The challenges and responses

The COVID-19 pandemic is placing extraordinary and sustained demands on health systems and providers of essential community services (Emanuel et al. Reference Emanuel, Persad, Upshur, Thome, Parker, Glickman, Zhang, Boyle, Smith and Phillips2020). The media focus on the number of cases, intensive care unit capacity and ventilator numbers reflect the national single-issue public health response warranted by the coronavirus threat. However, pre-existing community care needs persist, and medical and pharmacy practitioners have had to adapt and adopt professional role changes amidst a dynamic healthcare system architecture, all on top of already scarce resources. Community pharmacists have been designated an essential service and must, where possible, remain open during the pandemic to provide for the pharmaceutical care needs of the population. Their practice has had to adapt significantly, but the pandemic has also focused attention on the case for long-awaited professional role evolution.

The rapid evolution of the COVID-19 pandemic situation initially outpaced the public and regulatory guidance response. In tandem with the much-publicised early stockpiling of household provisions, prescription renewal requests were surging early in the crisis. The other immediate challenge for community pharmacists was protecting their staff and patients from the spread of infection within the pharmacy. Pharmacies adapted their premises to try and achieve ‘social-distancing’, installing perspex barriers or doorway booths, restricting patient numbers for access and implementing delivery services for those ‘cocooning’ at home.

Alongside premises changes, work practice changes also occurred, for example, closing for lunch breaks, and breaking staff into teams to avoid cross-infection and subsequent pharmacy closures. These measures have resulted in longer wait time for patients, contributing to patient anxiety and aggression. Heightened anxiety and stress levels among pharmacists have also been highlighted recently by the pharmacy regulator due to increased workloads, the threat of infection due to insufficient workplace social distancing, patient aggression and financial implications of the pandemic. Outside of their professional roles, pharmacy staff face the same stressors as the general public during the pandemic. Lack of childcare, risk of infecting loved ones and other personal worries persist. Normal adaptive coping strategies such as social connections, exercises and leisure time are severely restricted during the pandemic (Gavin et al. Reference Gavin, Hayden, Adamis and McNicholas2020). There is a consequent risk of increased workplace-related stress and burnout under this perfect storm for healthcare workers (McNicholas et al. Reference McNicholas, Sharma, Oconnor and Barrett2020).

Additional to pharmacy staff, several of their vulnerable patient groups, those most in need of continuity of care, are facing additional risk associated with the COVID-19 pandemic. Older people, under instruction to ‘cocoon’, are reliant on delivery services and may lose out on opportunities to discuss medication-related problems. Pharmacists must also now balance the risks of increasing supply to monthly amounts with the need to avoid non-essential pharmacy visits. The crisis has also created unique challenges for all patients – factors such as social distancing and self-isolation requirements, loss of employment and decreased access to healthcare services act as barriers to medication adherence (Cadogan and Hughes, Reference Cadogan and Hughes2020). Workarounds have, however, been created to address these service-level challenges. Virtual and telephone consultations have become commonplace, particularly to vulnerable patients. Pharmacists have implemented systems to dispense medications in advance of need to minimise wait times and duplicate visits. In case-by-case examples such as in palliative care, and for vulnerable patients, there has been anticipatory management of medication-related needs. All of these actions have the intention of reducing non-essential medical and pharmacy visits, maintaining continuity of care and facilitating social distancing where possible.

System and regulatory changes in pharmacy

Just as individual pharmacies have had to respond quickly to the pandemic, regulatory and health-system changes have also occurred at an unprecedented pace (Table 1). Indeed, pharmacists in regulatory and health service roles should also be acknowledged for efficiently developing and implementing these regulations, policies and guidelines in response to COVID-19. Example innovation includes the introduction of electronic prescriptions (email) within primary care via Healthmail removing the legislative requirement for paper scripts. The change equally applies to controlled drugs although the same level of documented prescription requirement detail remains. The amended legislation also extends the validity of many prescriptions from 6 to 9 months. Changes have also been made to the quantity of medicine that can be provided as an emergency supply at the request of a patient or prescriber. For the first time, an emergency supply of controlled drugs of up to 5 days’ supply may be dispensed. Full details of these changes are available from the regulatory bodies (Pharmaceutical Society of Ireland, 2020). In addition to the regulatory flexibility in prescription requirements, the health service has adopted a pragmatic and flexible approach to the community drug scheme payments. The health service is also assisting with stock management to ensure continued access to regular medication supplies.

Table 1. An overview of pharmacy responses during COVID-19 pandemic

Opportunities for further role development and recommendations

As the most accessible healthcare professionals during the pandemic, community pharmacists have shown they can ably assist with the public health response to COVID-19, maintaining the continuity of healthcare services and undertaking additional responsibilities to help in relieving pressure on other areas of the health service, such as general practice (Cadogan and Hughes, Reference Cadogan and Hughes2020). They have become an information hub on the coronavirus infection, both in having a direct role in combating misinformation and helping patients select healthy behaviours (Sheppard & Thomas, Reference Sheppard and Thomas2020). Emerging specific issues also arise with media exposure, such as providing evidence-based information on the safety of ibuprofen and certain anti-hypertensives alongside the COVID-19 threat. Pharmacists role during the COVID-19 pandemic in dispelling health misinformation, for example, dissemination of regulatory evidence-based safety information on hydroxychloroquine has been exemplary (European Medicines Agency, 2020).

Although the COVID-19 crisis has resulted in considerable hardship for many in the wider community, it has also shown how community pharmacy can integrate as a bridge between medical/psychiatric care and wider community services. Pharmacies have been able to lean on local authorities for support in the form of delivering medicines to vulnerable patients and this represents an area of promise for the future. Embedding community pharmacy input into comprehensive case management of patients with mental health conditions may be a natural post-pandemic expansion of this platform. More than ever, patients will need comprehensive case management with linkages to housing and social services programmes. COVID-19 and associated after-effects may cause disruptions in employment and also may lead to adverse outcomes, such as loss of housing, food insecurity and ultimately a downward spiral that increases relapse risk and damage to recovery (Alexander et al. Reference Alexander, Stoller, Haffajee and Saloner2020). Pharmacy input could ensure continuity of supply of medications and early identification and addressing of adherence barriers and other medication-related problems.

When a vaccine becomes available, community pharmacists are well-placed to ensure widespread coverage (Fitzgerald et al. Reference Fitzgerald, Kang, Bridges, Talbert, Vagi, Lamont and Graitcer2016). Decades of experience of pharmacists as vaccinators in the United States has shown that with increased accessibility, pharmacists have helped to improve immunisation rates, bring patients up-to-date on vaccinations and reach those who may not otherwise have an opportunity to be vaccinated (Bach & Goad, Reference Bach and Goad2015).

Technology, with suitable investment, can also play a large role in assisting with vulnerable patient groups such as those with mental health conditions. Funding for telemedicine infrastructure, including virtual counselling capabilities and remote delivery of medications, is warranted immediately (Alexander et al. Reference Alexander, Stoller, Haffajee and Saloner2020). There may also be opportunities for novel approaches such as automated pill dispensers that unlock daily medication doses and alert for missed doses or device tampering. Video-based ‘directly observed therapy’ could also be used to provide a video record of medication ingestion at home for those at risk of relapse or overdose (Alexander et al. Reference Alexander, Stoller, Haffajee and Saloner2020).

Pandemic-related professional role evolution comes amidst a long-standing appetite for further role expansion within the pharmacy profession. Prescribing rights for pharmacists have been in place in the UK for almost 20 years but are not currently in place in the Republic of Ireland (Tonna et al. Reference Tonna, Stewart, West and McCaig2007). International evidence suggests non-medical prescribers, typically nurses and pharmacists, are as effective as usual care medical prescribers at achieving comparable outcomes for various illnesses, as well as similar levels of medication adherence, patient satisfaction and health-related quality of life (Weeks et al. Reference Weeks, George, Maclure and Stewart2016). Mental health nurse prescribing has been established in the UK and Ireland, and independent nurse prescribing is now incorporated into Irish clinics (Ross, Reference Ross2015). During COVID-19, mental health-based independent pharmacist prescribers could be managing continuity of medication supply to community-based clients in collaboration with psychiatrists and community pharmacy colleagues and freeing up psychiatrists to manage an impending increased workload. Factors leading to non-adherence and therapy disengagement could be identified and mediated through feedback from community pharmacists to a clinic-based pharmacist. Furthermore, condition-specific arrangements such as in ADHD have shown that partnerships between psychiatrists and community pharmacists can allow the transfer of psychostimulant safety monitoring to the community (Hawkes, Reference Hawkes2018). This model is being evaluated for replication with community pharmacists in Ireland where psychostimulant access has been problematic, and persistence with treatment may benefit from a shared approach to care (Flood et al. Reference Flood, Hayden, Gavin and McNicholas2019; Hayden et al. Reference Hayden, Flood and McNicholas2016). For primary care managed patients, GP practice-based pharmacists are widespread in the UK and are currently being piloted in Ireland as part of a research study (Cardwell et al. Reference Cardwell, Clyne, Moriarty, Wallace, Fahey, Boland, McCullagh, Clarke, Finnigan, Barry and Smith2018). They may find a role in mental health services, similar to their role in the UK in the future (Buist et al. Reference Buist, McLelland, Rushworth, Stewart, Gibson-Smith, MacLure, Cunningham and MacLure2019). These efforts will require new partnerships, seamless use of technology and the dismantling of antiquated roles and regulations alongside leadership from the health service for expansion if benefits in health outcomes are shown.

Finally, as demand on pharmacy services increases during the pandemic, pharmacy staff are at risk of burnout and supports here are also required. Both the health service and community pharmacy owners must strive to create environments that facilitate an atmosphere of belonging and help-seeking and promote attitudes and perspectives of acceptance that make it routine to discuss stressful and overwhelming issues (Chisholm-Burns, Reference Chisholm-Burns2019). Work-hours and staffing levels need to be kept under focus to allow pharmacists to take time for personal activities and self-care, a protective mechanism against burnout (Jensen et al. Reference Jensen, Trollope-Kumar, Waters and Everson2008). Resilience is a protective mechanism against emotional exhaustion and must also be promoted in the workplace. Resilience can be enhanced through training programmes and these resources should be made available to pharmacists and their uptake promoted and additionally imbedded into pharmacist training for future preparedness (Guille et al. Reference Guille, Zhao, Krystal, Nichols, Brady and Sen2015).