Written evidence submitted by Pharmacy2U (DHS0011)

1. Introduction

1.1   We welcome the opportunity to provide evidence to the Health and Social Care Committee’s independent expert panel evaluation on the Government’s progress in digitising the NHS. Our evidence draws on our experience as the UK’s leading digital pharmacy, and insights as to how digital transformation in the pharmacy sector might be more effectively harnessed. To that end, our submission focuses on commitments made in the following areas:

• The role of digital technology in transforming the care and experience of patients and service users
• The potential to harness the role of digital pharmacy in the future of clinical research
• Our experience of contracting as a digital pharmacy provider 
   

2. Overview of Pharmacy2U’s business model

2.1   Pharmacy2U is the UK’s largest digital-only pharmacy. We liaise directly with GPs to deliver NHS prescriptions straight to people’s homes, from our automated dispensing facilities. We operate at scale, dispensing over 1.4 million NHS prescription items per month – comparable to over 200 brick-and-mortar pharmacies – providing a huge convenience to patients who rely on timely and regular access to repeat prescriptions. Our ambition is to transform the pharmacy sector, bringing greater convenience and access to the 29 million people who rely on repeat prescriptions every day, whilst delivering value-for-money for the NHS.

POLICY AREA 1: The care of patients and service users

3. Commitment 1 – “Our aim is that, by 2024, 75% of adults will have registered for the NHS App, with 68% (over 30 million people) having done so by March 2023”

3.1   We welcome the NHS’s focus on the NHS App as a key component of digital transformation, including through increasing usage of the service. However, we are concerned that a commitment to increase the number of NHS App users is not in itself a meaningful indicator of change. While the number of adults registered with the NHS App has increased significantly during the pandemic, due to its COVID-19 digital pass feature, we believe there is still significant scope to improve its functionality, and improve the experience of these new users. We are also concerned that the digital channels roadmap in ‘A plan for digital health and social care’ does not cite a specific role for digital pharmacy.

3.2   Pharmacy2U is industry-leading in its use of digital technology and is keen to share our insights as to how the NHS App might be enhanced to support the future of primary care. For example, the App would be an ideal platform – utilising application programming interface (API) innovations – to send reminders for patients to order their repeat prescriptions, helping further support adherence and reducing waste. This would allow patients to reduce the number of apps they need to use – and we would be happy for such a feature to replace the need for a separate Pharmacy2U app for our 700,000+ customers – ultimately providing a streamlined and holistic patient experience. However, there are a number of limitations in functionality preventing this from being realised, while we have struggled to identify a clear named contact with whom to discuss our suggestions.

3.3   Whilst we welcome recent changes to the NHS App that support patient right to nominate an online-only pharmacy, we are concerned by the current user experience. The inability to directly nominate a distance selling pharmacy in the NHS App impedes patient experience and choice, in contrast to a bricks-and-mortar pharmacy nomination where a simple nomination button can be clicked. A patient wishing to nominate a distance-selling pharmacy is instead directed to a list of online pharmacies, which can be confusing for patients given many of these pharmacies cannot deliver nationally and at scale. This may also undermine confidence in the service that digital pharmacies can provide. To improve accessibility, a fair and understandable list of national-level digital pharmacies should be developed, in which patients can have full confidence.
 

4. Commitment 2 – “By increasing digital connection and providing more personalised care, we can support people to monitor and better manage their long-term health conditions in their own homes, enabling them to live well and independently for longer.”

4.1   Pharmacy2U welcomes the commitment to digital connection and providing more personalised care, and we feel that our services, as well as those of the pharmacy sector as a whole, are well placed to deliver services that support primary care. It is now critical that such ambitions – such as that of defining clinical pathways where people are supported to self-monitor and self-manage by 2024 – are now translated into clear actions, setting out how the Government intends to involve the range of system partners in supporting all patients with long-term conditions. Digital pharmacies like ourselves can play a key role in driving this change through:

• Freeing up capacity in bricks-and-mortar pharmacies
• Supporting patients to adhere to their medicines regimes
• Partnering with hospitals to support discharge
• Empowering patients to manage their conditions independently

These are outlined in more detail below.

4.2   Digital transformation can help to alleviate some of the capacity pressures on bricks-and-mortar pharmacies – empowering them to provide more complex, patient-facing services – by providing services which lift the burden of routine tasks, for example the automation of repeat dispensing. Digital innovations such as those spearheaded by Pharmacy2U would enable bricks-and-mortar pharmacies to spend more time delivering frontline care to those patients who require ongoing management – supporting the whole primary care system to manage the continued repercussions of COVID-19 – while enhancing prescribing accuracy and medicines adherence. This stands to both improve patient outcomes and reduce long-term costs on the NHS.

4.3   Error rates and overprescribing present significant and growing priorities for the pharmacy sector – the National Pharmacy Association (NPA) reported a 5% increase in the number of patient safety incidents reported between Q3 and Q4 of 2021,[1] while the National Overprescribing Review acknowledges that reducing overprescribing will bring savings in preventable hospital admissions.[2] Pharmacy2U’s digital dispensing technology dispenses medication at an industry-leading clinical accuracy rate of 99.998%, aiding long-term health management for patients.

4.4   We have a growing evidence base suggesting that our service supports increased medicines adherence, with automated prompts reminding customers to reorder their prescriptions ensuring their access to medicines is not disrupted. Furthermore, the data collected through automated dispensing can better track patients’ usage of medicines in real time, supporting clinicians to identify problems with adherence and creating opportunities for intervention, resulting in improved patient experience and outcomes, with reduced medicines wastage.[3] This is particularly important for those patients who live with more than one long-term health condition – and may be using multiple medicines – helping to ensure that the patient’s medication regime is serving them as effectively as possible.

4.5   Pharmacy2U also believes there is a clear enhanced role for digital pharmacy in acute care settings, which might include a ‘click and collect’ style digital pharmacy footprint inside hospitals. By ensuring that medicines are ready for patients at the point of hospital discharge, the risk of delayed discharge due to prescriptions not being ready is significantly reduced. Earlier discharge can reduce the risk of readmission, supporting patients to manage their conditions at home, and it is critical that the right planning and tools are in place to make this a realistic and positive experience for as many patients as possible. 
 

4.6   Finally, through our technology, we can utilise secure data gathering techniques and knowledge of our customers’ needs to proactively provide our customers with personalised health advice and specific preventative tests (such as tests that measure kidney function in patients with diabetes), helping them to look after their health independently. This is underpinned by full patient consent and adherence to NHS data security standards, and provides a more efficient and holistic service to customers (especially those who may experience challenges accessing face-to-face services), whilst reducing the administrative burden on their GP.

4.7   The COVID-19 pandemic offers further useful lessons for the importance of providing more personalised care via increased digital connection, necessitating a significant expansion in the use of remote consultations. Pharmacy2U adapted quickly to the changing needs of patients and health systems during the pandemic, and is now keen to contribute to new remote care initiatives, such as providing digital consultations to counsel patients on how to take their medicines, or live a healthier lifestyle.

5. Commitment 3 – “Roll out integrated health and care records to all people, providing a functionally single health and care record that people, their carers and care teams can all safely access, enabled by a combination of nationally held summary data and links to locally held records, including shared care records”

5.1   The commitment to roll out integrated health and care records to all people by 2024 is a welcome one, and will be a vital enabler of integrated and streamlined care. As such, Pharmacy2U commends the NHS on existing initiatives, such as the Spine EPS, and roll out of the Real Time Exemption Checking Service API. National action to deliver this vision is vital given the current variation in progress towards digitising health and care records between Integrated Care Systems (ICSs). In many systems, work to put in place integrated health and care records has been delayed due to the outbreak of COVID-19, and the necessary diversion of resource and attention to tackling the pandemic.
 

5.2   The journey towards integrated health and care records has been further complicated by the multiplicity of commercial providers of digital health records, which results in different systems being used across different systems and providers. This is not conducive to creating universally accessible health and care data, and can lead to variation in patients’ ability to make their data available to services like ours. Often, this decision is based on the system used at a particular GP practice, rather than on the patient’s own choice. The exponential expansion of providers in this area, driven in particular by COVID-19, means there is now a clear need for the NHS to take national leadership on integration of health and care records.
 

5.3   To that end, we look forward to the publication of ‘Who does what’ in December 2022 (as outlined in ‘A plan for digital health and social care’), particularly the plans to enable the transition from “a largely heterogeneous current state to a target state underpinned by convergence, standards and APIs, national technology platforms, and federated secure data environments”.[4]

5.4   To ensure delivery of this commitment within the promised time frame – and that patients are able to benefit equally across the country – the NHS must do more to make data available to all health system partners in a structured, consistent, and systematic way. It should consider the greater use of APIs to share open-source data, with patient choice and control over how data is used at the heart. As Pharmacy2U engages with patients and providers in health and care systems all over England, we would be pleased to share our insights on the current landscape with national leaders, informing the development and implementation of a standardised and fair approach.
 

5.5   To truly leverage the benefits of integrated health and care records, it is critical that any work to fulfil this commitment recognises the central role of the pharmacy sector in patient care. Currently, pharmacy services are often unable to easily access patient records, restricting their ability to support patients with their medicines. Patient records and preferences should be integrated and interoperable across all primary care settings, with pharmacists able to seamlessly access health records and view prescription requests, and patients enabled to easily access their records and upload their own information. Ensuring that pharmacists have swift and streamlined access to this data is vital in empowering pharmacies to play a central role in a thriving primary care system, integrated care, and population health management. Pharmacy2U is confident that such mechanisms could be put in place without violating data privacy rights.
 

5.6   Interoperability between primary and secondary care datasets is also fundamental to achieving the integrated care ambition and delivering more care closer to home. As noted above, we would be eager to support secondary care to put in place swifter and more streamlined discharge processes.
This would however need to be underpinned by strengthened and connected health records, allowing services like Pharmacy2U to view conditions data as well as prescriptions, to facilitate a smoother and more efficient discharge service. This would also support clinical safety where patients are prescribed multiple (and potentially conflicting) medicines. To date, innovation and partnerships of this kind has been hindered by siloed digital infrastructure and funding streams, but Pharmacy2U is eager to see the opportunity offered by the integrated care agenda fully leveraged to overcome these barriers.

POLICY AREA 2: The health of the population

6. Commitment 1: “Through the Data for Research and Development programme we will invest up to £200 million to transform access to and linkage of NHS health and genomic data sets for data driven innovation and inclusive clinical trials, whose results will be critical to ensuring public confidence in data access for research and innovation purposes.”

6.1   Pharmacy2U believes that digital transformation has a clear role to play in enhancing clinical research, and has welcomed the steps taken towards delivering this potential through The Future of Clinical Research Delivery policy paper and accompanying 2022 and 2025 implementation plan.[5] However, it is notable that the commitment to invest “up to £200 million” to access and linkage of NHS health and genomic data sets is relatively vague, and we have not yet seen evidence of its implementation through our own involvement in large-scale clinical research initiatives such as the Our Future Health programme.
 

6.2   The potential contribution of digital pharmacy services in a clinical research infrastructure that is patient-centred, equitable, inclusive, and delivered in the community is thus far untapped, and we would be eager to see this addressed through work to deliver this commitment. The national reach and remote operating model of services like Pharmacy2U means we are well-placed to partner with the system in a new, digitally-enabled approach to clinical research, in line with Government ambitions for the future of clinical research delivery.
 

6.3   Online pharmacies with national reach can facilitate faster clinical trial recruitment through existing patient networks and targeted invitations, building on the confidence that patients already have in our services; manage the delivery of relevant trial products without the need for in-person interactions or travel; and provide data from a single secure source directly integrated into the clinical trial operator’s own systems reducing administrative burdens. This allows clinical research agencies to rightly focus on participants and outcomes, rather than logistics, and has been demonstrated through our own support of COVID-19 clinical trials.
 

6.4   A digital pharmacy can also support efforts to tackle existing inequalities in clinical research recruitment. Because our customer base is not constrained by geography we can offer improved diversity in recruitment, including patients who may live further away from research centres. This can also help simplify the complexities of large-scale Phase 3 or 4 clinical trials across wider geographies by removing the need to work with multiple pharmacies or hospitals.
 

6.5   In addition, enriched real-world evidence can be collected by digital pharmacies such as Pharmacy2U, spanning metrics such as the timeliness of medicines orders, levels of patient engagement with their own health outcomes, and how prescriptions interact with other medicines. This real-world evidence is often not available elsewhere and could help support the NHS to deliver ambitions on population health management and data-driven innovation, responding in real time to the needs of local communities.
 

POLICY AREA 3: Cost and efficiency of care

7. Commitment 1: “We will streamline contracting methods both to leverage NHS buying power and simplify the process of selling technology to NHS buyers (ongoing).”
    

7.1   We welcome any efforts to streamline – and standardise – contracting methods for NHS buyers, which would help to put in place a consistent system for patients in different parts of the country, overcoming the current significant variation in access to digitally-enabled services. For instance, in many areas, GP practices face restrictions – put in place by ICSs (and before that NHS Clinical Commissioning Groups) – which mean that their patients are unable to access the Pharmacy2U app, making it much more difficult to use our service even when this is the patient’s preference. Ensuring that GPs have streamlined and equitable access to innovation such as that provided by Pharmacy2U would facilitate universal access to digital services.
 

7.2   However, we have not yet seen evidence of this commitment being implemented – at least in the pharmacy sector – and continue to face the challenges set out above in many areas of the country. While initiatives such as the NHS Innovation Lab[6] and NHS Innovation Accelerator[7] should in theory help to make new technologies more easily available to NHS buyers, these have yet to focus on the significant digital opportunities in the pharmacy sector.

Contact details

We hope that this evidence is useful in informing the Expert Panel’s evaluation. If you would like to discuss any of the issues raised in this submission in more detail, please contact