Exploring the Structure of England’s Pharmacies
Key takeaways:
The United Kingdom has what many Americans might refer to as “socialized medicine.” The government owns the majority of healthcare facilities and employs the majority of healthcare professionals, under the National Health Service (NHS).
Medications must be approved by the Medicines and Healthcare products Regulatory Agency (MHRA) to be sold, and then undergo cost-effectiveness analysis in order to be covered by the NHS.
Pharmacists are able to give vaccinations, enter into patient group directions, and become pharmacist prescribers. Technicians are also given a lot of autonomy and can become trained to check the final product.
Community pharmacies are those that dispense medications to patients who aren’t hospitalized or in nursing facilities. This series explores how community pharmacy practice differs around the world. In doing so, it gives us the opportunity to view our own system in a new light and potentially find opportunities for improvement. We’ve crossed the globe, covering countries as diverse as Japan, Australia, and Switzerland.
In this post, we’ll look at the United Kingdom with a special focus on England. The U.K. has what many Americans might refer to as “socialized medicine,” in which the government oversees nearly all aspects of care. The government’s National Health Service (NHS) enjoys high patient satisfaction and is a source of national pride for Britons. While spending on healthcare increased globally due to the pandemic, the U.K.’s 2019 per-capita spending of £3,371 ($4,582) was lower than the Organization for Economic Co-operation and Development (OECD) average. And that figure is far lower than the most recent U.S. per-capita spending data, which stands at $12,530. Meanwhile, the U.K. system ranks among the highest in the world regarding outcomes that are used as a measure of health system effectiveness.
To better understand this model, we’ll take a closer look at pharmacies in the U.K., and specifically England. Read more below, including insight from Virginia Chachati, a pharmacist and medical writer in the U.K.
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How the UK’s pharmacy system works
Healthcare funding
The NHS is a mostly taxpayer-funded, public health system that covers all citizens, residents, and temporary visitors. General taxation and National Insurance charges collectively fund over 90% of all healthcare spending, with the remaining amount covered directly by patients. As of 2016, only a little over 3% of all healthcare spending came from private insurance. In the U.S., by comparison, 28% of all healthcare spending comes from private insurance.
England, Scotland, Wales, and Northern Ireland — the countries that make up the U.K. — are allotted money at the beginning of each fiscal year and are responsible for setting coverage determinations. Notably, prescriptions in Scotland, Wales, and Northern Ireland are covered completely, while residents of England must pay a fee. Though, by U.S. standards, this fee is nominal, at about $12 per medication.
Healthcare regulation
In order to be sold anywhere in the U.K., medications must go through an approval process with the Medicines and Healthcare products Regulatory Agency (MHRA), the U.K. equivalent of the FDA. Medications must also undergo a cost-effectiveness analysis before being covered by the NHS. In England, the National Institute for Health and Care Excellence (NICE) carries out that analysis.
Regular updates are made to the list of approved medications, as well as the so-called “NHS Blacklist.” The entire list of unapproved medications can be found under Section XVIIIA of the NHS Drug Tariff. Interestingly, many benzodiazepines that are ordered routinely in the U.S., like alprazolam, clorazepate, and triazolam, can be found on the blacklist.
Coverage
Services covered by the NHS are comprehensive and involve almost no cost-sharing at the point of service. The NHS covers preventive services, inpatient and outpatient care, medications, some eye services, maternity care, and even long-term care. Medications paid for by the NHS are listed on the Drug Tariff, a national formulary that also includes information on the prices and dispensing fees paid to pharmacies and rules to follow when dispensing.
The prescription fee is the same regardless of the prescription being filled. And England also offers a prescription prepayment certificate, which allows you to pay one fee and get all the prescriptions you need for the covered period. A year certificate currently costs £108.10 ($146.95).
England also exempts numerous groups of people from paying the prescription fee, including those who:
Are over the age of 60 or under the age of 16
Are age 16 to 18 and going to school full-time
Are pregnant or have had a baby in the last 12 months
Are an inpatient at an NHS hospital
Hold a war pension exemption certificate (i.e. are a veteran)
Have a specific medical condition, including diabetes, epilepsy, or cancer
Have a physical disability that prevents them from living independently
In practice, this means the vast majority of prescriptions in England are dispensed without a fee. As of 2018, nearly 90% of prescriptions were dispensed at no cost to the patient at the point of service.
About pharmacy practice in the UK
Pharmacies are one of the few types of U.K. healthcare facilities that are mostly privately owned. There are both chain and independent pharmacies. And pharmacies typically carry a wide range of front-end merchandise.
Pharmacy dispensing
In addition to pharmacists, pharmacies also hire technicians, who must be registered with the General Pharmaceutical Council, and support staff, like pharmacy assistants.
Pharmacy technicians’ roles are evolving rapidly in the U.K. and currently include taking medication histories and performing medication reconciliation, assessing medication appropriateness, and providing advice about medications. Accuracy checking technicians, who require additional training, check the final product, similar to the tech-check-tech model in the U.S.
Like the U.S., electronic prescribing is now the norm in the U.K. According to Chachati, pharmacies access electronic prescriptions through a portal called the Spine, using an access card. At the end of a billing period, pharmacies submit claims using prescription forms that are filled out and mailed to the NHS.
Pharmacies also package medications in compliance aids, known as adherence packaging in the U.S. According to Chachati, pharmacies are reimbursed four times the usual dispensing fee for packaging medications this way. While they take more time to dispense than a standard blister pack, compliance aids can help patients with multiple medications and/or chronic conditions stay adherent.
Controlled substances are regulated by schedules similar to the U.S. system. Chachati says that there are strict regulations on controlled substances, including that they have to be stored in a safe that’s attached to a building. She says that some pharmacies choose not to dispense them at all.
Pharmacy services
Like in the U.S., pharmacists in the U.K. are able to give vaccinations and provide a range of other services, including HIV testing, compliance packaging, substance abuse treatment, and dispensing emergency contraception without a prescription. These services are covered by the NHS.
Home delivery is also commonplace, and many pharmacies offer local delivery at no charge. Community pharmacies with extended hours bring in additional revenue by providing services for NHS 111, a 24-hour phone line that helps people determine whether or not they should go to the emergency room. Pharmacists can work at the call centers, and community pharmacies can provide medications after hours.
In addition, pharmacists can enter into a patient group direction (similar to a collaborative practice agreement in the U.S.) and provide additional services not covered by the NHS and on a cash-only basis. This can be a lucrative business for pharmacies and includes travel health, giving vaccinations and dispensing medications, and the treatment of minor ailments, such as diaper rash, uncomplicated urinary tract infections, and oral candidiasis.
Finally, the NHS pays for structured medication reviews, which are nearly identical to medication therapy management services in the U.S. According to Chachati, pharmacies can be paid £35 ($47) per patient, up to 400 patients per year, for these services. Community pharmacists can even take additional training to become pharmacist prescribers and prescribe certain types of medications.
The bottom line
England’s healthcare system is a highly efficient, universal system covering a wide range of services, including primary care, maternity care, medications, and long-term care. Their Drug Tariff, or national formulary, provides an efficient means to ensure the most cost-effective medications are covered. And the vast majority of patients in England and across the U.K. do not pay anything for their prescriptions.
Pharmacists enjoy a lot of autonomy and are able to provide vaccinations, structured medication reviews, and even become pharmacist prescribers. Technicians are also allowed quite a bit of autonomy and can become trained to check accuracy of the final product.
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