Written evidence submitted by Pharmacy2U (DEL0099)

Introduction

Thank you for inviting evidence to inform your inquiry into delivering core NHS services during the pandemic and beyond. Pharmacy2U is the country’s single largest distance-selling pharmacy, and we are pleased to have the opportunity to contribute.

This evidence sets out:

• Information on Pharmacy2U
• The support we can offer the NHS during the pandemic
• Our ambitions for the community pharmacy sector beyond the pandemic
• Our asks of the Government

About Pharmacy2U

Established in 1999, Pharmacy2U is the first and largest online pharmacy in the UK. We liaise with GPs to deliver NHS prescriptions direct to people’s homes, from our centralised and automated dispensing hubs.

Pharmacy2U is playing a crucial role in transforming the pharmacy sector through our automated model for dispensing repeat prescriptions. We operate at scale, in ordinary times dispensing over 900,000 NHS prescription items per month (comparable to c.150 High Street pharmacies), providing a huge convenience to patients who rely on timely and regular access to repeat prescriptions. We deliver patients’ NHS repeat prescriptions to any address in the UK free of charge. We also have the capability to deliver more complex medicines, such as controlled medicines and refrigerated medicines, safely and efficiently to the patients who need them.

Our model helps to take the burden of repeat dispensing away from High Street pharmacies. We are also more cost-effective to the NHS: Pharmacy2U are paid 15-20% less by the NHS per repeat prescription item than the average pharmacy.

The support we can offer the NHS during the pandemic

Our model lends itself well to safely providing the medicines that patients need during the pandemic. Like other home delivery services, we help ensure people can remain at home in line with government advice without having to make unnecessary visits to physical GP and pharmacy premises, thus minimising the risk of harm from coronavirus infection.

Given this, we have seen significant increases in demand for our service in recent weeks:

• In the week commencing 23 March, 32,639 new patients registered with Pharmacy2U, of which 23% were over 70. This is an increase of 395% compared to the same week in 2019, where 11% of new patients were over 70. Since this peak in late March, the number of new patients joining us has remained significantly higher than in previous years, with at least 15,000 new patients registering each week
• To meet this significantly increased demand, we have been able to substantially and rapidly scale up the number of prescription items dispensed each week. During the week commencing 20 April we dispensed 235,707 items, an increase of 107% on the same week last year

Our centralised operations means that our headroom to absorb further demand and our resilience is likely to be high compared to High Street pharmacies. This means that we can:

• Provide a reliable routine repeat prescription service to those with underlying health conditions who may be at risk of coronavirus
• Provide this service to the most vulnerable ‘shielded’ patients in a sustainable way
• Support the provision of additional services (such as home testing) as and when technologies become available

We have moved swiftly in response to rising demand to expand our operations. We have:

• Opened an additional site at Oldbury, West Midlands, which has expanded our capacity by 20%
• Brought forward the opening of our new site at Bardon in Leicestershire, which we expect to be fully operational and thereby able to double our existing capacity in the next three months.

To make sure that we are able to continue our work supporting patients, we are actively taking steps to ensure our staff, of which c.90% are deemed essential workers, are able to stay safe while at work:

• All employees are temperature checked upon arrival to Pharmacy2U premises
• All shifts are segregated with 30 minutes between them to prevent potential cross-contamination
• Break patterns have been split to avoid close employee contact in break rooms
• Hourly full wipe downs are conducted to all work stations
• We have implemented a permanent rota of cleaning down all general areas (door handles, bathrooms, etc)
• Some individual workstations have been closed to distance employees

We have also encouraged our employees to make use of the Government’s COVID-19 testing service for essential workers. Those who have been tested have found the process effective, efficient and easy-to-use.

Our ambitions for the community pharmacy sector beyond the pandemic

The pandemic is likely to be a challenging time for traditional High Street pharmacies. Community pharmacies are on the front line of the pandemic response; however, they have reported difficulties in accessing PPE through the national supply chain, putting staff at risk.[1] Concerns have also been expressed that pharmacies affected by staff sickness and medicines price increases may struggle to remain open after the pandemic,[2] while the ongoing issue of stock shortages at the wholesaler level will place particular pressure on smaller local pharmacies. The rapid increase of demand for our own service indicates that patients are unwilling to visit pharmacies in person for routine medicine collections, given the current situation.

In the future, therefore, it is likely that community pharmacies will continue their journey away from dispensing and towards providing more clinical services, and that the experience of the pandemic will accelerate this shift. This is in line with the direction of government policy.

We therefore see a role for Pharmacy2U and other distance-selling pharmacies in the future as supporting a thriving community pharmacy sector – taking on the dispensing burden through centralised, automated operations whilst freeing up scarce clinical time in High Street pharmacies to help care for patients. To this end:

1. Pharmacy2U is eager to collaborate with High Street pharmacies by taking on their repeat dispensing business to support them to spend more time delivering frontline and patient-facing services. However, under current legislation which prevents ‘hub-and-spoke’ operations, this is challenging.
    
2. Pharmacy2U is eager to see a fair reimbursement system for the community pharmacy sector. At present, elements of reimbursement in the pharmacy sector remain premise-based, which acts as a disadvantage to dispensing repeat prescriptions at scale. Large pharmacies operating from fewer sites must pay higher discounts back to the NHS, despite the increased efficiency of their model, because the discount rate depends on the value of medicines that a branch, rather than an overall company, dispenses.

3. Pharmacy2U is eager to see changes which support automated operations, such as reforms to facilitate full-pack dispensing. Currently, regulatory rigidities mean that we are unable to vary the set amount on an individual prescription (eg “30 tablets”) by an immaterial amount to allow full-pack dispensing (eg of 28-day packs).

Our asks of government

There are a number of steps we are encouraging the Government to take, to support the community pharmacy sector during the pandemic and beyond.

During the pandemic, we are seeking the Government’s help to:

1. Ensure the NHS App is as effective as possible. While we welcome recent changes to the NHS App which allow patients to nominate an online-only pharmacy, we are concerned that the current list of online pharmacies from which patients can nominate will be confusing given that many of these pharmacies cannot deliver nationally and at scale – and that this will undermine confidence in the service which internet pharmacies can provide at a time when they are most needed. A fair and understandable list of national-level internet pharmacies should be developed, in which patients can have full confidence.
    
2. Protect and support shielded patients. Online pharmacies are well-placed to ensure that shielded patients are provided with the medicines they need in a safe, reliable and efficient manner, rather than relying on pharmacists or local volunteers to deliver medicines. However, we have struggled to establish discussions with policymakers about how our service can be better utilised for this purpose. We would be keen to be involved more systematically in efforts to support shielded patients.
    
3. Keep pharmacy services running across the country. Traditional High Street pharmacies are particularly vulnerable to being forced to close by issues such as staff sickness and stock shortages. Pharmacies with capacity, including internet pharmacies, should be designated as ‘pharmacies of last resort’ in the case that a sole local community pharmacy needs to close. This will ensure that patients’ access to their medicines is not disrupted.
    

Looking beyond the pandemic, we are seeking the Government’s help to:

1. Allow full-pack dispensing. The agreement of a regulatory change to facilitate full-pack dispensing would unlock 25%-30% additional capacity. This will allow us to more efficiently take on the dispensing burden in both the immediate future and the longer term. Full-pack dispensing is also safer for patients, and this is recognised by the Royal Pharmaceutical Society, the former National Patient Safety Agency, the Association of the British Pharmaceutical Industry, the Pharmaceutical Services Negotiating Committee, and others. While proposals for this were put forward in 1997, this has not been taken forward since.[3]
    
2. Establish greater flexibilities to develop hub-and-spoke models for dispensing repeat prescriptions. In line with commitments made alongside the Medicines and Medical Devices Bill, which is currently progressing through Parliament, this would allow larger services like Pharmacy2U to work in partnership with smaller, independent pharmacies to drive efficiencies in dispensing at scale, while improving patients’ access to clinical services in their community pharmacies.
    
3. Agree a fairer system for pharmacy reimbursement. A system of reimbursement which is fair to different types of pharmacy operators should be considered. Financial mechanisms must support, rather than disincentivise, at scale dispensing of repeat prescriptions by larger operators.

The Government may also wish to consider in the future whether the medicines supply chain is operating as effectively and as efficiently as it should. There are aspects of the medicines supply chain which currently impede competition and may result in poor value to the NHS, such as a concentration of market power in a small number of wholesalers, vertical integration between wholesalers and retail pharmacy operations, and a number of exclusive supply arrangements between manufacturers and wholesalers.

May 2020

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