Contractor update: direction of prescriptions
Contractor update: direction of prescriptions
May 19, 2015
Following ongoing issues in some areas with the direction of prescriptions, NHS England will soon be publishing a poster designed to increase public awareness of their choice of service.
The intention of the poster, which will be sent to GPs and pharmacists, is to assure patients that they are free to choose any pharmacy they would like to use for the dispensing of prescriptions, and in doing so to reduce the direction of prescriptions.
Direction of prescriptions has been a problem for some contractors for some time and PSNC believes that the best solution would be changes to the NHS regulations to ensure that pharmacies and medical practices protect patients’ freedom of choice and do not do anything that seeks to use undue influence to direct a patient to a particular pharmacy. The roll out of EPS Release 2 has caused some particular concerns about inappropriate setting of nominations and PSNC has been raising this at every opportunity, stressing the need for effective policing and sanctions for direction of prescriptions.
The Department of Health prefers that alternatives to legislation are explored, and so in the first instance we have published guidance for GPs and pharmacies in association with the General Practitioners Committee and we have assisted LPCs in local discussions on the topic. The NHS England poster forms the latest phase of this work.
PSNC will continue to monitor the situation and will seek regulatory change if direction of prescriptions continues to be a problem. Contractors affected by the issue are advised of recent changes to the Pricing Authority’s data publication policies which mean that pharmacy level dispensing data is available online. The data identifies the medical practice where prescriptions originate, allowing analysis of potential direction of prescriptions or inappropriate setting of nomination (e.g. setting in bulk, without patient consent). The data can provide compelling evidence and may be of use to contractors affected by this issue. For example, they may be able to tell if a reduction in their prescription volumes is linked to any unusual dispensing or prescribing patterns elsewhere. Where local analysis points to direction of prescriptions, contractors are asked to raise this with NHS Regions and copy this to PSNC.
PSNC Director of Regulation and Support Steve Lutener said:
“The direction of prescriptions is a significant issue for some pharmacies and LPCs. PSNC wants to see patients able to choose their own pharmacy, based on the convenience to them and the quality of service that is provided. We hope that the communications expected to come from NHS England will help, but, if they don’t, we’ll certainly be pushing once again for regulatory changes. Where the system is not working, please do gather the evidence and share it with us so we can take action if needed.”
Q. What is direction of prescriptions?
On a general view direction of prescriptions can be seen as the sending of prescriptions to a pharmacy other than the one which the patient wanted them to go to. Sometimes it will be sent by the medical practice to a pharmacy; sometimes it will be a pharmacy collecting from a medical practice; and nowadays with the electronic prescription service, it could be the setting of the nomination without the patient’s informed consent. But on a wider interpretation it could also include action taken by pharmacies to encourage patients to use a particular pharmacy by misleading them or applying undue pressure. Overall – it is denying patients their free choice of pharmacy.
Q. Why is this such a bad thing?
For the network of pharmacies to provide the highest quality of service, there needs to be a degree of competition. If a patient has a completely unfettered choice of pharmacy they will choose a pharmacy that provides convenient access, but also provides the level of service and the quality of customer service that best suits the patient. Competition legislation is all about choice and PSNC feels that lowering patients’ freedom of choice interferes with competition and overall can reduce service quality over time. Of course we also want this competition to be fair for all the contractors we represent and direction of prescriptions, for example by putting undue pressure on patients, can interfere with this.
Q. What is being done about it?
PSNC and the National Pharmacy Association have been lobbying the Department of Health to seek amendments to the GP and the pharmacy NHS regulations to provide a more robust framework that ensures that pharmacies and medical practices protect patients’ freedom of choice and do not do anything that seeks to use undue influence to direct a patient to a particular pharmacy. We want to see patients able to choose their own pharmacy, and to be assured that where prescriptions are sent to a pharmacy by the medical practice, this is with the informed consent and at the specific request of the patient. Changing legislation can be a lengthy and complex process so the Department of Health prefers that alternatives to legislation are explored and has advised us to see if our concerns can be resolved in other ways.
We have therefore been working with the General Practitioners Committee and with Pharmacy Voice to highlight what is best practice in terms of the relationships between medical practices and pharmacies. We jointly published a guidance note to GPs and pharmacies, and also asked Local Pharmaceutical Committees (LPCs) and Local Medical Committees (LMCs) to work together to resolve local problems, giving advice to their members. As NHS England commissions both general pharmaceutical and general medical services we have also sought its assistance. It has hosted meetings with ourselves, Pharmacy Voice, representatives from the British Medical Association, as well as the professional regulators – the General Medical Council and the General Pharmaceutical Council. At these we have agreed that a poster will be prepared by NHS England for display in medical practices and pharmacies, informing patients that the pharmacy that they use is for them to choose. If this light touch approach does not work, then we and Pharmacy Voice will be renewing our call for changes to regulations.
Q. Is there anything pharmacies can do, if patients are unhappy with their prescription going to a particular pharmacy?
If a pharmacy is visited by one of their regular patients and told that their prescription has been sent to a pharmacy without their explicit informed consent, the pharmacy can help the patient by explaining how the local NHS arrangements work. If medical practices appear to have made a mistake in sending the prescription to the wrong pharmacy, the intended pharmacy can assist with contacting the medical practice and helping to identify the reason for the mistake, and they can help to ensure that the prescription is retrieved for the patient, or another one is issued. If the prescription has been sent electronically to another pharmacy through the setting of an EPS nomination, the intended pharmacy can help with resetting nomination and contacting the other pharmacy to ask that the prescription is released back into the system.
Medical practices cannot send prescriptions to a pharmacy or allow a pharmacy to collect prescriptions from the medical practice without the consent of the patient; that would undermine patients’ choice as well as being a breach of confidentiality because the prescription contains sensitive patient information. If the patient has not asked for their prescription to be sent to a particular pharmacy, then the medical practice will need to review this breach of confidentiality. If a medical practice were to deliberately ignore the patient’s choice, or continue to make mistakes, then the Information Governance lead at the NHS England region should be consulted. In extreme cases the Information Commissioner’s Office should be contacted. If the misdirection of prescriptions was not a one off, and/or more than one patient was involved then the patient should also raise their concerns with the NHS England region; the pharmacy can help identify the right people for them to contact.
Q. What can a pharmacy do if there has been a mailshot to significant numbers of people in the area, promoting a distant pharmacy?
All pharmacies are expected to promote their NHS services and so long as the promotional materials satisfy any regulatory or professional requirements, promotion helps to maintain competition and this helps drive up quality.
If patients inadvertently sign up for a service, misunderstanding about the identity or location of a particular pharmacy, then the pharmacy that they visit can help by explaining any relevant factors such as the identity and location of the pharmacies involved or how the electronic prescription service works if this is relevant. If the other pharmacy is an NHS distance selling pharmacy then an explanation can be given about the way in which these services are provided (e.g. by mail order or internet). The pharmacy can also help the patient to retrieve the prescription, and reset EPS nomination if required.
There tends to be greater promotional activity just as medical practices go live with the Electronic Prescription Service Release 2 (EPS R2). All pharmacies should consider informing their patients, perhaps through notices in the pharmacy or through leaflets put into dispensing bags, or through their own mailshots, explaining the benefits of the service and offering the patients the opportunity to use the new system. A template leaflet which pharmacies could use to do this is available in the EPS R2 section of our website.
Q. Is there anything that can be done by a pharmacy if a large number of patients have stopped coming to the pharmacy, possibly as a consequence of a mailshot by other pharmacies?
If patients have chosen to use another pharmacy, then that is their choice. If there are indications that they may have been misled or have made a mistake, then the pharmacy can help to unpick the mistake as outlined in the previous question.
If there are no signs of this being a mistake or that the patient has been misled or unduly influenced, then the pharmacy should consider carefully whether there is anything in the way it provides services that could be improved – after all, patients are unlikely to change their regular long-standing pharmacy unless the service has deteriorated or another pharmacy is offering improvements. A pharmacy that has had a sudden loss of regular patients could write to the patients that have stopped visiting the pharmacy and ask why they have chosen to do so – the pharmacy can then use any responses to help review the quality and range of services it provides. No undue pressure should be applied on patients, because that is likely to harden attitudes and deter the patient from returning to the pharmacy. PSNC has a template letter for patients who have stopped visiting a pharmacy which can be modified locally.
Q. Do the professional regulators have any role?
The General Medical Council and the General Pharmaceutical Council have a role where a registrant’s fitness to practise is called into question. The GPhC issues standards of conduct which must be complied with, and it also issues Guidance. There are some elements of the Council’s Guidance on pharmacies providing services at a distance that may be relevant to some of the previous questions.
Q. Is there anything that pharmacies can do to help PSNC secure the necessary changes to legislation?
PSNC has collated information sent by LPCs and contractors where this shows direction of prescriptions has taken place. We hope that with the work undertaken so far medical practices and pharmacies will ensure patient choice is respected and that undue pressure will not be used to interfere with free patient choice. The NHS England poster may also help and pharmacies are advised to display this and they may also wish to check that local practices are doing so.
However; we continue to monitor the situation. Contractors affected by the issue are advised to follow the advice above in the first instance. If the problems are significant then they may wish to involve their LPC or NHS England region, or to carry out some analysis to find out what is going on. Recent changes to NHS BSA data publication policies mean that pharmacy level dispensing data is available online. The data identifies the medical practice where prescriptions originate, allowing analysis of potential direction of prescriptions or inappropriate setting of nomination (e.g. setting in bulk, without patient consent). The data can provide compelling evidence and may be of use to contractors affected by this issue. For example, they may be able to tell if a reduction in their prescription volumes is linked to any unusual dispensing or prescribing patterns elsewhere. Where local analysis points to direction of prescriptions, contractors are asked to raise this with NHS regions and to copy this to PSNC. If we continue to receive evidence of improper conduct then we may pursue regulatory changes.
Q. Can you tell us any more about the NHS England poster?
The NHS England poster is being developed with input from a number of stakeholders including PSNC. The wording of the poster will be short and is designed to explain to patients in simple language that when they receive a prescription they have the right to choose to have it dispensed from any pharmacy that meets their needs. We hope that the poster will be ready and available to pharmacies in the next few months; but this will be dependent on sign off. We expect that NHS England will write to both pharmacies and GP practices to advise them of the need to display the poster.
Further information and guidance is available from our Direction of Prescriptions webpage.