Chetan Trivedi

Taz Sheikh is CEO of medicine delivery start-up Zottii. He talks to Curzon Consulting about pharmacy disruption, the impact of COVID-19 and future of pharmacies.

The gap in medicine delivery models for retail pharmacies has been exacerbated by Coronavirus, increased demand and changing customer expectations.

Interview with Taz Sheikh, CEO of Zottii

We live in a day and age where we can get almost anything delivered on demand and on the same day, whether it be items on Amazon, to your groceries to take-away food or taxis. So you’d think the same will be the case when it comes to prescription medicines, but sadly is not. So in early 2019, I set about looking at ways to change that.

I really thought that there’s got to be a better way a better experience for me as a potential patient, for doctors and for the whole healthcare system as a whole.

And hence I decided to create Zottii.

Challenges in retail pharmacy

1. It’s behind the times. And it’s not really set up for those people who need their medications in a hurry, or who physically cannot get to a pharmacy

2. It’s inconvenient. You know we all live very busy lives today. So find the time to visit a pharmacy, it’s not ideal, you know, particularly if you’re a busy working professional like yourselves, or you’re a single parent or you’re, you have young children

3. The biggest problem right now within retail pharmacies is the out-of-stock situation, it’s common for pharmacies to be out-of-stock of your particular medication 40% of the time. Most do not have the appropriate inventory systems to ensure a continuous supply of the right medications

4. This out-of-stock situation leads to something what we called poor drug compliance. And the inability of people being able to get their medications when they need which often leads them to not actually taking their medications at all. And this potentially causes further problems, not only for the patient, but also for the whole healthcare system as a whole as delayed treatment ultimately does result in worse outcomes.

5. Most pharmacies are just not set up to offer on-demand or same day delivery, and those that do somehow offer that service, quite often it’s complicated as it involves third party couriers, and it can be quite costly. The current suite of online pharmacies use the Royal Mail [UK’s postal service], which often means patients have to wait 2-5 days to receive their medications

6. [Retail pharmacies] are really designed to get people to the door because they’re selling makeup shower gels, toiletries. And most shelves are used up to stock those particular items. And if you actually look at their actual dispensary of prescription medicines, often is a very small space, they don’t always have the space to stock all the inventory

Benefits of online medicine delivery

Opportunity for pharmacy disruption

If new disruptors do not come into this sector and use technology to be able to streamline the whole process it will create more of a burden in the future, not only for patients and for doctors but for the whole healthcare system as a whole.

You’ve had many people look at the front end of healthcare, the likes of these very prominent video consultation platforms. Some of these platforms use AI technology but sometimes people forget about the most crucial element, you still need to get the medicines that are being prescribed into the patient’s hands. It doesn’t matter how many remote consultation platforms you have out there. If people are still not getting their medicines it means nothing.

Evolving customer expectations

We want to bring pharmacy as it is into the current time and we wanted to be a service that’s more aligned with consumer expectations today, as in getting your medications delivered on demand on the same day to a time and place or location that suits you.

The other thing is that we’re trying to make it more convenient.

Ultimately, our service is really designed to help those who need the service get their medications in a timely fashion. Whether you be elderly, single parent, busy working professional, or whether you be someone who’s incredibly tech savvy.

We’re already seeing a younger generation who are basically choosing healthcare on their own terms. They’re using services like video consultations, or chat enabled AI systems. All those systems lend themselves very well to a delivery service such as what we’re offering. It’s completely plausible to expect to have your medications delivered to your home if you’re having a video consultation with your doctor at home.

Predictive software

The reason we are also trying to avoid that no-stock situation is because we’re employing certain types of predictive inventory software and we’re looking at the data around what medications are most consumed. And we also look at the most commonly prescribed drugs of a doctor who uses our service to always ensure that we have an adequate supply.

Faster treatment

By offering free same day delivery, often within one to three hours, we’re quite setup for those people who’ve got time critical care needs. We’re helping people get treated faster, which results in better drug compliance, which results in better medicine adherence.

Continuity of care

Doctors love the service because not only can they send their prescription to us electronically but they also are notified the moment deliveries made so from a continuity of care point of view. And it’s also a value added service for them because as it stands today there’s a detachment from pharmacy and doctor.

Your doctor doesn’t know the challenges that you’re going to face as a patient to try to get your medication. They don’t even know necessarily if you’re going to take your medication because of the fact that you can’t get it, but with a service like AWS they have the comfort knowing that we’ve received their prescription.

Impact of COVID-19

The Coronavirus pandemic has seen the acceleration of digital transformation for many industries, including pharmacy disruption. We discuss the long term impact of the change in behaviour and customer expectations exacerbated by COVID-19.

Increase in demand

The demand for our services absolutely has gone through the roof.

We were originally delivering in (London) zones one to four. We have now stretched out to zones one to six.

Change in operations

What I’ve noticed over the past few weeks with the current COVID-19 lockdown is that a number of the pharmaceutical wholesalers have had to really streamline their delivery services.

Our delivery drivers have obviously had to change the way they operate and work within this current lockdown situation. We’ve had to focus purely on online payments.

Change in mindset

People don’t want to go out and pick up the medicine because they don’t want to risk exposing themselves to other people. And if anything, this whole pandemic really hits home two key things:

1. Sick people shouldn’t have to go to the pharmacy. When you’re unwell you can get anything else delivered to your home… Why should you not get your medicines delivered to you?
2. Sick people shouldn’t be going out in public: They shouldn’t be going to the pharmacy risking exposure to the pharmacist, they shouldn’t be using public transportation risking exposure to other people. They should stay at home and let services, such as Zotti or similar, come and deliver their medicines to them at home.

Future of Pharmacies

The role of robotics

By the year 2050 the majority of dispensaries will have some form of robotic dispensing capability because:

• they can operate 24/7
• they can be linked to whatever system they need to be. They can be linked directly to a doctor’s prescribing platform
•  the use of AI technology can also be in place to minimise any mistakes doctors may make

I think it’s a given pharmacy of the future will be more tech enabled, it will be more integrated and they will be a logistics element attached to the end of it.

The value chain

In terms of the whole ecosystem, I think a more integrated and more thorough pharmacy element is definitely required, certainly in terms of dealing with not only primary care patients but secondary care patients as well. A service such as what we offer does not have to be just focused on prescription medication. We could also be delivering Over the Counter (OTC) products and other products you would typically get in the pharmacy. We already know what the most popular Stock Keeping Units (SKUs) are within the pharmacy. And if you’re delivering medications to a particular individual, why not also deliver the other types of products that they would traditionally get from their pharmacy?

Pharmacists of the future

I think the reality is that there will always be a place for pharmacists… technology will not completely replace the need for a superintendent pharmacist.

But I think the question is who will they work for. There certainly will be in the future options to work for some of these technology disruptors within this space or the ability to embrace technology in their own pharmacy.

I think the industry as a whole needs to give more powers to pharmacists. We’re already seeing more and more pharmacists, with the ability to prescribe. And I think that will start to increase.

Is retail pharmacy ready for disruption?

Curzon Consulting Healthcare lead, Chetan Trivedi, argues that a perfect storm is approaching in Healthcare, and it’s been brewing for a while…

On one hand, we are seeing an ageing population, with growing multiple comorbidities, requiring more complex care. On the other hand, according to the International Monetary Fund (IMF), in 2017, global debt had reached an all-time high of $184 trillion in nominal terms, the equivalent of 225 percent of GDP.

In order to “move the needle”, Healthcare systems need to radically move away from “tinkering round the edges”, and instead, focus on delivering transformative change (focusing on prevention, implementing new care delivery models enabled by technology, better triaging and stratifying patients to determine best intervention point (hospital, community, home, etc.), leveraging appropriate skills set to treat patient (physician versus pharmacists versus nurse, etc.).

Some of the choices may not be popular, but if left unchecked, on the current trajectory, we will leave the future generation with a formidable challenge.

So, what are the 10 factors generating the perfect storm in healthcare?

Unprecedented level of total global debt-to-GDP (225%)* during peace time. Simply printing more money, creating more debt or throwing more funds at an outdated healthcare system is not going to help. Health systems need to improve quality and reduce cost-per-capita quickly. Focus on evidence-based disease prevention is key.

*Global debt has reached an all-time high of $184 trillion in nominal terms, the equivalent of 225 percent of GDP in 2017. On average, the world’s debt now exceeds $86,000 in per capita terms, which is more than 2½ times the average income per-capita. International Monetary Fund, 2019

We have just completed a major assessment of hospital, satellite and home dialysis delivery models.

We reviewed the efficacy and cost models associated with hospital, satellite and home dialysis models in multiple countries. In conclusion, whilst it’s not a one size fits all solution, home dialysis is a clear winner for the majority of people on dialysis.

Not only is a home dialysis solution 30-60% more cost effective over hospital and satellite models, it allows patients to perform dialysis in the comfort of their own home, significantly improving quality of life. No longer do patients have to visit a hospital or satellite centre 3 times per week/4-5 hours a session (incl. avg. commute time).

In addition, patients at home can perform nocturnal dialysis, which allows them to maintain a normal working life, which it itself results in wider benefits to the individual and society.

• There are 5 stages of Chronic Kidney Disease (CKD). Stage 5 is classified as end stage renal disease and is when a patient requires renal replacement therapy (transplant or dialysis)
• The Glomerular Filtration Rate (GFR) measures the amount of blood that passes through the tiny filters (glomeruli) in the kidneys, each minute
• The National Service Framework for Renal Services defies normal renal function as estimated GFR = />90 ml/min/1,73M2
• As Chronic Kidney disease (CKD) progresses the GFR falls
• Patients in ESRD have three treatment options:
  1) Conservative Treatment – manage symptoms of kidney failure via lifestyle changes
  2) Dialysis Treatment – conduct haemodialysis or peritoneal dialysis
  3) Kidney Transplant – replace kidney; more cost effective over 10 years than dialysis, but shortage of donors, means dialysis segment will grow
• Patients who commence dialysis can have their treatment at a hospital, satellite (standalone clinic) or home
• Haemodialysis and Peritoneal dialysis have similar long-term survival rates

• In England, there are an estimated 2.8m diagnosed and undiagnosed people (6.1%) of the population (>16 years old) that are thought to have CKD (Stage 3-5).
• In 2018, total population in England was ~56m, of which, >16 years old accounted for 45.4m (81%)
• CKD affects ~2.8m people over the age of 16. An estimated ~60,000 patients have End-Stage Renal Disease (ESRD), of which, ~30,000 are on dialysis
• Prevalence rates are rising, largely due to better detection (2.4% in 2007, 4.3% in 2010 and 6.1% in 2017), poor nutrition and lifestyles, which is likely to cause pressure on health budgets
• Prevalence of chronic kidney disease stage 3-5 is expected to increase to 3.2m people by 2021 and 4.2m by 2036
• There are ~40,000 premature deaths every year due to chronic kidney disease (that’s enough people to fill the Royal Albert Hall nine times over)
• Chronic kidney disease diminished quality of life for many people and represents a significant financial burden on the NHS
• Black, Asian and minority ethnic communities are five times more likely to develop chronic kidney disease than other groups

• NHS England spends £1.7bn per annum on CKD (more than the combined £1.4bn cost to treat breast, lung, colon and skin cancer)
• Patients with CKD are likely to develop other health conditions, namely Hypertension, Stroke and/or Myocardial Infarction, resulting in adjacent costs in other non renal areas
• Mean annual direct cost of Dialysis care per patient is estimated to be £577m/30,000 = £19,233
• Full reimbursement by NHS and free at point of care

Source: Public Health England, CKD Prevalence Estimates published in 2014; Chronic Kidney Disease in England – The Human and Financial Cost; Curzon Consulting analysis

Home dialysis solution is not for all patients. Based on our analysis, when home dialysis is utilised, it can cost up to 40-60% lower than dialysis performed in hospitals and 30-40% lower when compared with satellite clinics

The total annual cost of delivering APD and CAPD is substantially lower than that for HD.

Studies in Belgium, Canada, France, Germany, Italy, Japan, Netherlands, Spain, Sweden, Switzerland, UK and USA also found home-based modalities to be more cost effective.

In some countries, two patients can be treated on CAPD versus HD.

Despite overwhelming clinical and commercial evidence, home-based dialysis remains a small segment.

Payment models drive perverse incentives and therefore influence modality selection.

If you’d like to learn how to design and implement an evidence-based home dialysis proposition, which can significantly reduce cost and transform patient quality of life, please get in touch.

Curzon Healthcare lead Chetan Trivedi has just completed an extensive study of Mobile Stroke Units (MSUs) in Australia, Argentina, Canada, Germany, Norway and the United States of America.

Our study included a detailed review of the efficacy of stroke management solutions, including the impact on economic and social costs downstream. We have also performed a detailed assessment of people, process and technology required to implement such solutions in other countries. Whilst our example shared below is focused on the UAE, a MSU can be implemented by any health system.

By adopting a Mobile Stroke Unit model, a health system can increase stroke survival rates, reduce disabilities and optimise the associated economic and social cost of care for stroke survivors through drastically decreasing “alarm-to-scan” and “scan-to-treatment” times.

Given our extensive intellectual capital (research and analysis) on the topic, we are able to develop a high-level business case within a few weeks for a local, regional or national health system.

By adopting a Mobile Stroke Unit (MSU) model, the UAE can increase stroke survival rates, reduce disabilities and optimise the associated economic and social cost of care for stroke survivors through drastically decreasing “alarm-to-scan” and “scan-to-treatment” times.

• There are two key types of stroke: ischemic and haemorrhagic
• Globally, ischemic stroke is the most common, occurring 85% of the time; but whilst haemorrhagic strokes only occur 15% of the time, they are responsible for 40% of deaths
• In the UAE, stroke is the third leading cause of death – “10,000 people suffer from stroke… every year”
• Stroke is the “number one cause of disability” – with only “10% of victims reaching a hospital on time to make a full recovery”
• Stroke “is estimated to cost the UAE around AED 3 billion per year, with additional cost to the economy of a further AED 4 billon in lost productivity, disability and informal care”
• The UAE had no stroke units in 2014 versus 12 in 2019, which is a major step in the right direction
• “The average age of occurrence of stroke is 45 in UAE which is much lower than the world age of 60 years”

• 2,000,000 brain cells/ neurons are lost every minute after a stroke, which translates to “Time is Brain”
• The earlier the stroke patient is diagnosed and treated, the better the patient outcomes, leading to a significant reduction in total cost of treating the patient over the life of their associated disabilities

Typical traditional model for stroke treatment is:

• Patient transported via ambulance into Accident & Emergency (A&E) or a specialist stroke unit
• Type of stroke determined by CT scan (a stroke patient cannot be treated until the type of stroke is determined)
• Treatment is administered based on stroke type (ischemic and haemorrhagic)

Through-out the entire process (from acute symptom onset to treatment), significant time is lost, which results in higher mortality risk and additional complications downstream

• Instead of patients being transported to A&E or a specialist Stroke Unit, losing valuable time, a specialist Mobile Stroke Unit (MSU) can travel to the patient to deliver emergency point-of-care diagnosis and treatment onsite
• The Mobile Stroke Unit solution was pioneered in Germany back in 2011 and such solutions are being delivered in Australia, Argentina, Canada, Germany, Norway and the US

Key Mobile Stroke Unit attributes typically include:

• appropriately trained emergency response team (e.g. driver, paramedic, critical care nurse and CT technician, optional Vascular Neurologist)
• a Computerized Tomography (CT) scanner
• a point-of-care laboratory system (e.g., serum sodium, potassium, chloride, ionized calcium, total CO2, glucose, etc.)
• a telehealth solution, where a Vascular Neurologist and Pharmacist can video call into the Ambulance to provide guidance to the paramedic team
• an Artificial Intelligence solution to provide on-site diagnosis to rule out stroke-like symptoms (e.g. migraines, seizures, Bells Palsy, inner ear problems etc.), which may not be related to stroke

The most important benefit of the Mobile Stroke Unit is rapid diagnosis of the stroke type and treatment with intravenous tissue plasminogen activator (TPA) can be started more rapidly if appropriate

A randomised controlled trial shows, treatment with Intravenous TPA can be started within an average of 38 minutes when patients are treated in an Mobile Stroke Unit compared with 73 minutes under the existing model