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Patient Nomination of a Dispensing Site

Nomination is a new process that is being introduced in Release 2 of the Electronic Prescription Service. It gives patients the option to choose, or ‘nominate', a preferred dispensing contractor(s) to which their prescriptions can be sent electronically using the Electronic Prescription Service. This section of the site provides detailed guidance for contractors on this new functionality. Use the quick links below to access specific areas ofthe guidance:

Background on the new functionality

Controls to Ensure Patient Choice

Updating NHS Choices

Changing a Patient's Nomination Setting

Obtaining a Patient's Consent for Nomination

Nomination SOPs

Local PCT Nomination Policy

FAQs

Background on the New Functionality

When a nominated electronic prescription is generated, it is then sent to the Electronic Prescription Service and can be retrieved by the nominated dispensing system - without the need to scan a barcode on the prescription token.

Patients or their carers will be able to set their nominated dispensing site at any Release 2 enabled pharmacy, at the GP Surgery that they are registered with (if Release 2 enabled) and in time, online themselves on the NHS Healthspace website. The patient will be able to set up to three dispensing sites: a community pharmacy and/or an appliance contractor and/or a dispensing doctor. It will not be possible for a patient to select more than one dispensing site of the same type, for example more than one pharmacy, however consideration is being given to enabling this in the future. Also, it will not be possible for patients to nominate a chain of pharmacies, only a specific dispensing location.

Unlike with established prescription collection services, patients will be able to request that their prescription is sent to any pharmacy regardless of the geographical location or the working relationship between the pharmacy and the prescriber.

Dispensing doctors will continue to only be able to dispense to patients where the criteria in the regulations is satisfied, including that the patient is resident in a controlled locality, at a distance of more than 1.6 kilometres from any pharmacy. It would be a breach of a dispensing doctor's Terms of Service to use the Electronic Prescription Service to dispense for a patient for whom they are not entitled to provide pharmaceutical services. For this reason, patients will not be able to nominate a dispensing doctor online at Healthspace or through a provider other than the dispensing doctor that they are nominating.

Ensuring Patient Choice is Maintained

A number of safeguards have been introduced to ensure that patient choice is maintained when the system is in use.

The patient can choose whether to have an electronic prescription or a paper prescription. For the time being (during Phase 3 of implementation of the Service), an electronic NHS prescription can only be issued where the prescription is being sent electronically to a patient's nominated dispensing site. Patients who have not nominated a dispensing site or who do not wish their prescription to be sent electronically to one of their nominated dispensing sites on a particular occasion will receive a paper prescription form that can be taken to any pharmacy.

It is also the patient's choice which dispensing site they choose to nominate. In April 2005, the National Health Service (Primary Medical Services) (Miscellaneous Amendments) Regulations 2005 came into force which stipulate that when operating the Electronic Prescription Service, a prescriber must not seek to persuade a patient to nominate a dispensing site recommended by the prescriber. The regulations also state that, if asked to recommend a chemist, the prescriber is to provide a list of all chemists in the area that operate EPS, as provided by the Primary Care Trust.

GP systems will provide support to GPs in searching for a particular Release 2 enabled dispensing site at the patient's request. By typing in a particular postcode, the system will display providers in order of proximity to that postcode area. The information on Release 2 enabled providers will be provided by the NHS Choices Website (www.nhs.uk) therefore it is essential that pharmacy contact details held on the NHS Choices site are up-to-date and accurate.

The National Health Service (Pharmaceutical Services) Regulations 2005 prohibit pharmacies and appliance contractors from providing patients with inducements to encourage nomination of a pharmacy.

The Primary Medical Services (Electronic Prescription Service Authorisation) Directions 2008 (reproduced in Part XVIIID of the Drug Tariff) place an obligation on PCTs to proactively monitor the service and where they identify any unusual or unexpected distribution of nominations, consider whether further investigation or action is appropriate. This may include action for breach of contract. To support them in their monitoring role, PCTs will have access to nomination reports which will provide both summary and detailed information about nominations made and can consider any concerns raised by patients, dispensers or prescribers.

Changing a Patient's Nomination Settings

The patient's preference is held on the ‘Personal Demographics Service' (PDS) a component of the NHS Care Records Service. Pharmacies and GP Surgeries with Release 2 enabled systems will be able to send messages to the PDS to make a change to a patient's nomination settings.

Setting the nominated dispensing contractor will require the patient's NHS number. It is increasingly common for this to be printed on NHS prescriptions and is always contained within an electronic prescription message. If a pharmacy does not have ready access to this number, Release 2 enabled systems will support pharmacy staff, with patient consent, in conducting a simple trace on the Personal Demographics Service to locate a patient's NHS number. Pharmacy staff must enter sufficient information to achieve a 1:1 match, for example the patient's name, gender, date of birth or postcode.

Updating the patient's nomination status can occur at a convenient time to support smooth workflow; it does not need to be carried out at the same time as dispensing a prescription. Only staff with an individually registered smartcard will be able to set a patient's nominated dispensing site, but it is anticipated that any pharmacy staff members supporting the dispensing process will be able to apply for an individual smartcard with the appropriate access rights. Therefore, the administration of nomination change requests will not need to be undertaken by a pharmacist.

It will be possible to add, cancel or change a patient's nomination settings. Where a patient changes their nominated dispensing contractor, all nominated prescriptions that have not yet been retrieved for dispensing from the original nominated dispensing contractor will be transferred across to the new nominated dispensing contractor.

Pharmacies will not be notified when they have been nominated or when the patient changes their nomination setting. However, pharmacies can, with patient consent, query a patient's list of nominated dispensing sites, for example to aid patients who are trying to obtain their medication at an incorrect location.

Every time someone accesses information held on the Personal Demographics Service, a record is made about who is accessing that data and how it is being used. This would include when a pharmacy queries a patient's list of nominated dispensing sites. Privacy officers, in specific circumstances, are automatically alerted when actions have been taken by staff which may constitute a breach of confidentiality.

PSNC is pushing for a future change in the system to allow dispensing sites to be notified when a patient changes their nomination preference, for example adds or removes their nomination preference for a particular pharmacy. PSNC believes that the system should also be capable of generating a list, on request, of all patients that have nominated a particular pharmacy.

As the system only supports the patient to nominate one dispensing site of a particular type at a time, if two pharmacies change the nomination settings for the same patient, prescriptions will be sent to the pharmacy that last set the patient nomination request.

Obtaining Patient Consent for Nomination

Pharmacies must have ‘local accountable auditable processes' for obtaining explicit consent from the patient or their representative before changing a patient's nomination settings.

Pharmacists or their staff can obtain consent. The following information should be provided when obtaining consent:

• The service involves the electronic transfer of prescriptions in a secure environment. Paper is not required. Patients do not have to receive their prescriptions via the EPS however where a paper prescription is issued, services associated with EPS such as nomination cannot be used.
  
  
• Any dispensing sites operating full EPS (Release 2) can be nominated; patients are not restricted to nominating a pharmacy near their GP practice.
  
  
• Where patients have nominated a dispensing site, their prescription will automatically be received by that site unless the patient chooses not to receive a particular prescription in that way and notifies the prescriber at the time of requesting the prescription.
  
  
• Patients can change their nominated dispensing preferences at their GP surgery or any Release 2 enabled dispensing site (and in time via HealthSpace) at any time, including whilst part way through a repeat dispensing cycle. Any remaining repeat prescriptions, which have not been pulled down to the local system, will be accessed by the new nominated dispensing site.
  
  
• Where a patient has nominated a dispensing site, the site will be able to access the prescription in advance of the patient presenting at the site, in order to prepare the prescription. However, if the patient then goes to a different site, there may be delays before the non nominated site is able to access the electronic prescription.

This information could be provided in writing to the patient, for example a standard leaflet handed to patients, or it could be provided orally. Connecting for Health will be publishing a national patient leaflet that pharmacies can optionally use to support them in communicating this key information to patients.

If explicit consent is collected in advance of a pharmacy deploying Release 2, the pharmacy contractor should ensure before setting the patient's preference on the Personal Demographics Service, that there has been no change in the patient's circumstances, including their choice of nominated dispensing site, since the original consent was obtained.

EPS Release 2 Sign

To support patients in recognising which sites are Release 2 enabled, NHS Connecting for Health has developed a sign which can optionally be displayed within prescribing and dispensing sites. The sign will be supplied to a site at the time of going live with Release 2 and will be available in three different formats, A5 window sticker, A4 poster or A5 counter-top sign.

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Nomination SOP

In their Good Dispensing Guidelines, the RPSGB confirmed a requirement that pharmacies should put in place a SOP for Nomination. This is to ensure that nomination is communicated consistently to patients, and is captured in an auditable way so that, if challenged, processes are in place to back up information following on from a customer complaint or from an audit perspective. A template SOP has recently been published by the NPA.

It would not be appropriate for a PCT to request to individually sign-off a pharmacy nomination SOP or state that a pharmacy cannot begin to collect consent for nomination until the PCT has seen a SOP.

In joint PSNC/NHS PCC Guidance on monitoring the contract’s Essential Services, it was agreed that the monitoring should only extend so far as to whether a pharmacy has an appropriate SOP, for example ask to see it during a monitoring visit. PCTs shouldn’t carry out a detailed analysis of the content of SOPs. The guidance states that it would be unwise for a PCT to carry out any detailed examination, because it will be unable to determine what is appropriate for the individual pharmacy concerned, and any shortcomings not identified, or suggestions made which themselves cause problems in delivery of the services, could lead to the PCT itself being involved in litigation.  

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PCT Local Nomination Policy

In the NHS Primary Medical Services (Electronic Prescription Service Authorisation) Directions 2008 (reproduced in Part XVIIID of the Drug Tariff) there is a requirement that PCTs proactively monitor use of the service and take action where there is an unusual or unexpected distribution of nominations.

Linked to this, PCTs are being required as part of their EPS Release 2 deployment planning, to develop a PCT ‘nomination policy’. The purpose of the Nomination Policy is to provide all stakeholders with information on how nomination will be managed and monitored by the PCT to ensure that nomination takes place in a fair and equitable way. The key point of the policy should therefore be documenting the actions that the PCT will be taking to monitor use of the service and provide enforcement if necessary.

The policy could also be used to raise local awareness of the key regulatory and professional requirements that provide the framework for governing use of the service. It would not be appropriate for a PCT to use the policy to introduce controls that are in excess of the legal and professional requirements. Any controls proposed by the PCT that are out with the professional or legal requirements would not be enforceable.

Does consent have to be obtained to change a patient's nomination settings?

Yes, it is a professional requirement. The Code of Ethics states that pharmacists must obtain consent for the professional services, treatment or care they provide and the patient information they use. The RPSGB document, ‘Professional Standards and Guidance for the Sale and Supply of Medicines' contains standards for prescription collection services and the RPSGB document, ‘Professional Standards and Guidance for Patient Consent' details more general requirements on collecting consent from patients for the provision of services, including guidance on providing sufficient information and presenting this to patients. Failure to adhere to these standards could form the basis of a complaint of professional misconduct.

Does consent always have to be given by the patient?

No, in some circumstances, consent can be obtained from the patient's representative:

• on behalf of any child by either parent, or in the absence of both parents, the guardian or other adult who has the care of the child;
  
  
• on behalf of any person under 18 years of age who is in the care of an authority to whose care he has been committed under the provisions of the Children Act 1989, by a person duly authorised by that authority or in the care of a voluntary organisation, by that organisation or a person duly authorised by them;
  
  
• on behalf of any adult who is incapable of nominating a pharmacy, by a relative or the primary carer of that person;
  
  
• on behalf of any other person by any duly authorised person. A pharmacy contractor is not able to provide consent on behalf of a patient nominating his pharmacy.

My pharmacy serves a large care home. Do the patients need to provide their consent to nominating my pharmacy or could this be done by care home staff?

The regulations state that patients or in some cases their carers can set a patient's nominated dispensing site, therefore the care home staff can on behalf of the patient provide the required consent for the patient's nomination setting to be changed.

Do I have to change my Standard Operating Procedures?

Pharmacies must have ‘local accountable auditable processes' for obtaining explicit consent before changing a patient's nomination settings.

The RPSGB publication ‘Professional Standards and Guidance for Patient Consent' advises that processes for obtaining consent must be taken into account when developing SOPs and that consideration needs to be given to which members of staff may obtain consent, the information that should be provided in obtaining consent and the way that consent is collected (e.g. written, verbal).

Where and for how long should I keep a record that consent has been collected?

Pharmacies must have ‘local accountable auditable processes' for obtaining explicit consent. It is for the pharmacy to decide where records of consent are stored and for how long.

I have an existing repeat prescription collection service. Do I need to obtain consent to change the patient's nomination settings to nominate this pharmacy as their preferred pharmacy for electronic prescriptions?

Yes. Explicit consent must always be obtained from the patient or their representative before changing a patient's nomination settings.

Explicit consent can be collected in advance of the pharmacy deploying Release 2. If there is a delay between collecting consent and changing the patient's preference on the Personal Demographics Service, the pharmacy contractor should ensure there has been no change in the patient's circumstances, including their choice of nominated dispensing site, since the original consent was obtained.

If a patient has nominated multiple dispensing sites, how will they know which dispensing site has been sent their prescription?

The patient can set up to three dispensing sites: a community pharmacy and/or an appliance contractor and/or a dispensing doctor. It is not possible for a patient to select more than one dispensing site of the same type. If a patient has nominated more than one dispensing site, they will need to discuss with the prescriber which dispensing site they would like a particular prescription sent to, for example if they wish to have their medicines dispensed by their nominated pharmacy but appliances dispensed by their nominated appliance contractor.

A patient has visited my pharmacy and asked that I set their nomination for both my pharmacy and an appliance contractor that provides the patient with their stoma products. Do I have to set the nomination for the appliance contractor?

Yes. The Terms of Service require that where the EPS service is available, the pharmacist must update a patient's nomination settings as requested by the patient, this would include adding a pharmacy or appliance contractor as the patient's nominated dispensing sites. A nomination to a dispensing doctor is only possible at that dispensing doctor's location.

What if the patient forgets which pharmacy they have nominated, how can the patient find this out?

Pharmacy systems will support querying a patient's current nominated dispensing sites. Pharmacy staff with appropriate access rights will, with patient consent, be able to view the contractor type (i.e. pharmacy, appliance contractor or dispensing doctor) as well as the organisation name, address and postcode for the patient's nominated dispensing site. Prescribers will also be able to view this information.

Can I provide patient's with loyalty points or a free gift if they choose to nominate this pharmacy?

No, the Terms of Service in the National Health Service (Pharmaceutical Services) Regulations 2005 prohibit pharmacies and appliance contractors from providing patients with inducements to encourage nomination of a pharmacy. A breach of the Terms of Service could result in the Primary Care Trust taking disciplinary action against the pharmacy contractor.

Could staff in a GP Practice, for example a GP receptionist, change the nomination settings at a patient's request?

Yes, if the individual has a smartcard and has been granted the appropriate access rights, they could, with the consent of the patient or their representative, record a patient's nomination on the Personal Demographics Service.

If a patient has nominated a particular pharmacy, does a particular prescription have to be sent to that pharmacy electronically?

No. Even though a patient may have set a nominated pharmacy, they are free to request that the prescriber issues a standard paper FP10 prescription or a barcoded FP10 prescription. This may be preferable if the patient is, for example, planning to go to a pharmacy in Scotland or Wales, where the EPS is not available.

In time, following further regulatory change, it is anticipated that it will be possible to also issue electronic prescriptions to patients who have not nominated a pharmacy. When this happens, the patient would be able to request that they receive an electronic prescription and a prescription token that can be taken to any Release 2 enabled pharmacy.

Does a patient require separate electronic prescriptions for medicines and appliances?

If the patient requires both medicines and appliances, the prescriber must decide, as now, whether to generate two separate prescriptions. This will depend on where the patient wishes to have their medicines and appliances dispensed, for example if they wish to receive all items from the pharmacy or whether they would like an appliance contractor to dispense their appliances.

If I sell my pharmacy, will the nomination settings automatically be transferred to the new contractor?

PSNC is still in discussion with the Department of Health on this issue. Guidance, once it becomes available, will be published on the PSNC website.

How should I confirm the identity of a patient who has nominated my pharmacy to receive their prescriptions and does not have a prescription token?

As with repeat collection services, this would be for a pharmacy contractor to determine as part of local standard operating procedures, for example, if the patient is not known to pharmacy staff, the patient may be asked to confirm their address and date of birth or if there is doubt over the patient's identify, the patient may be asked to show some form of ID.

What is the timescale from a pharmacy deploying EPS Release 2 to NHS Choices being updated?

When a R2 system is installed a commissioning prescription is scanned and a message sent to NHS Prescription Services. This triggers payment of the EPS Release 2 allowance. Also NHS Prescription Services send a message to NHS Choices, this happens on a weekly basis (Thursday). Between commissioning and the next Thursday night the pharmacy would be able to set nominations.

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