Part 1 – Behind the scenes of Dispensary Green patient Q + A

In a Dispensary Green first, we recently held a virtual Q + A event giving patients the chance to find out more about the workings of Dispensary Green, and also about the wider medical cannabis ecosystem.

The session was chaired by Jeremy Roth, a medical cannabis patient, and Chris Ashton, our Superintendent Pharmacist, Richard Neilson, Director of Pharmacy Operations, and – all the way from Canada – Madeline Carter, Programme Manager at Northern Green joined to answer your questions.

We’ve broken the Q + A into several parts (because there were quite a lot of questions asked!) and tried to break them up into related sections to make it easier for you to read.

We’ll be sharing these across the week and in Part 1 of our Q + A coverage we get to know a bit more about the speakers, and answer questions relating to patient experience and industry standards.

In Part 2 we’ll be sharing the questions asked about pharmacy guidelines, product availability, COVID and Project Twenty21

In Part 3 we’ll be looking at the supply chain and the different types of product, and in Part 4 we’ll be answering questions on costs to patients, thoughts on the black market vs legal medical cannabis and hear what our panellists want to see happen in the industry in the next year.

You can also watch the webinar in full on our Youtube page.

Introductions

Jeremy Roth:  Hi everyone, welcome to the event. My name is Jeremy. I am a medical cannabis patient and was asked by Dispensary Green to chair this event. I came to medical cannabis from a background of desperation. I’d never used cannabis in any other form before, and I was struggling to manage my conditions and discovered medical cannabis. And it changed my life – and I’ve been involved with the industry ever since.

I’m not an employee of Dispensary Green or LYPHE Group or anything like that, but I am involved in the industry as a kind of vocal critic sometimes, and supporter and advocate for patients at other times. We’re joined today by a few people that we’re very lucky to have with us. We’ve got Madeline from Northern Green in Canada, one of the producers that Dispensary Green works with – who has got up bright and early to join us – which we’re really appreciative for.  I’ll just start by introducing Chris, who many of you know..

Chris Ashton: Thanks, Jeremy. And thank you for taking the time out to chair this event. It is appreciated. So, for those of you that don’t know me, I’m Chris Ashton and the Superintendent Pharmacist at Dispensary Green. I joined LYPHE Group, which is the holding company for Dispensary Green about two years ago, when the industry opened. My role has been to procure products and launch a system to give patients access to prescription medication.

Richard Neilson: My name is Richard Nielsen. I’m quite new to LYPHE Group. I’m really excited to be here. My background has been in urgent care and NHS 111. And I’m hoping to bring some of those skills to help people and improve their outcomes. I’m the pharmacy Operations Director for Dispensary Green, I also work one day a week for TMCC (The Medical Cannabis Clinics). So I support them with prescribing as well. And I also am an LP for a wholesale dealer as well.

Jeremy Roth: Brilliant, thank you so much – we’re going to pass it on to Madeline Carter, who we are incredibly lucky to have join us from Canada. Madeline, do you want to give us a bit of background about you, please?

Madeline Carter: Thank you guys again for having me here. My name is Madeline Carter, I work with Northern Green Canada. I am the Production Manager here at our facility, we grow our cannabis, manufacture, and package here. We’ve been working very closely with Dispensary Green and LYPHE Group over the past few years. I’ve been in the industry for four years now and very excited to give everybody some background information on how we produce the product and send it over.

Jeremy Roth: Great, thank you very much. Okay. I just wanted to start with giving Chris an opportunity to address everyone. Obviously, this is the first of several of these events, hopefully chaired by different people at different times. And I’m really glad that people are going to get an opportunity to ask questions. Obviously, we’re going to be somewhat limited for time but I will try and get as many questions as I possibly can in. Some of the questions have required a little bit of preparation, but others will be done on the fly. So there we go. Chris, I want to just kick it to you to start off with

A word from Chris Ashton, Superintendent Pharmacist…

Chris Ashton: I just want to take a moment really to acknowledge the difficulties that we’ve had at Dispensary Green and how the service has suffered and acknowledge the experience that a lot of patients will have had over the last year or so.  I don’t want to hide from the fact that we have struggled. We’ve struggled with how quick the industry has moved and the supply chain and many things. I certainly don’t want to make excuses. But I did want to offer a public apology.

We are working hard to address those issues. It isn’t easy, and it does take time. But we are investing in everything we need to in order to improve the service. And I’m confident over the next month or so we’ll see a dramatic improvement.

I’m sure we’ll cover some of those points as we go through the Q+A session. So I just wanted to put my hand on my heart and say look, I’m genuinely sorry if we have let anyone down. And that certainly isn’t our aim. And our aim moving forward is to help everybody that does come through the door.

Industry standards

Jeremy Roth: What is GMP? and how does this impact product availability?

Madeline Carter: So GMP stands for ‘good manufacturing practises’. It’s a quality standard that is given through a certification process. It’s an audit process that our company has gone through. We had some auditors come over from the European authority and give us our certification. It’s a very high standard for us to achieve which we received in March 2020. 

It impacts the supply because only the highest quality product is able to be sent under this GMP licence because the standards are so strict. So we have microbial standards that we need to meet, packaging standards and all of the quality standards that go along with that. That impacts the product availability because the standards are so high.

Jeremy Roth: How does GMP production differ from a non-GMP production?

Madeline Carter: So we follow the European guidelines. There are pharmacopoeias that we have to follow and European monographs. There are testing standards that we have to follow as well, which other producers may or may not have to follow. There are standards within Canada for all producers. However, through the European standards, they are much more strict. We have stricter quality systems that we have to follow stricter packaging processes that we have to follow as well. And all sorts of guidelines through the European Pharmacopoeia that we adhere to, for that.

Jeremy Roth: Could you just explain the difference between GMP and GACP?

Madeline Carter: Sure, so GACP stands for ‘good agricultural collection practises’. So it’s a set of regulations that governs the growing and cultivation of cannabis. GMP begins after the plants are harvested – so that’s the processing of the flowers where different standards are applied. The GCAP governs the use of pesticides, the use of nutrients and the use of different types of water in the growing process, and follows all sorts of standards in terms of labelling your plants and how the plants are grown. So for example, growing one strain per room to avoid any cross contamination, restrictive use of pesticides to reduce the harm to any patients on the back end. So the GACP process kind of goes hand in hand with GMP.

Jeremy Roth: We’re lucky because Madeline has had experience not just from the supply perspective but she’s been involved from the very grassroots level and from the growing process has quite an insight into the whole supply chain from the very start so thank you Madeline.

What are the GMP standards in the UK? Because it gets talked about a lot but I’m not quite sure many people understand what that means.

Chris Ashton: I suppose the first thing to say is that these are set by the MHRA which are effectively the people that control the quality of goods in the UK market. They focus around THC content, CBD content, terpenes, total yeast and mould content, aflatoxins, all sorts of unknowns that go into a medical cannabis flower. 

We actually now officially have the highest standards in Europe in terms of what is allowed into the country. A lot of countries focus on medical cannabis as a herbal product. So the tolerance for things such as yeast and mould and aflatoxins in it are slightly higher. The UK has taken an approach of dealing with medical cannabis now as a pharmaceutical inhalation product, which means that the tolerances are a lot lower. It can be found in the European Pharmacopoeia. It’s in chapter 5.1 point, I think four or point eight if people do want to check but they are higher standards than what you’ve seen in Germany, Australia, even Canada as the common market.

Jeremy Roth: And how does that impact the supply chain in the UK? Because I understand that there are countries that don’t necessarily always have a GMP supply line, or don’t require GMP in their supply chain.

Chris Ashton: Yeah, so certain countries have different rules. The UK won’t allow anything in that is not GMP and they won’t allow anything in if it doesn’t conform with those standards, so there are lots of products out there that are GMP but don’t meet those standards. 

So I suppose from a choice perspective, the UK has set standards so high that we have limited options as to what could actually physically cross into the territory and be dispensed against prescriptions. So it does make life a little bit harder for those growers to hit those standards, and then those importers to identify available product that’s out there.

Jeremy Roth: Where is the flower packaged?

Chris Ashton: I can answer that. We don’t pack any ourselves here in the UK, all the products that are imported for us to use are packed by the producers. I think there are differing packaging types and methods. I think some vacuum pack, some prefer foil bags, or there’s some in plastic bottles. All of the packaging processes have to be GMP approved, and they have to be validated that they are clean, there’s no contamination with the packaging and that they are then stable and secure during shipping. But it depends on the producers as to what type of packaging they use. I’m aware of a couple of others in the industry that might bring it into the UK in bulk and then pack it down here. But certainly none of the products that we engage to import are done that way. They’re all manufactured, they’re all packaged at the manufacturer.

Jeremy Roth: What’s the risk of that if it was manufactured and then packed here?

Chris Ashton: I suppose for me, it was a choice to not do those things. The funny thing about the GMP system is once it’s packed in its final pack, that’s when the expiry date clock starts ticking. I suppose the risk with bulk is that it could come here and sit in a vault for a year or however long until it’s packed into its final packaging. So, in theory, the product could be older before it reaches the patient. By getting it packed by the producer, we feel the product is fresher and therefore better. And the process itself is done on an industrial scale rather than almost by hand in some cases in the UK.

Jeremy Roth: What’s the difference between a recall and putting a product on hold?

Chris Ashton: The recall is where they ask for all the products back. The other option the MHRA have is a quarantine, of which there are a couple of products currently quarantined whereby they stop further supplies. It’s not an immediate health risk, but they’d like to do some further testing and further clarification just to ensure that the the results they were presented with are still consistent with the state of the material now. And then, of course, there’s markets that are free to dispense. So there’s sort of three categories, you know, recalled quarantined, or freely available.

Patient Experience

Jeremy Roth: What would you say to patients and clients who’ve been waiting for their prescriptions? And who are dealing with fluctuating stock levels with very little ability for a patient to see what’s in stock at any given time?

Richard Neilson: The first thing we need to do is apologise that this has happened to people, but it’s something that I personally am looking to make sure it isn’t something that people see in the future.

We have been unlucky with one particular product that went out of stock, which has then seen increased pressures on alternative products that were very similar. Hence, a couple of products went out of stock. 

And I think that explains the reasons why prescriptions were delayed because there was one prescription written for products, it then went to the pharmacy, and the pharmacy communicated with the prescriber that that was out of stock, and then a second prescription was written. So you think about it that even in the best case, the situation is going to take three or four days to have a turnaround. 

There are some products we can get in on the same day, which is very good. But others have to be ordered by faxing details of a prescription (obviously, without any patient identification information), and that can take three, four, or even even five working days to come in. 

And of course, that causes delays in people getting the medicine. Going forward, something that I want to do, and something that I was brought into the company to do, is to support clinicians. So I will be supporting clinicians by writing prescriptions for the pharmacy. I live about 30 minutes away from the pharmacy, and I’m able to help the consultants that would otherwise be too busy to write these prescriptions on the same day through a shared care agreement.

A shared care agreement is where the consultant looks after the patient but I’m able to continue the treatment and alter dosages within reason, to make sure people get the medicines in a timely manner. So that’s something that will be improved going forward, I can guarantee it.

Jeremy Roth: There have been lots of supply issues in the UK. And what are the plans there to improve this? How is that going to change? And what’s being done to secure a more reliable and consistent supply?

Richard Neilson: It’s been upsetting for us because the one thing that I want to do and what is best for me is to get the medicine to the patient. So when there are issues in the UK, that does make it very difficult.

There are limited suppliers of medical cannabis that are GMP approved. And of course, we will only use those that have been through those stringent standards. We don’t cut any corners, we want people to have safe and effective medicine. And that reduces us somewhat in terms of our supply chain. 

We’re constantly looking at other options. We’re constantly scanning the globe, we have a team that does that. So going forward, especially as more and more producers become available, there’ll be a larger range available to us and we’ll be able to offer that to our patients. I think at the moment that the fact there has been some shortages, in a way I know it’s really, really upsetting for patients, and I understand that some of them are angry. And I really understand that – but it is because of the strict rules that are in place to make sure everyone’s kept safe.

Chris Ashton: I’ve been doing this since day dot in the legal cannabis industry in the UK and finding suppliers is very hard, finding suppliers that are willing to go through the stringent approval process to import into the UK and then reliably have stock available is hard. I would say there’s less than a dozen global companies that are able to fit those standards. 

Whilst the UK is still a very, very expensive market, it’s the most discounted market in Europe. So you know, where there’s limited stock available, naturally some suppliers will choose to supply other countries to support a higher price point. That is why we’re very fortunate to have partners like Northern Green who understand the economics of the UK, and are keen to see the market grow. And I’m sure everybody on here would love to see the NHS embrace medical cannabis for all the benefits it can deliver. 

But we do have some new suppliers coming on board, they’re going through the approval process or have been approved. We do have current suppliers, like Northern Green have got some new strains coming into the market and I have to be careful what I say here, Jeremy, there are certain rules around advertising, but you know, we’re forever looking for new strains and new products that meet those standards. And I think over the next couple of months, you know, we do have some new products coming in. And, you know, hopefully that will plug a few of the gaps and also improve the the options that are there for the prescribers and and you know, those have been unsuccessful in finding a suitable product so far, hopefully, we’ll be able to help them as well.

Madeline Carter:  

Just to speak a little bit further to that, from a supply chain perspective, we’ve also noticed that the demand is very high. And as an indoor facility, we can only produce so much flower in the year – the demand is much higher than what we can produce right now. 

So we are in the process of expanding our facility, and expanding the variety of products that we can offer. That being said, each product does have to go through a validation process in which three lots are grown and tested very strictly to ensure that the process is valid. And then stability studies to get the shelf life for each of those products. So we are in the process of getting several new strains validated and ready to send, looking to do that in the early part of 2022 and we’re very excited. I know there’s some marketing lines I don’t want to cross but we’re very excited to continue to work with the UK and provide a variety of products for the patients there.

Jeremy Roth: Why does it take three, five or sometimes longer to dispense prescriptions when high street pharmacies can dispense in minutes? Or it could be at my door the next day?

Richard Neilson: Because the clinician has to actually post a prescription to the pharmacy – that’s one of the reasons why it will take a day or two, depending on when the clinician actually posts it. Then we’re relying on the Postal Service to make sure it gets there. Also, the pharmacy doesn’t stock medicines, with them being special unlicensed medicines, they have to be ordered specifically for the patient –  and that can take up to four or five days, or even longer with products. 

There are some products that are actually manufactured to prescription nevermind, distributed to prescription, and that can take several weeks. With it being medical cannabis, there’s much more of a process behind the scenes because there are records with it being a private prescription, as well as with it being a controlled drug. So that takes a lot longer manually than what it would do in a standard community pharmacy to get a standard prescription. That’s why it can often take about five days or more to actually get these products. 

But again, it’s because of the restrictions that are in place. I think this is another reason why the UK is quite safe and taking this seriously, because there are so many things that a pharmacy has to do. I’m hoping that explains it. We are trying to get as efficient as possible, in terms of the prescriptions getting into the pharmacy.  I really want patients to get that service as quickly as possible. And that’s what I’ll try and do in the future.

Chris Ashton: Something Richard didn’t mention there is where it’s a patient with a first time prescription most clinics then have to go through a secondary approval process where the initial doctors prescription and suggestion for that patient is then double checked by a team of clinicians to make sure it’s appropriate. Where patients move on to a more stable regime i.e. the same medication each month etc, that then becomes an easier process just writing the same prescription again, knowing full well that they’ve responded appropriately and safely. 

And then for those patients in the Channel Islands, so Jersey and Guernsey obviously, there is an additional permit process as well, which does take days to get approved in order to send it across the internal borders within the UK and its territories.

Jeremy Roth: What should patients do when there is a problem?

Richard Neilson: I think when you’ve got a problem, speak to us and explain that, and then we will deal with that as quickly as possible. 

I think now we’re getting an increased complement of staff and we’ll be able to answer calls a lot more quickly. And I think that’s still the best way to go about it. And once we have a larger team, looking after the customer service, after care in terms of clinical, and prescribes as well, they’ll all work together to actually rectify any issues that do occur much more quickly than what they have done in the past. So I’m hoping that that makes a big difference going forward.

Chris Ashton: Yeah. I was just gonna say, Jeremy, that, not wanting to make excuses, 

as a pharmacy and as a highly regulated industry, we have to follow the rules set before us. So the MHRA dictates what we can and can’t do or say, you know, so does the GPHC, which is our governing body. We are dealing with a schedule two unlicensed controlled drug as well, which puts further restrictions on what we’re able to do. You know, there’s no excuses for not answering the phone. And that is something we are dramatically working on. But at times the processes can be cumbersome and long. 

So the answer or response or remedy might not always be instantaneous unfortunately. We are still a very, very young industry and I think the regulations are hopefully going to be adapted to accommodate this plant. But that does take time in itself. As you all know, with your legal background, things don’t change overnight.

Jeremy Roth: It seems to me, I mean, from just the legal parameters, the goalposts seem to be constantly shifting. Like this recent change in the European Pharmacopoeia to reclassify cannabis flower or something else means a whole different set of guidelines.

Chris Ashton: I think that change has got a lot to answer for. And I know there’s there’s several brands of flowers that are out of stock in the UK. And I think that’s as a direct repercussion of these goalposts moving so you know, I’m hopeful this is it now with the MHRA, and they’ve made their bed and set the goalposts in concrete. 

But I suppose who knows, at this point in time there’s still a heavy stigma associated with medical cannabis. 

And it’s our job as a group of people, whether that be industry professionals, patients or enthusiasts to work together, hopefully, to improve the industry. And you know we want to have more of these events. We want to operate more transparently, we want to share as much information as we can, and we don’t want to hide from the issues we want to sort them out. We want to help this industry grow and help patients, you know that that’s what we’re here to do.

Jeremy Roth: I’ve got to ask this, both as a patient who’s experienced this, and having had lots of questions about this. What’s with the miscommunication? Because it certainly seems like there are times when I speak to different members of staff I’m getting different answers to fundamentally the same question. How’s that going to change?

Richard Neilson: I want to increase training with our staff. Because we’ve grown so quickly, we’ve had to onboard new people, and when you onboard people into a highly regulated market, there does need to be a lot of training – and that training can take two to four weeks sometimes. 

I think a lot of people have not had an adequate explanation because they’ve been speaking to people that have recently been trained –  of course they’re trying their best and there’s no malice in what they’re doing. But they may give misinformation accidentally. And I think that’s sometimes what happens. 

The moment we notice that we do try and rectify it as quickly as possible. But of course, we’re taking on more and more staff. I’m doing a recruitment drive at the moment, we’re upskilling people, we’re improving our training, we’re even improving and expanding our training team. So I think that going forward, people will start getting better customer service. 

And the other thing that we’re doing as well as we’re also implementing a new  IT system, which supports staff and supports the answers to them, to the patients, and it also lets them communicate within the team much more efficiently as well.

Chris Ashton: Since Richard has come onboard he has made a massive difference and brought some amazing ideas we’re implementing now. Number one – a patient representative board within LYPHE Group so patients will get a real time opportunity to feedback issues and, you know, operational processes and ask live questions more directly. 

We’re also implementing an aftercare team, whereby the day after every delivery, each patient will get a call to check they’re happy with what they’ve got and they know what they’re doing with it. If there’s any issues with those products, we can rectify them immediately. 

We’re trying to move from a reactive service to more of a proactive one where we communicate more transparently and more frequently with patients. One difficulty we will always face – and my criticism of the industry as a whole – is there’s not enough collaboration between operators. The information sharing, in my opinion, isn’t what it should be, which is focused purely on the patient. 

So there’s quite a lot of misinformation that gets passed about between operators, and I personally would love to see that improved. We’re reliant on multiple outlets for stock and sometimes we’re not always given a true reflection of what is or isn’t available. And that inherently affects the end user, which is the patient. And my view is that it needs to stop, it needs to improve dramatically, and the industry needs to work better together, and realise there’s patients at the end of every interaction.

Jeremy Roth: What support do you have in place for patients who have issues with their meds or need a replacement prescription? How do you deal with complaints? 

Richard Neilson: When we get complaints my ideal is that we deal with them as quickly as possible. I don’t like receiving complaints, but of course, we do occasionally get them. In terms of improving it going forward, we do have a nursing team that we utilise. So we’ve got a little bit more than just a customer service after team, we’ve got a clinical after team as well. And I think that will help in terms of what we can do with these complaints. 

And of course, as more stock becomes available, and as we get more efficient in terms of our systems, and as we train our staff – I’m hoping that people have less to complain about in the future because they get a much better service from us. As the industry grows, as we grow, we will get a lot better. So it’s not a hope, it’s more of a certainty I think in terms of us improving the services in the future.

Chris Ashton: And I think that aftercare function and moving to being more proactive and checking with patients after they’ve received delivery will reduce the uncertainty, it’ll improve the reliability and help reduce the number of questions and queries we get and where we are struggling to answer all those, it will reduce the the sorts of frustrations of not getting an immediate reply will be much more able to cope with the workload that does come in our direction. 

So, you know, I’m really excited for the next couple of months. I’m really excited to have Richard on board, I’m really excited that our producers are stepping up to the plate and giving more products and more variety. So, you know, I think in the next two months, I’ll be disappointed if we don’t see a dramatic improvement.

That’s the end of Part 1. Keep an eye out for part two in the coming days – and remember you can watch the full webinar on our Youtube page.