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Friday 30 September 2016
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EPS – friend or foe?

Systems & Information

Ailsa Colquhoun
Freelance journalist specialising in pharmacy

Complete confidentiality. Genuine medicines. No embarrassment. That's how Lloydspharmacy is marketing its online private doctor services that now include: impotence treatment, oral contraceptive services, sexual health tests and chlamydia treatment.

From April, online private GP services have also been rolling out in the independent pharmacy sector, thanks to the recent link-up between independent community pharmacy wholesaler Alliance Healthcare (formerly UniChem) and online GP services provider Dr Thom.

There is little doubt that consumers see the internet as a channel for purchasing goods and services with unrivalled access and convenience. Despite the risk of fake medicine and the lack of face-to-face contact with a healthcare professional, internet-based healthcare is an area of rapid growth. It is officially recognised that it improves patient access and choice of pharmaceutical services; accordingly, health and medical-related traffic now ranks in the top 10 of all UK internet traffic categories, according to internet traffic monitor Hitwise.(1)

Search terms such as "Boots" and "Lloydspharmacy" are most commonly used by men and women in all age groups with health-related needs, but particularly in the "silver-surfing" 55+ year age band. Perhaps of most interest to dispensing GPs are the regional figures, which list East Anglia and Scotland among the areas of mainland Britain with the largest health and medical surfing communities outside London.(2)

Internet pharmacy has been in existence in the UK since 1999, when it was pioneered by online retailer Pharmacy2U, and while early internet offerings related more to the retail side of community pharmacy, over the past few years there has been increasing interest from pharmacies in providing NHS services online.

Although the number of UK pharmacies registered with the Royal Pharmaceutical Society of Great Britain (RPSGB) as legitimate online providers of pharmaceutical services remains small – currently there are 94 – recent years have seen a renewed interest in the online NHS pharmacy services market.(3) In 2007-08, for example, 11.6% of the applications for pharmacies made to primary care trusts (PCTs) in England and Wales under exemptions from the control of entry regulations were for internet or mail order pharmacies. Of these, almost three quarters (73%) were approved, resulting in 27 new pharmacies in this field.(4)

It is, perhaps, an indication of the envisaged commercial potential that this is the only category of exempt pharmacy application to have increased each year since the exemptions were introduced. In 2007-08, applications to this category of exemption were up 37%, compared to the previous year.(4)

Pharmacies have embraced the business opportunities of the internet on different levels. Some, such as Prestwich Pharmacy, use their websites as a second shop-window for the bricks and mortar pharmacy, marketing services such as its prescription collection and delivery service alongside private retail services such as hypnotherapy and massage, as well as advertising clinics for cosmetic treatments, podiatry, massage clinics and physio.

Others, such as Reach Pharmacy, offer additional website functionality by enabling patients to order private and NHS prescription collection and delivery online. Additional services include a free health recorder area for items such as patients' medical history and diagnostic information.

In 2001, Pharmacy2U was selected to lead a two-year NHS pilot project for the electronic transmission of prescriptions (ETP), an experience it says "gave it invaluable technical and operational expertise, which it used to develop its own unique services and capability". In 2005, Pharmacy2U was one of the first pharmacies to be awarded an NHS mail order contract. Its online offering now includes a repeat prescription reminder service and prescription synchronisation that ensures patients are ordering and taking their medicines appropriately.

In an e-marketing statement, the company says that hundreds of thousands of people across the UK are already using its services to avoid long or difficult journeys to the doctors and the pharmacy, or to access improved confidentiality and cheaper products.

But now, with its eyes firmly set on the prize of e-prescriptions, Pharmacy2U has partnered with EMIS, whose IT systems are in common use in the country's GP surgeries. The internet retailers see big opportunities in the fact that the Electronic Prescription Service (EPS) will allow all patients who visit their GP to have their prescription delivered automatically to their home. It says: "Pharmacy2U will be able to manage prescriptions from request to delivery, providing patients with unique benefits such as the ability to request repeat prescriptions electronically."(5)

Testing times
Often fragile, the relationship between dispensing doctors and pharmacists has been tested many times over the course of the past year, and with the roll out of the national vascular risk assessment (VRA) programme from April this year, the situation could be set to heat up again.

The VRA programme has been on the Department of Health's agenda since April 2008 and, buoyed by key mentions in the pharmacy white paper, Building on strengths – delivering the future, pharmacists see the service as ripe territory for pharmacy service development.(6) Unperturbed by the government's failure to make this a directed enhanced service, English contract negotiators the Pharmaceutical Services Negotiating Committee (PSNC) have already published resources for local pharmaceutical committees designed to support VRA service development bids. Despite dispensing doctor warnings that the pharmacy VRA service is "uncosted" and "not piloted",(7) in some areas of the country the pharmacy VRA is already a reality.

Pharmacists and dispensing doctors have also come to blows over the subject of the forthcoming Responsible Pharmacist legislation. From October, this will enable pharmacists to be absent from an open pharmacy for short periods. Angered by the Dispensing Doctor's Association's (DDA) view that pharmacists should be able to delegate some dispensing in order to do clinically useful work, the then Royal Pharmaceutical Society president Hemant Patel said that the DDA response "vastly underestimates the role of the pharmacist in ensuring patient safety". The spat ended with the plea that the president's comments should not signal "a return to old animosities".

Then, on the publication of the white paper, pharmacists and doctors squared up again – over suggested new roles for pharmacies in minor ailment services, among others, plus proposals to allow dispensing doctors to sell over-the-counter medicines and to revamp the one-mile rule.

Citing the pharmacy minor ailment service, Dr Allan Tennant, DDA Vice-Chairman, said in a comment issued at the time of the white paper's publication: "It ends the holistic approach. Dealing with patients' minor illnesses is how the deep and trusting relationship develops. Patients often present with minor illness, before plucking up the courage to tell you what they really came about."(7)

Add in wider practice concerns about lost Quality and Outcomes Framework data, and it becomes evident that professional relationships between doctor and pharmacist are, as the white paper suggests, still strained.(8)

EPS – payback time?
Since the start of the revised pharmacy contract in 2005, pharmacists have been encouraged to invest in premises and in service development that makes more effective use of their clinical skills. Yet they feel they have been rewarded only by unpredictable NHS reimbursement and by service commissioning officially described as "variable, leading to inconsistencies … less mature in respect of primary care services generally" and ultimately "not yet at a stage where PCTs can be charged with full responsibility for contracting".(6)

Official statistics suggest there could indeed be room for improvement in commissioning. Stop smoking and the minor ailments service are two of the four most commonly commissioned local enhanced services – yet in 2007-08, stop smoking services were commissioned in just under half of all community pharmacies while minor ailments schemes were in place in around one in four.(4)

Patient nomination, as part of the EPS, requires all contractors to inform patients about their rights each time a prescription is written. These include the patient's ability to choose any one of their three nominees: a community pharmacy and/or an appliance contractor and/or a dispensing doctor.(9)

But, unlike with established prescription collection services, EPS patients will be able to request that their prescription is sent to any pharmacy, regardless of the geographical location or the working relationship between the pharmacy and the prescriber.(10) Clearly, well-marketed online pharmacy businesses stand to gain from this new business. A further challenge for dispensing doctors is that their patients can only nominate them at the practice itself, and not remotely – via Healthspace, for example.(9)

Despite ongoing problems with the implementation of the EPS, some 87% of NHS pharmacies are now EPS Release 1 enabled, and all have received guidance on patient nomination.(11) This makes clear that although pharmacists are prohibited from providing patients with inducements to encourage nomination of a pharmacy, like dispensing GPs, they will be able to display their EPS Release 2 sign once the service is enabled. It is hoped that at least one dispensing system supplier will have EPS2 systems through technical accreditation by the end of the summer.(12)

IT consultant Geoff Mackay regularly advises the dispensing community on the business opportunities IT presents. He says pharmacists are increasingly getting to grips with marketing using IT: "In the current uncertain financial climate, pharmacists are working very hard to find new income streams, and they are beginning to see IT as one way to tap into these."

In the absence of any EPS2 systems on the market, it is too early for actual nomination to take place. But as the PSNC notes, some pharmacists are already "preparing" customers for the nomination stage of EPS2. The question dispensing doctors should ask themselves is: are you?

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References
1. Medicines and Healthcare products Regulatory Agency. Buying medicines over the internet [homepage on the internet]. Available from: http://www.mhra.gov.uk/Safetyinformation/Generalsafetyinformationandadvi...
2. Hitwise data on file.
3. Royal Pharmaceutical Society of Great Britain. Internet pharmacy logo [homepage on the internet]. Accessed 9 March  2009. Available from: http://www.rpsgb.org/registrationandsupport/registration/internetpharmac...
4. NHS Information Centre. General Pharmaceutical Services in England and Wales 1998-99 to 2007-08. London: NHS Information Centre; 2008. Available from: http://www.ic.nhs.uk/statistics-and-data-collections/primary-care/pharma...
5. Pharmacy2U website statement. Accessed at: http://www.pharmacy2u.co.uk/static/aboutus/shapingthefuture.aspx?guid=4f...
6. Department of Health. Pharmacy in England: building on strengths – delivering the future. London: DH; 2008. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/DH_4122399
7. Dispensing Doctors' Association website statement. Accessed at: http://www.dispensingdoctor.org/content.php?id=447
8. Colquhoun A. Dispensing debate drums up drama – is battle about to commence? Management in Practice 2008;15:40-4.
9. NHS Connecting for Health. EPS and dispensing doctors – Factsheet. Available from: http://www.connectingforhealth.nhs.uk/systemsandservices/eps/communicati...
10.    Pharmaceutical Services Negotiating Committee . Patient nomination of a dispensing site [homepage on the internet]. Available from: http://www.psnc.org.uk/pages/nomination.html
11. NHS Connecting for Health. Latest deployment statistics and information [homepage on the internet]. Available from: http://www.connectingforhealth.nhs.uk/newsroom/statistics/deployment?sea...
12.    NHS Connecting for Health. Supplier status [homepage on the internet]. Available from: http://www.connectingforhealth.nhs.uk/systemsandservices/eps/suppliersta...

Resource
Further information on using Release 2 of the EPS can be found at: http://www.connectingforhealth.nhs.uk/systemsandservices/eps/staff/guida...