Pharmacists and their teams in every setting across Scotland have been put under unprecedented pressure by the Covid 19 pandemic.

For the profession it has meant adapting and innovating alongside other healthcare professionals, bringing into sharp focus the particular skills that pharmacists bring in their assessment of, often rapidly evolving, evidence about medicines and treatments.

Prof Angela Timoney is Director of Pharmacy for NHS Lothian and the first non-medic to chair SIGN - the Scottish Intercollegiate Guidelines Network - having previously been the first pharmacist to lead the medicines assessment body, the SMC.

In November she will chair the Pharmacy Management National Forum for Scotland looking back at the Covid 19 pandemic so far, and asking what it means for the future.

For Scottish Pharmacist, John Macgill asked Angela for her reflections on how the profession in Scotland has coped so far.

AT: 2020 has been a bit of a rollercoaster year but, when I think about the year so far, I like to think about things that didn’t happen. Medicines did not become a crisis area like PPE. The hospital service did not fall over. Community pharmacies, despite significant additional stress, remained open and functional. And I think we need to celebrate that.

Some of that was because our preparations for EU-exit. In Scotland and NHS Lothian, we had been reviewing our medicines supply and distribution systems and processes – and strengthened them – which put us in a better position. So much of that work was across the four home countries where the rules of engagement around fair shares, the use of the Barnett Formula for allocation of supply in terms of shortage, was already established. Other parts of the NHS didn’t have that kind of opportunity to prepare, so we were better able to cope with medicines supply challenges. I don’t think that was necessarily true in terms of workforce, medicines governance or clinical and therapeutic work, but the ability to get medicines supply issues addressed very effectively helped patients and the NHS.

I have to mention care homes. Undoubtedly there are lessons for all of us to learn about the care homes fiasco. I think that, for many of us, we were aware that this is a frail vulnerable population where pharmaceutical care needed to be strengthened. This client group would have been in hospital 10-15 years ago getting clinical pharmacy input, but many have not been getting clinical input despite the complexity of their care needs and dependency on rapid assessment and intervention. COVID shone a spotlight on this and I think that we must not now miss any opportunity to improve it.

I am so grateful to my wonderful pharmacy team. Everybody just stepped up, and I know that’s not just true of pharmacy. It was inspiring and I think that we coped.

Someone said at the beginning it was not a sprint, it was a marathon. The issue now is that what we are seeing is not a marathon. This is a series of marathons which makes it really important that we concentrate on staff wellbeing and sustainability. Because this is challenging – it’s still challenging every day – and we simply don’t know how long this race is.

Community Pharmacy has done incredibly well and has been very well received both by patients and the public. People recognise that the service managed to stay open and continue to provide for patients.

My clinical staff at ward level are really essential members their teams and are relied upon for their clinical knowledge and expertise but I do have some concerns around how clinical guidance in initial phases of COVID was developed. It became quite uni-professional. Doctors provided all the guidance, whereas we know that guidance needs to be multidisciplinary and multi-professional. In particular around medicines, pharmacy was sometimes considered at too late a stage. I think that lessons have been learnt, not just for pharmacy but for others. There is an inevitability that, because everybody had to act quickly, people probably just spoke to those colleagues they saw around them. But, in order for guidance and pathways to be robust there has to be a strong multi-disciplinary element, bringing in nursing and physio colleagues and other AHPs as well.

SP You are chair of SIGN, the Scottish Intercollegiate Guidelines Network, and have been for over a year – the first pharmacist in that role and the first chair who isn’t a doctor. SIGN is all about evaluating and grading evidence to develop guidelines. So how difficult was it to plot a course with a virus that nobody had met before?

AT: I would like to start by saying how much I enjoy working with SIGN and to encourage my pharmacy colleagues to put themselves forward for positions not usually part of a pharmacist career pathway. It challenges your thinking and develops your skills not just for the role but hopefully for pharmacy too and enables us to have a broader reach to improve patient care. In terms of COVID, a number of things happened with SIGN. As pharmacists we are used to the regulatory environment for medicines and have an expectation of the evidence base necessary to prompt a change in practice. We all like to work with prospective double blind randomised controlled trials where we have an intervention group and a group that doesn’t receive that intervention. That is not what we were dealing with COVID. Instead of the highest quality evidence, we were often dealing with retrospective observational data of varying quality cohort and case control studies and sometimes simply case reports. That is inevitable where you have a virus that did not exist year ago. In addition, people think “you have to do something” and in fact “doing something” may introduce harms. To stand against this desire to take action requires us to be steadfast and ensure best practice.

SIGN worked closely with the Clinical Cell at the Scottish Government to try and introduce that rigour and ensure that assessment, even of observational data and papers that weren’t yet published, was of a standard useful to help clinicians on the front line.

Because the evidence was emerging rapidly, we worked quickly and we revisited guidance. One example was guidance around signs and symptoms of COVID for primary care, because there really wasn’t any guidance on that. We worked closely with our academic colleagues at Glasgow University, the first time SIGN had co-produced with an academic institution, and we did it over three weeks where normally it takes 24 to 30 months to produce a guideline. Because the evidence was of such poor quality, we didn’t make recommendations. But, where we could, we said where there was a strong association: this is what we believe the evidence tells us in terms of the patients that present to you. We then updated the guidance two months later and we are looking at it again. We were able to continue to do what SIGN does best and to work in an international context: the evidence comes from across the globe and then we put into the context of what works and what is most applicable to the NHS in Scotland.

I think that pharmacy, our knowledge of medicines, our knowledge of evidence, of how to apply evidence and how to critically appraise evidence, is well recognised. That basic essential part of being a pharmacist – how we approach medicines – can be easily applied across all of the clinical spectrum and all therapeutic areas.

In terms of medicines for COVID, it has been interesting and challenging. There haven’t been very many medicines found to be effective against the virus but there was lot we had to do around standard critical care medicines. They were already available, but we have had to use them in doses that we wouldn’t normally use. There have been real challenges around end-of-life and palliative care medicines too, and pharmacists have been working to help to produce the best guidance for patients at a distressing time of their lives. That guidance played an essential role in supporting clinicians and patients, particularly in April, May and early June.

Then, as the evidence started come through about the effective treatments – remdesivir, dexamethasone and, more recently, hydrocortisone – our clinical colleagues asked us for our assessment of the data. I think dexamethasone is fantastic, it is a game changer. It is saving lives. Whereas our assessment of remdesivir is that it cuts hospital stays from an average of 15 days to 11 days, and that makes it a different decision. COVID has really challenged our skills as pharmacists and enabled us to practice at the forefront of our profession with issues that really matter.

Just as pharmacists have stepped up to the mark, so have pharmacy technicians, particularly around supply and distribution. Technicians often run those services and have been fantastic, they need to be thanked for the part that they have played in the pharmacy service. I think, as we move forward, we now need to give some thought to the role of both professional groups, pharmacists and technicians, making sure that we play to our strengths and to our underpinning knowledge and skill sets.

SP: You are chairing the Pharmacy Management National Forum for Scotland this year, which will be online. Why was it so important to you that this conference should go ahead despite the pandemic?

AT: I am really delighted to be chairing this conference. It is important that, having been through such a very difficult phase, we find ways to come together to share. We need to ensure that physical distancing does not stifle networking and indeed supports innovation. The fact that you can join the conference without being in Edinburgh or Glasgow is great.

The conference programme is really robust. We have a broad spectrum of leaders of pharmacy in Scotland and I think that the attendees will want to hear what they are saying. I’m delighted that the newly appointed Director of the Royal Pharmaceutical Society in Scotland, Clare Morrison, is joining us. She is an innovator with a depth of knowledge about digital capabilities and a history of delivering rapid change across NHS Scotland. We also have Alison Strath, Principal Pharmacist for the Scottish Government and Harry McQuillan from Community Pharmacy Scotland.

Ours is actually quite a small profession and I’m really keen that we work as one integrated profession. The workshops are diverse and I hope that people will want to dip into sessions that are not always connected with their day jobs, to find out what’s happening elsewhere as well as developing their expertise in their own sphere of practice.

This article is published in the current edition of Scottish Pharamcist magazine.

Angela Timoney is chairing COVID-19 – Looking Back and Moving Forward: What does this mean for the Future?, this year’s Pharmacy Management National Forum for Scotland on 10^th November 2020. Free registration for all healthcare professionals is at pharman.co.uk/events