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Can pharmacy move to hub-and-spoke dispensing?

The government is eager to tout it as the model of the future, but is this realistic?

It has been a labelled a false god, the saviour of pharmacy and an unevidenced fad. Mention the words ‘hub-and-spoke model’ in a room full of pharmacists and you are guaranteed to provoke a lively debate. So when England’s chief pharmaceutical officer Keith Ridge asserted back in September that two-thirds of the country’s prescriptions could be dispensed using this model, he must have expected to court controversy.

What he may not have banked on, however, was a unanimous backlash from the sector. Speaking to C+D, the hub-ready and hub-sceptic all shared the same point of view: it is unfeasible for the sector to roll out the model on this scale. And it is even more unfeasible to base a 6% cut to pharmacy funding – due to come into force in October – on the supposed cost savings it may generate. 

Mayberry Pharmacy, which has used a hub model to serve its pharmacies for five years, struggles to believe the hub format “will work widespread”.  Tech-savvy Boots stresses that automation is in its infancy, and that it is “too early” for Mr Ridge to make such an assertion. And Numark managing director John D’Arcy brands the suggestion “pie-in-the-sky”. 

All three believe there is some merit in the model – they simply doubt its viability on a large scale. The question is not so much whether hub pharmacies could dispense two-thirds of England’s prescriptions, but why they can’t. And the answer comes down to a variety of factors.

Pitfall 1: The financials are flimsy

The government’s enthusiasm for hub-and-spoke dispensing is based on one core belief: that it will save money. But where is the evidence for these cost savings? The National Pharmacy Association (NPA) set up a hub-and-spoke task group to answer this question, among others. So far, the case for financial benefit has proven “unconvincing”, says the group’s chair Mike Hewitson.

The NPA commissioned the University of Manchester to review the available evidence on the model, explains Mr Hewitson, who owns two pharmacies in Dorset. But it has found “next to nothing” that documents the financial impact of the model. The lack of evidence makes Mr Hewitson uneasy about the government’s stance. “I would feel uncomfortable making decisions where I don’t have evidence,” he says.

Even pharmacies that have adopted the model are unsure over its money-saving potential. Day Lewis has used a hub model for the past two years to serve a selected few branches and has plans to extend the service to all of its pharmacies by 2018. But director Jay Patel says there is no saving on the dispensing cost. The company hasn’t used the hub to reduce in-store numbers, so it simply frees up the existing team to conduct more services.

Paul Mayberry, director of Mayberry Pharmacy, did reduce his branch staff numbers when he introduced a hub model five years ago. But, as he points out, the business now has a “big hub team” – so any savings were minimal. “We didn’t do it as a cost-saving exercise,” he stresses.

For this reason, John D’Arcy is sceptical of the savings until he sees a robust business case. It’s not enough for the government to “have a chat” about the hub-and spoke model and conclude it’s a good idea – it must “put some numbers together” to support its view, he says.

Pitfall 2: It requires upfront investment

Even if the hub model does make long-term savings, it will require short-term investment. As Numark’s John D’Arcy points out, moving to a new way of working is “a big project that will take a number of years”. But the government is expecting pharmacy to make the change against the backdrop of a 6% funding cut. He brands the government strategy “a joke”. 

“[It] says, ‘we’re cutting your money and, by the way, we want hub-and-spoke’,” Mr D’Arcy says. “I want a gold bar, but I’m not going to get that anytime soon.”

Mike Hewitson is similarly critical. “Any system change requires front-loading of investment,” he says, adding that is “exactly the case” NHS chief executive Simon Stevens made in the health service strategy, the Five Year Forward View, in 2014. “Yet the government expects pharmacy to change with less money,” he says. It is a seemingly contradictory stance – and one that seems fundamentally flawed.


Hubs in practice

Lloydspharmacy

The multiple opened its first hub in 2008 to “free pharmacists from dispensing” and enable them to spend more time with patients. It clearly found the model beneficial – the multiple has since increased its number of UK hubs to four, which serve “hundreds” of Lloydspharmacy branches. The hubs look after “planned activity” such as repeat prescriptions, which are delivered back to the pharmacy to be given to the patient.

Boots

The multiple operates a dispensing support pharmacy – and it is keen to stress the difference between this and a traditional hub model. Under the Boots system, the prescription and electronic tokens never leave the pharmacy branch. The support pharmacy, which opened in March 2014, uses scanning technology to check the accuracy of items. But in-store teams remain responsible for data entry into the PMR, the clinical check and data accuracy check.

Mayberry Pharmacy

Five years ago, Mayberry Pharmacy opened a hub to relieve its branch teams from the pressure of dispensing. Since then, the model has flourished. The hub now deals with more than 60% of prescriptions for the company’s seven branches, based in southeast Wales.


Pitfall 3: Only services can make it worthwhile

One common argument for the hub-and-spoke model is that it can free up pharmacists to conduct services. This is one of the reasons why Mayberry Pharmacy made the leap. Mr Mayberry’s starting point was to look at how he could make the dispensing process as efficient as possible. “Part of that was to see where my most expensive assets – my pharmacists – added value in the process, and that was either by clinically checking [prescriptions] or spending time with the patient,” he explains. It made sense, then, for him to transfer a large part of a dispensing process to the hub, to enable branch pharmacists to conduct services.

Day Lewis went down the hub route for similar reasons – to enable its “very clinical pharmacists” to perform a range of services, from travel clinics to MURs. But this strategy will only work if the government is willing to commission services from pharmacy, points out the company’s director Jay Patel. This is looking less and less likely in light of the letter announcing the 6% funding cuts, which gave no promise of new service income.

Mr Patel says this leaves independents with little incentive to move to a hub model. “There needs to be more local services and another income stream,” he says. “There needs to be a carrot at the end.”

Pitfall 4: Potential patient risks

The hub model tends to rely heavily on automation. This has clear time benefits – but also comes with risks. Mr Patel says that when pharmacies rely on technology, there is scope for error. He cites the difficulties with Pharmacy2U’s automation facility, which resulted in the online business struggling to deliver medicines over the Christmas period, as an example of what can go wrong. So he questions the wisdom of relying on automation to dispense two-thirds of the country’s prescriptions. “Imagine if a hub [that is] dispensing 10 million items a month fails,” he says. “That’s enough to cause serious patient harm.”

Pitfall 5: Not all drugs can be delivered to a hub

Finally, there are logistical challenges in running a hub pharmacy. The NPA’s Mr Hewitson points out that the pharmaceutical companies operating the direct-to-pharmacy model will only deliver to branches. This could mean the hub is only able to dispense generics, which puts a further question mark over the model’s ability to generate efficiency savings.

This is a problem that could be resolved by a change in the system. But it’s a problem that the government needs to think about before rushing to hail the hub-and-spoke model as the future of pharmacy. As Mr Hewitson says, “there are more questions than anything else at the moment” over the system. And, before the sector can make a fundamental change to its way of working, these questions must be answered.

 


But there are benefits too...

1. Patient waiting times

Day Lewis’ Jay Patel says the hub-and-spoke model has proved useful in the company’s health centre pharmacies, which typically handle a high volume of prescriptions. Using the hub to handle some of the dispensing workload means the in-store team can process walk-in requests more quickly – a major plus for patients. “We believe if someone has waited half an hour to see a doctor, they don’t want to spend 15 minutes waiting in a pharmacy with a crying child,” Mr Patel points out.

2. Extra room

Stock-filled dispensaries can be squeezed for space, as Numark’s John D’Arcy can testify. “A typical pharmacy now is snowed under with scripts and some don’t even have space to manage the volume,” he says. For this reason, moving at least some stock to a hub can yield logistical benefits.

3. A greater focus on patient outcomes

At Mayberry Pharmacy, the hub dispenses 60-70% of all prescriptions. This leaves branch pharmacists more time to spend with patients, says Mr Mayberry. “This means we can concentrate on the patient and outcomes, and be proactive rather than reactive,” he explains.


 

 

More hub and spoke news...

Boots: 'Too early' for government focus on hub-and-spoke

NPA: Do not worship ‘false gods’ of hub-and-spoke

Hub and spoke: Where does pharmacy stand?

 

 

How would the hub-and-spoke model improve the way you work?

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12 Comments

Sami Khaderia, Non healthcare professional

Why not..all thats done is sticking a label on a bax

London Locum, Locum pharmacist

You're certainly not a friend to your fellow contractors. Your're like the magician who breaks ranks to tell the public that magic is all bull5h1t. Never popular that sort of behaviour.

R A, Community pharmacist

Given the difficulty these multiple operators have in understanding, how hub and spoke will save the government a fortune I will break it down for you:

1) Using industrial size dispensing robots will reduce the need for hiring dispensing staff/cover sickness pay/maternity/paternity cover/holiday pay and they will run 24 hours a day.

2) Under such setting it will also mean only hiring a handful of pharmacists to do clinical check on scripts leaving the dispensing check to be done by ACT.

3) This will remove the need for multiples to keep so many branches nationwide leading to a huge reduction of staff costs through redundancies of staff in branch/overheads for running a store and a very efficient hub model. 

Putting all these togather would save multiples a packet but they also know this government will adjust reimbursement to take this into consideration, which is why they are so hesitant.The only people who stand to lose out are the independents unless they form their own hubs like buying groups to compete with the big boys.

Personally I have no qualms pharmacy has become a very stressful and unrewarding profession it won't keep me up in the night if no work is available for me. I also think its poetic justice given how contractors have treated pharmacists and support staff alike its only right they face the music now. 

 

 

Bapi Patel, Work for a health/commissioning consultancy company

Did someone say a Pub in Stoke? That'd make far more sense!

I echo the sentiments in previous comments; this is a good blalaced article. Current moves are dogmatic and reflect the desperate blunderbuss approach of a group within this government that is fighting for economic credibility. Automation is here to stay but anyone with experience will tell you there are no substancial savings and most implementations are being carried out for other much more structured reasons.  

Pharmacists should be helping patients.  I think that the industry itself tacitly acknowledgs the need to commoditise dispensing - as far as safety allows - in order to concentrate on services.  But until there is a will and funding in place for services, and therefore an economic incentive, then Pharmacy is shackled and, apprently, is being excluded from participating the wider healthcare environment.

Sometimes the best way to save money is to invest; Trident or a health system fit for purpose? 6% = (ish) 1 military aircarft. (And before you start this is not a political comment just an observation...). 

Andy Beesley, Sales

Bapi,

The article would be balanced if more specific examples were examined. If this happened then it would be clearer that there are significant savings in the model.

As an example the article points to the progression of Lloyds from 1 hub in 2008 to substantial investment in the last few years. They only do this if they have proven there is a significant business case. It's also not in their interest to tell everyone the value as they want to be positioned to take advantage.

I also find it interesting the argument that says that we need additional services to make changes to improve our productivity. Are we saying Pharmacies are not embracing improvements in productivity and therefore save money as there is no new MAS?

Pillman Uk, Non Pharmacist Branch Manager

This is a good article that covers most aspects of the hub and spoke, although I am left pondering how the government thinks it will reduce costs.
In my experience where volume has been removed, more rxs or MDS have flooded in to the spoke, so no advantage there!
Also the robotics in hubs bring their own problems and requirements, so no dramatic staffing reductions. There usually are increases in safety and decreases in certain error rates, but the government are focusing on cost.

If we move all this volume to a central point and do the work for less money, what's left to fund the spokes and keep a reasonably paid pharmacist in there? Services currently are just lip service to the idea of pharmacy led services, CCGs are cutting costs on services rather than developing more at the moment.

I'm intrigued how this one will play out...

Harry Tolly, Pharmacist

"Five years ago, Mayberry Pharmacy opened a hub to relieve its branch teams from the pressure of dispensing. Since then, the model has flourished. " ........................................................... Maybe you need to pay these guys a visit to see why your experience is so different to theirs ? Was your experience with a big multiple or a smart small group independent ?? ............Just asking

David Kent, Community pharmacist

As a retired pharmacist I wish to be able to speak to the pharmacist that dispenses my Rx.  

Harry Tolly, Pharmacist

David, you and Alan did sterling work for independents when the then Tory Government tried to decimate small independents. Then, as now, its the PSNC that is the root cause of the problem. Our silver haired friend started the rot with the DoH many years ago and we are seeing the culmination of this only now. You and I know the history that most others here do not.

Angela Channing, Community pharmacist

Would there be a way for the PSNC to negotiate with the goverment to encourage multiples to consolidate and to try to protect independents in areas of need? 

Stephen Eggleston, Community pharmacist

While hub and spoke may benefit patients, the fact that services are being decommissioned at an alarming rate undermines the potential benefit

Harry Tolly, Pharmacist

Interesting that a small multiple has made a success of the hub model and yet the larger multiples (all CCA members by the way) allegedly have not. Hmmmmmm !! ............................................."But director Jay Patel says there is no saving on the dispensing cost." .............................. I suggest then that maybe Jay is doing something very badly wrong ?

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