The REMEDY Project
Can patient facing medication machines be used to safely issue medication to patients when community pharmacies are unavailable?
Patients assessed by GP out of hours services may need to start medication promptly, but in some settings (e.g. remote areas) they have trouble getting this medication in a timely way. This problem has worsened recently for a number of reasons including unfilled professional staff vacancies and an increase in remote forms of care. Patients calling 111, for example, can receive a consultation via telephone or video from a clinician based anywhere in the country, but there may be no local community pharmacist to dispense the medication prescribed. Some patients in Wales and Scotland have to make a round trip of up to 3 hours purely to collect medication. This represents a source of inequity in the provision of health care in the UK and may generate costs elsewhere in the system (e.g. when delayed medication leads to avoidable complications).
A number of NHS services around the country are considering introducing a technological solution to help address this issue. It comprises a patient-facing medication machine containing a restricted selection of out-of-hours medicines (e.g. antibiotics, inhalers), which the patient or their representative can access locally. A code number enables the medicine to be issued (in a similar way to an “Amazon Locker”, but with additional safety features). Such machines would be typically installed in a local community hospital and kept stocked by local pharmacy teams. In Wales and Scotland, they would be integrated within the Out of Hours and 111 digital systems, creating potential for them to be used in remote areas when local pharmacies are closed.
The technology for this service already exists and similar technologies are already in use. Products such as the Pharmaself 24 machine are installed in community pharmacies; their purpose is to allow contactless collection of dispensed prescription medication. Medication is dispensed by the pharmacy team and placed into a bag ready for collection. A patient then receives a text with a PIN code allowing them to collect from the machine at a convenient time. Such machines are not however able to issue any in-stock medication to the patient, at present they just act as a receptacle for medication that has already been dispensed. However the supplier is working on software updates such that a clinician could log in remotely to such a machine and instruct it to issue a PIN code to a patient linked to a particular item, allowing accurate issue of the correct medication for the patient’s need without further human involvement. NHS organisations have begun to work up business cases for purchasing them once the technology has been refined and deployed in a “real world” context.
Who is doing the service development project?
The project is led from the University of Oxford, with the Principal Investigator Dr Joseph Wherton. Out of hours GP Dr Rebecca Payne is leading the project, working with Dr Archie Lodge, who is a dual trained doctor and engineer, Prof Aileen Clarke, Prof Trish Greenhalgh and Aberdeen university's Professor Emeritus Christine Bond. This team encompasses expertise in human-computer interactions, out of hours and remote general practice, medical engineering, pharmacy and health service evaluation. They are in the process of developing patient and lay involvement.
The team are working with sites in Forth Valley and North Wales, with the project led locally led by Ric Atalla, Operational Manager for Emergency care and inpatient services and by Dr Adam Mackridge, Strategic lead for community pharmacy in BCU healthboard.
The key questions we would like to answer in this project are:
1. Who are the stakeholders in each pilot (e.g. patients, staff, local policymakers, vendor)? What are their hopes and expectations for this new technology-supported service? What would ‘success’ look like for different stakeholders?
2. How might stakeholders plan effectively for the technology’s successful introduction? To what extent is the local health system ready for the innovation? What features of the local context need to be factored in and how? What are the key uncertainties and interdependencies?
3. What happens in each setting when the technology is introduced? What are the intended and unintended consequences and how are these handled locally? What are people’s concerns and to what extent can they be assuaged?
4. Following implementation, to what extent has ‘success’ as defined by local stakeholders been achieved? How can (as appropriate) success, failure and partial success be explained? In particular, have there been any safety-critical or near-miss incidents and if so, what can we learn from these?
5. What are the main costs (financial and non-financial) of introducing this service?
What methods will we use?
The research team are providing expert help and support to each site in the planning and implementation of patient facing medication machines, and performing an evaluation tailored for each site. Each site is responsible for developing internal procedures for the implementation of the machine, such as deciding an appropriate formulary, integrating the machine into their existing processes and developing a mechanism to restock the machine. The sites are responsible for engaging with their existing governance mechanisms and retain full control of the planning and implementation at their site, with evaluation facilitated by the research team.
The sites and the research team are working with the supplier of the machine in order to develop their product for this new purpose.
The sites will go live on a staggered basis, allowing learning from the first site to inform implementation in the second.
The remotely operated patient facing medication machine supply robot service will run for six months, with the service being delivered during any part of the out of hours period where access to community pharmacy services are not available. Providers will lease and install a specially adapted Pharmaself 24 machine at the pilot sites, and install software for remote access onto the 111/OOH computer systems . The unit offers secure storage and issuing of up to 100 medications, which can be released via a pin code sent to a patient’s mobile, email or read out over the phone. Medicines to store will be selected from the local OOH formulary by the provider.
The Healthboard pharmacy teams will be responsible for the restocking of the robot, which will be carried out weekly, and more often during public holiday periods.
Counselling on prescribed medicines will be provided by the 111/OOH clinician during the advice call with the patient.
Implementation will be studied using the NASSS-CAT framework.