Hub and spoke: a new reality

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Hub and spoke: a new reality

The first thing you notice is how quiet it is. We’re in the excavated basement of Pearl Chemist Group’s pharmacy on Mitcham Road in Tooting, South West London. Along one wall, a 15m long by 3.4m high Omnicell Robotic Dispensing System (RDS) is sorting and storing a recent delivery and picking items for prescriptions. 

Around the middle of the room, Centred Solutions FlowRx technology takes over. FlowRx Connect software takes information from Pearl’s Proscript Connect PMR from any of the group’s 20 pharmacies across South London to drive the RDS, which picks items for up to 30 prescriptions at once. The medication is placed in a tote and one of the members of staff driving the whole system on the day of my visit adds packs of around 120 fast moving lines as the rest comes off the RDS conveyor. 

Next up is the FlowRx Hub automated labelling unit (ALU). Picked medication is taken from the tote and placed on the ALU conveyor, from where it is scanned and labelled for the correct patient at a rate of 25 packs per minute. As the packs emerge from the labelling unit, another operator sorts the packs into patient-specific baskets on RFID (radio frequency identification) LED Smart Shelves. 

When the shelf lights change to green, a prescription order is complete and the basket moves to the next station. Amber lights identify baskets that need clearing by a pharmacist or accredited checking technician. A prescription query thrown up at any stage of the process may need to be sorted out, or an item that is missing from the basket because it cannot be processed by the ALU labelled and added, before the basket can be moved on to the packing station. 

Finally, the Autobag presents an open plastic bag – the label is printed directly onto it by scanning the basket – and packs are individually scanned again into it, before the operator presses the release bar and the bag is sealed and cut. The patient medication bags are then sorted into store-specific totes – by the time you read this, that element of the process will also be barcode-driven. It’s the last bit of the process to be implemented at Pearl using Centred Solutions’ modular and scaleable system. Orders are normally accepted up to 4pm but can be accommodated up to 6pm. Full totes are delivered to spoke branches the following morning in one of Pearl’s seven, soon to be electric, vans. 

“Once the pharmacist has clinically checked it, the barcode scanning technology is there for the teams to manage an order all the way through to bagging."

The slick, multiple check system – I counted no fewer than seven separate barcode or RFID-driven checks on individual packs of medicines (there may be more) – has some neat touches. The labelling unit will label a pack square, regardless of the angle the pack is put on the conveyor, as long as it’s the right way up. Once assigned to a tote, items for a batch of prescriptions are processed randomly, and come back together as complete prescription orders on the Smart Shelves. Packs that should not be in a particular tote are ignored by the labeller and can be investigated as a result, although given the checks in place, this is likely to happen rarely.

It’s an impressive set up. When you take into account all the different types of technology being used, including six figures on the ceiling, it represents an investment of close to three quarters of a million pounds. It feels like the future. Unsurprisingly, Pearl Chemist Group director and superintendent pharmacist Mayank (‘Mike’) Patel is delighted with the result. “We try to be very cautious, but the investment we have put into this is a lot of money, but it will pay off.” 

The hub currently dispenses around 60 per cent of the prescription items for all 20 pharmacies in the Group. The operation currently runs 9am to 7pm, Monday to Friday, with a split lunch break. It’s running at between 30 and 50 per cent, producing around 18,000 packs a week for 3,500 patients, giving plenty of scope for ramping up. “We are future proofed,” Mike says. “From what I’ve been told, the Omnicell machine is the largest retail pharmacy robot at the moment, though there are a couple of hospital sites which have a bigger double unit.” 

Pearl has a blister packing hub, using an Omnicell VBM, on another site; Mike says that’s a more labour-intensive operation. Five people are occupied there full time supporting thousands of patients across the Group’s pharmacies. With the automation, the pharmacy group has been able to support nearby St George’s Hospital with a blister pack service supporting patients on discharge among other services. 

1. The Omnicell robot sorts and stores a delivery (top) 2. Items for up to 30 prescriptions at a time from any of Pearl's 20 pharmacies roll off the conveyor and into a tote (above) 3. FlowRx Connect software collects information from Pearl's PMR and batches the prescription information for each tote (below) 4. Fast moving items are added manually (bottom)

Automation journey

Mike says the company first got into automation five or six years ago, with blister packs. “We started with a manual process – one of the branches was having problems so we decided to offsite it, saw the benefit, started looking at machines and then took the plunge with our first VBM.” 

Pearl now has three of the small footprint machines on the same site. “It does the job really well,” says Mike. “We saw the benefit and the time released for staff. Dispensing is always going to be there. Before automation, it used to be 70 per cent dispensing and 30 per cent retail. Then the volume of dispensing increased that to 80/20, then 90/10. Now we have put automation in place and have freed up staff time for other services, in some places we are now 50/50, in some 60 retail/40 dispensing and even 70/30, and I’m including private services in that.

“It’s now about making our footprint work for us. We need to use our consultation rooms; we try to have two when we do a refit because it’s going to get busier. If we can create revenue from that, we can pay for other things.”

He says that now, with the hub in the Tooting pharmacy, he’s seeing an extra benefit in centralising purchasing, reducing the number of deliveries to branches, which means fewer people dealing with daily deliveries as well as fewer invoices and less cash tied up in stock. “Don’t get me wrong,” he says. “I love two deliveries a day, but environmentally, is that the friendly way of delivering?” He says he’s approached one supplier about once a day deliveries; they want a trial. “Most delivery vans in the afternoon carry a lot of air,” Mike says. “What’s the point? We have to make a change.” It means branch staff have more time to spend with patients too. 

Two standalone machines in branches will also shortly be retired as redundant, but Mike does plan on installing another element of the Centred Solutions technology – FlowRx InStore, which runs on the same principle as the software driving the hub. “Once the pharmacist has clinically checked it, the barcode scanning technology is there for the teams to manage an order all the way through to bagging. Only if there is an issue will the pharmacist be involved, so they are free to do other things. Freeing up the pharmacist’s time is key.”  

Mike has already said that his hub and spoke system improves stock management, but what about that other bone of contention – does it save time. “It depends on how you say it,” he says. “At branch level, a hub and spoke model creates time you can spend with patients. It’s a cycle. Prior to automation staff are running at 100 miles an hour. When we put automation in place they slow down as they get used to new ways of working. They run at about 50 miles an hour. The focus then is to support them to get back to up 80 miles an hour by introducing new services and work practices.” 

It’s an interesting way of looking at it. “You’ll never want to get back to 100 miles an hour because it becomes unsafe and quality and patient care can be impacted. The staff need to work hard doing different and enjoyable things,” says Mike. “You want people to come to work to enjoy the job and effect change. You want a happy work environment. So you want that 80 per cent, but at the same time they will be able to talk to people, deliver services. It creates that capacity. 

“Avanie, my sister-in-law, works in one of the branches. Two days after we put hub and spoke into her branch, she told me they had one or two boxes of stock coming in where before they had six or seven. They put that stock away in 10 minutes and can start doing everything else they need to do. Time isn’t being wasted. We are managing stock in the hub, so instore they aren’t having to worry about trying to chase certain goods.” 

He adds that dealing with manufacturers and quotas is now his biggest problem. “They don’t care about my operation. They’ll do it for larger organisations, but try and have a conversation with them and it’s ‘no’.” He does single out Viatris, however. “They’re brilliant, they get it.” As for the others, the problem still has to be resolved at branch level, even though Mike says the system gives him the exact pack a patient receives down to “the expiry date, the unique serial number and everything”. He hopes to solve the issue in time with a Wholesale Dealers’ Licence.

Original location for the hub  

Pearl started in this very location, in 2001. “Vijay, my brother, started it, then I joined,” says Mike. “It’s slowly grown over time, branch by branch.” The brothers – Vijay has always led on the financial aspects of the business while Mike has taken care of operations – added to the original ground floor pharmacy unit as neighbouring premises became available, while the group as a whole expanded. 

The space has now undergone a total redevelopment. As well as the hub and spoke operation in the basement, the refitted community pharmacy boasts a suite of consultation rooms for use by the eight to 10-strong pharmacy team and external healthcare providers, offices and a training space, as well as a novel environmentally-friendly feature wall of moss above the pharmacy counter. 

“When we got to a critical mass, we said, okay, we need to look at what we do and how we set up,” explains Mike. “At first, we didn’t think about hub and spoke – even dispensing for your other branches was not a thing. The solid model was dispense in the branch and serve the patient that way. But our contract has changed into a more service-driven contract. And if you look at it over time, we’re very good at services, but then you still have that dispensing workload, which pays the bills. 

“How do you do both? You have to spend money to be able to do something you are going to get rewarded for at a later stage. Yes, any automation is a massive investment, whether it’s the blister pack side or the full pack side, but rewards will come over time and hopefully it is now starting to pay off.”

Pearl has been able to improve its services – Mike says the team are doing a “cracking job” with the hypertension service, NMS is going really well too. The group is in a better place as a result. “We’re not one of those groups that has grown really quickly. It’s taken us 20 years to get to where we are; every step is considered. 

"It’s not about getting rid of people. It’s about retraining them to do something different or redeploying them doing something else they enjoy."

“We think of it as a family business still. Every single person is important to my business. If I mess up on something, I’m actually affecting their life and their family’s lives. Me and Vijay have a big ethos about family. Everything we do has to be considered, and we think about them as well. I could say we are going to cut staff in branches because remuneration has been cut, but that puts more pressure on them, and their families. It’s a vicious circle. So, how do we do things in the right way?”

Mike says automation has sped up the growth of the business. “Now, when we bring a branch on, we’re not stressed,” he explains. We used to take four months to bed a branch in. But when you put automation in day one, it’s doing 70 per cent of the work for you and the team feel less pressure and they’re more receptive to change. And you’ve got the systems in place to implement change better.”  

5. Medication from a tote is placed on the FloxRx Hub automated labelling unit (ALU) conveyor in any order (top) 6. The ALU links the pack back to the prescription data and labels at a rate of up to 25 packs per minute (above) 7. Labelled packs are scanned and sorted into patient-specific baskets on Smart Shelves (below) 8. Items for manual labelling are dealt with before the packing station (bottom)

Driven by family ethos

Pearl Chemist Group’s 20 pharmacies are located across South West London and out into Surrey, employing around 150 people (or, as Mike puts it, there are 150 families he feels a responsibility towards). Pearl bought its most recent pharmacy, in Cobham, Surrey, in February. “The minute we put hub and spoke in for blister packs and normal dispensing, the pharmacist said ‘now I can really do what I want to do. I’m a pharmacist; I want to spend time with patients. And he gets to do that now. He’s got a good dispenser and he’s spending more time in consultation with patients, effecting change in their lives, which is the important bit.”

Mike says he and his brother are very visible. “We’re on the ground,” he says. “It may be crazy, but we’ve got this real ethos that if I can’t do a job, I don’t expect somebody else to do it. So if that means mopping the floor, I’ll mop the floor. If they need me to dispense, I’ll dispense, because that’s what they need me to do at that particular moment, which is going to help them. And I need to know how to do everything as well. I’ll do shifts, deliveries. You name it, I’ll do it.”

Many of the staff have been with the business long-term. He mentions hub and spoke operator Afran. “He started with us 2001, 2002. He came from Sri Lanka, didn’t speak a word of English, started on our photo counter. He then said he wanted to work somewhere else, so he became a dispenser, then an accredited checking technician in the pharmacy upstairs. When we had this role as a manager for hub and spoke in the basement, he was the perfect fit because he had been with us so long. He knows how we work and he knows how much support he will get. It’s about developing people and taking them with you rather than leaving them behind. And he’s brilliant at it, running this place now.

“Everyone is suffering from workforce challenges, but we’ve got a really good team that we support really well. For example, we provide private medical insurance to all our staff, so we don’t treat pharmacists differently to other people. Pharmacists do tend to stay with us longer; we’ve got pharmacists whose branches we took over who have never left.”

He says, however, that independent prescribing (IP) is changing the conversation. “All pharmacists want to do IP. It’s great. I want them to do IP. The problem is: where is the role for IP pharmacists in community? What can we develop that keeps these pharmacists where they are? I’ve talked to a lot of pharmacists who work in GP surgeries, and they’re wanting to come back now, because they feel isolated. They’re not meeting people. Yes, they’re talking to patients, but they’re not really using their skills as a pharmacist. How do we bring those skills back into community pharmacy?

“We have to use the whole workforce. It’s not just about pharmacists. We’ve got really good team members. We’re running phlebotomy training at the moment. We’re training all our pharmacists and one or two key members in each branch to be phlebotomists. When the pharmacist is busy providing clinical care, these kinds of things can be done by other people. 

“The national protocol for flu was the perfect example. We trained about 50 non-pharmacists to deliver the service across the group. It was brilliant. A pharmacist told me: ‘I do the clinical bits, the consenting, but I don’t think I’ve adminstered a vaccine in three months.’ The staff actually do better than the pharmacists, because they go through everything so well. They appreciate it and it’s rewarding helping people get to where they want to get to.” Mike says Covid has prompted people to care more about their health and they want to look after themselves more; increasing numbers are willing to pay. “GPs are overwhelmed,” he says, “and there is so much more we can do.” 

Mike is chair of Merton, Sutton & Wandsworth LPC, where CEO Amit Patel has been working with TympahHealth on microsuction for ear wax. “We’re going to be doing a pilot trial in South West London, in 20 pharmacies. Hopefully, we’ll be part of that, but we’ve already signed up to TympahHealth as a private service, so we’re going to be doing that anyway. We’re inviting staff to sign up to get trained.” 

He says that sort of service resonates because “you are effecting change. In a normal pharmacy, we dispense medication, we give them a bag, we give them the advice and then they go off. You’re not seeing change there and then; that’ll happen weeks and months down the line.” 

Travel clinics are another example. “Travel advice isn’t just about giving vaccines; it’s about educating people and providing support. If it’s young travellers, it’s about asking them: ‘Have you thought about your safety? Have you been on the Foreign Office website to check what’s going on in that country? How are you going to communicate with family regularly, telling them where you’re going?’ Little things. Advising them to have the local consulate number in their phone, things like that. When people think travel advice, they don’t think about this stuff. It’s a holistic approach.”

9. Packs are scanned into an open plastic bag presented by the Autobag, which is labelled with the patient's details captured by scanning the basket (top) 10. Capacity and workflow across the system can be monitored at any time by its three or four operators. Pearl's set up is not yet running at full capacity and could be doubled again by adding a second FlowRx Hub (above)

What’s next for time created?

Mike’s been on the front foot for as long as I’ve known him. His LPC role provides insight into what might be coming down the tracks, but he’s never been afraid of thinking outside the box. “The future is in services, and that means looking at the horizon,” he says. “We’re going to be doing phlebotomy, micro-suction. I think pharmacogenomics is going to be massive. How do we make that work? For example, using targeted cancer drugs will mean you get better results and fewer side effects. This is not about saving money, it’s about providing a better service.” 

Meanwhile, Pearl’s small operations team has appointed someone to a human resources role. “Even with 150 people, pre-Covid, we could deal with the employment stuff, but recruitment is now a massive issue,” says Mike. “Everyone wants a portfolio career, so how do we build that portfolio career into everyone’s life?” Pearl has a package with St George’s which provides for cross-sector training, and Pearl’s pre-registration trainees are hosted by the Trust on their inhouse training days. “They can see what the hospital side is like,” he says.

Tourist destination

Mike is now used to a steady trickle of visitors keen to see his operation and take a view for themselves. “Once people see it, they understand it,” he says. “I’ve had people ringing me up, asking me: when you put the robot in, how many people did you get rid of? It’s not about getting rid of people. It’s about retraining them to do something different or redeploying them doing something else they enjoy. 

“I do spend time thinking ‘what can we do better?’ I think you have to enjoy life. When I was a kid, my grandpa always used to get me to read ‘Laughter is the best medicine’ in The Reader’s Digest. When you go to work, you want to be happy. You want to have a good laugh, because at times you spend more time with your work family than you do with your real family. So you have a really good balance.

“I sometimes go and sit in a branch and watch what’s going on. What can I do to make a change that is going to help make their lives easier? The simplest change I’ve ever made was a toilet in a pharmacy we took over,” he says. “Because nobody wanted to go to it. If you give staff a really nice fit out, they appreciate it more. It’s the smile you bring to a person’s face; that makes the difference.”

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