Community Pharmacy Wales response to the Welsh Government Health, Social Care and Sport Committee Inquiry into

The Covid-19 Outbreak in Wales

Date May 2020

Contact Details

Russell Goodway

Chief Executive

Community Pharmacy Wales

3^rd Floor, Caspian Point 2

Caspian Way

CARDIFF, CF10 4DQ

Part 1: Introduction

Community Pharmacy Wales (CPW) represents community pharmacy on NHS matters and seeks to ensure that the best possible services, provided by pharmacy contractors in Wales, are available through NHS Wales. It is the body recognised by the Welsh Assembly Government in accordance with Sections 83 and 85 National Health Service (Wales) Act 2006 as ‘representative of persons providing pharmaceutical services’.

Community Pharmacy Wales is the only organisation that represents every community pharmacy in Wales. It works with Government and its agencies, such as local Health Boards, to protect and develop high quality community pharmacy based NHS services and to shape the community pharmacy contract and its associated regulations, in order to achieve the highest standards of public health and the best possible patient outcomes. CPW represents all 715 community pharmacies in Wales. Pharmacies are located in high streets, town centres and villages across Wales as well as in the major metropolitan centres and edge of town retail parks.

In addition to the dispensing of prescriptions, Welsh community pharmacies provide a broad range of patient services on behalf of NHS Wales. These face-to-face NHS Wales services, available from qualified pharmacists 6 and sometimes 7 days a week, include, Medicine Use Reviews, Emergency Contraception, Discharge Medicines Reviews, Smoking Cessation, Influenza Vaccination, Palliative Care Medicines Supply, Emergency Supply, Substance Misuse and the Common Ailments services.

The normal functioning of the community pharmacy network in Wales has been significantly disrupted by the Covid-19 outbreak and as more and more GP practices moved to working behind closed doors the network found itself very much on the frontline of the primary care response to the outbreak. Now that we are two months into the outbreak, it is an opportune time to take stock and to reflect on our response to date ahead of a more formal review when the outbreak has passed.

CPW is therefore pleased to have the opportunity to respond to this important inquiry.

Part 2: The impact of the Covid-19 outbreak in Wales on the community pharmacy network

We have looked at the impact of the network under three areas: the adaptation of the network, the protection of pharmacy teams and the public and the financial impact.

The adaptation of the network

The pace of change in the initial few weeks was substantial. As the public became alert to the potential of a lock down panic set in, with patients, whose health is dependent on a regular supply of prescribed medicines, understandably seeking to secure their future supply of medicines. There was a sudden and dramatic increase in requests to GP practices for repeat medication and in patients visiting their local pharmacy to obtain common medicines such as paracetamol and ibuprofen together with antibacterial products such as hand sanitisers and disinfectants.

Despite guidance not to provide patients with more than one month’s supply of repeat medication, patients started to request prescription items earlier than usual (potentially driven by a need to ensure they had enough medication if they needed to self isolate for 14 days) as well as ordering medication that they did not routinely use leading to a significant increase in prescription numbers, putting pharmacy teams and the medicines supply chain under significant pressure.

This was accompanied by a surge in phone calls to pharmacies for advice and support from patients who were struggling to obtain repeat prescriptions. This was usually connected with a reduction in GP accessibility. Despite advancements in the use of digital processes in NHS Wales the inadequacies in the current repeat prescribing arrangements were cruelly exposed and resulted in unnecessary pressure on both prescribers and dispensers. Patients felt that the only people that they could suddenly access was pharmacies, either in person or by phone, so pharmacies were getting a huge number of queries. Where patients would have otherwise popped into their GP practice, they were now phoning community pharmacies, with many pharmacies reporting that they were spending more than twice as much time on the phone.

It was in this early pre-lockdown period that the good working relationships developed over time between CPW and the Welsh Government’s Chief Pharmaceutical Officer (CPO) came into their own. In a very short period, contractual requirements were overhauled so that the pharmacy network was able to focus on the priority activities of medicines supply, health and advice and the management of common ailments. We also agreed to adopt Welsh Government messaging to explain the changes in provision and to help alleviate pressures, and throughout the crisis, we have adopted the 5 steps guidance, which the Welsh Government developed.

As the lockdown period started, community pharmacies started to lose staff through self-isolation requirements, and with a large increase in workload accompanied by reduced staffing levels, the network found itself under unprecedented pressure. The flexibility provided in pharmacy opening hours and the ability to ‘work behind closed doors’ helped pharmacies get back on track. The response by pharmacy teams across Wales was tremendous, with everyone working harder and longer hours and giving their all.

The lockdown period resulted in many more people self-isolating and despite messages to encourage patients to ask family members and friends to collect their medicines for them, the demand for medicines to be delivered was exponential with a trebling of workload. Again the pharmacy network responded magnificently and through a combination of increased hours and the use of family members and local volunteers found a way, across the entire network to meet the needs of their patients and to ensure they received the medicines they needed. The Welsh Government pharmacy team responded to the demand by putting in place volunteer delivery arrangements through the British Red Cross and the Post Office and although later in the peak, this was welcomed by CPW.

Other changes were made in terms of substance misuse, and a lot of those patients had their medication regime changed e.g. daily patients moved to a couple of times a week. Substance misuse support is a supervised service that would usually be carried out in a consultation room face to face, but that had to be managed in a completely different way because of the fact that most consultation rooms do not allow for a 2m social distancing gap easily. Contractors found that has caused some issues in terms of throughput for pharmacies, but also in dealing with some of these patients who are sometimes quite chaotic as well. There were a couple of incidences early on where some patients didn't self-isolate who should have been self-isolating, which was causing concerns for those pharmacies where patients were turning up in pharmacies who shouldn't have been and were refusing to take advice.

More broadly – and not confined to those patients described above in any way - not all members of the public have treated pharmacy teams with the respect and consideration they deserve. Unfortunately, there have been many incidents of aggression directed to individuals and some pharmacy teams have been forced to employ security guards to protect their staff. We thank politicians for helping us to challenge this behaviour.

Protection of patients and the members of the pharmacy team.

As the aggressive nature of the virus became clear, community pharmacy teams quickly established infection control processes. A number of pharmacies introduced Perspex screens between the dispensary, healthcare counter, consultation rooms and their patients to seek to limit the risk for both staff and customers. In addition, social distancing processes were established.

Guidance on infection control procedures were provided by Public Health Wales, together with posters with information to the public and an initial supply of Personal Protection Equipment (PPE) although this was only to be used for isolating infected patients who may have presented at the pharmacy and for decontamination processes. The narrowness of the advised usage of PPE caused some additional workforce issues as staff did not always feel protected since, regardless of what the guidance said, we had reports from our contractors across Wales that their staff teams did not want to come to work unless they felt protected. This meant, in the interim position, that contractors were put under additional pressure and additional cost pressures to actually purchase PPE for their teams. This was a particular issue for smaller chains or independent community pharmacy practices that did not have the buying power or sourcing capacity.

Whereas the separation of patients and pharmacy teams is possible to some extent, even in the smallest pharmacies, it is not practical for pharmacy staff to work at a safe distance from each other. Despite pulling out all the stops members of the pharmacy teams feel extremely unsafe and even though there have been reassuring messages to pharmacy teams that PPE was not necessary the natural concerns for their personal safety and that of their families, inevitably resulted in some choosing to self-isolate putting even more pressure on the pharmacy network. We have subsequently received reports of entire pharmacy teams having to isolate providing evidence that perhaps PPE was in fact required. Despite the real support shown by Welsh Government to the pharmacy network this is one of the only areas that they really feel let down and left to find their own sources of PPE. Obtaining PPE is no longer an issue for the network which is again welcomed.

CPW is very concerned about the physical health and the longer-term mental health of its pharmacy teams as many are working extremely long hours in difficult circumstances and foregoing their normal holidays and welcomes the extension of Welsh Government mental health support to the network.

Key members of the pharmacy teams are now able to participate in the testing programme although there are reported challenges in obtaining a test result in a reasonable period of time in some health board areas.

The inclusion of pharmacy team members in the Welsh Government’s Death in Service Cover arrangements is a positive development and has been welcomed by the network as it sends a real message of inclusion.

The Financial Impact on the network

The community pharmacy network prior to the Covid-19 outbreak had endured a sustained period of austerity that has affected the capacity of the network and its resilience.

The outbreak itself has taken a further financial toll on the network with a number of key elements coming together such as:-

The almost complete loss of both healthcare and non-healthcare sales income as patients can no longer browse.
Safe-distancing requirements introducing added complexity and reduced efficiency.
The engagement of additional staff hours to meet increased workload.
An additional investment in security.
A significant increase in the demand for delivery of medicines and advice and support on self-care. Both of these are unfunded activities with pharmacies having to meet the costs themselves.

The network was reassured by early messages from the Chancellor of the Exchequer and the Welsh Government that whatever the costs were in defeating the virus they would be met. The reality however has been constant discussion between CPW and Welsh Government to provide the additional funding for the network. These discussions have yet to conclude. This is such a shame, as the other support has been so good and it compares very unfavourably with the very generous additional funding provided to our GP colleagues for example over Easter opening arrangements.

Part 3: Conclusion

This initial overview of the impact of the Covid-19 outbreak on the community pharmacy network is provided with a degree of hindsight and it must be recognised that the speed of change has been significant. We submit this response in the conscious knowledge that we may have further evidence and observations to impart, as the crisis is ongoing.

In situations such as this, not every decision taken will be carefully thought out and effective communication is immensely challenging. That is true for everyone involved. And while not everything has been handled as well as it could have been, overall the Welsh Government have genuinely set out to manage the outbreak as best they can and from a community pharmacy perspective have liaised well and provided a huge amount of support to the network, for which CPW is very grateful.

What the outbreak has exposed however is that some changes could and should be implemented to the structure of the way community pharmacy operates.

Changes in practice

Recommendation 1: Repeat Prescriptions - The archaic and labour intensive ways in which we provide the people of Wales with their repeat medication as we still have green pieces of paper moving between GP practices and pharmacies often via patients. CPW would suggest that one of the key priorities following this outbreak is to introduce an efficient Electronic Repeat Dispensing service and move the supply of repeat medication from GP practices to community pharmacies in its entirety, while at the same time ensuring that community pharmacies and GP practices are very digitally integrated. CPW recognises that this may take some time to achieve however work can take place as soon as is practical to move a significant number of patients over to the Repeat Dispensing /Batch Prescription Service.

Recommendation 2: Electronic Prescribing – We welcome the indication by the Welsh Government to approach the issue of EP with a new sense of urgency. The crisis has highlighted the inefficiencies of paper based prescribing systems but also their danger too, since infection can be spread via physical contact. Changing to EP would eliminate the situation where some English GPs refused to issue paper prescriptions for dispensing in a pharmacy in Wales. Ideally the use of EP should be available across borders and across secondary and primary care sectors which would allow hospital prescriptions to be dispensed in the community electronically.

Recommendation 3: Online consultation - CPW fully supports the decision that the Attend Anywhere initiative is extended to the community pharmacy network and would wish to see this happen at pace. This builds on the increasing practice of people connecting via the internet rather than in person. We recognise however the need to maintain consistency in the delivery of advice when done remotely in order to retain the “community pharmacy” element of the provision.

Recommendation 4: Community provision - There has been much discussion over the years of potentially more cost effective medicines supply operations. This outbreak however has driven home hard the real advantage of the Welsh Government’s strategy of ensuring that there is a local community pharmacy where in a crisis people can be assured of a local supply of medicines, treatment for common ailments and advice and support for themselves and their families, and how we really need to protect, and appropriately fund, the pharmacy supply function.

Recommendation 5: Pharmacist judgement – With issues around the supply of medicines highlighted through COVID-19, the limitations on what a pharmacist can and can’t do have been highlighted, especially in relation to therapeutic substitution and generic substitution. We need to really empower pharmacists and enable them to be able to make these small changes to prescriptions. That would require legislative change from UK Government.

Recognising the value of community pharmacy

Recommendation 6: Financial – Our negotiations with Welsh Government regarding provision during Covid are ongoing. However, regardless of any agreement made, we believe there is a case from a public safety perspective that NHS Wales should invest in the in physical infrastructure of community pharmacies to minimise the risks to staff and patients from the COVID-19 virus.

Recommendation 7: Designation – Thought needs to be given to make sure the public better understand the role of community pharmacies as part of the NHS family. Community Pharmacies should be treated no differently to nurses or midwives in terms of recognition of the dangers community pharmacy teams face. This would help reduce aggression levels but also things like clearly identifying community pharmacy teams as key workers with appropriate badging would ensure we are from the outset part of any key worker scheme. We know there were issues especially early on in failing to designate community pharmacy teams as key workers, especially in relation to provision of schooling. NHS ID key worker cards should be introduced as soon as possible for all members of the community pharmacy teams. This would have significant positive impacts on morale and feeling valued.

Recommendation 8: Workforce issues – COVID-19 has shown there's not enough resilience in the service at the moment to cope with this sort of demand on a regular basis. The introduction of the option of ‘closed’ periods for community pharmacists was vital for over stretched and over stressed teams. CPW would request that the one hour in the middle of the day for staff health and well-being is maintained post Covid. Moving forward thought needs to be given on how to protect the mental health of community pharmacy teams, especially if there is a second spike. Consideration should also be given to reviewing opening hours as standard in order to better protect time for paperwork and processing.

Recommendation 9: Contract renegotiation – CPW is beginning the process of negotiating a new contract with the Welsh Government for the first time in nearly two decades. We are committed to learning from COVID-19 in terms of what is included, but also ask that the current crisis informs the thought of Welsh Government as they approach the negotiation. This thinking underpins all our other recommendations.

CPW agree that the content of this response can be made public.