Is pharmacy prepared for a resurgence of COVID-19?

The number of daily new COVID-19 cases in the UK hit a low of 352 on 5 July 2020 — the lowest since new cases peaked at 6,201 on 1 May 2020 – and responsibilities began to lift, with pharmacies no longer required to ensure medicines were delivered to shielding patients and the so-called ‘Nightingale’ hospitals winding their operations down. Pharmacy staff who had been redeployed to critical and intensive care began to return to their usual roles.

They started recharging their batteries, taking much needed annual leave after months of record demand, long hours and — in some cases — incidents of abuse from patients.

However, completely relaxing is not an option. As cases of COVID-19 start to rise again in the UK — the number of new cases on 16 September 2020 was 3,991 — community pharmacy is attempting the “biggest flu vaccination programme in history”.

In hospitals, while there was some respite in May and June, the government has now piled on the pressure for activity to increase and the backlog of patients to be tackled.

David Corral, chief pharmacist, Hull and East Yorkshire Hospitals, says there is a big push at the moment to get back to normal.

“Workload is now cranking up again and we have had to do a lot of risk assessments of staff — that has been quite intensive.”

He adds there has also been a fair bit of work to support the provisional registration of foundation year staff under new rules announced in July.

Raliat Onatade, group chief pharmacist at Barts Health NHS Trust, says nothing is going to go back to normal because everyone is still being asked to do things differently, although they have had learning sessions looking at what they would change or what worked well.

There is now a lot of work going on on preparing for a second surge of COVID-19

“Staff who were moved around are back in their previous role and most of our shielding staff are back. There is now a lot of work going on on preparing for a second surge of COVID-19.”

And the toll of the first wave of COVID-19 lingers — although as the World Health Organization says, it may be unhelpful to think of the pandemic in waves: “The best thing is to flatten it and turn it into just something lapping at your feet,” a spokesperson reportedly said.

“I think it would be extremely difficult to lift ourselves and go again if we face anything like we faced when this all started,” says Nat Mitchell, pharmacist and director at JWW Allison & Sons in Cockermouth.

It is very difficult to plan for what we don’t truly know will happen

“It is very difficult to plan for what we don’t truly know will happen,” he says. “We are tired and are working very hard to deal with the here and now.”

The annual ‘Salary and job satisfaction survey’ carried out by The Pharmaceutical Journal between 23 June and 21 July 2020, two months after the first spike in COVID-19 cases, lays bare the impact on the pharmacy profession.

The survey of 1,409 non-locum pharmacists reveals that more than 90% of respondents feel stressed, with stress levels appearing to be highest among community pharmacists.

Staff absence (67%), demand for services (69%) and fear of infecting household members with the virus (63%) were all high on the list of factors influencing the stress levels of community pharmacists, whereas hospital pharmacists were most concerned about unclear guidance (63%).

Despite this, the Department of Health and Social Care has told The Pharmaceutical Journal that it has “no plans” to offer the confidential counselling service offered to GPs and other doctors to pharmacists.

While pharmacists are able to access a temporary NHS mental health hotline to help staff deal with the pandemic, Claire Anderson, chair of the Royal Pharmaceutical Society’s English Pharmacy Board, says the pandemic has highlighted the urgent need for comprehensive mental health support for all pharmacists to help with stress, depression and addiction.

Anderson says: “We knew that many were close to burnout even before the pandemic and the unprecedented demand for services over the past months will have only added to the pressures they are under,” she says.

In a Royal Pharmaceutical Society survey of pharmacists in December 2019, 80% reported that they were at high or very high risk of burnout because of exhaustion. More than half of the 1,300 respondents said that they had reconsidered their career and 44% were concerned about potentially making mistakes or providing a poor-quality service to patients.

Cut to six months later and, during a pandemic, more than half of pharmacists (56%) responding to The Pharmaceutical Journal survey said they worked more hours during the coronavirus pandemic, with the picture most acute in community pharmacy.

And, no wonder: the National Pharmacy Association (NPA) found that community pharmacists were dispensing between a quarter and a third more prescriptions.

Leyla Hannbeck, chief executive officer at the Association of Independent Multiple Pharmacies, says community pharmacy has shown “immense resilience” and went above and beyond when the pandemic hit.

Community pharmacies are operating at the limits of their capacity and they need proper support

“But they’re operating at the limits of their capacity and they need proper support and communication, as well as funding for the costs they have incurred,” she says.

Funding is a particular problem in England, where £350m has been provided to aid cash flow during the pandemic under the understanding it would be paid back at some point and was not in addition to what had already been agreed for 2020/2021 as part of the five-year funding deal.

By contrast, in Wales, a one-off increase in funding for community pharmacies of £1.5m was offered to support business continuity, followed by an announcement in June that community pharmacies would receive an additional £18.3m over a three-year funding settlement. In Scotland, an increase of almost £5m for the sector over the 2020/2021 financial year was announced in February. This was followed in March by additional funding of £5.5m to help community pharmacists cope with increased pressures from COVID-19.

In England, as of the end of August 2020, 155 pharmacies had closed in 2020, while 19 have opened — representing a 77% increase on 2019 net closures — with pharmacy trade bodies warning that more are on the way as the pandemic hit pharmacies that are already facing a deficit.

Simon Dukes, chief executive of the Pharmaceutical Services Negotiating Committee (PSNC), says community pharmacists in England should either stop offering services such as blood pressure measuring and medicines deliveries for free, or start charging patients on a “cost recovery basis”.

He said the advice was “not given lightly — of course all community pharmacies want to do all that they can for the benefit of their patients.

“But as a sector we have for many years offered services free of charge or at a tariff that does not even cover our costs, and this simply is not sustainable in the current funding environment.” The PSNC is urging that funding must be uplifted to reflect the pace of change and the significant changes happening within community pharmacy.

And the government is asking more than ever from community pharmacy in England, with a doubling in the population eligible for flu vaccinations and new clinical services starting to be brought in; the first new advanced service for hepatitis C testing starts on 1 September 2020 and a digital hospital-to-pharmacy referral service will begin in January 2021.

Michael Ball, managing director and superintendent pharmacist at the Broadway Pharmacy in Preston, says: “We have been trying to get back to providing more personal care and seeing patients with social distancing and the right personal protective equipment (PPE), and we’re doing our best to plan, but now we have that elephant in the room of the biggest flu vaccination campaign in history.”

In secondary care, Roisin O’Hare, president of the Guild of Healthcare Pharmacists, says that much of the nervousness about another surge in cases is because, despite having learned so much about COVID-19 during the early days of the pandemic, normal NHS services now need to continue.

“The [pop-up] Nightingale [field] hospitals, for example, how would they be staffed? In the first wave we had less of the normal work so we could do that.”

Redeployments have taken their toll, she adds. “It was stressful, and we were really, really tired, and that is something people are afraid of.”

Onatade agrees: “In March everything else stopped in order to concentrate on COVID-19, but that is unlikely to be possible this time around, so there is that huge pressure of trying to maintain normal services. Capacity is likely to be a problem.

“There is a high potential that we will have shortages of staff and shortages of medicines.”

In March everything else stopped in order to concentrate on COVID-19, but that is unlikely to be possible this time around

Pharmacists working in hospitals have also had to contend with critical care medicines shortages brought on by the extraordinary demand of COVID-19 patients. Indeed, Warwick Smith, director general of the British Generic Manufacturers Association, says some manufactures of intensive care medicines used up 12 months’ supply in two weeks.

He says the supply chain was upheld in part by some manufacturers stopping supply of other medicines to make intensive care drugs that were at risk of running out, while the NHS set up a special unit to find alternative sources of some medicines.

But he says that manufacturers will be able to replicate efforts to maintain intensive care medicines supplies in the event of another spike in COVID-19 infections, adding that “the government is looking at stockpiling for the really critical medicines, which we didn’t have last time, so that’s another bit of security”.

But it is not all bad news. The survey found that although more than a third (37%) of pharmacists said they felt unsafe at some point working during the pandemic, concerns over PPE have eased. This is due, in part, to the supply problems being eased and community pharmacists being finally allowed to order from the national online PPE portal in an emergency, after calls for access from the RPS.

Testing of the pharmacy profession for COVID-19 has been ramped up — meaning fewer pharmacists having to self-isolate for long periods — and some pharmacists have reported receiving a welcome boost in terms of their image among the public and other healthcare professionals.

The survey reveals that more than 40% of pharmacists believe that the public perception of pharmacy has increased, and a similar proportion think the perception of pharmacy among other healthcare professionals has increased (36%).

Recent polling among the general public by the NPA found 89% of people believe pharmacies are playing an essential role in the COVID-19 crisis, and 51% want pharmacies to have an expanded public health role.

Amish Patel, pharmacist at Hodgson Pharmacy in Kent and NPA board member, said every other person in the pharmacy was saying thank you for the work they had done during the pandemic.

“We’ve never really had that before. People have been showing their appreciation, even when we post things on Facebook and Instagram.”

That the pharmacy was open when the rest of the NHS seemed closed from a patient perspective has meant that pharmacists have had to make connections with primary, secondary and social care on behalf of patients.

Ade Williams, superintendent pharmacist, Bedminster Pharmacy in Bristol, says since the start of COVID-19 he has found himself helping patients manage mental health problems, IVF treatment, chemotherapy and more, which has boosted everyone’s understanding of the clinical expertise that pharmacists can offer.

“More than ever, there is an awareness of what community pharmacy can do. We are encountering and learning new things every day. The question now is how does the system capture that? How are we remunerated for this and how can it be embedded?”

Onatade says there has definitely been a change in public opinion for community pharmacy, but in hospital it was more about a greater understanding that pharmacy needs to be at the table.

“It was more about having pharmacy involved in those strategic decisions,” she says.