It is often said that the Chinese word for crisis is made up of characters for “danger” and “changing point”, the latter usually translated as “opportunity”, and never has this been truer for community pharmacy than with the current danger and opportunity presented by the coronavirus. The COVID-19 pandemic may not have made community pharmacy more skilful or more relevant than it is already, but it has demonstrated our skills and relevance to patients, public, parliamentarians and commissioners alike. This has resulted in development and relaxation of policies and guidance that, if continued beyond lockdown, will enhance and develop the profession.

Firstly, there has been increased recognition and acceptance of Pharmacy as an integral part of the NHS. Although GPs are also independent contractors they have always been assumed by public and parliament to be working directly for the NHS, but in this time of national support and pride in healthcare teams, pharmacies have now also been acknowledged as key workers. As well as continued child care provision, advanced Coronavirus testing, and primary access to food shopping, more important and fundamental recognition has come by way of confirmation that all pharmacy team members are covered by the Assaults on Emergency Workers Act 2018, entitlement to the death in service pay out through inclusion within the COVID-19 Life Assurance Scheme, and the precedent of an enhanced payment from NHS England for Bank Holiday opening.

Secondly there has been increased recognition and acceptance of the professional capability of pharmacists. Generally greater discretion for professional accountability was encouraged by the General Pharmaceutical Council (GPhC) who emphasised that professional judgment is acceptable and encouraged; for example splitting bulk packs of paracetamol to enable OTC sale, determining missing details from prescriptions including controlled drug prescriptions, and the repurposing of medicines. Practical support for such extending responsibility also came as insurers confirmed enhanced clinical negligence indemnity in response to coronavirus.

Finally, there are aspects that encompass both the previous points but that specifically expedite work and activity. These include the presumption of consent to view patient demographic information on Summary Care Record in order to identify shielding status, removal of the need for face to face vaccination training, and provision for the emergency supply of controlled drugs – either as an extension of the Severe Shortage Protocols (SSP), at the request of a patient, or varying the frequency of instalment prescriptions.

Such national health emergencies are very often the proverbial Burning Platform that delivers change, as evidenced with the Swine Flu epidemic in 2009 that saw the duration of treatment that could be made under an Emergency Supply increase from five to 30 days. Importantly, this change was not rescinded once the H1N1 virus had settled into background levels of transmission. Pharmacy must hope that this year’s battle colours awarded us in the fight against coronavirus continue to proudly fly, and that being a more fully integrated part of the NHS and treated as the capable clinical professionals that we are will continue and develop beyond the current pandemic.

By a CCG Assistant Director and Head of Pharmacy & Medicines Optimisation

During the Covid-19 epidemic, some pharmacy staff (e.g. including all staff in this CCG) have moved to 100% working from home.
Staying in contact with staff and within teams can be done using software such as Microsoft teams, Zoom, Facetime or Webinar interfaces to enable meetings to be managed from home. These systems use similar interfaces to those we are familiar with seeing on our TVs on news, current affairs and comedy programmes. They enable people to speak in turn and for each member to have a video view of each participant, which gives us access to some body language of each participant. Most interfaces also enable documents to be shared.

Advantages of home working
There are a large number of social advantages for the worker and employer. Home working reduces time spent commuting, and money spent on cars, parking and fuel. Reduced use of fossil fuels is becoming essential as our world resource use outstrips regeneration.

Home working gives you time and space to concentrate and allows you to plan your day effectively in advance. It is especially useful where a job needs complete concentration, since it can reduce the interruptions and distractions found in a traditional office environment.

Issues with home working
The available IT infrastructure of the organisation needs to support the use of the technology. Some computers may need additional capabilities such as extended memory & a camera view. Malware/virus scanners need to be robust enough to perform their essential functions but not be so robust that they prevent access to essential software. This is particularly pertinent in big NHS organisations where the flexibility to use new software may be determined by the IT department, not the user. I have found working between different organisations can require persistence to get the right interface working in each place
Home internet signals need to be robust. Without a robust signal, meetings may need to be curtailed or sections can be missed.
Very large meetings require the use of both a computer with camera and a phone concurrently – to enable functionality for larger teams to call in together so that the software is not overwhelmed. There is also a need to train staff how to get the best from the technology, which is not time-consuming but should not be overlooked.
Personal Contact. Working from home every day we have all missed the social contact and corridor chats with colleagues where relationships are built and soft information is gained. It is especially difficult to build new relationships or to be inducted into a new team remotely.
Finally, there has to be a high level of trust in staff for working from home to be feasible.

Conclusion
Overall, one beneficial effect of this terrible epidemic is that, where you have suitable work to undertaken, working from home for a portion of your week could become usual practice in the UK. In a results-driven environment, having the choice to periodically work from home in the future should improve productivity and has benefits for both the employee and their manager.

I was invited to speak at the Association for Prescribers’ Annual Conference last November. Being of a bolshie disposition, I chose to ask whether our prescribing is really patient-centred. Of course, we’ll all say it is, but when you look at some of the prescribing policies that commissioners seek to introduce you have to wonder whether the patient’s needs are coming second to the organisation’s priorities, particularly to keep saving money.

There is no pot of gold, but on the other hand pharmacy has met savings targets over and over again when other functions within CCGs have come nowhere near doing so. If the pips are not squeaking it may be because they have already been fully crushed.

Couple this with regular comments from patients in practice satisfaction surveys that they no longer feel that they have a personal GP, and you might wonder who is looking out for the patient. Patient advocacy groups complain that they are not listened to, local government complains that it sees no action from its comments, and the one potentially consistent voice the patient has is their pharmacist.

So how do pharmacists rise to this challenge and influence others to advocate for their patients? This is exactly the kind of practical question that we will be addressing in the 14th series of PM Academy meetings starting at the end of April. You can book your place at www.pmhealthcare.co.uk/events.

What is a sea view worth? According to a holiday brochure just received, the answer seems to be £6.44 a night, because the supplement for an ocean view cabin for a 9 night cruise of the Greek islands is £58. On the other hand, it’s also £58 for 5 nights in the Norwegian fjords, so presumably the Norwegian coast is 1.8 times as desirable. Whether that is actually the case depends on whether our assessment of the value of these experiences tallies with the cruise companies. If it is, we’ll pay the extra. If we think it isn’t, we don’t. As a tall person, I don’t often think the extra legroom seats are good value on short flights, but there’s a price I am willing to pay on long ones. Even then, I draw the line at paying an extra £150 each way, but I’ve paid £60.

This is an example of the difficulty of comparing the value of benefits when they are not expressed in cash, and it is a major problem for healthcare, because when we make business cases for interventions we commonly have to reduce everything to money and pose the question “Is this a good use of resources?” This process might work if judgements were objective, but often they are not. For example, the value of saving the sight of an eye depends upon whether it is the first or second eye. Should we be prepared to spend more on treating the hand of a concert pianist than a roadmender?

The standard NHS approach is to use Quality Adjusted Life Years, or QALYs. This a good attempt to reflect that extending a life is less valuable to some than others, but it has limitations. There are some people whose quality of life is so bad that they would objectively be better off dead; that is, a QALY value <0. And back in 1987 John Harris pointed to a concern about the way in which we use QALYs that he called the double jeopardy. His argument was that if someone is disabled such that they will never again have a QALY of 1, they will be disadvantaged in any resource allocation based on QALYs because they can never benefit as much as the rest of us, although a move from 0.2 to 0.3 may make more of a difference to those patients than a move from 0.7 to 0.9 in others. The counter argument is that we should be rating the expected improvement of an intervention regardless of prior impairment and comparing it with other interventions on the same basis, so the starting point of any particular patient is irrelevant. And the counter argument to that is that if the entire class of patients requiring a particular intervention are starting from a low base it may be that no intervention for them will pass the benefits threshold that sees them introduced.

In the next series of the PM Academy we’ll be looking influencing decision making. This is not just about influencing the things that affect us personally. How we demonstrate value in the things that we care about and do is also an issue.

NHS England has set a target for the uptake of biosimilars. In order to save £200-300m p.a the aim is that at least 90% of new patients will be prescribed the best value biological medicine within 3 months of launch of a biosimilar medicine, and at least 80% of existing patients within 12 months, or sooner if possible. That is a fairly challenging target for many health economies.

The difficulty that immediately springs to mind is that the users of the originator drug may have no real incentive to switch. They’re happy with what they’ve got. They’re reimbursed for what they use, so they have no financial incentive. And from the quality point of view, they know the characteristics of the treatment they’re using, whereas there may be a little question mark in their minds as to whether the new product will prove to be as satisfactory in practice as it has apparently been in clinical trials.

So how does the commissioner encourage change? One or two commissioners may decide simply to tell providers what they expect them to do, or to use financial penalties if they do not switch promptly. However, there may be good clinical or service reasons why an abrupt change is unwise.

This is just one of the questions we will be addressing at our Biosimilars conference on 1st November. You’ve never had an opportunity like this to discuss the introduction of biosimilars with all stakeholders present. We’re working with UKCPA, the British Oncology Pharmacy Association (BOPA) and Rheumatology Pharmacists UK to make this a day to remember. Come and be part of it.

Agenda and booking at https://www.pmhealthcare.co.uk/events/2017/11/biosimilars-how-will-pharmacy-manage-the-challenge