By a general practice pharmacist

March 2020 is one that many of us working as front line Pharmacists will not forget in a hurry. Methods of patient care and interactions with colleagues we took entirely for granted were turned on their head. Rapid decision making had to be taken to prioritise workload and patient care. Pharmacists worked collaboratively with GPs and others within the MDT team to deliver on this. The learning curve was one of the steepest and fastest paced I had experienced in my clinical career to date to ensure effective delivery of patient care in the most unprecedented of times.

As I now take stock, I have to reflect on those changes which will bring meaningful and long lasting change to how I work. A common word I settle on is collaboration. Covid-19 has encouraged collaboration across all the various pharmacy sectors working together to deliver patient care. The improved collaboration has been derived from another “c”, communication. New methods of communication have been embraced from using text message and video calls to contact patients, emails between community pharmacy colleagues and secondary care colleagues and the various online training platforms utilised, completely new to many of us pre March 2020. These platforms delivered the training so vitally needed to keep us up to speed with the evolving clinical picture associated with COVID-19.

I am hopeful that these new methods are here to stay; the new ways to communicate with patients allows us to reach those previously unreachable patients who couldn’t attend for review due to work commitments for example. The fears regarding our older patients not being able to use these methods are unfounded as many are confident silver surfers. The online learning has done much to increase the competence of us Pharmacists and that in the long run will do much to improve the care we deliver to patients in the longer term.

As a leader in Pharmacy, a further “c” I focus on is compassion, primarily compassionate leadership. The weekly Thursday night clap demonstrated the compassion and gratitude of the general public for those working front line during the COVID-19 pandemic, it meant so much to each off us continuing to work for the NHS.  As a leader I have learned that demonstrating compassion to those I lead; regularly checking in with members of my team, recognising when times are hard giving people the time to reflect and adapt and demonstrating kindness creates a cohesive and resilient team in the long run. These are behaviours I intend to maintain and build on going forward.

COVID-19 has undoubtedly brought many challenges and difficulties, tough days in work and I won’t miss the daily donning and doffing of PPE. However, this reflection has brought some other words beginning with C- Compassion, Collaboration, Competence and Communication, which I hope will remain the lasting positive legacies from COVID-19 for Pharmacists.

The Carter 2 review found that ‘no two NHS community healthcare trusts deliver the same set of services’. This heterogeneity partially explains the wide variations in the perception and understanding of our services and the role of pharmacists within this vital, yet understated, part of the NHS. This account therefore may not be fully representative of other service delivery models elsewhere in the UK.

As per all NHS organisations we have business continuity plans. This meant that, as unprepared as the world was for this pandemic, we had a starting point for swiftly prioritising, scaling up and stepping down each service and team. For the pharmacy and medicines team this meant prioritising medicines supply, our inpatient wards and medicines safety, whilst stepping down policy and protocol reviews, audits and provision of training. Implementation was rapid and with few problems.

The fundamental function for the trust pharmacy team: to support patients, doctors and nurses to choose, prescribe and monitor clinical outcomes of medicines to drive optimal use hasn’t changed, however we have increased the proportion of pharmacist time for patient-focussed services on the wards. This has been very well received and valued by the ward staff and pharmacists alike.

Our rehab and neuro-rehab wards would normally treat relatively medically stable patients. This changed as we received patients with Covid-19. Patients would develop new symptoms or rapidly deteriorate. Supporting staff with the skills and knowledge to confidently and accurately use relatively unusual medicines, including palliative care meds and intravenous antibiotics has further raised the profile of pharmacists in supporting patient care. Moving to 7-day working was essential initially, however this has been scaled back more recently as needs have changed.

We support our patients across a double interface – with secondary care on one side and general practice, community pharmacy and our community teams on the other. Regular contact with the other pharmacists across the Integrated Care System (ICS) has been hugely helpful, to help manage this smooth transfer of patients and information across interfaces, in such a busy and rapidly changing healthcare system. Existing relationships have been strengthened, as traditional boundaries have blurred.

We also have good examples outside of the wards. To reduce patient risk of exposure to the coronavirus, we have worked with our nurses to develop a service whereby patients with ulcerative colitis and Crohn’s disease now receive monoclonal antibody intravenous infusions at a community clinic setting instead of attending hospital outpatients.

As part of the local response to provide greater support for care home residents, our pharmacists have been rapidly deployed along with other pharmacy colleagues to provide system-wide support, drawing on the wide breadth of expertise across sectors. This integration heralds a positive legacy that needs to be nurtured further, so that it continues long after Covid-19.

When thinking about Covid and Pharmacy it might be useful to consider what didn’t happen……

Medicines did not become a crisis area like PPE and the service did not fall over; community pharmacies despite significant additional stresses remained opened and functional. These are things to be celebrated and we should reflect on why this was the case. I would contend that our preparations for EU Exit meant that our medicines supply and distribution systems and processes had been recently reviewed and strengthened. In my own area, the preparation for EU Exit meant that teams across Primary, Secondary and Tertiary care had worked more closely and we had firmer foundations than would have been the case two years ago.

It is perhaps inevitable that a new virus with no vaccine and no established effective treatment would make demands on unusual parts of the service. Oxygen became a major area of CPD for most of us. As a senior manager in the first few days I was blindsided by how much I hadn’t known about Oxygen. Up until that point, I had thought of it as a POM but not really something of much importance, it came through a pipeline and as long as the suppliers kept delivering, I had thought we were well placed. We already had frequent monitoring on site and off site through telemetry and were assured by suppliers that there wasn’t a shortage. When it became clear that our hospital wards were not built to deliver high flow rates to every patient on that ward then the potential for problems became apparent. The QA team came into their own and they ensured that supplies were maintained.

For me the past 10 weeks have been about workforce, the wonderful workforce to whom I am in debt, repeatedly staff has stepped up, worked across new teams, went where they were needed and shared their expertise and insights to deliver a high quality service. I am immeasurably grateful to them. The creation of a more flexible and responsive workforce is possible as has been demonstrated.

MS teams has been a vital link and quickly replaced teleconferences. Now however, we are becoming aware of limitations, where parts of the NHS do not have Windows 10 or O365 then full functionality is not available, this requires to be addressed. Judicious use of MS teams is helpful but in some cases it has not enabled the softer skills of team working to be fully practised. The water cooler conversations are not enabled in a system where everyone comes online at 1pm exactly and leaves promptly at the end. It may be that we need to think about how we do that better.

The increase in Joy at work and Well Being conversations has worked well and needs not to be lost. Staff wellbeing is always a priority. As we move into an era of “blended” learning for school pupils the pressure put on staff to manage work and home increases. Evidence suggests this pressure falls differentially on women and as with the rest of the NHS, pharmacy services are female dominated. I think we need to think more deeply about how address this going forward.

Finally, from a clinical and therapeutic perspective pharmacy was in a strange place, apart from the usual example of oncology and haematology the clinical and therapeutic decisions about the medicines to be used for populations of patients were often made by specialist medical groups with less input from pharmacy, nursing or other groups. I know that there is some reflection in medicine about this too and I welcome it. As a senior manager, I certainly spent much less time on clinical and therapeutics issues and more time on supply than normal and the balance did not feel right. We need, as a profession to also think about how best to address this for the future. I think oncology and haematology worked better because there is a long history of a well-resourced multidisciplinary service but that is not the case for many other areas and in a command and control situation old ways of working came to the fore.

It is easy with a retrospectroscope to identify that social care was not given enough emphasis by any of the home countries and the impact on residents of Care Homes was shocking. Could pharmacy have done more there? I think residents of Care Homes do need more pharmaceutical care and if this pandemic enables that deficiency to be addressed that would be a positive.

My reflections are just that, my reflections, I am not sure if we are at the beginning of the end or the end of the beginning but together with the views of others in these articles we can use this time to improve for next time.

How did the Covid-19 experience impact on pharmacy staff in terms of their roles and ways of working?

The COVID 19 pandemic has had a significant and potentially long lasting impact on the Pharmacy services within the NHS.  The below reflects the change and impact experienced in an integrated Trust supporting a medium sized district General Hospital with a tertiary oncology centre and community services (including 2 community hospitals).

Communication and Leadership

The rapidity of change within the organisation necessitated significant change in the pharmacy leadership and communications structure.  Senior leadership team meetings were initiated twice daily, once in the morning to assess the current pharmacy operational situation, and again after lunch to plan changes required to meet the emerging Trust needs.  This reduced to daily once Trust COVID plans were more settled.  A COVID whiteboard was set up to ensure staff could easily understand changes (hot/cold areas, PPE etc) without needing to seek out information.  Update emails were regularly sent to Pharmacy staff and they were asked to give feedback on changes or suggest improvements.

The rapid decision making and clear communication during the pandemic highlighted where we can work more efficiently.  The senior team reviewed our business as usual ways of working and several changes have been made to meeting structures, length and how we operate as a team.  Whilst it is too early to fully evaluate, the changes appear to be adding the benefits seen within the COVID operations to normal working in the department.

Operational Changes

A significant number of operational changes were made during the pandemic, in order to support wards and the changing care they were providing, ensure patient safety within the hospital and reduce footfall where possible.

The primary change which delivered all three of the above objectives was the drive-through Pharmacy.  The Trust provides tertiary cancer services, and these patients were highlighted as a high risk group.  In mid-March a request was made of Pharmacy to reduced hospital wait.  By the end of March a portable cabin had been transformed into a drive-by medicines hand-out & counselling point, and a courier service implemented for patients unable to travel to the Trust. The Pharmacy tracker system was upgraded to send messages to patients when their medicines were ready, and processes were redesigned to ensure prescriptions were not lost or delayed in the new system.  This service has proved to be highly appreciated by patients, and is now being scoped as a main priority for the Trust as an initiative to carry forward in a more permanent structure.

The Pharmacy clinical structure changed to support services.  A 7/7 ICU rota was implemented (The Trust has not previously provided 7 day services).  The clinical service model changed from a ward specific deployment to a model based on numbers of new admissions and assumed acuity.  Unfortunately without ePrescribing or an electronic patient record (both due 2021) full prioritisation based on known acuity is not yet possible, but this way of working has led to ongoing changes with how we run our clinical service.  The support for ICU has also ensured all divisions have requested the 7 day Pharmacy service is prioritised post COVID.

 It quickly became apparent that the ICU in the hospital was the area most needing support.  It doubled in size, and was being staffed with many non-ITU nurses.  Our licensed aseptic manufacturing facility had capacity due to the reduction in chemotherapy.  This was used to produce pre-filled syringes (PFS) for ICU.  As patient numbers increased during the peak, plans were created for manufacture of PFS in an unused theatre using pharmacy and nursing staff.  These plans were signed off through formal governance processes but here not needed as patient numbers started to significantly reduce.  They are ready for immediate implementation if a second wave occurs.

It has been a difficult time for all NHS staff during COVID19, staff resilience and professionalism has been astounding.  The above is a snapshot of some of the larger schemes, but significant amounts of other changes have also occurred over the period.  The ability of the team to work together, contribute and adapt to change, and support each other has ensured the safety of patients throughout this period.

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.