and investment to deliver this service which appears to be comprehensive and includes additional safety mechanisms such as DBS checks and the use of Pro Delivery Manager. However, the time lag between letters being sent to the shielding groups advising them to arrange delivery of medication at the end of March and the launch of the scheme in early May has resulted in some community pharmacies proactively investing in their own strategies.
21. We also have concerns that lists of vulnerable patients requiring delivery was not shared with pharmacies who decided not to participate in the scheme. This places an expectation for patients to make themselves known to their community pharmacy.
22. The capacity of the volunteer scheme will need to be monitored as more people return to work and as lockdown measures are relaxed.
Recommendations 5: A sustainable solution to medicine delivery to vulnerable people who remain isolating must be in place when the number of volunteers reduces. The solution should include supply from both community and hospital pharmacies, that continue to supply essential medicines.
Training, Mental Health and Wellbeing Support
23. We are incredibly proud of the resilience of the pharmacy profession in responding to the COVID-19 pandemic. However, we have concerns about the immediate and longer-term impact on the profession’s mental health and wellbeing from coping with such unprecedented pressures. Initial results from an RPS survey of pharmacists published in December last year showed that 80% were already at risk of burnout[3].
24. In correspondence to the Welsh Government we have emphasised the importance of establishing emotional and wellbeing support for pharmacy teams, including those teams who are not directly employed by the NHS. Good progress had already been made in this area including:
· The development by Health Education Improvement Wales (HEIW) of a web-based portal to wellbeing resources.
· The extension of the previously doctor only, ‘Health for Health Professionals Support’ service to all health professionals.
25. Access to wellbeing resources such as these and opportunities for one-to-one emotional and psychological support will continue to be important during and following the pandemic. This should extend to greater occupational health and wellbeing support for all pharmacy professionals in line with that provided for other health professionals contacted by the NHS including GPs and dentists.
26. Professional development has continued to be important to the pharmacy profession throughout the pandemic. The pandemic has further demonstrated the need for developing an adaptable and flexible pharmacy workforce in Wales which must be supported by access to consistent and quality-assured professional development. This should be underpinned by the development of a common post-registration career framework that ensures pharmacists in all settings can practice to the full extent of their education and training.
Recommendation 7: NHS mental health and wellbeing services should continue to be available to all pharmacists and all health professional groups within and contracted by the NHS.
Recommendation 8: Protected education and training time should be mandatory within workforce planning for all pharmacists.
Sustaining essential medicines supply
Medicines Shortages
27. We have heard from pharmacists concerned about the potential longer-term impact of the pandemic on medicines manufacturing. We are aware that the Government is monitoring how COVID-19 could affect the medicines supply chain and we would welcome further engagement on this issue.
28. Contingency planning is critical to mitigate the effects of any worsening of medicines shortages due to the COVID-19 pandemic. This should take into account flexible plans for returning, re-using and the storage of medicines and the possibility that supply of certain medicines will become increasingly difficult. We welcome the End of Life COVID-19 Medicines Service to supply ‘Just in Time’ Emergency Medicine Packs[4] and advice on re-use of end of life medicines in care homes[5].
29. Hospital pharmacy teams have played a key role in maintaining supplies of critical care medicines and haemofiltration fluids at times of peak demand. We understand the supply chain of these medicines is fragile across the UK and believe it is imperative that health boards recognise and address this in their planning for services for the pandemic as well as future routine services.
Empowering Pharmacists to Manage Shortages
- The pressures of the pandemic, coupled with the potential shortages of essential medicines, has reinforced the importance of enabling pharmacists to manage shortages of medicines. Prior to the outbreak of COVID-19, the UK Government was already reviewing the effectiveness of Serious Shortage Protocols, which our members tell us have been overly-burdensome to date. We maintain that medicines legislation should be amended to allow pharmacists to use their professional judgement to make minor amendments to prescriptions in the event of a medicine being out of stock, such as: different quantities, strengths, formulations or generic versions of the same medicine (generic substitution).
31. A change in legislation on managing medicines would save patients having to go back to the prescriber and reduce the workload of GPs. For pharmacists in secondary care these substitutions are standard practice and in Scotland, processes are already in place to allow pharmacists to make interventions to deal with medicines shortages. We believe it is time to address this imbalance and improve access to medicines by enabling community pharmacists to make these simple changes. Our proposals to mitigate the risks of medicines shortages are laid out in our policy position on medicines shortages[6].
Recommendation 9: Welsh Government support is needed to progress legislative change to maximise the ability of pharmacists to use their clinical knowledge and professional judgment to more efficiently manage medicines shortages.
Pre-prepared Medicines
32. Work to prepare medicines so that they are available and ready for use by intensive care nursing and medical staff can be time consuming. This is particularly the case when caring for patients at peaks of demand and when wearing PPE. Time taken to prepare and manipulate multiple medicines for critically ill patients would be better used for direct patient care.
33. With other NHS services paused due to Covid-19, numerous hospital pharmacy aseptic units have repurposed their time to prepare these medicines into syringes so that they are ready to administer. This has been very well received by front line staff colleagues. However, increased capacity will be required to sustain this service at peak demand and when more day-to-day services such as chemotherapy are restarted. We understand that a centralised ‘once for Wales’ unit hosted by NHS Wales Shared Services Partnership is being considered. This is a very welcomed development and should be supported by the Welsh Government.
Recommendation 10: An ongoing centralised intravenous additive service (CIVAS) of ready prepared medicines should be developed in Wales.
Delivering vaccination services
34. Given their accessibility and experience in administrating vaccinations, pharmacists are well-placed to support potential vaccination against COVID-19 as well as continuing to support the seasonal flu vaccination programme. The delivery of such vaccination programmes will require assurances that health professionals can work safely and be appropriately protected. We would welcome early discussions with the Welsh Government and NHS Wales on how this could be taken forward.
Increasing the pace of digitisation in pharmacy services
Electronic Prescribing
35. The current pandemic has reinforced the urgent need for electronic prescribing systems in both secondary and primary care. Electronic prescribing systems allow prescriptions to be sent digitally to be dispensed in community pharmacies or allow remote access within hospital environments, eliminating the need for paper prescriptions, increasing efficiencies and improving the patient experience.
36. The electronic prescribing systems in England, and to some extend in Scotland, have proved particularly useful during this time. They have:
o ensured timely access to medication for patients
o avoided logistical problems
o provided real time data on medicines use
o reduced the risk of infection transmission by reducing footfall and eliminating paper use.
37. The need for a robust electronic prescribing system in Wales has been recognised for some time. Plans for a system for secondary care has been in place in Wales for over a decade, however a system is still not in place. This was also an issue highlighted in the Public Account Committee’s 2018 report into Medicines Management which noted it’s concerns around the need modernise prescribing systems[7].
Recommendation 11: National development and roll out of electronic prescribing in both secondary and primary care is urgently needed to ensure efficiencies and patient safety.
Video Consultations
38. Responding to current needs, the Welsh Government in March rolled out a video consultation solution to all GP Practices throughout Wales. We understand that plans are in place to expand the Attend Anywhere service into secondary and community care. We would welcome this development so that patients can continue to benefit from existing community pharmacy services. We also believe this step will prove to be a positive long-term investment which will meet the aims the Welsh Government’s plan for health and social care as outlined in ‘A Healthier Wales’
Recommendation 12: Video consultation solutions should be supported and rolled out to all community pharmacies in Wales.
Digitisation and integration of health and care records
39. The pandemic has highlighted the importance of full integration and digitisation of health and care records to improve efficiencies and patient safety. While we have welcomed the recent roll out of access to patient’s medicines information in emergency situations via the Welsh GP Record to all community pharmacists, we maintain there is still a need to complete the digitisation and integration of health and care records, including read and write access to shared electronic patient records.
40. The Topol Review argued that this is urgently needed if the full benefits of digital medicine are going to be realised for the NHS, including earlier diagnosis, personalised care and treatment[8]. We fully support the Topol Review’s conclusions and believe that steps are now urgently needed to propel long term investment in technology to support patient care going forward. The COVID-19 pandemic has underlined the need to realise these ambitions.
Recommendation 13: Reduce the risk of medication errors and emergency hospital admissions by allowing all pharmacists to access and update a shared electronic patient record.
We trust these issues are helpful in highlighting the experience of the pharmacy profession throughout the COVID-19 pandemic to date. We remain committed to working constructively with the Committee, the Welsh Government, NHS Wales and key stakeholders to minimise the impact of COVID-19 and to ensure pharmacy’s contribution to patient care can be sustained and developed going forward. Please don’t hesitate to get in touch should the Committee require any further information as this important inquiry progresses.
Yours sincerely
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Suzanne Scott-Thomas Elen Jones
Chair, RPS Wales Pharmacy Board RPS, Director for Wales