Written evidence submitted by Becton Dickinson (PHA0016)

Summary

In recent years, there has been increasing demand for pharmacy services in both secondary and primary care. This partly reflects the wider trend of increased demand for health services caused by an ageing and growing population as well as the ongoing impact of the Covid-19 pandemic. However, efforts to meet this wider demand trend by enhancing the role of pharmacy professionals and encouraging them to take a more active role in the delivery of clinical services has placed additional demands on the service.

There is a clear opportunity for the faster and more widespread adoption of proven digital and automation technologies that can alleviate the burden on pharmacy workers of undertaking routine and mundane tasks and allow them to concentrate on delivering high-value patient-facing services. These technologies can unlock new productivity and efficiency gains for the NHS and support the system in meeting the continuing rising demand for its services. Increasing use of automated solutions can release staff time not only for the pharmacy workforce but also for other health professionals such as nurses who also have a significant role administering medicines. However, more support is needed to enable the sector to acquire and implement this transformative technology.

We have several partners within the NHS who are using our technology to enhance their pharmacy services. BD would be delighted to invite the Committee to visit one of these sites to see first-hand how the technology is being used and the benefits it is already providing to the NHS today.

1. What does the future of pharmacy look like and how can the Government ensure this is realised?

1.1               The common theme across all aspects of future pharmacy services will be the increased use of technology to release staff time to deliver more high-value tasks and have more patient facing time. In all pharmacy sectors technology can help unlock new productivity and efficiency gains and improve patient safety standards.

1.2               In community pharmacy, this will mean delivering the core services of dispensing and supply of prescription medicines more efficiently to increase capacity for the delivery of more clinical services. In hospital pharmacy, where clinical services are more developed, it will further release staff to deliver high-value tasks that can support the delivery of high-quality clinical care. When deployed at ward level, automated technology will free up a substantial number of nursing staff by making the drug administration and ordering process much more efficient (see below), as well as freeing up pharmacy support staff for other tasks.

1.3               This will help support growing demand for healthcare services and allow pharmacists to take a much more active role in the care of patients. This shift is being supported by the changes in pharmacy education and training, which will mean that from 2026, all newly registered pharmacists in the UK will be able to independently prescribe medicines and therefore deliver more clinical care. It is likely the pharmacists of the future will have less interest in dispensing activities.

1.4               To support the move towards more clinically led services, the government needs to encourage the uptake of digital and automation technologies, that can support the storing and managing, dispensing, delivering and administration of medication – helping to unlock time for pharmacy professionals to concentrate on tasks that can add more value for patients and the NHS. Research has shown that over 50% of a pharmacist’s working time is spent on tasks considered to be non-value adding, such as for example, preparing prescriptions and documentation tasks.[1] Equally, Government could make the drug administration and ordering processes at ward level much more efficient for nursing staff through the deployment of automated medicines storage cabinets.

1.5               The move toward ‘hub and spoke’ dispensing is one way the government and NHS is making better use of technology to support the community pharmacy workforce and unlock efficiency savings. However, the full benefits will not be realised without the passing of legislation to enable the inter-company operating of hub and spokes. We welcome the government’s recent public consultation on this topic and support calls for legislation to be introduced to enable the hub and spoke model to flourish. Equally, recent legislative changes to facilitate original pack dispensing is welcome because it will facilitate automated processes and free up staff further. This should be implemented as soon as possible.

1.6               While hub and spoke dispensing in community pharmacy is correctly viewed as a potential driver of significant efficiency savings for the system, there remains considerable unlocked value in hospital pharmacy services, where faster and more widespread adoption of connected medication management (CMM) technology has the potential to transform workflows and release numerous benefits for the wider service.

1.7               CMM is a term used to describe several digital and automation technologies used in pharmacies and on wards, which, when used together, have the potential to create a closed-loop medication management system. For example, a hospital electronic prescribing can be fully integrated to the patient record system. The prescribing drives the ordering of medication from the hospital pharmacy. In the hospital pharmacy, automated technologies are used to store, dispense, and label medicines assigning unique barcodes that allow tracking of the medicine as it makes its journey through the hospital and can track use down to individual patients. This includes injections as well as oral medications, and controlled drugs.

1.8               At ward level, CMM uses secure, automated dispensing, and storage devices, linked to the patient record and administration system, to guide nurses to the medicines a patient is prescribed, speeding up the drug round, whilst the bar code system enables the nurse to confirm the right drug for the right patient. The patient’s medication record is updated accurately and automatically. Medicines stock levels at both pharmacy and ward levels are optimised, as is wastage. This ‘closed loop’ approach to medicines use is safer and more efficient. The data generated by the system enables the chief pharmacist and other clinical staff to have much greater visibility on medicines use and can also drive relevant planning and efficient procurement. Whilst this can apply to controlled drugs to some extent, there are practice barriers that need to be addressed. For example, a common understanding of what can and cannot be done legally would reduce variable approaches to the deployment of relevant technology and free up both pharmacy and nursing staff further. Consideration should also be given to any legislative changes that might also be necessary, for example making an electronic signature legal for controlled drugs prescriptions in hospitals.

1.9               In the future, the patient will continue to be managed within the connected system even once they have been discharged from hospital, with the technology supporting the long-term treatment and medication supply from community pharmacy.

2. What are the challenges in pharmacy workforce recruitment, training and retention, and how might these best be addressed?

2.1               Like many parts of the NHS there is a shortage of pharmacy professionals which is impacting in both hospital and community pharmacy services. In recent years, there have been several independent surveys indicating that the workforce has struggled to keep pace with growing demand for pharmacists’ clinical skills in hospitals and primary care, stretching pharmacists’ capacity, and impacting community pharmacy too.[2] Medicines are becoming more complex, such as CAR-T and genomic medicines which need different pharmaceutical skills and resources, and at the same time innovations such as virtual wards and the planned Pharmacy First service are placing additional demands on pharmacy professionals. The commitment in the NHS Workforce Plan to expand training places for pharmacists and to grow the number of pharmacy technicians is welcomed, but there need to be efforts to ensure that the existing and future workforce can be retained.

2.2               There is limited publicly available official NHS pharmacy services workforce data. To fully understand the scale of the problem there is a need for the collection and publication of more robust and transparent workforce data, which captures both vacancy rates and the profile of workers leaving and joining the service. This would help the sector better plan the workforce and devise long-term strategies that can ensure the workforce is fit for the future. We welcome the change in community pharmacy terms of service that have made Health Education England’s annual community pharmacy workforce survey mandatory but believe its success in delivering robust workforce data should be monitored to ensure it is positively impacting the planning of services.

2.3               A major contributor to the workforce shortage is burnout, with pharmacists reporting that they feel overworked and have a poor work-life balance, which can lead to workers reducing hours or moving sectors, creating shortages and pinch points within pharmacy services. This is highlighted by a survey conducted in 2020 by the Royal Pharmaceutical Society which found that 89% of the pharmacy workforce were at high risk of burnout.[3] The most recent NHS staff survey published in March 2022, reinforced the concerns about burnout as approximately 50% of all NHS staff – including pharmacists – reported they did not have a good work life balance.[4]

2.4               One way to address the risk of burnout could be to alleviate some of the routine and mundane tasks pharmacists and pharmacy technicians regularly undertake, which can contribute to low job satisfaction amongst these professionals. This makes it challenging to retain the current workforce, but also creates barriers to attracting people to the profession who may think other careers offer a more interesting and challenging work environment. For example, recent General Pharmaceutical Council workforce data showed that a high percentage (77%) of pharmacists were responsible for routine tasks such as managing medicine supply.[5] It is reasonable to expect that pharmacists who are prescribers are likely to want to use their clinical skills to undertake patient-focused tasks and will not want to spend large parts of their working day managing medicines supply. In addition, the introduction initiatives such as of the Pharmacy First service, allowing pharmacists to supply medicines for several common conditions, will need to be supported by better use of technology to ensure pharmacy professionals are able to respond to patient need.

2.5               Wider use of digital and automation technology can play a significant role in helping to address this challenge, by speeding up and automating many routine tasks for pharmacists and pharmacy technicians, helping to balance out or even reduce operational demands on pharmacy professionals and freeing them up to conduct more complex tasks that deliver greater patient benefit. It can also remove some time-consuming tasks altogether – for example 24/7 medicines collection from automated pick-up terminals can reduce the number of patients collecting medicine inside a pharmacy, delivering a better standard of service for patients, and enabling pharmacy staff to concentrate on delivering advanced clinical services.

2.6               There is evidence that pharmacies that are mature in their adoption of digital technology find it easier to attract and retain staff and that working with state-of-the-art technology helps attract younger people to the profession.

2.7               Technology has a role to play in workforce safety too, particularly in aseptic pharmacy units in hospitals, where staff are at risk of being exposed to hazardous substances when preparing and administering medicines. The Stop Cancer at Work campaign has highlighted the risk to healthcare workers of being exposed to hazardous materials such as carcinogenic, mutagenic and reprotoxic substances, all of which can impact the health and safety of health workers.[6] Technology such as closed-system transfer devices, can help prevent the escape of hazardous drug vapours into the environment, and contribute to a safer workplace for health professionals within pharmacies and on wards. The risks of exposure to hazardous substances were highlighted in Lord Carter’s 2020 review into aseptic pharmacy services, where he recommended a review of global evidence to the risks of exposure for health professionals.[7]

3. To what extent are digital systems used in pharmacy sufficiently interoperable with those in general practice and hospitals?

3.1               Increased interoperability between primary and secondary care is key to unlocking the full benefits of digital and automation technology in pharmacy services, by allowing data to move safely and securely between different organisations within a system. For NHS organisations, this can enable systems to manage their medicine inventory and spend across a much greater area, whilst also improving the patient experience as their records can be more easily shared between different organisations. More broadly, increased interoperability can enhance the system’s ability to deliver joined-up clinical services, as community pharmacists become digitally connected to other pharmacy sectors and the wider health eco-system.

3.2               In addition, it can help reduce pressures on the workforce, as staff moving within and between health organisations are not required to learn multiple different digital systems, which creates a flexible workforce that can be more easily deployed to meet changes in demand profile.

3.3               However, improved interoperability between organisations is just one part of the challenge, and there is a need for improved interoperability between different digital systems within a single organisation, for example a hospital Electronic Patient Record is unable to communicate with the hospital pharmacy IT system, preventing the realisation of efficiency savings. This is often cited as barrier to the adoption of innovation, as the cost and challenge of connecting new and existing technologies of different suppliers is prohibitive.

3.4               Standardisation has a central role to play in overcoming this, as it can both improve the interoperability of systems and make it easier for the workforce to easily adopt and use new technologies. There is a need for the NHS to develop an agreed set of data standards and protocols, ensuring that the NHS’s digital pharmacy infrastructure has a common language allowing the easy, safe and secure transfer of data across and within systems.

4. What innovations could have the biggest impact on pharmacy services and why?

4.1               Connected Medication Management, has the potential to have a major impact on pharmacy services and help tackle some of the NHS’s biggest challenges, including productivity, patient safety and medicines spend.

4.1.1         Productivity: First, it can help increase productivity by releasing the workforce to conduct more high-level complex tasks that are of higher value to patients and the NHS and can increase job satisfaction. This does not just benefit pharmacists but can impact the wider workforce, through, for example, freeing up time that nurses currently spend managing and administering medicines on hospital wards. Research has shown that less than one third of a nurse’s work time was spent with patients.[8][9] There are further potential efficiency savings to be made in the management of controlled drugs, where digitisation and automation can reduce time spent on manual record-keeping, audit and investigating stock discrepancies, as well as discouraging diversion.

4.1.2         Patient Safety: Second, it can support patient safety by reducing the prevalence of medication errors. Research commissioned by the Department of Health and Social Care estimates that there are approximately 237 million medication errors in the UK each year, 66 million of which are clinically significant.[10] These errors can be linked to a variety of factors, including healthcare professionals’ fatigue, misinformation, staff shortages, or suboptimal training.[11] However, preventing medication errors is complex and research has shown that in medical surgical units, experts have observed as many as 50 steps in the medication management process[12], each of which has the potential to cause a medication error. The automated approach of CMM technology can help prevent errors by reducing the scope for human error, at any point along the medication journey from ‘goods-in’ to the patient’s bedside.

4.1.3         Spending on medicines: Finally, CMM can support NHS in better managing the drugs bill. The NHS in England spent £17.5bn on medicines in the year 2021/22, the second highest area of spending in the NHS, with only staffing costs using more of the NHS’s budget. This cost is expected to increase in the coming years, due to a combination of an ageing population and the growth of costly new and novel therapeutics. CMM can support medicines optimisation, assisting the NHS in reducing medicines wastage, enhancing prescribing practices, managing inventory better and improving patient compliance to medication.

4.2               Internationally, the potential benefits of CMM can be seen at the Cleveland Clinic Group which has end to end CMM technology integrated into design and build of the hospital. Connecting each element of the medication management process, the hospital has demonstrated how technology can transform hospital pharmacy services.

4.3               Within community pharmacy, technologies such as automated stock input/output, enhanced inventory management, tele-consultation and 24/7 collection terminals are all enabling the provision of advanced pharmacy services by helping to free up staff time.

4.4               There is also an opportunity for community pharmacies to accelerate the wider use of diagnostic technologies for patients as well as supporting both the wider NHS prevention agenda and attempts to enhance the role pharmacists play in clinical care. For example, community pharmacists are well positioned to take advantage of new Point of Care diagnostic technologies, which can help to rapidly differentiate between viral infections (e.g. flu) and bacterial infections (e.g. Streptococcus) and inform whether prescribing antibiotics is appropriate.

4.5               Moreover, there are opportunities for community pharmacies to take patient blood samples which can then be sent to and tested in central laboratories. This can both increase the accessibility for patients to testing and reduce the burden on GP clinics and outpatients. The technology to facilitate this exists in terms of venous blood collections systems and capillary blood collection.

4.6               Additionally, community pharmacists can use innovative technology to support patients in adhering to their often complex medication regimens through the use of pouch packing or the more widespread single and multi-dose blister cards. These can significantly increase patient compliance to their medication, particularly for example in residential or care homes, where residents may be reliant on someone else to support them in taking their medication. Pouch packaging has been shown to result in reduced admissions / readmissions to acute sites, as well as reduced medication errors.

4.7               Overall, CMM can enable efforts for community pharmacies to have a larger role in the care of patients, as it helps support the seamless connectivity between primary and secondary Care. With Integrated Care Systems assigned the task of redesigning services and improving the planning of care in their areas, CMM can be a key enabler to more patients being treated in the community, including both at home and in residential or care homes.

4.8               Finally, CMM has a role to play in supporting the collection of real-world evidence on medicines, enabling clinical staff to link medicines to patient outcomes and support the research and delivery of higher standards of care and enabling the shift to a preventative health system.

4.9               There is a need for more clearly defined and ring-fenced transformation funding, that can support organisations in adopting new technologies that can have wider benefits to the service and patients as outlined above.

4.10           Current funding to support the uptake of transformative technology is opaque and many Chief Pharmacists who are responsible for attaining funding, struggle to navigate the innovation landscape and thus receive the funding required to adopt new and innovative technologies.

5. To what extent are funding arrangements for community pharmacy fit for purpose?

5.1               As community pharmacies begin to deliver additional services, such as the Pharmacy First service and preventative services like blood pressure monitoring and vaccinations there will be a need to review the funding arrangements. These new services will require investment in technology and staff training and education, which will need to be supported. In addition, there will need to be consideration of how to manage the different funding mechanisms for dispensing – which is currently based on community pharmacies claiming fees for transactions – and for clinical services which may be designed and funded differently. It is important that sufficient funding is available for the range of services community pharmacies are being asked to deliver.

6. What factors cause medicine shortages and how might these be addressed in future?

6.1               There are several factors that can cause medicines shortages, with challenges throughout the complete medicines journey occurring at any point from manufacturer to the patient. This can include manufacturing issues, logistical and supply-chain issues, changes in demand as well as wider global market dynamics.

6.2               This can have a significant impact on pharmacy services, which are crucial to the smooth delivery and provision of medicines to patients. The impact of this can be wide ranging, from not being able to fulfil prescriptions, to meeting patient needs, to increased workload and stress on pharmacists who can expend large amounts of time and effort trying to source alternative suppliers of medicines.

6.3               It can also increase the risk of patient safety incidents as pharmacists are forced to make difficult decisions about patients care and may need to recommend different therapeutic substitutions or dosages that may not be 100% suitable for a patient.

6.4               Digital technology can play a key role in helping better manage medicine inventory and reduce the risk of medicine shortages. For example, technology can support improved inventory management, by allowing greater oversight and transparency of an organisation’s medicines stock levels, supporting the organisation to identify potential shortages at an earlier stage and enabling increased time to order new medication or if needed, find alternative sources of supply. It can also help increase oversight of medicine inventory across a wider area, enabling the rebalancing of stock by moving it to different parts of an organisation or network to meet demand spikes, including in emergencies, whether local or national, thereby supporting emergency planning, resilience and response.

6.5               It can also provide real-time data on medication usage, which can identify trends and patterns, such as where medicines are being potentially wasted or underutilised. This can help support organisations to optimise medicines usage, reducing the scope for shortages to occur.

6.6               Automating processes such as ordering systems, can mean that medicines are re-ordered automatically when stock levels reach a certain threshold, helping to free up staff time as well as reduce scope for human error.

6.7               BD’s technology has been shown to optimise inventory management by reducing drug deliveries by 75%. It has also shown to support a saving of 72 hours per month managing pharmacy inventory by increasing the traceability of medicines.[13]

7. To what extent does community pharmacy have the resource and capacity to realise the ambitions in DHSC's Primary Care Recovery Plan?

7.1               The development of a ‘Pharmacy First’ described in the DHSC’s Primary Care Recovery Plan is to be encouraged and needs to be appropriately funded. For the benefits of this approach to be realised there needs to be an increased investment in community pharmacy IT systems and interoperability to allow pharmacists read and write access to patient records, particularly as community pharmacy starts to take a bigger role in preventative services and long-term condition management. 

8. Are there the right number of community pharmacies in the right places, and how can we ensure that is the case across the country?

8.1               As ICBs begin commissioning pharmacy services across a whole system they should ensure this element is addressed as part of their Pharmacy Needs Assessments (PNA) and the size and number of their community pharmacy estate should be considered as part of this.

9. To what extent are commissioning arrangements for community pharmacy fit for purpose?

9.1               It is important that commissioning reflects the changing role of pharmacy professionals and leads to better use of technology and pharmacists’ clinical skills to maximise the potential benefits of community pharmacy. The future of pharmacy provision could look very different, the Pharmacy First approach is a clear example of how the capabilities within pharmacy can support the health service more broadly. Similarly preventative services such as blood pressure measurement and vaccination are set to increase in community pharmacy, as well as long term condition management. Equally, services that connect between different parts of the health service will increase. In pharmacy, the discharge medicines service is a good example. Commissioning arrangements will need to support this and, in some cases, pre-empt new approaches to ensure that the NHS can take advantage of the opportunities to deliver services differently.

9.2               Technology suppliers will also need to think innovatively about the support they can offer to community pharmacists as their role and services change, for example providing additional data insights or supporting interoperability with other systems and other parts of the health service. This could lead to new funding models and partnerships which will also need to be addressed through appropriate commissioning arrangements.

9.3               Whilst there has been a longstanding policy focus on developing the role of community pharmacy, there has not been a similar, recent focus on hospital pharmacy. Hospitals have led the way in the development of clinical pharmacy services but there is scope to improve and extend those services further, including extending their reach into settings closer to people’s homes. Virtual wards are good example of how hospital pharmacy services have had to respond to this new development. This has stretched resources as has the movement of hospital staff into Primary Care Networks. In addition, medicines used in hospitals are becoming more complex, such as CAR-T and genomic based medicines, needing a different balance of pharmaceutical skills and resources. Lord Carter’s report on modernising aseptic medicines provision is step in the right direction but it is only part of the reforms necessary to free up clinical pharmacy and nursing staff, whilst improving safety and productivity. Many hospital pharmacy departments have used automated dispensing technology in the central pharmacy to free up staff, but there has been less use of similar technology at ward level, and the advantages of CMM have not been fully exploited. In turn hospital pharmacy staff, whose clinical career can now extend to consultant level, are not fully utilised in clinical research, including clinical trials. There is a need for a more strategic approach to the deployment CMM technology whilst considering how best to maximise the skills of hospital pharmacy staff, including outside of a hospital and across a local health system. This would help prepare for both independent prescribing by all new pharmacists from 2026, and the increased numbers of pharmacists, as set out in the NHS Workforce Plan.

9.4               The NHS workforce plan highlights the Importance of Robotic Process Automation (RPA). This extends to mundane processes surrounding medicines management where CMM can support operational capacity, speed and safety whilst in the long run guaranteeing a return on investment. Any future commissioning arrangements must take this into account.

About BD

BD is a global medical technology company that is advancing the world of health by improving medical discovery, diagnostics and the delivery of care. BD leads in patient and health care worker safety and the technologies that enable medical research and clinical laboratories. The company provides innovative solutions that help advance medical research and genomics, enhance the diagnosis of infectious disease and cancer, improve medication management, promote infection prevention, equip surgical and interventional procedures and support the management of diabetes. 

The company partners with organisations around the world to address some of the most challenging global health issues. BD has more than 75,000 associates across 50 countries who work in close collaboration with customers and partners to help enhance outcomes, lower health care delivery costs, increase efficiencies, improve health care safety and expand access to health.

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