History of the electronic prescription service
The notion of digitalising the prescription service was first conceived in 2003 as part of the bigger National Programme for Information Technology (NPfIT). Although the initial project had a budget of £6.2bn, it failed to deliver changes and subsequently did not improve services or patient care as expected. The mantle to digitalise the service has gone through various iterations over the years – Connecting for Health, Health and Social Care Information Centre (HSCIC) and finally NHS Digital.
In July 2019 a new unit, NHSX, was created as a working collaboration between the Department of Health and Social Care (DHSC), NHS England, NHS Improvement and industry. NHSX is rolling out an electronic prescription service (EPS) via phased software releases.
The principle of an EPS system is that an electronic prescription is generated and is sent to the NHS spine (a secure NHS database) where it can be retrieved by the pharmacy team. One of the main benefits is that the electronic prescription can be tracked throughout the system and therefore cannot be lost.
According to the online version of the NHS long term plan, EPS has been successfully implemented across primary care and is now used in 93 per cent of England’s 7,300 GP practices, with more than 67 per cent of their prescriptions delivered via EPS.
Our experience of EPS at Inclusion
In 2021 following collaboration with NHS digital and Cleo Systems (a subsidiary of IC24) the Midlands Partnership NHS Foundation Trust (MPFT) was chosen to be a ‘first of type’ pilot site for testing the EPS in secondary care. Inclusion approached the MPFT programme manager and sought approval to be included in the pilot. Our Telford substance misuse services (SMS) site was chosen for the Inclusion pilot as it was a small enough team to ensure that control mechanisms could be implemented and maintained. It was also the closest service to the trust, so support from the programme manager could be assured. Preliminary work started for the trust at the end of 2021 and initial testing began at the start of 2022.
We were aware from the outset that the platform would not enable us to electronically send prescriptions requiring instalment dispensing (FP10MDAs), packaged doses or supervised consumption. That limited our ability to use the system for the majority of our work. As this was a stand-alone system which did not interface with our current clinical system, we had to have an additional process to ensure the clinical system was updated. We identified a cohort of stable service users who were on weekly pick-up of their opioid substitution therapy (OST). To maintain control and to allow us to work collaboratively with pharmacy we limited our pilot to one main provider. Although service users are not always directly involved in how their prescription gets to the pharmacy we wanted to ensure they were asked if they wanted to be included in the pilot. The Cleo Solo EPS has the ability to send the service user an SMS message with the address of the pharmacy and a Google Maps link pinpointing its location. We wanted to test this functionality as it would be beneficial in the future if we had to send a prescription to an alternative pharmacy (such as what we’re seeing with short-notice pharmacy closures).
As you would expect with any new system there were stops and re-starts as issues were identified and resolved by the system supplier. As we knew it would be difficult for us to react quickly should the pilot be halted we planned to start our prescribing at least one week after the other trust sites.
On 4 April 2022 we sent through seven electronic prescriptions to the nominated pharmacy. Unfortunately after a few hours a message came through from NHS Digital to tell us to stop. Their reason for this was based on safety – unlike the EPS system employed in primary care the Cleo Solo EPS did not have the functionality to post-date prescriptions. The EPS clinicians felt that there was a risk that any prescription that had a post-dated instruction in the body of the text could get dispensed as the only date on the electronic prescription was the date generated. Although we fully appreciated the reason for us being pulled from the pilot it was still disappointing for the service and the service users who had agreed to participate.
Digital services can support the NHS net zero agenda
The NHS is now required by an amendment to the Health and Care Act 2022 to contribute towards compliance with the Climate Change Act 2008. The NHS must therefore support the UK net zero emissions target, and in response to this commitment NHS England have published Delivering a ‘net zero’ National Health Service in which digital transformation is a requirement.
What happens next?
For a digitalised service to replicate the current model we need a system that allows the pharmacy to dispense and be remunerated for instalments and to allow for post-dating. The ideal EPS system would also take into consideration part-filled prescriptions as well as letting treatment service providers know when an instalment has not been dispensed. Currently these features are not available.
As substance misuse providers we all support the urgent need for an EPS for OST prescriptions. We can be assured that FP10MDA (instalment) prescriptions are on the digital road map, however there are a number of complexities which NHSX are looking to overcome in the coming years.
HOW AN EPS COULD BENEFIT SERVICES AND SERVICE USERS, AND SUPPORT THE NHS GREEN AGENDA
Having an electronic prescription enhances safety and quality:
- It reduces the likelihood of prescribing or dispensing errors.
– The barcode on the prescription means it is read electronically, removing the need to interpret prescribers’ handwriting. It also prevents fraudulent alterations.
– It minimises the risk of there being duplicate prescriptions.
- It simplifies the process thereby increasing efficiency.
– Services can be more reactive to short-notice pharmacy closures, speeding up the process for the service user. They would not have to wait for a prescription to be printed, signed and sent to the pharmacy.
– Prescribers sign the prescription electronically using their NHS ‘smartcard’, removing the requirement for a ‘wet’ signature as there is no paper prescription.
– It allows for remote working so a prescription could be generated by another prescriber working elsewhere in the organisation. This removes the need for ‘runners’ who currently drive miles around services to get a new prescription.
- It saves healthcare costs.
– The online version of the NHS long term plan has already identified that EPS has saved the NHS 136m in three years (2013-2016).
– Removing the need for paper prescriptions reduces the costs associated with: Manufacturer: Paper production, printing, transportation and security.
Our services: Ordering, receipting and invoicing of controlled stationery; storage of bulky prescriptions forms and the requirement to store them securely and fully account for them; staff time conducting annual audits (as a minimum requirement) to ensure adequate security; hidden costs associated with printer ink, staff time for printing, transportation – postage, delivery.
When cancelling existing prescriptions consider the costs associated with shredding and disposal of confidential waste.
- Prescriptions cannot be lost.
– The electronic message is end-to-end encrypted.
– Authorised personnel can track prescriptions through the system. This removes the time spent ringing the pharmacy or vice versa.
- Prescriptions can be sent for dispensing anywhere in England.
– It is useful for holiday prescriptions where you have concerns about security of medicines.
– EPS prescriptions generated in England cannot be processed in Scotland or Wales
- Prescriptions can be cancelled
– Up until they have been dispensed
- Prescriptions in the system are automatically cancelled when the Personal Demographics Service is updated with notification of death.
Linda Geddes is the pharmacist lead and Dr Georges Petitjean is the substance misuse medical lead for Inclusion, part of Midlands Partnership NHS Foundation Trust
The NHS Addictions Provider Alliance: www.nhsapa.org and www.inclusion.org