The UK government’s push towards hub-and-spoke dispensing (as expressed in its community pharmacy reforms letter dated 17 December 2015) has caused concern, particularly among representatives of the independent community pharmacy sector. One of the challenges in the discussion lies in the definitions. The terms ‘hub and spoke’ and ‘centralised dispensing’ have been used interchangeably, including by The Pharmaceutical Journal, and this confusion is weakening the arguments on both sides.
Hub and spoke is a fairly clear concept. In a hub-and-spoke system, prescriptions are brought or sent to the spoke pharmacies, and the information is sent (generally electronically) to the hub pharmacy. The prescription is assembled at the hub, whether as boxes and packets of drugs in a bag or as individual tablets in a monitored dosage system (MDS) tray. The assembled prescriptions are delivered back to the spoke, where the pharmacist dispenses the drugs and offers advice to the patient or their representative. The definition of centralised dispensing is more ambiguous, and should perhaps be applied to the concept of prescriptions being assembled and dispensed at a hub and delivered to the patient by post or, potentially in the future, to a collection point such as a secure locker. Interactions take place online or over the telephone. It is this concept that has been referred to, somewhat disparagingly, as the ‘Amazonisation’ of pharmacy.
One of the drivers behind the government backing for hub-and-spoke dispensing is the idea that it will create major efficiencies and savings in community pharmacy. The Pharmaceutical Journal has given its support to the innovation behind hub-and-spoke dispensing in the past (2015;295:420). If a machine can assemble prescriptions more accurately and more quickly than a human then the technology should be exploited for the benefit of patients.
But questions remain and community pharmacists are right to be cautious. There is not enough evidence yet that the envisaged efficiencies will materialise. Hub-and-spoke dispensing will only be used for repeat prescriptions, and assembling these is not necessarily the most time consuming part of a pharmacist’s job. There are other important steps in the dispensing process, such as clinical and accuracy checks, which arguably take more time than picking the product off the shelf.
The process also may not be suitable for cold chain drugs and controlled substances, and automated systems struggle with liquids and with large or heavy items — but these problems should not be insurmountable. On account of the shipping time, turnaround will generally be around 48 hours, at least for now, so it cannot be used for short notice and emergency prescriptions. Pharmacists have also raised concerns about the security of data and medicines between the two sites, the costs of set up, and the validity of automated picking, as well as how hub and spoke can meet the terms of the forthcoming EU Falsified Medicines Directive.
Hub-and-spoke dispensing certainly has potential to improve reproducibility, particularly for repetitive manual processes such as creating MDS trays, and the automated systems have accuracy checks and traceability built in at each step of the process. The early proponents of the concept have also reported that it gives their pharmacists more time to be able to interact with their patients, and set up and support new services.
Automated hubs are still in their infancy and there are not enough data to assess the full impact of the technology. But if the benefits of speed and accuracy can be translated across the sector, opportunities will be created for greater not less interaction between pharmacists and patients.