Direction of prescriptions
Direction of prescriptions
The term ‘direction of prescriptions’ is used to describe the exercise of undue influence by a medical practice over the choice of where a patient takes or sends their prescription to be dispensed. It can also be used to describe situations where pharmacy owners and pharmacists encourage medical practitioners to recommend their pharmacy, by way of offering a gift or reward.
Prescription direction should not take place. Patients are entitled to take decisions about where they want their prescriptions to be dispensed; therefore, if a patient prefers to use a particular pharmacy, the NHS Constitution requires that this preference is respected. This page sets out how PSNC has been working to support community pharmacy contractors and LPCs who are concerned about potential prescription direction issues.
Click on a heading below for more information.
Direction of paper prescriptions
Although there are legal safeguards in place to prevent the EPS nomination functionality being used to facilitate the direction of prescriptions (see section below), there are no similar safeguards to protect patient choice for paper prescriptions. PSNC believes that as paper prescriptions will continue to be issued for some time; there should be a change to the regulations to prohibit the direction of prescriptions.
Although there is currently no legal prohibition, the GMC have guidelines (see the section called “Decisions on Patient Care”) linked to the direction of prescriptions which make it clear that patients should be free to choose from which pharmacy to have their prescribed medicines dispensed and doctors must not allow their own or their employers’ financial or commercial interests in a pharmacy to influence the way they advise their patients. A doctor’s failure to adhere to these standards could form the basis of a complaint of professional misconduct.
EPS nomination and direction of electronic prescriptions
In April 2005, the National Health Service (Primary Medical Services) (Miscellaneous Amendments) Regulations 2005 came into force which stipulate that when operating the Electronic Prescription Service (EPS), a prescriber must not seek to persuade a patient to nominate a dispenser recommended by the prescriber. The regulations also state that, if asked to recommend a chemist, the prescriber is to provide a list of all chemists in the area that operate EPS, as provided by the local NHS England Team (this provision is continued by the National Health Service (General Medical Services Contracts) Regulations 2015 – see Regulation 58 (4)).
Promoting my pharmacy and the electronic prescription service
All pharmacies are expected to promote the NHS services that they provide. When an area goes live with EPS release 2 there is sometimes an increase of promotional activity, particularly from distance selling pharmacies whose business model is better suited to EPS. Many pharmacies will not have considered the need to promote their pharmacy before, and may not welcome the competition. However, competition is healthy as it helps encourage pharmacies to provide a high quality service that is responsive to the needs of the public. Pharmacies that wish to promote their own pharmacy through leaflets handed to their patients, or through mailshots, sometimes ask for guidance on how to inform patients of the benefits of EPS and to clear up any potential misunderstandings about the ways that pharmacy services are provided.
PSNC has prepared a template that can be used in these circumstances – the text can be modified to reflect local circumstances.
Background and NHS England poster
2014: Representative bodies send joint letter
PSNC, the BMA and Pharmacy Voice (now defunct) sent a joint letter to the Department of Health and NHS England to reiterate concerns about schemes that encourage or have the potential to encourage the direction of prescriptions. The joint letter built on previous expressions of concern made by PSNC and Pharmacy Voice about direction of prescriptions, especially in cases where GPs may have a financial interest in the pharmacy in which their prescriptions are dispensed.
Since then LPCs and LMCs have also been working hard to address problems that arise locally when financial considerations affect the freedom of patients to choose their pharmacy.
2015: Action by NHS England
As part of ongoing work to address the direction of prescriptions, NHS England wrote to all general practices and pharmacies to ask for their help in ensuring that all patients are aware of their right to choose freely where they have their medicines dispensed and can exercise this right without influence. A poster which sets out this right was sent with NHS England’s letter, and a copy of that poster can be downloaded below.
Additionally, PSNC produced the following briefing as guidance for LPCs and LMCs:
PSNC issued this set of FAQs (see below) on direction of prescriptions for help in addressing any local issues and NHS England will be sending a poster to GPs and pharmacists which assures patients that they are free to choose any pharmacy they would like to use for the dispensing of prescriptions.
Q. What is direction of prescriptions?
A. 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 (EPS), 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?
A. 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?
A. PSNC and the National Pharmacy Association (NPA) have been lobbying the Department of Health and Social Care (DHSC) 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 DHSC 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 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 (now defunct), representatives from the British Medical Association, as well as the professional regulators – the General Medical Council and the General Pharmaceutical Council. In 2015 it was agreed that a poster would be sent by NHS England for display in medical practices and pharmacies, informing patients that the pharmacy that they use is for them to choose. PSNC will continue to monitor the situation.
Q. Is there anything pharmacies can do, if patients are unhappy with their prescription going to a particular pharmacy?
A. 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?
A. 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 EPS 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?
A. 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?
A. 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?
A. 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. Changes to NHS Business Services Authority (NHS BSA) data publication policies in recent years mean that pharmacy level dispensing data is now 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.
Joint BMA and PSNC guidance on prescription direction
One of the notable successes recently has been agreeing with the British Medical Association, that direction of prescriptions should not occur – and we have agreed the above guidance notes to support that position.
Poster on freedom of choice
NHS England sent a copy of this poster to all community pharmacies and GP practices in October 2015. It is intended to help ensure that all patients are aware of their right to choose freely where they have their medicines dispensed.
Template letter for patients who have stopped visiting a pharmacy
A pharmacy that has had a sudden loss of regular patients may wish to use this letter 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.
Template patient leaflet for EPS promotion
Pharmacies may wish to use this leaflet to promote their pharmacy whilst informing patients of the benefits of EPS and clearing up any potential misunderstandings about the ways that pharmacy services are provided.
PSNC Briefing 023/15: Providing pharmacy services at a distance (April 2015)
The General Pharmaceutical Council (GPhC) has issued guidance for registered pharmacies providing pharmacy services at a distance. This will apply to most community pharmacies, both distance selling and bricks and mortar, as many now provide collection and delivery of prescriptions as part of their dispensing process. This briefing summarises some of the key aspects of the guidance and how pharmacy contractors can ensure they are following them.
PSNC Briefing 008/15: Directions of Prescriptions (February 2015)
Patients must be allowed a free choice between any community pharmacy and the NHS Constitution requires that this preference is respected. This briefing explains what GP practitioners and pharmacists must and must not do.
PSNC Briefing 095/13: Direction of Prescriptions (September 2013)
This PSNC Briefing includes summaries of the regulations and guidance relevant to this topic, as well as an update on PSNC’s work in the area, and may be of use to contractors and LPCs affected by the issue.