Research in Social and Administrative Pharmacy 13 (2017) 394e397

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Research in Social and Administrative Pharmacy

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Commentary

Disruptive innovation in community pharmacy e Impact of

automation on the pharmacist workforce
Jean Spinks, Ph.D., M.P.H., M.H.Sc.(PHP), B.Pharm. a, *, John Jackson, M.P.H., B.Pharm. b,
Carl M. Kirkpatrick, Ph.D., B.Pharm. b, Amanda J. Wheeler, Ph.D., B.Pharm. c, d
a
Centre for Applied Health Economics, Menzies Health Institute, Queensland, Australia
b
Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Australia
c
Menzies Health Institute Queensland, Griffith University, Brisbane, Australia
d
Faculty of Medical and Health Sciences, University of Auckland, New Zealand

s u m m a r y
Keywords: Pharmacy workforce planning has been relatively static for many decades. However, like all industries,
Community pharmacy health care is exposed to potentially disruptive technological changes. Automated dispensing systems
Workforce
have been available to pharmacy for over a decade and have been applied to a range of repetitive
Automation
technical processes which are at risk of error, including record keeping, item selection, labeling and dose
packing. To date, most applications of this technology have been at the local level, such as hospital
pharmacies or single-site community pharmacies. However, widespread implementation of a more
centralized automated dispensing model, such as the ‘hub and spoke’ model currently being debated in
the United Kingdom, could cause a ‘technology shock,’ delivering industry-wide efficiencies, improving
medication accessibility and lowering costs to consumers and funding agencies. Some of pharmacists'
historical roles may be made redundant, and new roles may be created, decoupling pharmacists to a
certain extent from the dispensing and supply process. It may also create an additional opportunity for
pharmacists to be acknowledged and renumerated for professional services that extend beyond the
dispensary. Such a change would have significant implications for the organization and funding of
community pharmacy services as well as pharmacy workforce planning. This paper discusses the
prospect of centralized automated dispensing systems and how this may impact on the pharmacy
workforce. It concludes that more work needs to be done in the realm of pharmacy workforce planning
to ensure that the introduction of any new technology delivers optimal outcomes to consumers, insurers
and the pharmacy workforce.
© 2016 Elsevier Inc. All rights reserved.

Background
‘Access to medicines’ is a key component of primary health care.
According to the World Health Organization it is underpinned by
four factors: (i) rational selection and use of medicines; (ii)
affordable prices; (iii) sustainable financing; and (iv) reliable health
and supply systems.1 Pharmacists are integral to all of these factors,
particularly as part of a reliable supply system. In most countries
the majority of the pharmacist workforce is employed in commu-
nity pharmacies where they are remunerated to dispense or supply
medicines under either private or public financing arrangements.
* Corresponding author. Tel.: þ61 07 33821523.
E-mail address: j.spinks@griffith.edu.au (J. Spinks).
This often forms a key component of the pharmacy's income and
consumes much of the pharmacist's productive time. Whilst it is
suggested that the current system of dispensing through commu-
nity pharmacy is inefficient and outdated there has been little
incentive for widespread change.2
Like all industries, health care is exposed to potentially disrup-
tive technological changes. Automated dispensing systems have
been available to pharmacy for over a decade3e5 and have been
applied to a range of repetitive technical processes which are at risk
of error including record keeping, item selection, labeling and dose
packing. Theoretical benefits include efficiencies in pharmacy
workflow,6 improved stock control7 and enhanced safety through
the reduction of dispensing errors.8,9 The most common applica-
tions to date have been within localized systems such as hospital
pharmacies or single-site community pharmacies.3 However, if

http://dx.doi.org/10.1016/j.sapharm.2016.04.009
1551-7411/© 2016 Elsevier Inc. All rights reserved.
 J. Spinks et al. / Research in Social and Administrative Pharmacy 13 (2017) 394e397
more widespread adoption of automation was to take place, this
may have significant implications for the organisation and funding
of community pharmacy services as well as pharmacy workforce
planning. In turn, the requirement for modified workforce capa-
bilities would need to coincide with changes in university curricula
and graduate training programs to support these opportunities.
When viewed through this prism of potential automation-driven
upheaval, pharmacy workforce planning requires a much greater
sense of urgency than in recent decades.
Currently the application of automated dispensing technology is
still evolving, and it is unclear how technology will ultimately
impact pharmacy services and be integrated into different health
systems. The scenario where an automated dispensing machine is
installed in an existing community pharmacy dispensary, repli-
cating existing work practices in a more efficient manner might be
thought of as a fully decentralized automation model. At the other
end of the scale is a fully centralized model. This involves a ‘wide
area network’ of multiple pharmacies with dispensing computers
connected over a large geographical area with a single large-scale
automated dispensing facility. Prescriptions presented at the
pharmacies could be dispensed at the central facility and dis-
patched back to the original pharmacy, directly to the consumer or
to another designated pick-up location. While less common than
the decentralized model, examples include centralized automated
multi-dose drug dispensing for elderly consumers as found in
Australia, Scandinavia and the Netherlands,10e12 selective central-
ized dispensing for consumers with chronic (stable) conditions in
South Africa13 and the ‘hub and spoke’ model currently being
debated in the United Kingdom (UK).14,15
In the decentralized automation model, gains in efficiency are
realized within the individual pharmacies. This provides little
impetus to change other aspects of the health system, including the
funding of dispensing. Efficiency benefits are generally not passed
to consumers or funding agencies. However, widespread imple-
mentation of a centralized model could cause a ‘technology shock,’
delivering industry-wide efficiencies, improving medication
accessibility and lowering costs to consumers and funding
agencies. Furthermore, some of pharmacists' historical roles may be
made redundant and new roles may need to be created, decoupling
pharmacists to a certain extent from the dispensing and supply
process. It also creates an additional opportunity for pharmacists to
be acknowledged and renumerated for professional services that
extend beyond the dispensary, which already occurs in some
countries.16
The impact of the above scenarios highlights the need for a far
greater understanding of our workforce. As such, supply and de-
mand side factors related to the pharmacy workforce need to be
reconsidered to enable a platform where robust simulations of the
potential impact of new technologies, practice models or automa-
tion models can be evaluated in an objective manner.
Current pharmacy workforce literature
A systematic review of 69 papers on the pharmacy workforce
was undertaken in 2009.17 The key trends identified included the
feminization of the pharmacy profession (more female pharmacy
graduates than males); more males in the over 50 year age bracket;
mal-distribution across urban and rural areas; and a planned
expansion of university places in a number of countries in response
to a perceived under-supply. Many of these trends are common
across a range of health professions and are not specific to the
pharmacy workforce.
The ‘stock and flow’ forecasting approach used to estimate the
required pharmacist workforce in many of these studies has been
criticized. Scott et al18 noted that health workforce planning has
395
historically focused on analyzing workforce issues in ‘silos,’ that is,
in isolation from population health outcomes, consumer demand
and the activities of other health professionals. These estimates
provide relative numbers of professionals available but mask the
more important question of whether they are being used in the
most efficient way.
Further, when estimates of consumer demand are considered,
the current level of services (for example, the number of pre-
scriptions dispensed) has often erroneously been accepted as a
predictor of current and future workload and workforce demand.
On one hand, this fails to recognize the efficiencies created by
changes, such as automation, and so overestimates workforce de-
mand. On the other, it may underestimate demand by not recog-
nizing types of professional practice that may be offered in the
future by pharmacists, or including an estimate of unmet demand
(including consumers who cannot afford or cannot access a
service).
A more meaningful approach to workforce analysis requires
more comprehensive estimates of consumer demand alongside
better estimates of supply. Given that the proposed benefits of
centralized automated dispensing systems are likely to hold appeal
with funding agencies and insurers, it seems prudent that phar-
macists consider how their professional roles might change under
such a system. It is likely that the requirement for pharmacist labor,
their roles and consumer demand for their professional services
will change to varying extents under different models and in
different countries. This paper details three models of centralized
automated dispensing that have been selected for the purpose of
illustration. Two are already operating and the third is currently
being debated.
Existing and proposed centralized automated dispensing
models
Of the three examples of centralized automated dispensing
systems, the first two models are limited to particular consumer
groups e the elderly and those with stable chronic conditions,
whereas the third has general application. The first is a centralized
automated multi-dose drug dispensing service, predominantly for
elderly consumers.10e12 Consumers can be residents of nursing
homes or community-dwelling consumers who take multiple
medicines and have difficulty with keeping track of and taking their
medicines. Repackaging of medicines into dose administration aids
can assist safe administration however manual repacking can be
tedious and carries risk of error19,20 whereas automated repack-
aging into single dose disposable sachets, labeled with the contents
provides enhanced accuracy and safety. Due to the capital costs,
repacking is increasingly being consolidated at central locations
and distributed to the consumer or to the local pharmacy for
collection.
The second is a ‘chronic dispensing unit’ provided through the
public health sector in South Africa.13 This unit was established due
to the growing pressure of maintaining medicine supply to those
with stable chronic conditions, including HIV/AIDS. In this model,
once patients are stable their health facility pharmacy sends their
checked prescriptions to the central dispensing unit which utilizes
a semi-automated dispensing process for on-going supply.21
Dispensed medication(s) are sent directly from the centralized
unit to the health facility for collection by the consumer.
The third model has been dubbed the ‘hub and spoke’ model
and is currently being debated in the UK.14,15 This model is similar
to the South African model, except it is provided through the pri-
vate sector and could potentially account for two thirds of England's
prescriptions.22 Here, a central ‘hub’ dispenses medication from an
electronic prescription which is then delivered to the pharmacy
396 J. Spinks et al. / Research in Social and Administrative Pharmacy 13 (2017) 394e397
‘spoke’ for collection by the consumer. Currently, this can only be
undertaken within pharmacy chains or large groups which belong
to the same legal entity. A number of variations of this model have
been proposed by the National Pharmacy Association15 including
the hub and satellite model which separates the legal entity of the
of the hub and collection point; a co-operative model which is
made up of pharmacies with different legal entities; the ‘Dutch hub
and spoke’ model where pharmaceutical wholesalers supply
labeled medicines directly to spoke pharmacies; and nationalized
centralized dispensing undertaken at a small number of hubs with
centralized purchasing. The UK government is considering legis-
lative change to facilitate adoption of the model.23
Preparing for change
If centralized automated dispensing was implemented, what
might ‘consumer interaction with community pharmacists’ ser-
vices' look like and how might they differ from existing in-
teractions? What services would be offered and how would they be
remunerated? One way of conceptualizing medicine supply is to
separate the mechanical process of dispensing (recording, labeling,
selecting, packing etc.) from the pharmacist's role of promoting the
quality use of medicines (QUM).24 Has the medicine been pre-
scribed appropriately? Does the consumer understand what the
medicine is for? How to take it? Does the consumer have questions
about the medicine that are as yet unanswered? Might it interact
with other medicines, either over the counter or prescribed, that
the consumer takes?
Adequate safeguards will need to be put in place with central-
ized automated dispensing to ensure QUM and consumer safety
more broadly. The situation where an electronic prescription is sent
from a prescriber to a centralized dispensing facility from which the
medications are sent directly to the consumer may have negative
impacts on consumer safety. Pharmacists are ideally placed to
continue to enhance their role in QUM by interacting with the
consumer before the submission of an electronic prescription,
when the medication is delivered, or both. However, it could be
envisaged that this interaction is delivered using technology rather
than face to face requiring updated legislation and practice guide-
lines to maximize QUM.
The pharmacy profession has claimed the provision of QUM
services as core to its existence for many years, yet to date has failed
to have them clearly described, measured, valued and remuner-
ated. Although some professional pharmacy services are renum-
erated,16 QUM services in community pharmacy are usually not
explicitly funded but are instead funded by a combination of
dispensing fees and front-of-shop sales. Therefore, a direct remu-
neration model for QUM services becomes a clear priority as a
result of automation causing the potential disruption of the existing
dispensing models and a loss of dispensing based income. What
would QUM services entail under a centralized automation model?
Would they be required for every consumer or every medicine
supply? What would consumer preferences be for the type, fre-
quency and location of such services? All of these questions would
need to be articulated and measured to adequately estimate con-
sumer demand for community pharmacists' services.
On the supply side, how would pharmacists respond to this
change? Perhaps pharmacists could provide QUM services using
communication technology, over the phone or by Skype or similar
software. Perhaps home visits to discuss and optimize medicines
might become common. Perhaps some community pharmacies will
transition from supply to counseling services while their shop-
fronts will be dramatically reduced, lowering the operating costs.
The next obvious question is: who would pay for QUM services?
Would consumers be willing to pay this out-of-pocket, or would
governments or insurers pay on their behalf? Would pharmacists
be willing to accept the price offered or would many of them leave
the profession?
The changes brought about by automation and other techno-
logical changes represent a big opportunity for community phar-
macy.25,26 The loss of income for the ‘mechanical’ process of
medicines supply will be seen by many as a negative, which is
countered by positives such as an increase in available productive
time for pharmacists, lower overhead costs (especially if pharma-
cists are not required to stock a large range of prescription medi-
cations) and higher professional satisfaction. It also means that the
QUM component of medicines supply must be explicitly valued and
funded by consumers, governments or insurers. Through this pro-
cess, consumers, and possibly pharmacists themselves, might bet-
ter understand which aspects of their current role are lower-level
processes that can be automated and which are higher-level
cognitive skills that are valued by society.
In addition to explicit QUM functions, there are numerous
extended practice roles that pharmacists may involve themselves
in, including the provision of vaccinations, screening, support to
manage chronic conditions and expanded prescribing roles within
the concept of the ‘medical home.’27 These evolving roles need to
be incorporated in future workforce models.
A comprehensive pharmacist workforce analysis should also
incorporate consumer health outcomes. There is some evidence
that automated dispensing lowers the rates of dispensing errors.8,9
However, as mentioned earlier, other QUM aspects, such as inap-
propriate prescribing are also important,11 so on balance it is
difficult to say if automated dispensing may improve, decrease or
make no difference to consumer outcomes.
In terms of the next steps in pharmacy workforce planning, a
more comprehensive analysis is warranted. From the data gath-
ered, it would be prudent to build simulation models using updated
estimates of demand and supply under different practice models to
test the effects prior to implementation. As these models are being
built, assumptions will need to be made as to what the role of the
pharmacist entails if the mechanical part of dispensing is removed.
This is where community pharmacy needs to be ready to provide
alternatives.
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