how to start a distance selling pharmacy – Online Prescribing

What stock levels do I need as a new UK primary care community pharmacy?

Mike Bereza — Thu, 01 Jul 2021 23:24:44 +0000

How much stock will your new pharmacy need?

One of the major costs associated with starting a new pharmacy in the UK is the initial cost of stock. It is a requirement of the NHS Pharmacy contract, that licensed pharmacies are required to dispense all medicines presented by patients on NHS prescriptions in a timely manner. If the pharmacy does not have the item, contingency arrangements need to be in place to source supply where stock is unobtainable from regular wholesalers, this may include having reciprocal arrangements with neighbouring pharmacies when required to meet urgent patient needs, and the use of manufacturers’ contingency order arrangements.

The good news for new licensees is that 90% of medicines prescribed via the NHS are regularly available to pharmacies, in this article we will look at how best to predict which lines should be initially prioritised to ensure patients rarely run out of medicines.

Fast mover / ‘next patient’ stock

Fast movers is the term associated with medicines that are dispensed most by pharmacies. What is included in a specific pharmacy’s as a fast mover category differs in regards to the local demographic served, however, if the pharmacy has a Distance Selling Pharmacy license where the remit is to serve patients nationally the following Top 10 most nationally prescribed medicines in primary care will be of relevance…

BNF Paragraph Name	Prescription Items	Actual Cost	Commonly Used For
Atorvastatin	45,792,988	£55,759,286	Statins-high cholesterol
Levothyroxine	32,934,807	£62,757,734	Low thyroid levels
Omeprazole	31,791,795	£50,092.650	Indigestion or stomach ulcers
Amlodipine	30,541,931	£29,329,631	High blood pressure – heart disease
Ramipril	29,318,773	£41,931,828	High blood pressure – heart disease
Lansoprazole	27,723,751	£33,480,232	Indigestion or stomach ulcers
Bisoprolol	24,905,410	£21,124,240	High blood pressure – heart disease
Colecalciferol	24,004,981	£86,331,206	Vitamin D deficiency
Metformin	22,375,503	£84,576,576	Diabetes
Aspirin	22,205,029	£817,,516,108	Reduce the risk of heart attacks and stroke

Figure 1. Top 10 most prescribed medicines in NHS primary care¹.

Dependent on the predicted prescription volumes, staffing levels and available space within the pharmacy the Top 10 fast movers might be the Top 20 or even Top 30. The size of the fast mover catergory is dependent on the ergonomic layout of the pharmacy, fast movers should be easily physically reached by staff or in a prime location within an automatic dispensing machine. The next level of stock catergory are the Medium Movers…

Medium Movers

Rank	Drug, class or BNF grouping	Most commonly prescribed example(s)	Prescribed in primary care (%)
1	Statins	Simvastatin, atorvastatin, pravastatin	6.50%
2	Proton pump inhibitors	Omeprazole, lansoprazole	5.50%
3	Angiotensin-converting enzyme inhibitors	Ramipril, lisinopril, perindopril	4.30%
4	Calcium-channel blockers	Amlodipine, felodipine, diltiazem, nifedipine,	3.70%
5	Beta-blockers	Bisoprolol, atenolol, propranolol	3.60%
6	Anti-depressants, selective serotonin re-	Citalopram, sertraline, fluoxetine	3.20%
7	Thyroid hormones	Levothyroxine	2.90%
8	COX inhibitor	Aspirin	2.80%
9	Corticosteroids, topical	Hydrocortisone	2.40%
10	Beta₂ agonists	Salbutamol, salmeterol	2.30%
11	Analgesia	Paracetamol	2.30%
12	Calcium and vitamin D deficiency	Calcium and vitamin D	2.10%
13	Non-steroidal anti-inflammatory drugs	Naproxen, ibuprofen	2.10%
14	Corticosteroids, inhaled	Beclometasone, fluticasone, budesonide	2.00%
15	Biguanides	Metformin	1.90%
16	Angiotensin-II receptor antagonists	Losartan, candesartan, irbesartan	1.80%
17	Diuretics, thiazide and thiazide-like	Bendroflumethiazide, indapamide	1.70%
18	H₁ receptor antagonists	Cyclizine, cetirizine, loratadine, fexofenadine, chlorphenamine	1.60%
19	Anti-depressants, tricyclic and related drugs	Amitriptyline	1.60%
20	Vitamins	Folic acid, thiamine hydrochloride, vitamin B	1.50%
21	Opioids: weak/moderate	Tramadol, codeine, dihydrocodeine	1.40%
22	Diuretics, loop	Furosemide, bumetanide	1.40%
23	Penicillins, broad spectrum	Amoxicillin, co-amoxiclav	1.40%
24	Alpha-adrenoceptor blocking drugs	Doxazosin, tamsulosin	1.30%
25	Opioids: strong	Morphine	1.20%
26	Vitamin K antagonists	Warfarin	1.10%
27	Neuropathic pain	Gabapentin and pregabalin	1.00%
28	Anti-depressant drugs, other	Venlafaxine, mirtazapine	1.00%
29	Emollients	Zerocream, Zerobase Cream, Diprobase cream, Doublebase gel, Aveeno cream, Cetraben cream, Zeroderm ointment, Diprobase ointment, Emulsifying ointment, Hydromol ointment, White soft paraffin and liquid paraffin 50:50, Dermol 500 lotion, Dermol cream	1.00%
30	Benzodiazepines	Diazepam, temazepam, lorazepam	1.00%
31	Laxatives – osmotic	Macrogol, lactulose	0.90%
32	Anti-platelet drugs	Clopidogrel	0.90%
33	Sulfonylureas	Gliclazide	0.80%
34	Bisphosphonates	Alendronic acid	0.80%
35	Anti-psychotics: 2nd generation	Quetiapine, olanzapine, risperidone	0.80%
36	Corticosteroids, systemic	Prednisolone	0.80%
37	Ocular lubricants (artificial tears)	Hypromellose	0.80%
38	Iron	Ferrous fumarate, ferrous sulfate	0.70%
39	Laxatives, stimulant	Senna, docusate sodium	0.70%
40	Nitrates	Isosorbide mononitrate, glyceryl trinitrate	0.70%
41	Insulin	Novorapid, Levemir, Lantus, Humalog, Actrapid, Humulin, Hypurin, Insuman, Insulatard	0.70%
42	Anti-muscarinics, genitourinary uses	Solifenacin, tolterodine, oxybutynin	0.60%
43	Anti-fungal drugs	Clotrimazole, ketononazole	0.60%
44	Z drugs	Zopiclone	0.60%
45	Anti-muscarinics, bronchodilators	Tiotropium, ipratropium bromide	0.60%
46	Gout and hyperuricaemia	Allopurinol	0.50%
47	Macrolides	Clarithromycin	0.50%
48	Alginates and antacids	Gaviscon, Gaviscon Infant, Acidex Advance, Peptac	0.50%
49	Histamine (H₂)-receptor antagonists	Ranitidine	0.50%
50	Tetracyclines	Doxycycline	0.40%
51	Prostaglandin analogues	Latanoprost	0.40%
52	Penicillins, penicillinase-resistant	Flucloxacillin	0.40%
53	Urinary Tract Infections	Trimethoprim	0.40%
54	Nocturnal leg cramps	Quinine sulfate	0.40%
55	Dipeptidyl peptidase-4 inhibitors	Sitagliptin, linagliptin	0.40%
56	Dopaminergic drugs used in parkinsonism	Co-careldopa (carbidopa/levodopa)	0.40%
57	Seizures	Lamotrigine	0.40%
58	Cardiac glycosides	Digoxin	0.30%
59	5α-reductase inhibitors	Finasteride	0.30%
60	Epilepsy	Valproate	0.30%
61	Anti-muscarinics, cardiovascular and	Atropine, hyoscine butylbromide	0.50%
62	Eye infections	Chloramphenicol	0.30%
63	Aldosterone antagonists	Spironolactone	0.30%
64	Direct oral anticoagulants	Rivaroxaban, apixaban, dabigatran	0.30%
65	Epilepsy	Carbamazepine	0.20%
66	Urinary Tract Infections	Nitrofurantoin	0.20%
67	Penicillin	Benzylpenicillin, phenoxymethylpenicillin	0.20%
68	Aminosalicylates	Mesalazine	0.20%
69	Mucolytics	Carbocisteine	0.20%
70	Rheumatoid arthritis	Methotrexate	0.20%
71	Anaerobic infections	Metronidazole	0.20%
72	Anti-motility drugs	Loperamide	0.20%
73	Anti-emetics, dopamine (D₂)-receptor	Metoclopramide, domperidone	0.20%
74	Focal seizures	Levetiracetam	0.20%
75	Local anaesthetics	Lidocaine	0.10%
76	Anti-psychotics: 1st generation	Haloperidol	0.10%
77	Drugs used in substance dependence	Nicotine, methadone	0.10%
78	Anti-proliferative immunosuppressants	Azathioprine	0.10%
79	Antivirals	Aciclovir	0.10%
80	Cephalosporins	Ceftriaxone, cefalexin	0.10%
81	Arrhythmias	Amiodarone	0.10%

Figure 2. Top prescribed medicines UK²

Figure 5: Prescribing trends.

Figure 3. How we got here: Prescribing Trends³.

Medium movers, in traditional pharmacies, are often positioned a little further out from the centre of the dispensary as they are used relatively less than fast movers.

Whilst the medicines discussed thus far are a requirement of the NHS Pharmacy License there are some recommendations made by local authorities for minimum stock of “emergency medicines“. Whilst this list is not a requirement of the NHS contract it is worthy of attention as local authorities can commission Enhanced services that can provide additional revenues to the business.

Local emergency medicine expectations

Drug	Form	Strength	Qty
Codeine	Linctus	15mg/5ml	5 x 200mls
Codeine	Tablets	15mg	56
Codeine	Tablets	30mg	56
Cyclizine	Injection	50mg/1ml	4 x 5
Dexamethasone	Injection	3.3mg/1ml	1 x 5
Diazepam	Rectal Tubes	5mg/2.5ml	1 x 5
Diclofenac	Injection	75mg/3ml	1 x 10
Diclofenac	Suppositories	100mg	1 x 10
Glycopyrronium	Injection	200mcg/1ml	2 X 5
Haloperidol	Injection	5mg/1ml	1 x 10
Haloperidol	Oral solution	10mg/5ml	2 x 100mls
Hyoscine Butylbromide (Buscopan)	Injection	20mg/1ml	2X10
Levomepromazine	Injection	25mg/1ml	2 x 10
Lorazepam	Tablets	1mg	2 x 28
Metoclopramide	Tablets	10mg	1 x 28
Metoclopramide	Injection	10mg/2ml	2 x 10
Midazolam	Injection	10mg/2ml	4 x 5
Morphine sulphate	Concentrated	20mg/ml	1 x 120ml
Morphine sulfate immediate release	Tab/caps	10mg	56 (or 60)
Morphine sulfate immediate release	Tab/caps	5mg	56 (or 60)
Morphine sulfate	Injection	10mg/ml	8 x 5
Morphine sulfate	Injection	30mg/1ml	8 x 5
Oxycodone (OxyNorm)	Capsules	5mg	1 x 56
Oxycodone	Injection	10mg/1ml	1 x 5
Morphine Sulphate (Oramorph)	Solution	10mg/5ml	8 x 100mls
Water for injection	Injection	10ml	8 x 10
Sodium chloride solution	Injection	0.009	4 x 10ml

Figure 4. Local emergency medicine expectation.

Pharmacy staff should advise patients to request their prescription in good time. This is particularly important for patients taking medicines with a significant clinical consequence where missing any doses (e.g. anti-psychotics, anti-epileptics, anti-cancer, etc) can cause harm.

Initial Volume

So, we know what percentage of stock should be proportioned to each medicine, however, what overall volume should be stocked? The answer to this is dependent on what the initial predicted prescription volumes will be. To get a ballpark of this figure keep in mind that the average amount of items dispensed monthly by UK pharmacies in 2019/20 was 6.6 thousand, however over 2,400 pharmacies dispensed an average of over ten thousand items a month.

References

¹https://www.thedatalab.org/blog/123/what-are-the-most-commonly-prescribed-medicines-top-10-prescribed-medicines-in-nhs-england-primary-care-for-2019/

² Audi, S., Burrage, D. R., Lonsdale, D. O., Pontefract, S., Coleman, J. J., Hitchings, A. W., and Baker, E. H. (2018) The ‘top 100’ drugs and classes in England: an updated ‘starter formulary’ for trainee prescribers. Br J Clin Pharmacol, 84: 2562– 2571. https://doi.org/10.1111/bcp.13709.

³ https://openprescribing.net/

How to set up a distance selling pharmacy in the UK.

Mike Bereza — Mon, 13 Jul 2020 05:45:26 +0000

5 Steps to owning your own pharmacy.

In the UK, a business which can dispense Prescription Only Medicines (POMs) against a prescription is termed a ‘Pharmacy‘ and must be registered with the General Pharmaceutical Council (GPhC), the UK pharmacy regulator. “Pharmacy” is considered a protected title by the UK government, meaning using the title in regards to a business without registration can result in prosecution by the GPhC for “risk to public safety“. It is often prohibitively expensive to purchase an existing pharmacy as prices can range between £50,000 and £1,000,000+, entrepreneurs often find it easier to start one from scratch with the guidance of experienced veterans in the industry. This article has been created for business people looking to start an online pharmacy and acquire the ability to dispense POMs against a legal prescription.

How to set up an online pharmacy?

On average (we have dealt with over 1,000 applications), it takes 3 months to start an online pharmacy. The most important thing to understand is that there are two kinds of pharmacies in the UK, one which has been awarded a contract to serve the NHS and one which has not. Put simply:

An NHS-contracted pharmacy must abide by stipulations of both the Regulator, the GPhC (via the 5 principles) and the NHS via the Community Pharmacy Contractual Framework. Whereas a private online pharmacy, only needs to meet the requirements of the GPhC.

The next stage after deciding whether to pursue an NHS or Private Pharmacy is that you will then need to choose whether you want to have a presence on the high street or not. The following decision matrix can help you make this decision:

NHS contracted pharmacy – this is the most common type of pharmacy you find in the UK. and includes the common high street pharmacies such as Boots, Llyods or Well. These pharmacies are contracted by the NHS to enable the UK public to hand the pharmacist a standard green FP10 prescription which was obtained from their NHS GP and receive the dispensed medicine at the standard NHS prescription charge which currently is £9.15.
Private Pharmacy – are less common in the UK as the majority of healthcare provision is by an NHS-commissioned GP and Pharmacist. However, in recent years due to the lack of funding of the NHS, there has been an increase in the number of private prescribers and private pharmacies offering services to patients who are willing to pay for more convenient medicine.
Easiest route – is to follow the right-hand path of the image to the left. i.e. dispense only private prescriptions via a distance-selling pharmacy.

Stage 1: Create or use an existing Companies House registered entity.

You do not need to be a pharmacist to start an online pharmacy (termed Distance Selling Pharmacy by the GPhC) in the UK. The essentials of the GPhC application process entail that you simply require to be a director of a Limited company / NHS trust / sole trader / partnership and be associated with a pharmacist who will represent your business as a “Superintendent“. By far the easiest mechanism to achieve this is to register a new limited company and contract the use of a remote Superintendent. A Superintendent is a special class of pharmacist who has at least 3 years of pharmacy experience and is not a superintendent of any other organisation.

Stage 2: Find a suitable location.

Once the fundamentals of the Companies House entity have been established, the next stage is finding a suitable location, this can be broken down into four distinct stages:

A great way to get a head start would be to open a pharmacy within a GPs centre, i.e. make a jeweller next to a gold mine, however, this has been explicitly excluded by GPhC stipulation. The site should not be next door or in the vicinity of any other Primary Care setting (GP Surgery, another pharmacy).

Stage 3: Making the GPhC application.

If you are making an application for an NHS Distance Selling Pharmacy this is initially done on a local level, you will need to find what local health authority your pharmacy will be under by consulting a list of local Clinical Commissioning Groups (CCG). Once you know which CCG you will be applying to you will need to contact NHS England to get their contact details via their website.

If you intend to register a private distance-selling pharmacy, you can bypass this first step and make an application directly to the GPhC using this form. Filling out this application form is simple up until section 5 where you have to give examples of how you intend to meet the GPhC’s five principles, we have created an automatic distance-selling pharmacy compliance tool you can use to check these points. Applicants often get stuck when they are asked for the following:

Feedback and your complaints systems – the GPhC require all pharmacies to have a system in place which allows patients using the service to complain about the service.
Standard Operating Procedures – this is usually required by the GPhC for submission ensuring that the pharmacy has sufficient clinical safeguards to ensure the safe dispensing of medicines.
Online prescribing – this is a relatively new development in online pharmacy service provision. Because pharmacies in the UK are CQC-exempt, they may employ prescribers to prescribe medicines online. However, specific clinical governance requirements first must be met. These must include systems to ensure the safe management of:
- Antimicrobial or antibiotic medicines
- Medicines that are liable to abuse, overuse or misuse
- Medicines that need to be monitored or managed

Stage 4: Making the MHRA Application

Due to Brexit in the UK, the Medicines and Healthcare products Regulatory Agency (MHRA) has temporarily decided to not make this step mandatory, you can read their full release here. We have included some information about what the requirements were previous to 2021 as it is likely that they will be reinstated at some point in a different form. Pre-2021 a new DSP would have had to pay the MHRA ≈£200 to ask them permission to use your GPhC license to offer medicines online. Once the application was complete the MHRA would have given the online pharmacy an additional logo with a hyperlink to their verified online pharmacy register.

Optional Stage 5: NHS Contract Application

Before a registered pharmacy can dispense prescriptions issued under the National Health Service, it must be included in the pharmaceutical list relating to a Health and Wellbeing Board Area, maintained by NHS England (administered by the local team). Applications to join this list can be submitted to NHS England via their Primary Care Support England (PSCE) website.

Within the NHS Distance Selling Application, you will be required to submit the following details:

Opening hours – you will need to specify within what hours the service will be provided.
What Advanced & Enhanced Services you will offer – will you offer smoking cessation? Needle exchange?
Health and Wellbeing Board needs assessment – is there a need in the area?
Pharmacist Declarations – you will need a pharmacist on board.

Online Pharmacy Issues

Once you have set up correctly and are up and running there are a few other attributes to your business you should consider. One is how does an online pharmacy check a patient’s identity will you do this in-house or use a third party, another is how to mitigate the medico-legal risks of online prescribing. For further information, we have made a list of the most common online pharmacy issues.

Conclusion

Overall, each application to the GPhC costs ≈£750. We provide a wide range of consultancy services to help you get online prescribing and dispensing to Best Practice in no time, get in contact with one of our consultants today.