The Big Debate

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Big Debate #4 – Could a hub-and-spoke model ever truly work for independent pharmacies?

Started 3 months ago

Good evening everyone and welcome to our fourth Big Debate. Tonight we’ll be asking whether independent pharmacies can ever truly benefit from a hub-and-spoke dispensing model.


It’s been the subject of years of intense debate within the sector, but with the Medicines and Medical Devices bill receiving royal assent in early February – potentially paving the way for all community pharmacies to operate a hub-and-spoke dispensing model, regardless of whether they are part of a chain or an independent – hub-and-spoke looks set towards being rolled out across the sector.


So, what is the current legal framework? What can we learn from pharmacies already utilising hub-and-spoke? And how do we ensure that patient safety is at the forefront of any model adopted sector-wide?


Let us know your thoughts by commenting below. The debate will formally close at 8pm, but feel free to continue the debate for as long as you like.

And we're off!


Thanks everyone who is tuned in to join this Big Debate on hub-and-spoke dispensing - especially on an incredibly busy day.


Noel, I wondered if you wouldn't mind starting things by outlining the legal situation regarding hub-and-spoke and what the Medicines and Medical Devices Act 2021 means in practice?

Yes no problem.  At the moment the law on hub and spoke dispensing only allows it to be carried out by pharmacies owned by the same legal entity – so it is not permitted for Company A to assemble a medicinal product on behalf of Company B which supplies the product to the patient.  That restriction is contained in the Medicines Act 1968 and so can only be changed by amending the Medicines Act itself.  Now that the Medicines and Medical Devices Act 2021 is in force, it will be easier for the Government to change the restrictions on hub and spoke dispensing, for example to allow assembly to be carried out by Company A for supply to the patient by Company B.  The Department of Health has indicated that it intends to consult on changes to the law this year.

So, essentially the government has the powers to change the law and implement the model, but a public consultation will determine what that looks like in practice? 

Yes that's right - the Government will consult on proposed changes, will consider the comments made and then decide on what changes to implement.  The process is likely to take several months.

Mike, I know you've been back and forth on the use of the dispensing model - what was the turning point, as it were, when you decided pursue opening up the hub-and-spoke opportunities for independent pharmacies?


Evening Grace,


Are you happy about where community pharmacy is today? 



I’m not either. 



There are threats on multiple fronts: Amazon, funding, changing needs of the public, indifference of the NHS, I could go on and on. We can spend our lives paralysed by fear of being ‘done to’, or we could embrace change as something positive and try to forge a better world. Technology isn’t going anywhere and anyone who wants to bury their head in the sand will soon find the rest of themselves buried alongside. 



I’ve spent 6 years looking at Hub & Spoke and led the NPA’s research programme in 2016 which concluded quite rightly at the time that there were questions which needed to be resolved. But things have changed. For a start we have the fixed-cost contract, which gives us both the breathing space to look at new models, but also the incentive to try and innovate or else we could find that we get swamped with increasing costs.



HubRx is looking to set out some really positive responses to those unanswered questions from 2016. We want to make Hub & Spoke work for independents, we have no conflict of interest, owning no pharmacies of our own, and no wholesaler. We want to enable all independents to benefit from the opportunities of large scale automation: sharing any purchase margin gain directly with you the customer, rather than your competitors. 



For me personally I am looking at Hub & Spoke as an opportunity to invent an entirely different business model: built around clinical care, excellent service and new technology. Am I relying on NHS England for this? Emphatically, NO! But I will be reflecting what my community needs and wants, and looking for opportunities for local service development, private services and expanding our scope of practice. I’m fed up of being ‘done to’ and want to be in control of my own future, Hub & Spoke is a tool, like any other to achieve that goal.  

"I’m fed up of being ‘done to’ and want to be in control of my own future." Think that's a pretty fair want for your business and career :)


It's really interesting to see how and why your views have changed over the years, Mike.



We've also got Paul Mayberry on the chat this evening. Paul, you've become a bit of a poster boy, I suppose, for an independent group using the hub-and-spoke model. In your view, what benefits does the dispensing model offer independents? Should indies be wary of anything, in your experience?

Hi Mike, sounds like a very positive innovation and I agree with a lot of what your saying.


Could you expand a little on the positive responses to 'those unanswered questions from 2016'? What were they? and how have they been answered?


Thank you


Jon

I started hub and spoke 12 years ago. Its not as easy as it sounds


But even with out H&S life could be easier in the pharmacy


Innovation in Community pharmacy has been stifled for too long by the PMR suppliers. They decide how the work flows through the dispensary, and their workflows haven’t changed in years.


They want to control the development of new initiatives such as Prescription Ordering apps or Delivery apps and make it difficult and/or too expensive for 3rd parties to integrate with their systems.


 


I want a dispensary management system that reconciles prescriptions when I receive them, order missing items that were expected automatically, allows me to only need to clinically check a prescription if its new or if something changes, rather than having to view every prescription every time.


 


I want a system that can control my stock accurately and order from the best value suppliers without me having to think about it


 


I want my dispensing integrated with my deliveries and route planner for my vans, and the ability to text a patient when their prescription is ready to collect.


 


If a dispensary management system did that, I would be able to save so much time I wouldn’t need Hub & Spoke

A PMR that reduces the need for pharmacists to clinical check, and for labels to be produced after barcode scanning the products would be safer and deliver the benefits that some think would be enjoyed used a H&S model


That's really interesting, Paul. Do you think that if, hypothetically, a script management system like the one you're describing existed you'd stop using a hub-and-spoke model?

Hi Jonathan, One of the big questions from 2016 was about the risk of Hub & Spoke only being possible for the large vertically integrated operators. There were concerns that this would lead to manipulation of margin and a more lop-sided playing field than the 'level playing field' everyone says they want. The HubRx model for me was a game changer - no wholesale conflict of interest.  


When I started off looking at this subject I aimed to follow the evidence, I was never opposed to the concept as such, but had concerns about the potential implementation. 

I'm also interested to hear from any contractors that use H&S dispensing systems here - Paul included - on how COVID has affected things for you this year. One of the benefits of H&S is that it frees up pharmacists' time for clinical services, but obviously those haven't necessarily been as easy to complete this year because of social distancing, etc. So have you continued to see the benefits of H&S over the past year?

I have been able to develop what I've described for use in my pharmacies. I could because I practice in Wales and therefore I haven't had to go through the onerous process of connecting to the Spine.


We send the easy prescriptions to the Hub - a prescription that only contains full packs - and can be labelled using barcode scanning


More difficult prescriptions are kept in the branch



I don't know that I would start H&S now, if i didn't already have a robot in the Hub


Probably also a good opportunity to hear from Gareth Jones at the NPA at this point. 



Gareth, I know the NPA has been concerned about the potential impact on patient safety, reduced competition and a possible rise in medicines prices.



Do Paul's suggestions above sound like ways to avoid some of these concerns?

Thanks Mike. And great point Paul- a PMR system that could do this, and there is no reason why it couldn't, would be a gamechanger. I haven't used or seen it but some colleagues have been raving about the TITAN system freeing up time

Luckily Beth, we have Darryl Dethick from PCT Healthcare online:


Darryl, does PCT Healthcare currently adopt a hub-and-spoke model? What has your experience been with it?


As an independent group of almost 150 community pharmacies we’ve been investigating the benefits and risks associated with hub & spoke dispensing across our estate for a while, and have had an original pack manual hub up and running for almost 12 months, servicing a small number of our busier pharmacies.  We plan to continue to roll this out further over the coming months.  Additionally, we have just set up an MDS hub to start taking MDS production into an automated solution.  Our hope is to free up time in the pharmacies so that they can spend more of their time with their patients and focus on service delivery.  However, for this to be truly successful we need to have a range of funded services available to better use their pharmacists skills and enable better patient outcomes to be delivered.  We see this as a great opportunity for community pharmacy to free up some capacity, whilst being able to maintain true face to face patient contact and help serve patients best in their local community pharmacy.

During Covid we were concerned that staff members may catch Covid and have to isolate, or even that a branch would have to close. So we started to run 2 shifts in the hub. The staff of each shift never met and so couldn't cross contaminate each other. If one shift got infected, the other could carry on. Neither team are patient facing and so were less likely to be infected by a patient coming in to the pharmacy

Hi Jonathan, yes Titan is a big step in the right direction. They do encourage 3rd parties to integrate with them

The NPA remains very sceptical about some of the grander claims made for hub and spoke dispensing. It’s right to explore the proposition that hub and spoke could release time in pharmacies for patient-facing care.  But there may be other ways to achieve this which should be given just as much attention, such as investing in automation within the local pharmacy itself.


One danger of hub and spoke is by overestimating the likely benefits and continuing to use overblown cost saving calculations, government can wrongly justify cuts to pharmacy funding. 


The other big danger, of inter-pharmacy hub and spoke, is reinforcing the unhealthy dominance that some wholesalers have in their relationship with independent pharmacies. If we are going to deal with the competition issues we need to create a vibrant hub market - with all hubs able to access all medicines. 


If government does believe that hub and spoke has a future, it needs to do more to ensure that independents have the opportunity to engage with it on a level playing field with the larger companies. And it needs to create the clinical service opportunities so that pharmacists can use the time released from dispensing to generate revenue in other ways. 

Hi Gareth - totally agree about the clinical service opportunities.  We've been promised lots for a long time, but not much has been forthcoming so far.  But as dispensing income is squeezed we need to do something to try to manage costs as well as maintain safety and customer service

That sound sensible, Paul.



And a great point, Darryl. For the government to see pharmacy get the benefits of H&S that it purports, ie more time for patient-facing care, it's going to need to commission those services!

Interesting Darryl. It seems a lot of pharmacies are testing the H&S waters with MDS first.


What measure are you using to justify rolling the model out to more branches? 

Exactly Gareth, using technology within the dispensary to make efficiencies releases the pharmacists to take advantage of that time to embrace the perceived benefits of H&S without the drawbacks


There are also issues about potential liability - both in terms of professional accountability for an error and financial liability if the patient suffers harm.  We would need clarity around both of these to give the pharmacy owners, pharmacists and staff reassurance, I think.  It's one thing enabling hub and spoke through legislative change, but another thing to think through all of the potential consequences

Hi Grace - particularly for MDS, a lot comes down to efficiency.  The automated MDS processes are generally a lot more efficient, and processing MDS in bulk centrally gives other benefits too.  As branch volumes increase we review workload, and in some area's it's harder to recruit so using the hub, even temporarily, really helps the branches manage their workload.

We've used the time to help non-adherent patients. We try to identify patients who aren't coming in for their medicines regularly enough and spend time with them to help them get the most from their medication, either by educating them or offering them MDS (robotically dispensed, obviously!)


Adherent patients should be control their chronic condition better, which in turn leads to less complications later. They live a healthier, happier, longer life. Better for the, cheaper for the NHS and dispense more prescriptions . Everybody wins.......

Paul, that's fine, if you can afford the capital investment, and have the physical space to accommodate. Lots of pharmacies don't have one or both. 

We've grown original pack hub & spoke work over the last few months too, and this really helps the branches manage spikes in workload - particularly at times like this, running up to Bank Holidays

cheaper for the NHS and WE dispense more prescriptions . Everybody wins....

We agree with Noel about the liability issues. A hub and spoke process is so much more complicated that standard dispensing. It is a challenge even within single corporate entities, and even more problematic when the law changes to allow the hub and the spoke to be in different legal entities. It is not an insurmountable problem - but it will require a lot of work to ensure that we have a safe process and clarity about professional accountability. 

I think we have to be more careful in England Paul! For me this is about the capacity and business model changes than it is about cost savings. 

Yes Mike, I spend a fortune every year on my PMR which isn't fit for purpose. I better designed PMR gives me efficiencies without the need to invest in new premises or robot. Gaining the benefits of H&S without H&S.


Does anyone have any thoughts on what patients think about all this?  For, against or indifferent?

Gareth - I think in general the accuracy levels coming out of hubs is generally higher than that of standard dispensing in branch, partly down to the automation and partly down to the fact that they are solely working on dispensing without other interruptions.  Agree there are issues that need to be clarified and some clear lines of accountability though

Yes Mike. All the time that my staff waste following the procedures forced on us by the PMR suppliers. The double handling of adding information to the Ordering app software at the beginning of the process, and then adding it again to our Delivery app software goes. ACTs no longer need to check full boxes of barcode scanned products. 


All this time saving with improved safety means our capacity had also increased dramatically. As well as cost savings

Noel - our experience so far shows that 95%+ of patients really aren't that bothered, as long as they get their prescription when they need it and everything is as they want.  We've only had the very odd one ask for work to not be sent to a hub

Noel, I don't think the patient minds either way as long as they get their medicines in a timely manner. But we've  seen that there can be delays when the Big Boys use H&S, and they don't like that

Paul, how long was it before you realised the cost-saving benefits?

When we introduced H&S 12 years ago, we paid for the robot just by reducing our stock holding over 7 branches



There was no improvement in Purchasing margins as we are part of Cambrian Alliance, hardly any reduction in staff time as staff moved from the branches in to the hub. But we did increase our capacity and delivered more paid for services


Yes that's what I anticipated - that it's not their main priority.   If patients are indifferent and find the hub and spoke service convenient, I wonder if there is any concern amongst community pharmacies that the might lose "their" patients to the hub eventually?  In a normal commercial setting you would try to reduce that risk by having a non-compete or non-solicitation clause so that the hub supplier is prevented from "taking" the patient and dealing directly with them.  That isn't possible for NHS supplies as there is no property in a patient.  Is this a concern for contractors do you think?

I guess it comes back to what Mike was saying about having the capital investment and space for a lot of pharmacies.


The Medicines and Medical Devices Bill also included proposals to allow large pharmacy chains with automated hubs to charge smaller chains and independent pharmacies “prescription assembly services”.


What do you make of this suggestion? Or does that defeat the point of trying to create a level playing field?

Interesting, Darryl, that patients don't seem to mind whether their meds have been dispensed via H&S or not. Did the patients who didn't want their meds to be dispensed that way give you a reason?

On the point about safety, I think it is likely that the hub, as with any form of automation, can reduce picking errors. What we really need to see is the end to end safety data which accounts for any new errors that this more complex process could introduce.


With regard to patients, I think the key issue will be transparency. If you are transferring their data to another company and their medicines will be dispensed offsite - they need to be told. 


 

The trouble was we were still using a PMR that didn't help us, and most of the work still needed doing in the branch.


I had under estimated how much time it takes to order prescriptions, reconcile them , send them toi the hub, reconcile them back from the hub and then hand out to the patients


And all the tricky prescriptions were still done in branch

Hi Beth - the general theme was that they wanted their prescription dispensed in their usual pharmacy by their usual team, as that was what they were most comfortable with.  One key thing we take out of this is the key benefit of bricks and mortar community pharmacy and the real value the face to face contact gives to the patients

You're right Noel. I don't know of any pharmacist who would be happy to send their prescription data to Boots or Lloyds for them to dispense. How do you stop them putting a flyer in their delivery from Echo?

Noel makes a very valid point about hubs taking business away from spokes. Choosing a hub will be an incredibly important business decision - you will want to know that their commercial terms are fair, that their professional processes are reliable and that they will not try to circumvent your relationship with your patient. Pharmacies will need to address these points in a robust contract with their preferred hub. And again this is why a vibrant hub market will be essential. 

Gareth and Paul - totally agree with this, and that's the main reason we decided to start our own.  If we have all our eggs in one basket this seems to be a huge risk - therefore I agree that a vibrant hub market will be beneficial

I agree Darryl. Community Pharmacy is all about the patients and nothing beats that face to face contact. The threat comes from companies like Pharmacy2U if they can work out how to deliver a prescription directly to a patient profitably 

Paul, those are legitimate concerns about partnering with a competitor, but the prescription will always rest with the Spoke pharmacy. Would you even have to send the patient's address to the Hub? If it is all going back to the Spoke pharmacy why would you need to? The message architecture could help to overcome some of these concerns? 

Yes Mike. HubRx is definitely a better option than your wholesaler


 

Paul - Pharmacy2U can't get my antibiotics to me to start taking today, but they shouldn't expect that the local community pharmacy to just pick up the odd acute here and there and still survive.  That could be really risky for the health of the population in general.  A well run community pharmacy, supported by efficiencies through things like hub & spoke, and the local face to face contact has to be a much better proposition?

Mike - that's a fair point but I suppose it depends what the hub is doing.  If it carrying out the clinical check and entering information on the PMR then they would need the patient details?

Thank you all for your really interesting contributions.


I'm now signing off this "live" element of the discussion, but the thread is available for people to catch up on. Please feel free to carry on the conversation or dip back in at a later date.


My takeaway: Gareth is right that rolling out H&S that is fit for the whole sector will require a lot of work, but we've been having this debate for over a decade now and I can imagine the various 'task and finish' groups around this are pretty rowdy places with plenty of valid concerns that need to be addressed. 


I wonder how close are we to a model actually being implemented, even with the government's new legal powers?


Thanks again

Agree Darryl, this time last year the NHS were very concerned that very vulnerable people would be going without food and their prescription medicines. But thousands of community pharmacies through out the country were able to step up and deliver medicines to all those that needed them. Putting a high percentage of Prescription volume through a few wholesaler run hubs may not have coped

Clinical check stays in the spoke for me. That's where the clinical relationship is. They need a data set to assemble the order, but they don't need all the data. The Spoke will be the Data Controller. The Hub a Data Processor. Can GDPR be used to reduce the risks of malfeasance? 

Hi Grace, 


I wanted to add my personal experience to this debate. I am superintendent pharmacist for a small chain of pharmacies by the name of Wellbeing Pharmacy. We have recently started a Hub & Spoke services for two of our pharmacies.  Our main purpose of adopting this model was lack of space in the pharmacy for providing services to care-homes. 


But since we have started to use this model, it has turned out to be very helpful in maintaining a balance of work in our branches. Yes, it is true that the staff cost has been increased but it will be cost effective since we would be able to recruit more care-homes. 


I have read different opinions about Hub & Spoke  model in this debate but I think every individual speaks from their own experience.  Looking at the current circumstances in our pharmacy business ..I cannot see any hope of winning unless we adopt ourselves to the new changes.  I pray for the betterment of our profession (at least our profession was acknowledged during this pandemic by the government)  



Mohsin Raza 

Thank you very much for contributing Mohsin and interesting to see your motivations behind adopting a hub-and-spoke model. Glad to hear that you're seeing the benefits too.


There was also an interesting back-and-forth on Twitter, with one locum pharmacist saying that he "loved" the dispensing model, so definitely comes down to an individual's experience with it:


https://twitter.com/pharming247/status/1388895919995826180?s=20