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Hub and spoke 2.0

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Hub and spoke 2.0

The Government is again consulting on proposed changes to the Medicines Act and Human Medicines Regulations to enable all community pharmacies to access ‘hub and spoke’ dispensing. The aim, it says, is to support efficiencies for pharmacies and free up pharmacists and their teams for other tasks, such as providing clinical services to patients.

Hub and spoke dispensing is currently only possible when the hub pharmacy forms part of the same retail business as the spoke pharmacy. The new proposals would change legislation to enable the use of hub and spoke dispensing between pharmacies of different legal entities and also propose that dispensing doctors are allowed to act as spokes. Specifically, the proposals focus on two different models of hub and spoke dispensing:

Model 1, where the medicines are returned assembled from the hub to the spoke pharmacy before supply to the patient

Model 2, where the hub pharmacy supplies medicines directly to the patient.

Differing views

As this consultation has restarted the debate about hub and spoke, pharmacy organisations have restated their views.

From initially opposing hub and spoke in 2016, PSNC agreed to work with the Department of Health and Social Care (DHSC) and NHS England and NHS Improvement (NHSE&I) in 2019 to support changes to legislation to allow hub and spoke dispensing between different legal entities, on the basis that the models for NHS dispensing would allow both multiples and independents to benefit fairly.

Gordon Hockey, PSNC’s director, legal, says the negotiator “will be carefully considering” the proposals, as well as proposals for changes to the NHS pharmaceutical regulations, to make sure the models taken forward will “allow the whole sector to benefit fairly”. 

“For example,” says Mr Hockey, “we believe that the only appropriate model is for spoke pharmacies with NHS pharmacy contracts to supply medicines to patients, and not hubs. Distance selling pharmacies are available for remote supply of dispensed medicines, if that is what the patient chooses.” 

PSNC also points out that in its impact assessment for the Medicines and Medical Devices Act (the Act that provides the powers to make these changes), the DHSC recognised that the costs and benefits of hub and spoke dispensing remain uncertain for contractors, while the regulatory changes are permissive, and no contractor would be required to use them. With this in mind, Mr Hockey says PSNC is keen to ensure a level playing field for all contractors: “An actual level playing field, not simply a legal level playing field, for those who use hub and spoke and those who don’t.”

The Company Chemists’ Association (CCA) says it welcomes the consultation, but is calling for an evidence-based approach to the proposals because, in the experience of its members, hub and spoke “only delivers capacity benefits if there is additional investment to either move the workload to a hub, or fund additional activity in the spoke”. 

Its concern, says CEO Malcolm Harrison, is that there is not enough service income within the current flat national funding envelope to warrant a network of hubs across the country. “We estimate that locally commissioned services now account for less than 1 per cent of overall pharmacy funding,” he says.

Supporting services

The DHSC’s stance is that hub and spoke will save time at spokes for reinvestment in clinical services. Not everyone agrees.

The NPA has long been sceptical about some of the potential benefits, and maintains that hub and spoke has been used as cover for funding cuts. “It’s right to examine the idea 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,” says a spokesperson. “We also need more clinical services to be commissioned by the NHS to help build a business case which is fundamentally about
redeploying staff from assembly to clinical service based activity.”

Pharmacist Daniel Lee founded HubRx in February 2020 in a bid to get ahead of the hub and spoke curve by developing the UK’s first centralised automated pharmacy to enable independent pharmacy contractors to contract out up to 70 per cent of their dispensing workload. “We know that the appetite for more professionally and financially rewarding services is there among independent pharmacists as they look to transform the way they service their communities,” says Mr Lee, “and what hub and spoke does is allow them time to do that. 

“According to independent research commissioned by HubRx in 2021, lack of time is the biggest barrier preventing
43 per cent of independent pharmacies from extending their clinical services. So, by outsourcing the dispensing of some of their repeat and more straightforward dispensing via the hub, an independent pharmacy can free up valuable skilled time of pharmacists and technicians to take on more NHS commissioned and private services.” 

Another real-world example of freeing up clinical time comes from pharmacist Paul Mayberry, in his Mayberry Pharmacy branches in Wales. “Moving MDS to a robotic hub saves considerable time,” he says. But when it came to replacing a legacy PMR system with a cloud-based version of his own design called Pharmacy-X in order to send all non-MDS prescriptions to his hub robots, he got an unexpected result. 

“Using Pharmacy-X in the branches negates the need for a hub,” he says. ”The inefficiencies in the dispensary caused by the previous PMR was removed.”

At Pearl Chemist in Tooting, Mike Patel rejects the notion that automation ‘saves time’. He says his hub and spoke operation ‘creates time’ that can be spent with patients. “You want people to come to work to enjoy their job and effect change. They are able to talk to people, deliver services. They’re not wasting time with six, seven boxes of deliveries, or chasing manufacturers for certain goods.” 

Counting savings

While pharmacies will always need to hold stock for more complex, clinically urgent prescriptions, another proposed benefit of hub and spoke is that it could reduce overall stockholding in the system.

Mayberry Pharmacy has seen a £20,000 reduction in stock per branch on average, and HubRx has created a calculator that works out the potential savings that could be made by switching to a hub and spoke model. As well as savings passed on from higher volume purchasing margins at the hub, Mr Lee says the calculator takes into account “a £30k one-off capital release from stock that independents will no longer need to hold”. 

The NPA says its research suggests that, taking into account conflicting evidence on the size of the opportunity for stock reduction, and the risk of consequences relating to stock reduction, it is “appropriate to exercise caution in accepting this as a clear benefit of hub and spoke”

Reducing errors

Proponents of hub and spoke say that large scale automated dispensing will reduce dispensing errors. “Many claims for the patient safety benefits of large-scale automation have been made,” says the NPA, “but more rigorous independent research is required. “People often make the mistake of considering the safety of automated assembly in a hub in isolation, without considering the full end-to-end process.”

Independents with store automation have reported a reduction in errors, but for many it is not an option, for a variety of factors, including floor space and high set up costs. 

As it has done from the start, the debate continues to divide opinion. Even if the law changes, time and cost constraints may hinder many independents from implementing hub and spoke. You have until June 8 to respond to the Government’s consultation and share your views here.

Myth busting

Q: Will every pharmacy have to be part of hub and spoke dispensing if the new legislation is passed?

A: Indications are that regulations will make hub and spoke “permissible” for all pharmacies, but no pharmacy will be required to set up, use or offer hub services. 

Q: Will hub and spoke only work in pharmacies with automation?

A: While hub and spoke dispensing is associated with automated dispensing and may include this, it is not necessary. Hub and spoke dispensing may be possible between two or more pharmacies on a local level without any automation, and with assembly or part dispensing carried out manually. 

Q: Will hub and spoke mean pharmacies lose control of their own dispensing?

A: No, see above. Even where a pharmacy, once permitted, chooses to use a hub for prescription assembly, decisions as to which prescriptions are sent to the hub will be taken by the pharmacy.

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