It’s life…but not as we know it.

A view from North Wales

At the start of 2020, no one could have predicted the impact that COVID-19 would have on the world. Almost overnight, the pharmacy teams across Betsi Cadwaladr University Health Board have adapted to working differently to manage the crisis. Presented below are some changes already implemented. We need to reflect after the worst is over, keep what works and let go of what does not. When we look back, will we see it as the turning point of how BCUHB pharmacy services are delivered?

Community Pharmacy

Repeat dispensing has been rolled out to help pharmacies and GPs to manage their workload and provide a more resilient system for surges in demand. Mobile phones are being used for dedicated ‘healthcare professional lines’ and local collaboration has led to new ways of sharing patient information securely. Community pharmacy has increasingly been recognised as a vital part of the wider NHS family, e.g. with COVID 19 testing and PPE provision.

GP practice working

At the start of the COVID-19 pandemic the GP practice pharmacy teams focussed on the supply of medication to patients by increasing batch prescriptions to ensure access to medicines without causing shortages. More patients have been encouraged to use My Health Online ordering system to negate the need to travel to their pharmacy or GP to order medication. With social distancing being difficult in some of the smaller GP practices, the pharmacy teams have delivered some services remotely such as medication reviews, telephone consultations, and giving advice on medication issues. NMP pharmacists have been able to support queries and acute requests in GP practices, which has allowed the GPs to concentrate on the red hubs and local assessment centres.  We are also training our pharmacy technicians to undertake POC INR testing.

Community Hospitals

As beds have increased and the patient type has become more complex we have had to re-train pharmacy staff to undertake the role of supporting community hospitals. This has involved staff being trained in aseptic non-touch technique to support nursing staff in preparing intravenous injections. It has also been necessary to develop ways to support community hospitals remotely.

Pharmacy Technical Services

Technical services has adapted to provide aseptically prepared products to meet new demand. The service has prepared over 3000 doses of ready to administer injectable medicines, saving valuable nursing time. The use of a new automated syringe-filling device has significantly helped to meet this demand along with redeployment of current and recently retired staff. In order to maintain social distancing, there has been centralisation of some aspects of the service onto one site and shift working has been introduced. Looking towards the future, improved scheduling of chemotherapy, provision of aseptic products to critical care and utilisation of the syringe filler will all be carried forward.

Medicines Procurement

Medicine procurement has been a critical function during the pandemic to ensure the right medicine reaches the right patient at the right time. The supply chain for medicines has been under extreme fragility with the demand for critical care medicines unprecedented. Our pharmacy procurement teams built on existing working relationships to work collaboratively at regional and national level to ensure extensive and responsive medicines procurement. Our collaborative and mutual working with Health Courier Service Wales (HCSW) and national pharmacy teams has transformed access to medicines across Wales with the provision of an alternative logistic solution for distributing critical medicines to the greater area of need.

Medication Safety

The safety lead pharmacists and medicines management nurses have produced a ward guide for a range of gravity-administered medicines to allow removal of pumps from acute wards for reallocation to critical care units. This followed a stocktake in BCUHB early in the pandemic, which identified a shortfall to meet the anticipated demand with minimal chance of receiving an additional supply due to international demand. Existing IV administration-training programmes were adapted and a rapid training cascade put in place. This ward guidance for gravity or bolus injection will continue to offer a safe alternative for low risk medicines.

Clinical pharmacy service

Shift working has been introduced to provide a 7-day week service as well as to manage potential staff illness and limit the viral spread.  Pharmacy staff have been equipped with the basic knowledge and skills to look after critically ill COVID-19 patients utilising UKCPA, RPS and other resources, which have been made available on a BCUHB pharmacy website that all staff can access. Technician support has been introduced to critical care areas to track critical medicines and carry out stock top-ups ensuring that procurement and medicine supply is responsive to needs of patients.

The front line in Wales

Principality Nightingale

I look out from the hospitality suite over the Stadium pitch, an array of temporary structures housing 1200 hospital beds, where once I witnessed Wales beating Ireland to carry off the Grand Slam – surreal!

Over the past few weeks, our team has worked hard with colleagues across the Health Board to create this “surge capacity” “field hospital”, both phrases a part of our new vocabulary. The forecast demand for beds to provide care for patients infected with Coronavirus means it’s all hands on deck. We must expand critical care capacity, converting theatre and recovery spaces and considering how we provide cover with knowledgeable and skilled pharmacy staff to contribute to the multi-professional team; an exponential learning curve, navigated at breakneck speed.

Responsive, flexible and patient-focussed – claims we all shared previously but now taking on a whole new meaning at this weird and challenging time. Adjusting ward stock lists, learning how to “don” and “doff” personal protective equipment, working out how best to deliver patient-facing pharmacy services whilst minimising the risk of viral transmission, supporting implementation of new treatments and clinical trials, managing the fragile supply chain of critical care medicines and getting palliative and end of life medicines to care home patients in need. Learning at pace and responding to the demands of daily changes while the wider world learns about shielding, social distancing and catching up with loved ones via Facetime.

Proud to be part of the NHS and of the pharmacy professions, with a clarity of purpose and unique contribution to patient care, our focus is safe, effective and appropriate use of medicines. As changes came thick and fast, we had to ensure that all our staff had the resilience and support to fully utilise their skills and work with MDT colleagues. Pressures of patient numbers at ward level were felt quickly and required a review of service provision. Early expansion of opening hours, especially at weekends, were positively supported by staff across all teams.

Building on a collaborative working culture across the NHS, we established positive sharing of solutions to common challenges and problems. Acceptance of the principle of mutual aid allowed us to maintain essential medicines supplies across healthcare organisational boundaries. Within pharmacy, specialists from procurement, technical and clinical services came together to apply their individual and team expertise for patient benefit. With strong and effective leadership, adapting to virtual meetings using Zoom and Skype, we minimised duplication of effort, developing and sharing standard operating procedures.

Working across primary and community care, with medical, nursing and paramedic colleagues, we learned how best to ensure patients (and their carers) who needed timely access to palliative care medicines, got them. The experience of military personnel in delivering logistics solutions allowed us to map and establish systems to supply the medicines for optimal end of life symptom management, across urban and rural locations.

A learning culture has ensured we have responded at a local and national level, to maintain and develop responsive and patient-focussed pharmacy services. “Every day is a school day” but who can have expected that in 2020, all our schools would close but our learning on all other fronts would accelerate.

Hiding in plain sight – a view from Scotland

May 2020 and Scotland embarked on its first tentative steps out of lockdown. In March, as Covid-19 paralysed the globe, the First Minister announced that we were in the midst of a global pandemic unlike anything we had ever seen before. In line with the rest of the United Kingdom, Government advice is clear; ‘stay home, save lives’. On reading this back it still feels strange somehow, despite living and breathing Covid19 for the past 12 weeks.

The NHS moved rapidly to implement Command and Control Structure, activating major incident plans and business continuity plans. NHS Boards continued to deliver pharmacy services to meet population need across community pharmacy, pharmacotherapy services and acute pharmacy against a challenging background of service retraction and redesign across other independent contractors and managed services.

Locally, acute hospitals mobilised staff and resources to discharge patients in order to free up beds for the expected surge in Covid19 cases. In the community, dental practices closed and GPs turned increasingly to telephone triage, video consultation with limited face to face appointments. NHS Pharmacy teams were deployed to support colleagues and critical services in care homes, community hospitals and hospital at home.  Meanwhile, isolated and alone on high streets and in communities, pharmacies remained open for patients and the public. As the last remaining source of health advice and support available for face to face consultation, community pharmacy teams wrestled with social distancing, with 94% unable to maintain social distancing of two metres (PJ May 2020) and confusion over guidance on the wearing, and availability of PPE. Perspex screens were rapidly installed to protect staff and patients as systems of ‘one in, one out’ were implemented.

Queues formed outside pharmacies as demand for medicines and repeat prescriptions rose dramatically. As anxiety levels increased, tempers frayed with episodes of public disorder and in some cases violence and threats to pharmacists and staff. Police increased visibility and patrols close to pharmacy premises and contacted pharmacies offering guidance and local contact numbers; support welcomed and much needed.  Social distancing and limited space within community pharmacy and across the NHS will mean we will be learning and adapting practice for some considerable time.  

The introduction of ‘Test and Protect’ brings specific risks to service delivery, especially in community pharmacy as there is the potential to lead to all members of the team at risk from exposure being required to self-isolate for 14 days which could result in closures. Although the detail is still being discussed and worked through this has the potential to impact significantly, particularly on communities who rely on a single pharmacy.  

Community Pharmacy teams have shown exemplary resilience during Covid-19, while I and my colleagues in NHS Boards have worked in partnership to support pharmacy networks through prioritised retraction of non-core services, changes to working arrangements and opening hours and extensive guidance and support.

As we adjust to a new, uncertain normal, I am humbled by all the key workers in the NHS, in social care, those in carer roles in care homes and in care at home and the emergency services and in retail, transport etc. Volunteers and deployed staff have worked with us selflessly collecting prescriptions and delivering medication to those in the shielded categories, vulnerable and those self-isolating with no family and friends locally to assist – THANK YOU.

It is now crucial that we take much needed time to rest, (note to self, start using that annual leave), recuperate and use this once in a lifetime opportunity to re-imagine delivery of services. There is no going back to the old ways. Decision making has been flexible, agile and rapid and rightly so – why would we revert back?

As I reflect personally and professionally on the most challenging 3-month episode of my 32 year career in Pharmacy, I would like to commend my profession and colleagues for their resilience, flexibility and generosity of spirit. Huge thanks to teams working tirelessly in the NHS and in the 1,258 pharmacies across Scotland who made sure your Grandparents, your children, your parents and friends could continue to access essential, life saving medicines and clinical services. So to the pharmacists, pharmacy technicians and an array of pharmacy support workers – we owe a huge debt of gratitude. No longer, to coin a phrase, are we ‘hiding in plain sight’, we are forefront and centre, right in the midst of healthcare in Scotland and, I must say, rightly so.

What has Covid-19 meant for hospital pharmacy?

The immediate impact of the COVID-19 pandemic required all the pharmacy team to be deployed to support acute services. Many of the changes implemented have either remained in place or have provided a legacy that will continue to influence the way in which pharmacy will function going forward.

The most significant impact has been the investment in Information Technology that the organisation supported. For pharmacy this enabled a faster roll out of mobile technology at patient level (wards and outpatient settings) which ironically, we had been attempting to implement for several years but funding had been a barrier to success.

The teams now have a sufficient number of devices to be able to work almost paper free which has improved efficiencies through easier access to patient results and other relevant notes and information resources.

The organisation also rolled out Microsoft Teams. The majority of meetings continue to be held virtually. This not only reduces the need to travel but also has facilitated improvements in communication as it possible to hold more frequent and targeted meetings. Over time it is intended that meetings will be a combination of virtual and face to face as the latter does allow discussions before and after and allow some informal dissection of decisions over coffee or strolling to the car park.

A number of staff continue to work from home due to shielding or social distancing requirements in the workplace. It is intended that home working will continue but likely to be on a rotated basis where possible to allow for social interaction in the workplace and the positive impact this has on mental health and wellbeing.

The need to ensure appropriate social distancing has resulted in the introduction of staggered start and finish times as well as staggered breaks. The different start and finish times have been maintained but in a way that reflects service needs so pharmacy has the right person in the right place at the right time.

The majority of outpatient clinics were suspended in response to COVID-19. There are a number of pharmacy led clinics and these were redesigned so that where possible patients were reviewed remotely, and discussions were completed by phone. The team is currently reviewing the use of virtual clinic packages and the intention is to continue to operate clinics in a combination of face to face and virtual settings.

Finally, working relationships both within and with main stakeholders have improved. This includes multidisciplinary working with clinical leads (most notably with critical care) and their teams as well as better understanding of working practices across the whole pharmacy team.

Managing Staff and Patient Safety in a Time of Covid-19

A view from Northern Ireland

It all happened so fast.   A local TV journalist was almost punching the air with delight as he announced our first local Covid-19 case and it all kicked off.  It was a Thursday night and cynically I thought we’ve heard all this before; SARS, MERS, Swine Flu even Ziki Virus but this was somehow different and what that journalist did was tip the public over a cliff into a river of sheer panic.

Raising my pharmacy shutter at 9.00 am Friday a group of twenty swamped the pharmacy demanding hand-sanitizer.  Staff, still with their coats on, had to reassure that handwashing was best in this the “containment phase” of the disease. Over 200 visits before lunch-time were asking for the same product. 

Then over the weekend it got worse but we had no formal processes to follow.   A staff meeting was called for Monday morning and after repeating government directions on; (1) identifying symptoms of Covid-19 (raised temperature and new dry cough) and (2) stopping infection spread; washing hands, self-isolating and social distancing, I listened very carefully and respectfully to staff concerns.  It was so important at that time that their concerns were heard and where possible actioned.  Staff demanded face-masks, hand-sanitizer and a safe working environment.  We supplied masks but pointed out that, in low risk environments which ours was, masks were unnecessary and if used inappropriately might increase viral spread.  We could not access hand-sanitizer but I promised I would (and eventually did) get some but again pointed out that washing hands and a scheme/routine for surface cleaning was vital.  This routine was implemented immediately through a SOP.   

We agreed staff would communicate with line-managers on symptoms they or their family suffered.  This protocol was used the following Monday.  A staff member stayed at home suffering from a viral sore throat.  No temperature, no new cough.  I spoke to her by telephone and she agreed to return to work.   This was a difficult call and it would have been too easy to err on the side of caution and ask her to isolate.  Testing for pharmacy staff was four weeks away so I made a plan for business continuity should key members of staff fall ill.  This split staff into teams; one would take over if another team went down and we might even close a pharmacy and dispense from another site. 

Social distancing with customers was a major staff concern.   We placed tables at each pharmacy door and had a policy initially of only four at one time in the pharmacy at identified spots where they stayed until directed to move to the next spot.   We had no advice on this and were making it up as we went.  Four was then reduced to two and then eventually to one-in-one-out.   Shopping the shop stopped.  Our primary purpose was to maintain and sustain dispensing,  the supply of medicines and we focused on that.   We identified high use medicines and secured sufficient supply where possible.    We reduced the public opening hours; 10 am to 1.00 pm and 2.00 pm to 5.00 pm.  This was essential to reduce public contact but also to safely deal with the 30% increase in prescription activity that lasted for two weeks.  This put a huge strain on pharmacy processes.  

 GPs required pharmacies, designated by patients, to collect prescriptions and told patients to pick up the medicines at the pharmacy.  Contact with GPs was very difficult.  It took our CCG area two weeks to get GPs alternative numbers and give GPs pharmacies’ alternative numbers.  Again, there was no outside help and this was done locally by contractors using a WhatApp group in conjunction with the prescribing advisers network.  It made a huge difference but electronic scripts must now be implemented as this mayhem should never be allowed to happen again.  Patient safety was severely compromised. 

We collected brick-size batches of prescriptions from surgeries and struggled to safely assemble in reasonable time.  As patients had no access to surgeries, we had people visit perhaps six times over 48 hours looking for their medicines they were told we had.  We had so many assembled prescriptions awaiting collection we couldn’t easily find an individual patient’s and this further slowed the system.  We moved to putting collected scripts onto the PMR as “owed”, only assembling the medicines when the patient arrived and made this process easier. We worked so hard in those two weeks which ended with our first Covid-19 death announced by the same TV journalist but by then our new systems were beginning to work. No staff member isolated and no pharmacy had to close.   I am so grateful to, and so proud of, my staff and I sincerely hope they know my appreciation.