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Where does the pharmacy sector stand now on hub-and-spoke?

The Department of Health and Social Care (DH) is engaging with the community pharmacy sector as part of preliminary work that will inform its hub-and-spoke consultation.

Under the Medicines and Medical Devices Act 2021, the DH has powers to roll out a hub-and-spoke dispensing model across community pharmacy. However, any plans for the model must be subject to a “full public consultation” before they come to fruition.

At present, the DH is consulting key pharmacy stakeholders to understand what issues need addressing before a hub-and-spoke model is introduced. The feedback gathered through these engagement sessions will inform the basis of a consultation, a DH spokesperson told C+D last month.

The Association of Independent Multiple Pharmacies (AIMp), the Company Chemists’ Association (CCA), the Pharmaceutical Services Negotiating Committee (PSNC), the Pharmacists’ Defence Association (PDA) and the National Pharmacy Association (NPA) are some of the bodies currently participating in those discussions.

They told C+D what advantages a hub-and-spoke model could bring to the sector and flagged the potential pitfalls to be addressed before any model for automated dispensing is introduced.

AIMp: A “huge cost”

AIMp CEO Leyla Hannbeck told C+D that her organisation regularly attends engagement meetings on hub-and-spoke dispensing.

However, those meetings are often attended by more than 50 delegates, which make it harder “to put the message across”, she said.

One of AIMp’s main concerns with the service is that the introduction of an automated dispensing model might come at a “huge cost, as robotics are expensive and require investment, maintenance and eventual replacement”.

The assumption that the model will help pharmacy staff focus on the provision of other services is “OK in principle, but if the services commissioned are not properly remunerated, this will threaten the existence of pharmacy”, Ms Hannbeck said.

AIMp is also “extremely concerned” that discussions around the hub delivering directly to patients are “not being brought to this debate”.

“If the 'direct-to-patient hubs' are given a regulatory advantage over the ‘hubs-to-pharmacy’, they will add this to their industrial economies of scale and create a competitive advantage, allowing them to hoover up prescriptions nationally,” Ms Hannbeck said.

The risk is pharmacies might be left with insufficient income for their dispensing activity, which might “result in the collapse of the community pharmacy network,” Ms Hannbeck warned.

NPA and PSNC: Not enough evidence

Gareth Jones, head of corporate affairs at the NPA, told C+D that the lobbying group has been in “correspondence and in detailed conversation with [DH] officials for several years on this topic”.

“Whatever the next steps are in exploring this concept, the government should weigh the practical experience to date, [both] in the UK and internationally, [rather than] just relying on unproven theories. The real-life experience of hub and spoke clearly shows that it is no panacea and mustn’t be rushed,” Mr Jones added.

He said that the NPA is still “sceptical” about some of the claims that have been made about the model, as it is not backed up by “studies of the impact on patient safety of the full end-to-end process”.

While the NPA believes it is right to explore how this model could “release time in pharmacies for patient-facing care”, it fears the government might overestimate the benefits of it and use them to “wrongly justify cuts to pharmacy funding”, Mr Jones added.

The NPA’s concerns over the lack of evidence in support of the benefits of a hub-and-spoke model are echoed by PSNC.

In a response it submitted during the passage of the Medicines and Medical Devices Bill in June 2020, the English negotiator wrote that “the efficiencies that [the model] may bring are as yet unproven, and there are several patient safety concerns that must be addressed before it can be widely implemented”.

PSNC also said that “there is no clear evidence that the model improves the overall efficiency of dispensing as compared with the existing model”.

CCA: Multiples found model “invaluable during the pandemic”

Several pharmacy chains are currently using hub-and-spoke models within their own branches.

CCA CEO Malcolm Harrison told C+D that, based on CCA members’ experience, the model can move workload and "the associated cost" out of pharmacies, allowing pharmacy teams to focus on delivering “more clinical care”.

“Our members who use hub-and-spoke models have found it invaluable during the pandemic, by providing business resilience and relieving pressure on frontline teams,” Mr Harrison added.

However, he recognises that the model is not a “magic bullet” and “comes with extremely high set-up costs and ongoing operating costs”, he said.

“Once a hub-and-spoke model has been embedded in a pharmacy, new clinical services need to be commissioned to allow the pharmacist to utilise the capacity released,” Mr Harrison added.

PDA: Not a "silver bullet"

PDA director Paul Day told C+D that there are fears that the introduction of greater automation in the dispensing process could results in job cuts, “with potential risk to quality and safety”.

Employers taking this approach could “harm the long-term prospects for their own business and the wider sector”, he warned. However, the greater use of automation should instead help the profession move to a “more clinical role”, Mr Day argued.

“This would also enable the sector to change how it is often perceived by the public – from a retail supplier of products to consumers, to that of a healthcare professional embedded in the local community and enjoying clinical relationships and increased face-to-face contact with patients,” Mr Day said.

But he added that the introduction of this model alone “should not be seen as a silver bullet to increase patient-facing activity in a community pharmacy”.

“Pharmacy skill mix and the role of the responsible pharmacist are significant areas that still need to be addressed as part of this conversation,” Mr Day said.

In 2016, the government argued that allowing independent pharmacies to legally operate dispensing hubs would “create a level playing field” and give them a greater choice of which business model to operate.

But pharmacy organisations – including PSNC – argued at the time that there was no evidence that hub-and-spoke dispensing would save money or improve patient safety.

The DH showed renewed interest in a hub-and-spoke model in 2019 when it announced in the five-year funding contract for England that it would explore legislative changes with PSNC to allow all pharmacies to “benefit from more efficient hub-and-spoke dispensing”.

Additional reporting by Valeria Fiore

Share your thoughts on this topic by joining the Big Debate on C+D's Community platform, 7-8pm Thursday April 29 on the topic: Could a hub-and-spoke model ever truly work for independent pharmacies?

What do you make of the proposals to introduce a hub-and-spoke model?

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