The internet’s a wonderful thing, apart from when it isn’t. Recently, at The Pharmacy Show in Birmingham, The Pharmaceutical Journal reported on insights gathered by the General Pharmaceutical Council (GPhC), following a series of inspections of online pharmacies. Roz Gittins, chief pharmacy officer at the GPhC, told delegates that some online pharmacies presented issues around leadership and governance by using prescribing services that are “deliberately trying to circumvent existing arrangements in place by registering, for example, overseas”.
This is a significant issue, as it means that these services fall into a regulatory gap. If they are not UK-registered, they are not required to adhere to either GPhC or Care Quality Commission (CQC) regulations.
It also appears that online prescribing services — which supply medicines in a similar way to a regular pharmacy — who employ only pharmacist prescribers are able to avoid regulation. These services are not registered pharmacies and, therefore, are not covered by the GPhC for regulation. Additionally, they’re not covered by the beleaguered CQC, which doesn’t regulate services run by pharmacists. It should be noted that UK pharmacists working in these prescribing services are regulated as individuals by the GPhC. However, Gittins also said at The Pharmacy Show that the GPhC has 40 active fitness-to-practise cases linked to online pharmacy provision.
The GPhC first started commenting publicly on this loophole back in 2018 in the wake of comments to The Pharmaceutical Journal made by Mohammed Hussain, then senior clinical lead for life sciences at NHS Digital, that online prescribing services only had to register with the CQC if they employed a listed healthcare professional. This listing, unhelpfully, does not include pharmacists. The CQC does regulate the rest of primary care (insofar as it regulates anything, which, according to the recent review of the CQC by Penny Dash, chair North West London Integrated Care Board, is not very effectively at all).
It’s a neat bureaucratic Catch 22, no?
In 2019, the GPhC told the CQC that it would favour the CQC in taking on the regulation of pharmacist-run online services outside of a registered pharmacy — this did not happen.
The internet isn’t about to go away, so we need to assume that online prescribing businesses won’t go away either
Then, in 2021, the CQC proposed legislative changes that would have improved its ability to regulate independent care providers that are currently “putting people’s lives at risk”. This came in response to a coroner’s report to prevent future deaths, which recommended that the CQC should assume regulation of “all online prescribing services accessible by patients in England”, regardless of the prescriber’s location and the professional group undertaking the prescribing.
The Department of Health and Social Care proposed to publish its ideas on resolving these problems “shortly” back in 2022. I guess the word “shortly” can be broadly defined.
The Pharmaceutical Journal has been reporting, for some time, on the dangers of online pharmacy providers:
- ‘Online pharmacies are eight times more likely to fail regulatory standards, data show‘, April 2022;
- ‘Online pharmacy boom prompts concern over patient safety‘, April 2022;
- ‘”Pandemic of tragedy”: the deaths caused by gaps in online drug supply regulations‘, March 2023.
The internet isn’t about to go away, so we need to assume that online prescribing businesses — which are not regulated by the GPhC or CQC — won’t go away either.
So, what are the drivers of online prescribing businesses’ growth and attractiveness to customers?
It’s much the same as any other online retail business, surely. Convenience and price will both be big factors, but they are surely not the only ones. If an overseas online pharmacy is unscrupulous and beyond both regulation and prosecution, then the barriers to obtaining prescriptions from online pharmacies may be too low.
There must be uncertainties about product safety. Some of these businesses are based in major pharmaceutical and generics manufacturing territories: Is the quality assurance of what is being sold overseas to a high standard in those suppliers’ national markets? How can we know?
Another possible driver is a topic often addressed in these columns: the ongoing and serious unavailability of medicines. (A brief anecdote on which: two weeks ago, I took my mum to a pharmacy for her flu and COVID-19 vaccinations. We arrived quite early and in the 25 minutes we were waiting, every single person coming in for prescriptions was told that part of their order would not be available that day and in a couple of cases, for several days.) Patients may be motivated to purchase questionable medicines online if they’re unable to obtain what they need from within the UK.
This ties in with one-third of the new Labour government’s ‘triple shift’ policy: the area of moving to a digital-first policy in health. The issues of online pharmacy and its safety and regulation are a canary in the coalmine for health systems moving to ‘digital first’. Whether we like it or not, the internet exists, can provide online consultations and won’t be going away.
Measurement and transparency over the problems would be helpful here, and it would also be helpful in the massive issue of medicines shortages. Who’s going to have the courage to stand up and be the body that takes this role on?
Andy Cowper is editor of Health Policy Insight
