Digital Pharmacy and the Impact on Dermatology Care: A 2023 Outlook

In the last three years, there has been huge growth in dermatology services moving digitally. Dan Scott reflects on the outlook for the Digital Pharmacy space, and where Dermatica is improving access to Dermatology for all at a low cost.

From brick and mortar to home delivery

In 2016, it was estimated that there were 450 million visits to Community Pharmacies in the UK, and 37% of people visited their local pharmacy at least once. This correlates to the amount of people that take a long-term medicine (1).

Adoption of online pharmacy services is predicted to increase over the next five years, going from 35 to 50% of patient adoption from US statistics (2). Pressure also exists in the retail pharmacy sector, where there have been over 800 stores closed since 2015 in the UK (3).?

When the first lockdown was announced on 23rd March 2020, then PM Boris Johnson recommended that online supermarkets and pharmacies be used where possible to minimise community exposure. The pharmacy sector was put under huge pressure with a spike in online-first services taking a massive share of the market for growth they had not foreseen, needing to implement waitlists to orders akin to grocery giants to keep up with demand.?

A retail pharmacy’s accessibility and frequent interactions with patients can help to improve medicine compliance while providing beneficial eyes and ears in a multidisciplinary team on a patient’s social health. As more services go digital or vertically integrate, this encounter looks to change hugely.

Digital Pharmacy in the UK

Pharmacy2U, LloydsDirect, Boots, Phlo and Well are the major players that offer an online pharmacy service for repeat prescriptions. They offer free delivery via Royal Mail to patients within a 7 day time span of requesting a prescription from an NHS GP, with over 1.3 million nominated patients in NHS England alone (4). If their GP is registered for electronic repeat prescriptions, their regular medicines can be ordered in time based on reminder functionality built into their technology stack.

In Dermatology, we are aware of where challenges come based on the nature of treatments. Lead times for acute prescriptions and recent medicine shortages for items antibiotics and corticosteroids can delay timely treatment. Much reminder focused solutions for patients rely on an oral medicines' frequency rather than on a topical cream, which can provide confusion and inaccuracies in trying to estimate. This can lead to downstream issues for patients if this is not clear from the beginning, which can lead to more of a headache based on the implied simplicity. Care should be taken to counsel these patients to maintain their correspondence with online pharmacies to make sure they are up to date, and when they need to collect their next batch of medicines as a local pharmacy might be in a better position to cater to them specifically.

Formal initiatives such as medicine reviews have helped to improve patient compliance and reduce medicines wastage, while formalising the value of the pharmacist in their advice provision. The New Medicine Service in the NHS has also shown to reduce overall costs through increasing medicines adherence by approximately 10%, where patients are provided with targeted counselling for newly initiated medicines (5). This initiative has also been validated through a telehealth model with an online pharmacy as effective and can be adopted by online pharmacies (6) which can help to build loyalty and as a new revenue stream for reimbursement. For topical treatments in particular, a consultation with a pharmacist may provide an important time for a patient to discuss whether they are satisfied with treatment or identify miscommunications with treatment. While the evidence for this is still very limited, it’s also interesting to see that patient adherence to topical treatments often increases around the time of followup visits (7) where pharmacists can provide an extra point to encourage and optimise medicine use.?

From secondary to primary care transitions, medicines reconciliation service that hospital-based pharmacists offer on admission and discharge is becoming common practice in most NHS settings. This helps to reduce medication discrepancies within the care pathway for patients, to ensure appropriate prescribing (8). Further evidence is building which can support a pharmacist’s role further post-discharge. Readmission rates for patients reduce with a follow-up call from a clinical pharmacist over a 90 day period. Majority of patients felt more confident with taking their medicines following the intervention, allowing for greater health self efficacy (9).

Over the counter products can be also purchased online outside of a pharmacy under some licences privately: emollients from Amazon and other marketplaces are often a preferred option for those with eczema or psoriasis based on value and convenience. There’s also a rise in online pharmacies that offer short term, low risk prescription items privately with an integrated prescribing and dispensing service at low cost, such as MedExpress or Pharmica.

Digital Primary Care

Primary Care Networks have come into effect albeit controversially in the NHS. Teleconsultations have scaled in the UK to make up approximately a third of all GP appointments to date (10). Tools such as e-Consult have helped prioritise and triage patients based on their presenting complaint as well as widen the breadth of multidisciplinary consultations.?AccuRx, another system which allows practices to text patients has had a significant improvement in patient engagement and? communication (11).

The role of the Pharmacist in GP practices has also been a relatively new, but widely expanded asset. They help to provide expertise to more complex patients with multiple morbidities and repeat prescribing, with proven improvements to health outcomes and expenditure (12). Pharmacist prescribers are building competencies in specialist areas as the qualification expands, which allows the scope for more of a specialty in dermatology to come as the workforce changes. The electronic repeat dispensing service (eRDS) also allows GP Practices to delegate monitoring of patient progress on long term medicines where community pharmacies can manage repeat prescriptions for up to 12 months, saving on administrative costs (13).

As NHS Primary Care services adopt more technology, some practices are moving to remote-centric. Babylon has expanded hugely to provide NHS and private clinical services which are often pharmacist prescriber-led, and other providers such as Livi and DoctorCareAnywhere provide an accessible one-off private consultations out of pocket or as part of insurance plans. While there’s been some scepticism to the efficacy of a fully remote primary care service, early evidence shows that this is not just for patient convenience. The Pharmacy Team at Babylon Health have shown a significant improvement to the appropriateness of antibiotic prescribing in a remote setting through audit, education and quality improvement frameworks, surpassing outcomes achievable in typical primary care settings (14). Specialist services are also becoming more accessible to patients remotely, such as the Leva Clinic which offers medicinal cannabis and specialists treatments for those with chronic pain and contributing to observed clinical trials (15). These services have been predominantly consultant-led in their early stages, but will hopefully see the adaption of nursing and pharmacy practice in future.??

The bridge between private and public healthcare is costly in the UK for patient care where waiting times are high, or discretion is front of mind. With the adoption of consumer technology and straight to door subscription services, prescription medicines have moved to easy access within more human, patient centric brands. Teledermatology services such as Dermatica offer patients with selected skin concerns such as acne, rosacea and melasma the opportunity to receive prescription treatment by a specialist Dermatology team within less than a week from sign up and a fraction of the cost compared to a private consultation alone.

Evidence for Digital Health Interventions and Therapeutics?

Beyond care provided virtually, there are what have been coined as “Digital Therapeutics” or “Beyond the Pill” initiatives to provide patients with clinically effective software for certain conditions. In the last two years, digital therapeutics have been acknowledged equivalent to medicines where they can be prescribed and reimbursed by healthcare providers. In the NHS, Big Health, the conglomerate that offers digital CBT for insomnia and anxiety is the first and currently only provider to achieve this status with NICE (16). Psychodermatological programmes could be delivered where applicable first line through apps for consumers in years to come, but the main focus on digital therapeutics is likely to be in supporting diagnosis through AI, and remote monitoring for patients (17).?

There are challenges to the implementation of future digital health solutions in Dermatology. While patients are enthusiastic to take up these services, barriers come where only 40% are comfortable to submit photos of their condition for monitoring (18).?

Conclusions and Outlook

Digital healthcare is no longer a vision, but something that we have adopted rapidly in the past few years. The NHS Long Term Plan embeds plans to make healthcare more accessible, patient centric and intelligent as future technologies such as AI and genomics show promise in delivering the best outcomes for care of the right person, at the right time (19).?

Nursing along with pharmacy remain one of the most accessible and impactful professions in the multidisciplinary team, offering monitoring and social support through more frequent contact in Clinic and in GP Practices to coordinate better care and relationships (20) While the evidence base on innovation with digital interventions applied to Dermatology are still at an early stage in this field, the opportunities across different disciplines gives a clue to some of what we will have accessible to work with in the near future. Watch this space!?

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