Have online pharmacies been judged too harshly; and how should they be regulated?

In this episode, reporter Emily Warner delves into concerns about fake online pharmacies and unregulated medicines as well as the benefits of digital care.

She is joined by Earim Chaudry and Danielle Brightman –  part of the recently established Coalition of Responsible Digital Health (CORDH) – alongside Dr Anju Verma, GP and clinical lead for weight-loss at Boots Online Doctor, and Sarina Mughal, a pharmacy director in London.

They discuss the challenges and opportunities for online pharmacy as it gains popularity and the role of bricks-and-mortar pharmacies in this evolving landscape.

The guests also consider how the heavy regulation of digital providers, designed to prevent unsafe practice and the sale of illegal medicines, may be stifling innovation.

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This epsiode was produced by Emily Warner. 

Transcript

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SPEAKER_03 0:06

Hello and welcome back to the Pharmacist Podcast with me, Emily Warner. Today we are talking about a pretty hot topic in the pharmacy world, and that is online pharmacy. There's a lot to love about online pharmacies. They're discreet and convenient, they allow patients to access healthcare more easily and order medicines from their own homes. However, the bad behavior of some online pharmacies and the rise of fake online pharmacies set up by criminals has also raised concerns about safety and regulation. A survey by the National Pharmacy Association in April found that one in ten pharmacies had had their websites and social media posts cloned by criminals to sell fake weight loss medication online. In some cases, the MPA said it had seen the fake provider copy regulator logos, including the GPHC and CQC, making it difficult for patients to separate legitimate pharmacies from fake ones. Another survey revealed that almost two-thirds of people worry that their medication could be fake or substandard. A report in March found that patients who bought medicines from unregulated online sources said they felt compelled to take the risk due to a lack of alternatives, which raises some serious questions about access to medicines. The same month, pharmacy leaders were questioned by MPs on this topic. They actually raised concerns about heavy regulation of online pharmacies, shutting down the opportunity for reputable digital providers to improve access. Dr. Simon Doyle, who is a GP and public policy lead for the online weight management platform Juniper, said regulators should focus on working with digital providers to establish best practices rather than tarring them all with the same brush. To try and understand the complex world of online pharmacy, I've enlisted the help of Iram Chowdry and Daniel Brightman, who are part of the recently established Coalition of Responsible Digital Health, also known as Cord. I also have here with me Dr. Andrew Verma, GP and Clinical Lead for Weight Loss at Boots Online Doctor, and Serena Mughal, a pharmacy director in London. So, Iram and Danielle, tell me first of all what Cord is all about.

SPEAKER_01 2:31

Cord really the genesis of it came about in creating this regulated coalition of digital first providers that are really putting high quality care at the heart of what they do and really ensuring that we're upholding very, very high standards across evidence, care delivery, and outcomes. And really it's the bringing together of some of the organizations that feel that they want to champion this and bring it to the fore and really radically change the relationship with regulators, stakeholders like patients, and other interested parties.

SPEAKER_02 3:02

So Cord is made up of Newman, VoI, Juniper, Shemed, EMED, and Simple Online Pharmacy. And between us, we represent around 15% of the online prescribing market for obesity medications. And the reason we've come together, as Iram's already said, is about championing the patient-first digital approach where we're delivering that wraparound care that isn't always delivered on online providers. So you get different types of treatment pathways and different types of interactions. And what we all believe in is the interactions of ongoing care beyond medication and from the beginning throughout the treatment journey.

SPEAKER_03 3:41

And what are the biggest challenges facing online pharmacies at the moment?

SPEAKER_01 3:46

I think for myself it's around the reputation and the narrative that all digital providers sit in a bucket of unregulated, unscrupulous provision of healthcare. And I think it's really, really important to try to bifurcate those two domains and really look at what are regulated providers that provide clinically safe, effective care that are regulated by the GPHC, MHRA, and CQC, and actually what are some of the stories that we've been hearing about provision of care that's being provided without any of those guardrails. The other thing I think is about not seeing things as one or other. And really the way I say that is that we sometimes talk about digital versus face-to-face as though they can't exist in the same ecosystem. I think the key thing here is being able to demonstrate what digital care really means, which is ultimately technology-enabled healthcare, and secondly, how it can coexist within with existing systems and how we can facilitate for its growth alongside those systems rather than seeing it as something that really we need to look with a with kind of a negative lens.

SPEAKER_03 4:58

That's really interesting. I want to turn to Andrew now, who's here from Boots Online Doctor. What are your main challenges and how is it working for a company with both online and in-person pharmacy services?

SPEAKER_00 5:11

And so just thinking about Boots Online Doctor itself, firstly, we launched in 2021 as advice and prescription medications. We are one of the leading online pharmacy providers in the UK. And I think within that, uh, we are now also offering 48 different services across our digital platforms. And I think that really reflects how this rapid expansion are changing with people's habits of how they want to access care. So I think bearing that in mind, it's it's quite fast. One of the challenges that comes through that then is how a digital pharmacy helps to establish that trust and that the services that we're providing are quality and better than, if possible, than a physical establishment. You mentioned our sort of unique position of having our digital Boots Online Doctor, then our community part of within the Boots Pharmacy Healthcare. So I think what we can do is work with each other. I think that's something that I personally really value.

SPEAKER_03 6:14

Thanks for that, Andrew. Serena, you work for an in-person pharmacy in London. Do you think that the minority of online pharmacies who are not providing safe and effective care are actually damaging the reputation of the whole pharmacy profession?

SPEAKER_04 6:31

Of course, because as pharmacists and anyone in the healthcare profession, we have to put our patients first. Patients must be our first concern. And whilst I appreciate some pharmacies are businesses, especially online pharmacies, you do have to put the patient first. Now, some pharmacies where they are working online and they're not doing all the regulatory procedures and they're not working correctly is actually really disheartening because there are some brilliant online pharmacy businesses out there who are doing it correctly, who are doing all the appropriate checks, who are having proper video consultations with the patient, who are having proper communication with their patients. So I think the people who are not doing it correctly really are creating a negative environment for other businesses.

SPEAKER_03 7:14

That must be really frustrating. And it also shows why organizations like CORD are so important. On a more positive note, where do you think online pharmacies can have the greatest impact? Uh we'll start with you, Danielle.

SPEAKER_02 7:29

In general, it's conditions that tend to be stigmatized, so patients may not feel confident enough to seek help face to face, or they tend to be maybe unable to access that type of treatment on the NHS. So for patients with those types of conditions or diseases, they may prefer digital care. But it's also about what type of job they might have or what's their working pattern and whether digital care might just be more convenient for the patient at the time, or do some and some patients prefer to access care through an async setting or a remote setting or through their phone. But for others, they may prefer that face-to-face, they may prefer to go into a DP practice because that's the more traditional setting that they're used to. So it really depends on the conditions or diseases and where that patient their working pattern is.

SPEAKER_03 8:15

Is it the same for you at Boots, Andrew?

SPEAKER_00 8:17

Certainly, skin conditions, sexual health, and women's health have continued to see demand from day one. And one of our most recent services is the insomnia service, and that has had a really strong interest. Um, and the feedback so far from patients actually has been very, very positive. So that's another area that you know we're moving into. Online care shouldn't be judged as just on convenience. That's not the right thing. It's not just a log on and get on and get what you need at that time. Although it may appear convenient, what we have in the background is robust clinical governance frameworks, patient verification, continuity of care for patients, and certainly if it's online doctor, we want to have a communication with the wider healthcare system.

SPEAKER_03 9:06

So you've both spoken about how online pharmacies are fantastic for treating more private conditions, such as obesity or menopause. But is there a risk that online pharmacies might become mixed up with the stigma surrounding those conditions? Daniel and Irim, I'm I'm gonna come to you first.

SPEAKER_01 9:25

I think it goes at the heart of why obesity is considered such a stigmatized condition. It's a condition that's put through a lens that no other chronic disease suffers. And I think because obesity is a condition you wear, and it's synonymous with laziness, people not looking after themselves. We're told it's so simple, you should move more and eat less. And the reality is that condition itself is at the intersect of your metabolic health. 80 to 85% of people who are obese are going to go on to become diuretic, but we don't apply that same lens to diabetes. And because this stigma exists, we hear words like weight loss jabs, sort of almost making it such an easy intervention that it's just a once-off and that's all you need, and you're sorted and you're met gala-ready. Media themselves are sort of really thirsty for anything that could either be seen positively or negatively about the obesity epidemic and the kind of avalanche of demand for treatments. So I think what we see is that providers themselves get mixed in with this stigma. Ultimately, healthcare exists to serve patients, and we know the demand exists, which means people do want to look after those disease areas. And so digital providers really sit within that intersect of supporting those individuals, seek the help that really isn't provided, or that there's just so much stigma around they wouldn't go through a traditional route or have the means to do so.

SPEAKER_02 10:54

Yeah, I think again, and it's sort of the throwing everyone under the with the same brush with that's digital providers. There's quite a big difference between like an unlicensed practice versus a digital, like a regulated practice online. But the difficulty is at the moment it's really the onus is on the patient to understand um whether you're regulated or not. So we do a lot around educating people around how to spot unlicensed providers, things like looking for their GPHC or CQC regulation on the home page, looking it up on the CQC or GPHC website. But it really shouldn't have to be on the patient to know whether they are getting treatment from a regulated provider. And there should also be more that we can do and more that we will try from a core perspective to support our regulators so that we can explain the differences between how we practice versus those unlicensed providers as well.

SPEAKER_03 11:44

I mentioned at the beginning of this podcast that criminals are actually cloning the websites and social media posts of online pharmacies. Is this something that's on your radar, Andrew? And uh, what's Boots doing to tackle it?

SPEAKER_00 11:58

Firstly, the the problem itself. Um, so yes, we are aware of the circulation of these sort of fake adverts for unlicensed medications, lead being lead of the weight loss service. Yes, I'm always on the lookout for this sort of thing. And they appear in social media, appear to be endorsed by boots, and our compliance teams are monitoring for these types of scams. They take proactive action to remove these fake adverts as soon as they're identified. Certainly for boots, we will only run adverts through official accounts, for example, our Boots Online Doctor YouTube channel. Just thinking about it from the the person perspective, people are coming to user services. Wider Boots research has shown that about a third of patients or a third of GLP1 users were concerned that the medicines might not be genuine, which in itself is worrying. And then two-thirds actually reported sort of receiving content or seeing content about counterfeit medicines or from unlicensed providers in social media places. So all of that is something that I think does need to be clamped down as best as we can. And a large part of this, I think, is uh recognition of these red flags and making sure that online pharmacies are on their websites displaying the right credentials of that they are regulated. So the care quality commission logos, the GPHC General Pharmaceutical Council registration numbers should all be available, not just on the provider's website but on the regulators' website as well. And I think sort of what we do more for people, I think, would be for people coming to use online providers, just look for those credentials. If there's no GPHC number, it's a red flag. A few others would be if if the provider is selling prescription medications without either a prescription or an actual quite thorough consultation, promising miracle results when especially when we're looking at weight management, it's a long-term treatment plan that we advise for patients. And also prices are just too low.

SPEAKER_03 14:14

It's definitely concerning to think that these fake online pharmacies exist and they are a real threat to patient safety. From a cord perspective, what can be done or what is being done to tackle the problem?

SPEAKER_01 14:26

I think firstly it's demonstrating what good looks like. As cord members, we are subject matter experts. We've spent years and years dealing with patients, understanding how to leverage the human doctor plus the technology. So the one-hour one equals three scenario and giving an outsized impact. We've also published and we've demonstrated that we're able to do this with large, large numbers of patients, give differentiated outcomes of the clinical wraparound services from medications alone. So, first showing what GREAT looks like. Then I think it's supporting regulators to understand how to better manage and regulate technology-based services. What does GREATE look like? What's the limits of the technology? Where are the areas of vulnerabilities? And then I think lastly, around ensuring that we're educating the public on what those standards should look like, what they should look like to make sure that they're not going through black market solutions, but also meeting them at a level where they think they can afford and access the healthcare through recredible providers. Because ultimately, why does the demand exist for a black market? Either that people are getting to a sort of financial level where people feel that they need to go there, or they just can't differentiate between what's high quality or not and what the risks are. Also, for the regulators to come on this journey to look at how they can tighten the current punishments and the legislation to make sure that they are on top of isolating when these events are happening.

SPEAKER_03 15:52

Interesting. Um, but do you think regulation is too harsh for some digital providers who are following the rules? Should we be relaxing regulation at all?

SPEAKER_02 16:02

Yeah, I think it's not about um necessarily relaxing guidelines. What we really want to work closely with the regulators is about how to regulate based on like outcomes. Because if you start putting in very like process-driven regulation, you're then um you're not necessarily improving the safety, but you are definitely dampening any innovation. And if you focus on regulating through what good looks like and what outcome you're expecting to see, then um it allows companies to innovate to increase the safety profile. And because again, like digital health is always evolving, there's many ways at demonstrating safety, and because we across cord we actually prescribe for so many patients, we're able to demonstrate that our safety profile is is really really strong and that we actually provide good health outcomes for patients through the data that we are collecting together.

SPEAKER_01 16:57

So I think firstly, I wouldn't want to have all digital providers in the same bucket, and and I think that has still been the overwhelming messaging that digital providers are providing a substandard service, and often that is quite broad brush, including providers that don't necessarily follow the regulations, have not been inspected, etc. I think it's also really tightening the definition of what it means not to meet standards, because sometimes those standards have been built based on incumbent healthcare systems which have a certain way of delivering healthcare, which actually is either not available to digital providers, for example, access into NHS records when you're a private service, that hasn't typically been the standard. And secondly, also for some of those private providers to be able to demonstrate what incredible quality can look like that hasn't been seen through traditional models. And so for that to also be appreciated on an outcome basis rather than simply that the template says you need face-to-face consultations to collect X history or to collect Y form of clinical information. Actually, for it to be put through a really robust risk assessment and for that to be clinically driven based on evidence and science, and then deciding as to what's appropriate for patients. And I think really being cognizant of what's the path the patient takes if there's no options here for them. We know the demand exists and we know that will then divert demand into the black market as well. And so, really supporting the new innovative models of care regulators getting much tighter in understanding what we're doing, how we're doing, because it's not a click and collect type of service. It's not that you have one interaction and the and a prescription is given to a patient. The reality is that patient has multiple touch points and it's not just a traditional direct clinical interaction. It's actually a tiered care model where you have support from a digital tool, you'll have a messaging uh facility, you'll have content and information, webinars, behavioural change, medication, side effect management, and all of that amalgamates together to provide the service. So I think it's just having a very tight understanding of that.

SPEAKER_03 19:02

Serena, do you want to jump in here and add anything?

SPEAKER_04 19:06

I think safeguarding is probably one of the most important factors. As mentioned earlier, a video consultation is probably one of the most safest ways people can do this. GPHC and MHRA may want to go in that direction. I know some online pharmacies are doing this already. They have so many strict robust procedures in place that you can actually tell that is the correct patient. The only other thing is I'd say maybe there needs to be a bit more regulation in terms of accessing medical records because right now online, a lot of online pharmacies are actually private pharmacies. Some have NHS contracts, but with a private pharmacy, you can't always access the patient's SCR. So I think maybe there needs to be some work done with other healthcare professionals and multidisciplinary teams.

SPEAKER_03 19:49

That's a really great point. I think we hear a lot of pharmacists asking for better access to patient records and better information sharing across the healthcare system. And so I can see why that would be really beneficial for online pharmacies. We've already touched on this, but I wonder if you, Andrew, could tell us what is the best and safest way to deliver weight management services.

SPEAKER_00 20:12

Being Boots Online Doctor and having community pharmacy, we have a kind of a unique position to provide care digitally and in person. And so we can utilize that framework when and if required to make sure that we have robust safeguards and we can do all our checks as required. So we carry out age verification, the official ID reviews, the medical assessments, the live photos, as well as GP notification details. We have the option, you know, the live photographs of patients in terms of our BMS, BMI assessment, as well as all the other medical history that comes through the digital consultation. And I think what's important is that this is a rapidly evolving space, this weight management sphere. So we are led by the clinical and real-world trial data and use that alongside our clinical experience and expertise in our team to make sure patients get sort of a whole person care if required. Yes, we can ask patients to go into a store more local to them weight verification if required. But I think the process I hope comes to patients as being quite robust. There are so many steps that I'm pleased and proud of the service and what it offers.

SPEAKER_03 21:36

And what do you think about the recent approval of two new weight loss pills in the UK?

SPEAKER_00 21:41

As a doctor, the expansion of treatments is wonderful. There's greater choice for many more people, uh, whether it be someone who didn't get on so well with the medicine, others who might struggle with the idea of injection. So these tablets or pills offer them an option. And then we've got people Who may be considering perhaps coming off injections but still require support with weight maintenance. And actually, I think that's really important to consider because finding an option that helps with maintaining weight can be just as important as the weight loss itself. They are all still going to be sitting behind all that appropriate safe prescribing with our patient education, with our wraparound care and our continuity and all the support measures that I've spoken about.

SPEAKER_03 22:28

Okay, I have one final question for all of you, and it's a big one. Will online pharmacies ever replace in-person ones? I'll come to you first, Danielle and Aram.

SPEAKER_01 22:39

I think we need all of those services to sing and dance together to support patients. And so I don't see it as either or. Ultimately, pharmacy services do an incredible job of supporting patients across a range of conditions, whether that's prescriptions being dispensed and supporting patients because the 10-minute GP consultation is often not enough to provide all the information on how do you take a medication. I think we've seen pharmacy first models, we're seeing the increasing role of pharmacists as well within PCNs and ICBs as well. And so I think they do an incredible job, and I think that's only ever going to increase. We know pharmacists are going to be prescribing in the community as well. And so I think there's just there's certainly enough uh healthcare problems for them to be supporting. And I see cord members really just being an alternative model for people who want to have digital healthcare and they want maybe potentially technology-enabled services that were supporting them on a wraparound basis because we know one of the primary drivers is the medication for outcomes, but often actually behavioural change is really key as well. How do you embed those habits that actually lead to lasting lifelong change? And so I say it's just a just part of an entire ecosystem for population health. I can see that the direction of travel in healthcare right now is that we are crying out for technology to support the number of humans because we simply cannot scale humans enough. And patients, what we're seeing in the real world, and I think we should really bring this to the fore, is that at the moment members like the the CORD group have some of the largest real-world evidence data sets within the disease areas that they serve. And that provides us a lot of insight into how are people utilising the service and what are the kind of outcomes that they're getting. And so what we're seeing is that there is a massive role for these services, technology enabled, to support being able to serve the number of patients that have problems. And certainly we're seeing the direction of travel is that we need to accelerate the uptake of those technologies to be able to serve the net volume of patients that we have. And then we also need to go a little bit more upstream to prevent conditions. And so, really, if you look at healthcare services and almost as an infinity loop on its side, you have two areas. One is the sick care model, where actually you intervene with interventions and you do that high-quality at scale and supporting doctors to have an outsized return. And then actually you try to move people a bit more upstream in conditions where you can actually have a preventative care model and you try and keep the population as much more in prevention as possible. And again, in order to do that, you're likely to need to use something that can leverage the number of human doctors or human healthcare professionals that you have. And that looks like it would be a model that's supported by AI and technology, and again, so I think that's a really interesting area. And so we also see that being mirrored in the 10-year plan about moving to prevention, moving closer to home, and actually the utilization of technology. So I think all sort of indicators are that that's the direction of travel. Will it replace incumbent healthcare systems? No, I don't think so, because I think there's again a universe that exists of multiple healthcare professionals through a tiered care model where people need to be seen face to face or in intensive care. But the reality is if we want to have an economically viable healthcare system, we need to we need to keep people as much in well health and proactively looking after their health at lower tiers rather than the very expensive financially intensive or healthcare professional intensive interventions.

SPEAKER_00 26:04

And what do you think, Andrew? Well, I think being in the fortunate position that I have at Boots Online Doctor and working with our Boots pharmacies, I see them as absolutely complementary. We're not competing with each other, we're offering services so that they can be accessed when people need them. And there's definitely an important place for both. If you're wanting that flexibility of online or if you want to speak to someone, it just means you can do either. I think that's important for people to hear as well. And certainly some of our services, such as emo emergency contraception, outweight loss service, are available both in store and online.

SPEAKER_03 26:50

And last but not least, Serena, from the perspective of an in-person pharmacist, do you think you will ever be replaced by online models?

SPEAKER_04 26:59

I definitely think the future is both models, just because you have a lot of demographics in society that actually are very lonely. Some of our elderly patients they want to come into a pharmacy to speak to a pharmacist or pharmacy teams. I also think you have a society where digital health is massively growing, and there is an advantage for a different type of demographic. So I definitely think the best procedure will be both businesses working alongside each other. I don't think you could ever replace an in-person consultation, but that's with a pharmacist, a doctor, a dentist. However, I think the way society is moving, I think there'll be a lot more digital health options now, and I think there will be a lot more online pharmacies.

SPEAKER_03 27:40

It sounds to me like you're all in agreement. The future of pharmacy is not only online or only in-person, but a combination of both. And hopefully, as regulation improves with the help of groups like COD, the existence of illegal or substandard online pharmacies will disappear. I would like to thank all four of our wonderful guests for coming on the Pharmacist Podcast and giving us plenty of food for thought. And I also want to thank you for listening. I hope you've enjoyed it. We'll be back in a couple of months with another exciting guest, so make sure that you've hit follow on your podcast platform of choice to ensure you don't miss out. In the meantime, you can keep up to date with the latest pharmacy news on our website, www.thepharmacist.co.uk, where we've been covering all sorts, from flu vaccinations and dengue to pharmacy YouTube channels. You can also sign up to receive our newsletters or follow us on social media. Details on how to do this can be found in the description.