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How electronic repeat dispensing was a 'saving grace' for one pharmacy

Emma Bisson set up a "drive-by" service for patients to collect items

A quiet, rural pharmacy in Devon shares how its team has fared during the COVID-19 pandemic so far

Electronic repeat dispensing has long been touted for its efficiency benefits, which were fully realised by Chagford Pharmacy when the COVID-19 pandemic hit.

A quiet pharmacy in a rural Devon town, the eponymously-named Chagford Pharmacy suddenly saw its phones ringing off the hook in March, its shelves bare of paracetamol and a noticeable increase in prescriptions to process – “definitely not double, but a lot more than normal,” pharmacy manager Emma Bisson tells C+D.

At the same time, an influx of students and elderly relatives returning to the county for lockdown meant dealing with a whole set of new customers and having to retrieve prescriptions from surgeries elsewhere.

But the pharmacy had done a lot of the legwork for its regular customers already.

“We have taken up electronic repeat dispensing in a massive way, so actually we have everyone’s prescriptions here and we [prepare them] all in advance,” says Ms Bisson. “That for us was a bit of a saving grace. Maybe that’s a good handle for other [pharmacies] to start doing it as well, because it really does help.”

A “drive-by” system

The pandemic also meant that Chagford Pharmacy adopted some temporary systems. With continued demand for over-the-counter products from people shielding and self-isolating, the pharmacy set up a “drive-by” service, where patients would order items from the pharmacy over the phone and pay online after collecting them – “just like a tab”. 

“We don’t have the facility to take payment over the phone, so they would come and get the goods, we would give the bank details and then check they’d paid,” Ms Bisson explains.

“Luckily, we know most people anyway here, but that took up a lot of time, as well as having to go around the [pharmacy] to do their shopping while on the phone to them.”

Before COVID-19, the pharmacy had never operated a delivery service, Ms Bisson adds. But when the national pandemic medicines delivery service was launched in April, the team had to adapt quickly.

They used the NHS volunteering service via the GoodSAM app to deliver the medicines, which Ms Bisson says has worked “incredibly well” on the occasions they’ve used it.

“The volunteers have all been amazing and local people that we know, which is quite nice because pharmacies have been worried about giving out medicines [in this way] and getting them to the right people,” she says.

HRT shortages

Medicine shortages have been more of a problem than usual for Chagford Pharmacy during the pandemic, with inhalers and paracetamol among the worst-affected items. The longstanding issues with hormone replacement therapy (HRT) products are also ongoing, Ms Bisson says, with many still unavailable.

“We’ve got quite a good relationship with our surgery and normally if something is out of stock, I would request an alternative and get it done for the patient.

“But, when it’s been really busy, I haven’t had the time to do that. I’ve had to send patients back to the surgery and get them to sort it out, which isn’t ideal.”

Counselling for pharmacy teams

Months on from when the UK lockdown came into force, the phone is still ringing. Chagford Pharmacy is starting to see an increase in footfall again as the restrictions ease, although overall the pharmacy is returning to its usual, quieter pace.

Sue Taylor, chief officer of Devon local pharmaceutical committee, says pharmacy demand is starting to get back to normal. Contractors are opening for regular contractual hours again, having made use of the flexibility offered by changes to the community pharmacy standard operating procedure.

But the burden placed on pharmacies in the early weeks of lockdown left staff “stressed, anxious and frightened”, Ms Taylor says, to the point that she was approached several times by contractors about access to counselling.

“We managed to secure access to the local NHS counselling support programme for our pharmacy teams, which was a real boost,” she says.

Temporary closures

The wellbeing of staff has been a key factor behind some temporary closures, Ms Taylor says, as pharmacies have struggled to get hold of adequate personal protective equipment (PPE). “I’m aware of some contractors that had to apply to close for one or two days to have the headspace and give the staff a bit of a break,” she explains.

One pharmacy had to close for a week after the pharmacist came into contact with a staff member at the adjacent GP practice who had tested positive for COVID-19, Ms Taylor says. This meant an emergency supply of repeat medicines had to be commissioned by NHS England locally, but the pharmacy was able to buddy with another nearby pharmacy and transfer the care of vulnerable patients.

“We’ve been fortunate not to have similar experiences across the county, but it emphasised the importance of having a robust business continuity plan in place,” she says.

Security guards

Abuse towards pharmacy staff has increased since March – a C+D survey published in May found almost two thirds (64%) of 859 respondents had experienced an increase in abuse from patients as a direct result of COVID-19.

Devon has not escaped the problem. Ms Taylor says the way people have behaved when their prescription wasn’t ready or there were stock shortages has been an issue. She has heard of one contractor who had to ban four patients from the pharmacy on the same day.

“Some contractors have also had to contract with security personnel to manage the queues outside. I don’t know if that’s still in place, but in the first couple of months people were having to employ security guards to help,” she says.

Looking ahead, Ms Taylor says contractors are starting to find out how they can get services like medicines use reviews and the new medicine service up and running again, but her anxieties about not being able to access PPE remain.

“There does seem to be a more streamlined approach [to PPE] now but I do know the cost is going up, and I’ve had independents in particular reporting that they are getting out-of-stock messages from their wholesalers again,” she adds.

Thankfully, back at Chagford Pharmacy this has been less of an issue. Ms Bisson says they’ve managed to make their initial stocks of PPE last and the installation of a Perspex screen early on helped to reassure staff.

“Everyone says, ‘oh, the pharmacists are brilliant’, which is really nice, but the counter staff are the frontline in this, and without they screens they are vulnerable.”

“Everyone has got their own families and their own worries about the risks [of COVID-19] and perhaps childcare issues, but our staff have been amazing,” she adds. “They just got on with it.”

3 Comments
Question: 
How has your pharmacy been affected by COVID-19?

Alexander The Great, Community pharmacist

Thanks for your long reply and suggestions. We have been running eRd for around 3 years, we do 14000 items per month. ITS VERY HARD WORK.

You can provide all the training you like, but people miss things, in my case my staff miss a lot of things because we are so busy. We employ around 13 people, open 100hours, and during the day we have 5-6 staff working at one time. We are not understaffed and we have more "quiet" periods to filing and paperwork.

We order scripts 1 week before its due date, yes you can iron out a lot of problems, but still it creates a lot of problems compared to the old days where you simply tick your order sheet and wait for prescriptions to come through.

We have fed PRN meds on eRD to the surgery, but they like to forget. Its too much effort to constantly harass them to cancel and change scripts.

Short dated scripts, we highlight the date if its due to expire within 3 months!! (because made up scripts can sit on our shelf for up to 3 months max). |And reorder new batches if its due to expire within a month.

I think if we were a quiet pharmacy doing 6000 items a month its great. For a busy pharmacy, its a nightmare.

Practice pharmacists, i dislike them. They take ALL the profitability away from the pharmacy. Branded generic prescribing. I know its the CCG pushing it, but thats where the profit in pharmacy is generated and they shouldnt be messing with it. Everything should be prescribed generically.

I have disliked eRD from day one because its shifted more responsbility and work on to the pharmacy. More costs involved in printer toner and drums, processing downloads, filing them away and ordering scripts. This is a pharmacy owners perspective.

Alexander The Great, Community pharmacist

I tell you the downsides of this system. People come in and want it straight away. Then you tell them its 2 working days. They argue and want it there and then cos the drs told them the rx is here. Then one day, you use the last batch of repeats, and they want it, but cant have it, its the weekend and they have run out of medicines.

Then Drs like to put acute items like painkillers and inhalers on with tablets that are 28 days. Then sometimes the patient wants 1 of the items out of the 3 on the rx, 2 weeks later they come back and want the other 2, too late, rx submitted. Have to use the next one, have to explain to the dr why we need the next batch early, they dont believe you and it takes 2 weeks to get a new rx.

Then we have to look out for expiry dates. It runs out after 12 months from prescribing. Your staff dont notice this, we dispense it, they collect it a week later, but it has just expired, and you only notice this when you go and submit the rx at the end of the night. Mmmm was it an illegal supply that I just made? UH OH.

So all your patients get put on repeat dispensing, you have to find somewhere to store THOUSANDS of bits of paper. Your daily download is MASSIVE cos hundreds come in everyday that you have to sort out... did we order this? did the patient order this? we already have a batch of RDs for this patient that hasnt expired, why has the dr given a new batch that is exactly the same???

Your staff mistakenly files away 6 of 6 in the patients wallet after they submitted it. The patient comes in to collect their script, you go to type it up and oops, its been used. Uh oh. No rx.

The ONLY saving grace is when people are genuinely forgetful and ran out of their medicines and we have a rx ready. Apart from that, the drs surgery has literally passed the buck onto us and we have to process every single order. Instead of just writing an order out or ticking repeats, we have to check against all the rxs we hold in the pharmacy, adding TONS of work to a busy pharmacy.

SAY NO TO ELECTRONIC REPEAT DISPENSING!

,

Thanks for taking the time to comment on the eRD story, and sorry that you have haven't had a good experience with it. I do think that it is important for us all to recognise that community pharmacies differ in many ways, and the systems that we adapt are unique to each one. For our pharmacy, eRD works really well (80% of our total Rx items) because we prepare our prescriptions and iron out any problems in advance, avoiding the examples of conflicts you have listed. It also makes our life easier in terms of workload management and stock levels.

We have been running RD for quite a while now so our patients are very well trained! They know when to collect prescriptions via verbal and written info that we supply after each collection. They especially know when they have to renew their batch as we have several reminders in place. I think patients would literally hit the roof if we went back to the 'normal dispensing' .....and so would I! 

Collaboration with prescribers is of course key in all this. We have daily communication with our surgeries (via email) who are very supportive because, of course, this system benefits them too.  You make a very valid point about acute/inappropriate/PRN meds going on RDs. This doesnt work, but could you feed this back to the surgery? I know its an extra thing to do in a busy day, but perhaps a quick email to the practice manager/practice pharmacist might save a lot of hassle in the longrun. We  actually do have PRN items on eRD (if pt is stable) but I request that it goes on a separate RA so pt can request adhoc compared to the rest of their meds.

The RD script expiring after 12 months could be a problem, as you say, if it slips through the net. We have overcome this by staff training and flagging short dated scripts the month before. Also making sure the patient starts their RD 1 asap rather than waiting until a previous set of batches has finished. Practice pharmacists are a good option to helping synchronise prescriptions.

Paperwork wise, we use drawers rather than folders. Because we work in advance, the morning download batches get filed rather than being dispensed, a job that is delegated each morning.

So in summary, yes there can issues, but there are also solutions which can be worked through collaboratively to create a really successful service. 

Emma Bisson

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