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.

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.

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.

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.

It is often said that the Chinese word for crisis is made up of characters for “danger” and “changing point”, the latter usually translated as “opportunity”, and never has this been truer for community pharmacy than with the current danger and opportunity presented by the coronavirus. The COVID-19 pandemic may not have made community pharmacy more skilful or more relevant than it is already, but it has demonstrated our skills and relevance to patients, public, parliamentarians and commissioners alike. This has resulted in development and relaxation of policies and guidance that, if continued beyond lockdown, will enhance and develop the profession.

Firstly, there has been increased recognition and acceptance of Pharmacy as an integral part of the NHS. Although GPs are also independent contractors they have always been assumed by public and parliament to be working directly for the NHS, but in this time of national support and pride in healthcare teams, pharmacies have now also been acknowledged as key workers. As well as continued child care provision, advanced Coronavirus testing, and primary access to food shopping, more important and fundamental recognition has come by way of confirmation that all pharmacy team members are covered by the Assaults on Emergency Workers Act 2018, entitlement to the death in service pay out through inclusion within the COVID-19 Life Assurance Scheme, and the precedent of an enhanced payment from NHS England for Bank Holiday opening.

Secondly there has been increased recognition and acceptance of the professional capability of pharmacists. Generally greater discretion for professional accountability was encouraged by the General Pharmaceutical Council (GPhC) who emphasised that professional judgment is acceptable and encouraged; for example splitting bulk packs of paracetamol to enable OTC sale, determining missing details from prescriptions including controlled drug prescriptions, and the repurposing of medicines. Practical support for such extending responsibility also came as insurers confirmed enhanced clinical negligence indemnity in response to coronavirus.

Finally, there are aspects that encompass both the previous points but that specifically expedite work and activity. These include the presumption of consent to view patient demographic information on Summary Care Record in order to identify shielding status, removal of the need for face to face vaccination training, and provision for the emergency supply of controlled drugs – either as an extension of the Severe Shortage Protocols (SSP), at the request of a patient, or varying the frequency of instalment prescriptions.

Such national health emergencies are very often the proverbial Burning Platform that delivers change, as evidenced with the Swine Flu epidemic in 2009 that saw the duration of treatment that could be made under an Emergency Supply increase from five to 30 days. Importantly, this change was not rescinded once the H1N1 virus had settled into background levels of transmission. Pharmacy must hope that this year’s battle colours awarded us in the fight against coronavirus continue to proudly fly, and that being a more fully integrated part of the NHS and treated as the capable clinical professionals that we are will continue and develop beyond the current pandemic.