With a review of pharmaceutical care in the community under way, Holyrood considers what lies ahead for pharmacy

When the doors close at night and the rest of the staff have headed home, the tireless Spencer stays behind to put away the final delivery of the day and carry out any housekeeping. The new recruit at Crawfords pharmacy in Shotts has settled in well and made himself quite at home. Indeed, Spencer the robotic dispenser is so much a part of the pharmacy that it was rebuilt around him.

Laura McGregor, who runs the pharmacy with her mum, Isobel, had read about robot-assisted pharmacies and decided to go visit one when they were planning a shop refit.

“We went to see a robot up in Fraserburgh and I kept saying it is too soon, there is going to be too much change,” says McGregor.

In the end it was her mum who persuaded her.

“Which means when it goes wrong it is my fault,” her mum jokingly interjects as she bustles past, mid-prescription.

For the most part, however, Spencer, who was named by the local primary school, works like the well oiled machine ‘he’ is. When an order comes in, the packets of medicine are emptied into a big hopper. The robot scans each barcode and the pack continues along the conveyer belt and into a glass-fronted room where Spencer’s robotic arm grasps each pack and neatly arranges them on the shelves with the most commonly dispensed items closest to hand. On the other side of the wall, three workstations have been set-up where the technicians scan in the prescriptions. While they calmly look over the prescriptions, Spencer seeks out the requested medication and dispenses it to their station, ready for them to label and the pharmacist to do the final check.

Large pharmacy robots have also been installed in hospitals such as in NHS Forth Valley’s Royal Hospital in Larbert, however, the use of robotics to underpin the supply function is still quite rarein Scotland’s community pharmacies. Installing Spencer was a huge investment, but McGregor says it means she now has more time to devote her skills and expertise to other services. The pharmacy now has two gleaming consulting rooms where services such as weight management classes, smoking cessation support, cholesterol and blood pressure checks, methadone (also sped up by a computerised methadone dispenser called MethaMeasure) and needle exchange are offered.

Reducing dispensing errors and improving safety was another motivating factor. While it also means McGregor has more time to spend training and upskilling her staff.

“It gives me time to go and do these things, whereas before I would be pulling packs off the shelves and dispensing myself,” she says, pointing out that in a busy pharmacy it can be all hands to the pump at times.

Peaks and troughs, such as the traditional winter rush, are also more manageable.

“One of the days in December we did 1200 items in the one day and it was fine. I’m not saying it wasn’t a particularly hard day, but it was possible.”

Now, she says she can’t imagine the pharmacy without Spencer.

“If you had to go back you would but I think I would rather lose my left arm!”

The high-tech pharmacy is now a very different place from the one run by McGregor’s grandfather. However, Spencer is not the only sign that pharmacies and the role of the pharmacist is changing.

Over in Edinburgh, Barnton pharmacy has its own blog where it keeps patients updated about latest offers, services and entertaining facts ranging from the number of aspirin tablets counted and dispensed over the year (70,379) to the number of awards it has won (five last year). The newly refitted pharmacy also has an interactive SMA touchscreen display where patients can access demonstration videos on useful topics such as what to pack for the hospital and how to wind your baby, as well as a consulting room where it offers services such as seasonal flu vaccines, smoking cessation, emergency hormonal contraception, consultations and advice free of charge for minor ailments, and chronic medication services. Its owners, Leanne Carey and Sally Arnison, are also both independent prescribers and run respiratory clinics in two local surgeries, as well as offering advice to patients who come into the pharmacy.

Patients have been “very receptive” to the services offered and “appreciate” the opportunity for a more in-depth discussion with the pharmacist, says Carey. Because they don’t need an appointment, patients often pop in to see them and this presents the pharmacy with an opportunity to spot issues early and signpost them to the appropriate services.

“Patients come in here and collect their prescriptions – whether they go to the surgery or not, they come in here and get it so it is capturing these patients while they are in here to see them for these things.”

One example of this is with spotting early signs of dementia, she explains.

“We are the ones who are probably seeing the early dementia patients before anybody else. They come in asking to buy their pork pies and totally random things. They are coming in asking for prescriptions on a daily basis when they are not there and looking a bit confused. We do try and flag these patients up to the surgery but you do have an element of patient confidentiality. Do you say something? Is it in the patient’s best interest?

“But certainly, I think the early dementia signs is a huge part of what community pharmacy should be involved in because we see these patients.”

These examples illustrate how much pharmacy has changed in a short period of time.

From compounding and counting out pills by hand to robots and clinical services, pharmacy is entering its next chapter, explains Alex MacKinnon, director for Scotland, Royal Pharmaceutical Society (RPS).

“The next stage is very much dependent on making sure pharmacists’ position is accepted, that their skills are recognised and valued within that integrated healthcare team, within the integration of health and social care agenda, and that is very much about partnership working,” says MacKinnon.

In Scotland we’ve been “very lucky” that the role of the pharmacist has progressed in a system that has been based on “cooperation and collaboration,” he says.

“That has nurtured the ability to get things done. That has helped relationships, whereas England is competition and choice. Time will tell which one works better.”

Scotland’s pharmacists have also benefited from cross-party political support and commitments from successive governments, he says. In October last year the current Scottish Government announced that the role of pharmacists was to be reviewed. The review of NHS Pharmaceutical Care of Patients in the Community, which is being carried out by Dr Hamish Wilson with support from Professor Nicholas Barber, aims to enhance the role of pharmacists and encourage closer working with GPs and other communitybased services.

“We see this as a massive opportunity to develop the role of the pharmacist further and we welcomed that because we think it is a commitment from the Scottish Government that it can make better use of pharmacists’ skills to improve patient care,” says MacKinnon.

RPS would like to see the outcomes of the review being an “evolution” of what has been achieved to date, building on the strategy for pharmaceutical care in Scotland, ‘The Right Medicine’.

“I think if you look at ‘The Right Medicine’, the key to its success as a strategy was it was a strategy for pharmaceutical care of patients, rather than a strategy for pharmacy,” MacKinnon explains.

“It started to focus pharmacists right in more on a clinical role and clinical outcomes. So it set the scene for pharmacists as prescribers, as public health practitioners and as clinicians in that integrated team.”

MacKinnon hopes the review will lead to a new strategy for pharmacy in Scotland.

“I’m sure there may be some quite radical things to come out of this. I would hope for nothing less because we need to keep moving pharmacy practice forward and the professional body is certainly committed to doing that.”

Harry McQuillan, chief executive, Community Pharmacy Scotland (CPS), agrees that a new strategy is needed.

“‘The Right Medicine’ has really been delivered, in the main. If you look at the many recommendations over the four-year period that were in that, the vast majority of them have been delivered. So, yes, it is the time for something new.” The fact that it was deliverable was one of the strengths of ‘The Right Medicine’, he says.

“Therefore, people got behind it. They could see the vision. They could see what the benefit was going to be for patients and the NHS at large. So we are looking for something similar that could be deliverable.”

CPS and the RPS submitted their responses to the review earlier this month. In the former’s response, it describes the pharmacy as a “hub” in the community, enabling patients to access their medicines and pharmaceutical care in one setting at the same time, thus removing unnecessary steps in their healthcare journey.

“I think the headline messages [from CPS’ submission] are that the network is the ideal place to deliver services from. I think that the supply of medicines gives you the access to deliver the care that goes with it. I think it would be a real shame if not a mistake to separate the two,” says McQuillan.

It also notes that there remains a lack of knowledge amongst the public as to what pharmaceutical care represents for them and suggests there is a need to raise awareness of what is currently happening in community pharmacies across Scotland, while at the same time, seeking to involve patients in further service development to ensure services meet their expectations and needs. There is also a need to publicise services such as the Chronic Medication Service – a service which allows patients with long-term conditions to register with a community pharmacy of their choice for the provision of pharmaceutical care as part of a shared agreement between the patient, community pharmacist and general practitioner. McQuillan believes it is now time to relaunch the service, but adds that this will need to be sufficiently resourced if it is to be embedded across Scotland.

In its response to the review, RPS highlights the need for pharmacists to have full access to health records.

“This shared electronic information is really important to improve the patient care journey and especially around discharge between the hospital sector and into the community when someone comes out of hospital. All of this should be electronic and interlinked,” says MacKinnon.

Pharmacists need to be able to access this information in an “appropriate and safe manner”, he adds.

“The Scottish Government, I think, is committed to doing that within their eHealth strategy. There is a commitment to start sharing this information but obviously looking at making sure patient confidentiality is paramount.”

The RPS submission also calls for closer working relationships between primary and secondary care and different health professionals. Earlier this year, RPS Scotland and RCGP Scotland issued a joint statement outlining how pharmacists and GPs could work together to improve patient care.

“We are committed very much to moving that partnership forward, exploring things like joint education and how we can work better to improve the care of people in care homes as well,” says MacKinnon.

Understanding each other’s role and considering where they fit together can improve working relationships, and avoid duplication and unnecessary costs.

“It is not being in competition, it is about complementing each other,” adds MacKinnon.

“If you look at the minor ailments service as an example, that was launched as a service that would make pharmacy a first point of call for common clinical conditions…things like athlete’s foot, that is easily treatable by a pharmacist, it doesn’t require a doctor’s appointment.”

MacKinnon hopes the review will further empower pharmacists and enable them to play their part in the improvement of patient care.

“That may involve prescribing, that may involve a public health element, but mostly it is about pharmaceutical care and working very closely with the GP. It is about improving the relationship between the GP, the patient and the pharmacist.”

McQuillan agrees that the focus of the review should be the patient.

“This isn’t a review of pharmacy, it is a review of pharmaceutical care in the community for the patients. So it shouldn’t rely on what people might think would be good for a pharmacist, it is about what would be good for the patient.”