In a previous post, we noted how a hub and spoke model for community pharmacy had been promoted on the basis of a limited safety case. The hub and spoke model that was described was one in which items would be assembled at a hub site that would serve a number of dispensing sites, such as community pharmacies. Although the hub and spoke model has been used by a number of companies, changes to the law were required to allow community pharmacies to buy access to hub services from a company other than their own.
It appears though that the case for hub and spoke is limited, in terms of its financial case, and also with regard to the ease with which the proposed legislative changes could be made. Perhaps unsurprisingly, on the 7th June 2016, the then Minister for Pharmacy, Alistair Burt announced that plans to allow hub services to be open to all community pharmacy contractors were abandoned for the time being. This was originally due to have been enacted on the 1st October, 2016, but has now been delayed following a consultation with community pharmacy and their representative bodies.
The reluctance of community pharmacy to engage with the provision of hub pharmacy services by another party might be partly based on the business case. Although the hub and spoke model has been proposed as a means of reducing costs in community pharmacies, there is limited evidence of financial benefits. For the large and small community pharmacy chains using hub and spoke dispensing, the numbers of community pharmacy branches, the spokes of the service, remain unchanged, as does staffing, as pharmacy technicians move from the spokes to the hub. The limited effect on the numbers of community pharmacy branches reflects the recognition that between 40% and 70% of pharmaceutical medicines would have to be assembled at spokes even with a hub dispensing service in operation.
In our reflection on the safety gains associated with hub and spoke dispensing we noted that the pliability inherent in the present community pharmacy system supported improved safety and suggested a need to maintain the status quo. In a recent article for Chemist and Druggist, Noel Wardle, a solicitor for Charles Russell Speechlys described some of the legal factors that would support the maintenance of the status quo. In this case, the rigidity of the legal constraints that define the borders of a sociotechnical system’s operation would also lead to pressure in support of the status quo.
For Wardle, there were three legal issues that needed to be addressed. Firstly, there was the question of where legal liability lay in the hub and spoke system, and the consequences of this for creating a more efficient service. Secondly, the requirements embodied in the European Union’s Falsified Medicines Directive, due to be completed in 2019, would demand that a check of the identity of a medicinal pack is conducted at the point of dispensing, which appears incompatible with a hub and spoke model. Thirdly, and potentially most problematic is the need to comply with the Data Protection Act. Any clinical review of the prescription conducted at a hub, will require explicit consent from the patient to access either the patient’s centrally held NHS Summary Care Record (SCR), or the record of medicines held on the spoke community pharmacy’s computerised Patient Medication Record.
Clearly, there is pliability in these systems, although gaining sufficient pliability to move towards hub and spoke dispensing takes time. In the case of the primary care solution for the electronic transmission of prescriptions, the Electronic Prescription Service (EPS), it has taken considerable time to bring into scope all pharmaceutical products, controlled drugs proving the most resistant legally, and to enable community pharmacy to access SCR, the latter requiring technological workarounds to provide access to this. However, such change does take considerable time, in the case of EPS over a decade since conception to the delivery of the final service.
The Chemist and Druggist news article on Dr. Keith Ridge’s advocacy for hub and spoke dispensing across English community pharmacy can be found here. Analysis of Dr Ridge’s claims over expected hub dispensing volumes, again from Chemist and Druggist can be found here, whilst another article recounting practical experiences of hub and spoke dispensing can be found here. The announcement by Pharmacy Minister Alistair Burt on the delay to the change in the law to allow hub and spoke dispensing across the whole community pharmacy estate can be found here. Finally, Noel Wardle’s description of the legal problems associated with the use of hub and spoke dispensing can be found here.