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It is “not acceptable” for online pharmacies to prescribe medicines based solely on a questionnaire, the Royal Pharmaceutical Society (RPS) has said.
In its response to draft guidance from the General Pharmaceutical Council (GPhC) on pharmacies providing services at a distance, including online, the RPS said a two-way interaction between the prescriber and patient must be available.
“There should always be the means for the prescriber and the patient to communicate outside of the questionnaire,” it said.
“Questionnaire-style prescribing alone should never be the norm or accepted practice, especially when considering POM medicines and also P [pharmacy] medicines with additional risk factors including misuse potential,” the RPS added.
The Pharmacists’ Defence Association (PDA) and the National Pharmacy Association (NPA) also criticised the inclusion of a section in the draft guidance that discusses operating models of online pharmacies that could see prescribing decisions made “just on answers given to a questionnaire”.
The ‘Draft guidance for registered pharmacies providing pharmacy services at a distance, including on the internet’ — which was published on 18 September 2024 and was open for consultation until 9 October 2024 — proposes new measures to improve patient safety in response to concerns relating to inappropriate supplies of medicines from online pharmacies.
The guidance says the GPhC would “expect the pharmacy website and the websites of associated companies to be arranged so that a person has an appropriate consultation with a prescriber before any supply of a POM [pharmacy-only medicine] is made”.
“There should be a means to allow two-way communication between the prescriber and the person. This is so the prescriber can ask for more information from the person if they need it,” it continues.
However, the guidance adds: “If the operating model involves prescribing decisions being made remotely, based just on answers given to a questionnaire, there must be careful consideration of whether it is safe to prescribe and supply medicines.”
In the PDA’s response to the consultation, it described the wording of this section of the guidance as “poor” and argued that it will “create risk for practitioners and patients”.
“The PDA recognises that there may be a role for questionnaires used to gather information prior to a consultation but they must not be used to replace consultations and especially for medicines requiring additional safeguards,” it said.
The NPA, in its response, said: “While we welcome the updated guidance around asynchronous prescribing using online questionnaires, we believe that it still leaves the door open for medicines to be prescribed/supplied without appropriate two-way direct patient consultation and access to GP records for a full clinical picture, particularly where high-risk medicines are involved, and the risk to patient safety remains.”
The RPS said the proposed guidance will improve patient safety overall, stating that the guidance “supports improved access to pharmacy services for members of the public with additional safeguards to promote high-quality care and ensure patient safety”.
However, it said that it had identified a “notable over-reliance on risk assessments” in the guidance and that it should emphasise the need for a “dynamic risk management process”.
“Not only should risk assessments be conducted, but there should also be a continuous feedback loop where risks identified are addressed through proactive control measures that are monitored, reviewed and updated based on experiences (e.g. near-misses or patient safety incidents),” the RPS said.
The RPS also noted that the guidance “can at times be complex to understand and difficult to interpret”, giving examples such as a lack of clarity around whether it is always applicable to both pharmacy medicines and POMs, and NHS versus private services.
The PDA said the proposed guidance will not improve patient safety, arguing that while certain proposals will “strengthen some aspects of the guidance… other proposals are likely to weaken the guidance and some of the proposals are not clear and may cause confusion”.
“Whilst there have been positive steps to include drugs which can be harmful if misused, the watering down of content from the 2022 guidance and inclusion of certain practices are a significant cause for concern and may increase patient risk,” its response said.
The PDA also argued that the proposed guidance is worded in a manner “which will not prevent future harm” and referenced The Pharmaceutical Journal’s investigation into online pharmacy, which showed coroners had identified a theme of harm from medicines being purchased online.
Analysis by The Pharmaceutical Journal revealed that coroners had written 20 regulation 28 reports as of March 2023 warning that having “freely marketed” drugs available online, with “no regulation” in their supply “clearly constitutes an ongoing risk to the lives of other vulnerable people”.
