Patient safety spotlight: Improving the provision of weight-loss services through shared learning

Helen Ireland, Chief Pharmaceutical Officer’s clinical fellow and Neha Ramaiya, Senior Clinical Pharmacy Advisor at the GPhC share examples of unsafe practice in providing weight loss services our inspectors have seen in recent months and highlight best practice examples to help pharmacies provide these services safely and effectively.

June 2023

Weight loss medicines such as orlistat, liraglutide and semaglutide can be abused, misused, and overused, so it’s important that pharmacies reduce the risks and safeguard people accessing their weight loss service. When prescribing and supplying these treatments, pharmacy professionals must consider the person’s mental wellbeing as it may play a part in the reason for people requesting these medicines.

We’re sharing the poor and good practice we’ve gathered from inspections, grouped under the key themes, and with references to the relevant standards for registered pharmacies.

According to the NHS website, 1 in 4 UK adults are living with obesity. According to guidance from National Institute for Health and Care Excellence (NICE), pharmacological approaches for weight loss medicines may be prescribed where non-pharmacological interventions have been unsuccessful.

Risk management and governance: (standards 1.1, 1.2 and 1.8)

Our learning shows that risk assessment and management was a driver for both and good and poor outcomes for pharmacies providing weight loss services. 
The issues our inspectors saw included:

  • pharmacies did not always have adequate risk assessments specific to the weight loss service, including the medicines and treatments they provided
    The risk assessment didn’t include consideration and mitigation of any additional risks of the service they provided, such as providing services at a distance. 
  • pharmacies could not always demonstrate that they sought sufficient assurance to verify the reliability of information thoroughly such as the person’s weight or identity
    This means that a vulnerable person could inappropriately be prescribed the medication or use another person’s ID to obtain a medicine.
  • pharmacies had not picked up prescribing trends 
    These trends may have indicated inappropriate prescribing and supplying to people.
  • pharmacies did not proactively audit or review the quality and safety of their weight loss service
    This meant that they may not have been aware of opportunities to improve their service and implement best practice, including when things had gone wrong.

Good practice examples of risk management

  • Some pharmacies had specific guidelines and prescribing policies for weight loss treatments, and others required people to consent to information being shared with their regular practitioner, so the practitioner had up to date information and could offer follow up and monitoring. 
  • To reduce risks, some pharmacies did not post every supply of the weight loss treatment to the person and instead required them to collect some or all their supplies from a pharmacy premises, so they could have their height and weight verified.

Clinical effectiveness: - (standards 1.6 and 4.2)

We expect prescribers to clearly document prescribing consultations, treatment prescribed and any follow up arrangements for the pharmacist prescriber, GP, or other healthcare professional. 
Inspectors identified examples of poor practice, which included inadequate documentation of prescribing rationale with Ozempic (an off-label treatment) and poor recording of clinical interventions.
Medicines prescribed to people must be safe and appropriate.

Inspectors identified inappropriate practice where:

  • some pharmacies provided weight loss treatments solely based on a questionnaire model, without verifying the reliability of the information provided by the person
  • treatment was prescribed to people with a lower BMI than that recommended or was continued despite no reported weight loss over a period of time. For instance, the manufacturing license for liraglutide (Saxenda) requires 5% weight loss after 12 weeks of treatment, which if not achieved should lead to discontinuation of treatment. So, regular follow up and monitoring needs to be undertaken. 
  • some pharmacies did not have adequate mechanisms in place to prevent over supply of weight loss medication, meaning people could receive more medication than needed for a course of treatment

Good practice examples of managing services safely and effectively

Some pharmacies had comprehensive prescribing notes, which were accessible to other prescribers and the pharmacy team, such as the patient’s height and trends in weight to enable a thorough clinical check by another healthcare professional.

Some pharmacies had automated systems to flag when a person may change an answer in a questionnaire to progress a request, so this could inform the prescriber’s decision making.

Some pharmacies had unique consultation and counselling methods such as bespoke information leaflets, administration videos and follow-up by video or telephone.

Patient and public involvement: (standard 3.1)

Poor practice was seen where:

  • pharmacy websites allowed people to select medication prior to a consultation with a prescriber, this suggests a transactional approach to healthcare and medicines supply. This is not in line with our guidance for registered pharmacies providing pharmacy services at a distance, including on the internet
  • unlicensed and off-label medicines, such as Ozempic were promoted and advertised on pharmacy websites. Medicines are not normal items of commerce and are subject to the Medicines and Healthcare products Regulatory Agency’s (MHRA) guidance for advertising and promoting of medicines

Education and Training (Standard 2.2)

Good practice examples of education and training we saw include:

  • pharmacy team members had ongoing and specific e-learning training modules on weight loss medicines to ensure competence for their role
  • prescribers having ready access to a medical or clinical lead for support for further advice and to extend learning

Find out more

Below is a list of resources to help you make sure you are meeting our regulatory standards and guidance and working in line with good practice when providing weight loss services.

GPhC information

Information from other organisations

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