The single clinical hub and NHS Electronic Prescribing challenge

Many organisations, both NHS and independent sector healthcare providers, that offer NHS primary care services would like to manage multiple NHS contracts across England from a single clinical hub. The primary reasons for this are financial and service efficiency. While GP Connect can facilitate single hub working by enabling access to GP records, appointment books, and the ability to send documents back (e.g., consultation notes), the Achilles' heel is electronic prescribing through the NHS Electronic Prescription Service (EPS).

To complete an electronic prescription, which is an NHS Spine service, a medical prescriber (e.g., GP) must log in to the NHS Spine using a Smartcard. They log in by selecting a Smartcard role associated with an organisation code, which is also a Prescribing Cost Centre (PCC) code. Every GP practice in England (currently around 6,300) is assigned a unique PCC (in the format of a letter followed by five digits). Each PCC is linked to its parent Integrated Care Board (ICB) code (currently there are 42 ICBs), as the ICBs manage the medication budget. The Smartcard role is also synchronised with a Role-Based Access Control (RBAC) role in the Electronic Patient Record (EPR) system the medical prescriber uses, typically EMIS Web, SystmOne, or Vision.

- PCCs must be sponsored and approved by an ICB.

- PCCs are created and managed by the NHS Business Services Authority (NHSBSA).

Every EPR system used by GP practices in England is configured with their PCC and the endpoint, linked to the PCC, configured on the NHS Spine services. Therefore, a GP working for a practice with a PCC code of M81065 will have a Smartcard role under M81065, and the EPR will also have the PCC M81065 configured in the system. When a GP completes an electronic prescription, it is registered against the correct NHS endpoint service (GP practice) so that the correct ICB will cover the costs. There are many other parameters associated with the endpoint that have additional functions, but for this article, the focus is on the cost of medications and the correct budget holder.

It is also worth noting that when a GP works within their own practice, they use their Doctor's Index Number (DIN), which identifies the GP on the prescription (both electronic and paper) and is linked to the practice's PCC. The DIN can only be used in the GP's own practice. If the same GP works across multiple services, they will need to be assigned (in the EPR) either a Spurious Code or a PPA ID (usually six digits), which will be linked to the provider organisation's PCC.

The challenge is how a provider can use a single clinical system (EPR) to complete electronic prescriptions for patients registered at GP practices across England. Currently, as far as I am aware, this is not possible. Here is why:

To complete electronic prescriptions, the medical prescriber must log in to an EPR with a Smartcard role linked to a PCC organisation. It is possible to obtain PCCs for a single EPR that are not linked to a GP practice. For example, Primary Care Networks (PCNs) may purchase a single EPR and obtain a PCC, which usually begins with the letter Y (e.g., Y54312). However, this PCC will still be under a single ICB. This is not a problem for organisations providing services within a single ICB, such as a PCN, as the patients they prescribe for are all registered at GP practices under the same ICB.

If an organisation wishes to provide care for patients registered with a GP practice outside the Integrated Care Board (ICB), there is a challenge. While the medical prescriber can access the patient's GP record via GP Connect (since all GP practices have GP Connect activated under the National Data Sharing Agreement) and send consultation notes back to the patient's GP practice (via GP Connect Send Document), they cannot provide an electronic prescription if one is required. This limitation arises because both their Smartcard and Electronic Patient Record (EPR) endpoint are linked to the Primary Care Centre (PCC) that operates under a single ICB, not the patient's GP practice ICB.

Note:

• Medical prescribers can only log in to a single Smartcard role at any one time
• EPRs currently do not support multiple PCCs
• EPR prescribing users can only be assigned a single Spurious Code or PPA ID

For example, in the graphic below, if an organisation has set up a single EPR and obtained a PCC (Y00564) that sits under the North East and North Cumbria ICB, Patient A, registered at a GP practice whose PCC also sits under the North East and North Cumbria ICB, will be able to receive an electronic prescription, as the costs go back to the same ICB.

Patient B can still receive a consultation where their GP record is visible via GP Connect, and a consultation note can be sent back to their GP practice. However, if they receive an electronic prescription, the medication costs would be charged to the incorrect Integrated Care Board (ICB). This is because they are registered at a GP practice that falls under a different ICB.

I must stress that while electronic prescriptions are not currently possible, it is feasible to issue paper prescriptions (FP10s) to patients registered at GP practices linked to multiple Integrated Care Boards (ICBs) using service-level prescribing within an Electronic Patient Record (EPR) system. This allows for the selection of an alternative service (set up in the EPR) linked to a different ICB during the prescribing process.

The solution?

• EPRs that can support all 42 ICB cost centres
• Smartcards that automatically switch to the correct Prescribing Cost Centre (PCC) code based on the patient's GP practice information on the NHS Spine.
• Service-level electronic prescribing (linked to above)
• A single non-ICB PCC on the NHS Spine, with medication costs redirected back to the patient's registered practice ICB.
• A mechanism for organisations to invoice ICBs for patients who have received medications outside of their ICB area.

Useful Links

Electronic Prescription Service

NHS Prescription Services

Independent Sector Healthcare Providers