The big online pharmacy clampdown

Georgie Aldous, who lives with an eating disorder, was five months into taking Mounjaro (tirzepatide; Eli Lilly and Co) when things started to go wrong. “At first, it was great. It did what it was supposed to do, and I started to lose weight,” he told ITV’s Good Morning Britain in January 2025.

Soon, though, he started to feel weak and unwell. One night, his heart rate began to soar to as high as 150 beats per minute. The palpitations ended with an A&E visit at 04:00. He would end up making two more trips to the emergency department within the next 48 hours.

Having bought the medicine through an online pharmacy prescribing service — where he simply filled out a questionnaire and submitted a video of himself standing on some scales — Aldous is now campaigning for tighter regulations around the drug. “This is me trying to [stop it] falling into the wrong hands like it so easily can at the moment,” he wrote in an Instagram post, referencing the death of Susan McGowan, a nurse at University Hospital Monklands, after taking Mounjaro in September 2024.

It is a story that reflects growing concerns over the safeguards in place at online pharmacies — many of which follow a similar protocol. To address the issue, the General Pharmaceutical Council (GPhC) published new guidance in February 2025 stipulating that online operators must conduct thorough assessments, such as a video consultation or an analysis of a patient’s clinical records, rather than relying on online questionnaires for high-risk medicines, such as glucagon-like peptide-1 (GLP-1) receptor agonists.

However, it is not clear whether this guidance goes far enough, given that online pharmacies continue to fail inspections at a higher rate than bricks-and-mortar operations — as shown in a new analysis conducted by The Pharmaceutical Journal.

Rapid growth

For the GPhC, the latest guidance is just one step in tackling the rapidly evolving area of online pharmacies — a sector that has soared in popularity since the COVID-19 pandemic, points out Roz Gittins, chief pharmacy officer at the GPhC.

“Particularly since [the] COVID [-19 pandemic], patients have been choosing to get their healthcare needs met differently and, in turn, healthcare providers have been responding,” she explains.

“We’ve seen some positive outputs from that. Online options, such as delivery, can have some real advantages — for example, if someone is in a rural area — and it can very much complement that more traditional face-to-face provision.”

The appeal of online pharmacy is evident in the latest electronic prescription service nomination data. Online operation Pharmacy2U is the most popular provider by some margin, with almost 1.3 million nominations for the week ending 28 March 2025.

LloydsDirect — which was purchased by Pharmacy2U in 2024 — is the second most popular provider, with around 225,000 nominations. Boots — which has the largest physical pharmacy network in the UK — had just over 50,000 nominations, putting it in eighth place.

While convenient for patients, the rapid growth of online pharmacy services has presented challenges for the regulator.

In March 2022, the GPhC updated and tweaked its 2019 guidance, which specified the need to be aware of the patient’s health and medical history when making prescribing decisions. Essentially, the updated guidance was aimed to better ensure medicines are clinically appropriate for patients and to establish further safeguards for certain categories of prescription-only medicines.

In October 2022, the GPhC published an analysis of common issues that arose in fitness-to-practise (FtP) cases regarding online pharmacies. The inappropriate use of online questionnaires, a transactional approach to prescribing and inadequate governance structures were all cited as common themes.

Ongoing concerns

Yet, the concerns identified by the GPhC three years ago appear to be continuing today. In February 2025, a “target-focused” pharmacist was suspended from the GPhC register for taking a “transactional” approach to high-risk beta blocker prescribing — and this is not an isolated case (see Box 1).

Analysis of GPhC inspection reports, conducted by The Pharmaceutical Journal, shows that some progress has been made in the past few years. However, there are still ongoing issues.

In April 2022, The Pharmaceutical Journal previously reported that online pharmacies were eight times more likely than bricks-and-mortar pharmacies to fail on GPhC regulatory standards between April 2019 and March 2022.

A new analysis of inspection reports, published between 1 April 2022 and 14 January 2025, shows that, of the 230 distance-selling pharmacies inspected, 24 (10%) pharmacies were failing to meet all standards within the five principles of governance, staff, premises, services and equipment and facilities. That number is twice the failure rate of bricks-and-mortar businesses — of which 91 out of 2,002 (5%) pharmacies did not meet all standards within the GPhC principles.

Poor management of services and governance remain at the heart of online failures (see Figure 1). Of the 24 distance-selling pharmacies that did not meet all standards, 22 (92%) pharmacies failed on governance arrangements. Issues included an online system that failed to give the pharmacy team “access to relevant records of online orders and supporting information” and a lack of work to “identify all the risks associated with providing services at a distance”.

Meanwhile, 16 of the non-compliant online pharmacies (67%) failed on adequate safeguards for pharmacy services. Inspectors noted issues, such as pharmacies neglecting to “adequately assess the risks involved in selling medicines online that may be abused” and not managing “all its services safely, including its private prescribing services”.

Those points are the particular focus of the GPhC’s latest guidance for online pharmacies. While much of the media attention was on weight-loss jabs, the work had a much wider remit, says Gittins.

“The weight-loss injectables, which we’ve really seen take off over particularly the past year or so, have definitely been a driver but it’s not been the only thing,” she explains.

“We were picking up on issues through our inspectorate findings, listening to feedback from the sector, and we’ve also seen some particular cases come through the FtP process — there have been scenarios where we’ve got high volumes of medicines that are liable to misuse.”

In its February 2025 guidance, the GPhC stressed the need for safeguards when prescribing for patients without a regular prescriber, such as a GP.

The regulator stipulates pharmacies can no longer rely solely on online questionnaires when prescribing higher-risk medicines — for example, antimicrobials, medicines liable to misuse, medicines that have a higher risk of death or serious harm if taken in overdose, and medicines that require ongoing monitoring.

Instead, pharmacies must independently verify the information the person provides by conducting “timely two-way communication”, accessing the person’s clinical records or contacting a third party with knowledge of their history.

In the case of weight-loss jabs, video consultations are cited as one recommended way of verifying the patient’s weight, height and body mass index.

Changes welcomed

The changes have been largely welcomed by pharmacy bodies. The National Pharmacy Association (NPA), for example, has long expressed concerns over the lack of proper consultations around high-risk medicines. In January 2025, Ashley Cohen, member of the NPA board, told BBC Breakfast it was “really disturbing” to see members of the public accessing medicines, such as GLP-1 agonists, through what was essentially a “tick-box exercise”.

“It’s so important that patients have a proper two-way consultation with a registered clinician,” he stressed.

The Royal Pharmaceutical Society (RPS) takes a similar view. “The inclusion of measures to ensure prescribers independently verify information provided by the patient, and weight-loss medicines being added to the list of medicines that are not suitable to be prescribed by questionnaire alone, are key steps toward protecting patient safety,” says Wing Tang, head of professional standards at the RPS.

“Questionnaire-style prescribing should never become the norm, particularly for prescription-only medications and those with additional risk factors,” he stresses.

That message is reinforced by Community Pharmacy England (CPE). “Whether online or in person, we always encourage improved prescribing and dispensing practices to support safe supply of medicines and to improve patient safety,” says Gordon Hockey, director of legal at CPE.

Although the GPhC guidance has garnered almost unanimous support, there is controversy over the approach taken by the GPhC.

For the Pharmacists’ Defence Association (PDA), a tougher line is necessary to tackle the problems in the online pharmacy sector. Among its concerns, the PDA argues that access to an NHS GP patient record should be mandatory when prescribing weight-loss medicines.

“The consultation still overuses the term ‘should’ when in many instances a ‘must’ is required. It is also concerning that some of the guidance is still unclear and open to interpretation,” says Jay Badenhorst, director of pharmacy at the PDA.

The GPhC’s latest guidance has also drawn the ire of some online players. On 12 February 2025, Chemist4U, for example, hit out at the guidance in a LinkedIn post. The online pharmacy said it “always checks the central NHS record [summary care record] of every patient that has been supplied weight management medication” and has done so for the past three years. Chemist4U fears the video call requirement could have unintended consequences.

“We have concerns that the new regulations provide insufficient recognition of the real concerns from patients who report feeling embarrassed by video call requests asking them to stand up and show off their body,” it argued. 

“Many patients have battled with body image issues and anxieties for most of their life.”

Enforcement

Arguably, the real test will come in the enforcement of the guidance. The GPhC vows to take a proportionate approach when considering the principles in inspections. “For weight-loss injections, we wouldn’t expect them [online pharmacies] to be using a questionnaire and nothing else, and we’d look at broader stuff in governance,” says Gittins.

As she points out, this new guidance forms part of broader, ongoing work to tighten up standards in online pharmacies. Gittins says the GPhC will continue using mystery shoppers, which were an essential part of its response to a BBC investigation into online pharmacies in 2024 that revealed journalists had been able to buy prescription-only medicines from 20 online pharmacies without checks, such as GP approval.

The regulator will also maintain its policy of inspecting new online pharmacies within six months of registration, given that the “biggest challenges have been at the initial inspection”.

It is by no means “job done”, Gittins adds. The GPhC will continue to keep an eye on emerging trends in online pharmacies and will “cascade the findings” to the sector, she says, to raise awareness of best practice.

Skills gap

That latter point is crucial for Sehar Shahid, founder of The Pharmacy Consultant, which helps online pharmacies ensure they have the right processes in place. She has witnessed a skills gap among pharmacists who have not owned their own businesses before and believes many issues stem from a lack of knowledge.

“I worked in community pharmacy for ten years and my job was to make sure my team followed and implemented standard operating procedures. But my job was never to think about how to write one,” she points out.

“They’re different skills. At university, perhaps, you’re not told how to write a risk assessment for a service.”

Shahid has carefully studied how to run an online pharmacy safely and has put that knowledge into practice in her own online pharmacy business. Alongside education, she believes enforcement of GPhC standards is vital to “reduce variance” in service provision. Without uniform standards, rogue online operators will continue to tarnish the image of the sector, she fears.

“I have an online pharmacy, and I definitely feel people raise an eyebrow when they hear that,” she reports. “Generally, they don’t have a good name, and my passion is to change that narrative because I think digital healthcare is the way forward.”

While bad patient experience with online pharmacies could have ramifications for the wider profession, it should be noted that not all the controversy surrounding online pharmacies falls within the remit of the GPhC (see Box 2).

As pharmacy looks to play a wider role in primary care, that reputational damage takes on an even greater significance. “Consistent good practice is important in terms of maintaining a reputation for clinical competence — both for individual pharmacies and the profession as a whole,” stresses Nick Kaye, chair of the NPA. “This has always been the case but will become ever more so as we navigate a path to more integrated clinical services in the future.”

Against that backdrop, the GPhC’s approach to distance-selling pharmacies could prove crucial, because stories like that of Georgie Aldous do not just tarnish the reputation of online operators but the entire pharmacy profession.