The Pharmaceutical Journal
Vol 280 No 7494 p344-345
22 March 2008

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Pharmaceutical Services Negotiating Committee

White Paper to prompt contract review

The forthcoming White Paper is expected to trigger a review of the community pharmacy contractual framework, predicted Chris Hodges, chairman of the Pharmaceutical Services Negotiating Committee, in his opening address. He added that the PSNC will seek to ensure a contract that incorporates:

• A set of nationally agreed services with service level agreements, which will be available from all community pharmacies

• Nationally negotiated enhanced services with SLAs for local commissioning, with prescribed prices, with a commitment to increased provision of services by pharmacies and supported by funding provided to primary care trusts

• Local service commissioning determined by open processes incorporating joint strategic needs assessment and tendering, to permit provision by any willing provider meeting quality standards

• A national service for provision of medicines management, supporting safe supply and effective use of medicines and chronic disease management

Mr Hodges emphasised that the PSNC will promote development of minor ailment, public health and long-term condition management services, relevant role-based access to patient records and recognition of independent and supplementary prescribers, with prescribing services included in the contract. “Fair funding for these services will of course be critical to our success,” he admitted.

In her report, Sue Sharpe, chief executive of the PSNC, covered a number of issues, including Category M, devolving the global sum to primary care trusts, low-volume pharmacies (PJ, 15 March 2008, p296), the Darzi review and the White Paper. On the White Paper, she said: “At its meeting last week, the committee recognised that, if the White Paper does not meet our needs, then we may well move into campaigning, as we did against the Office of Fair Trading back in 2003.”

Turning to financial matters, she explained how the pharmacy contract funding formula works and said that there is a misconception that because the £500m allowed purchase profit income has not increased, this means that total funding is being depressed. “It is not. But the addition to total funding from the formula is provided by adjustment to fees and allowances.” She added that March should bring some relief for contractors since they will see the effects of the increase in practice payments from January (PJ, 8 December 2007, p635).

Mrs Sharpe stressed that the PSNC is committed to making adjustments to Category M reimbursement prices earlier in the year to prevent a repeat of this year’s fluctuations.

Further financial concerns relate to the capacity improvement programme, which is being introduced with a raft of problems, said Mrs Sharpe. “Sorting of prescriptions has not been welcome and the initial introductory phases revealed failings that need to be put right.” She assured representatives that the PSNC is working with the Prescription Pricing Division to identify these failings and to ensure that they are addressed.

Mrs Sharpe added that agreement was reached last week to a claims process to investigate cases where contractors believe the number of prescriptions that have been switched from unpaid to paid under the new scheme is incorrect.

Scrap the new pharmacy contract

The new contract in England has failed to deliver either the clinical benefits for patients or the financial stability for contractors that was promised, according to Hertfordshire LPC.

Steve Brill proposed a resolution that called on the PSNC and the Department of Health to produce a new model contract which will deliver on these promises.

“Pharmacists are still clearly underutilised, largely because the commissioning of enhanced services has been patchy to say the least. Moreover, there is still only one advanced service,” he said.

Kathryn Featherstone (Sunderland) disagreed. “While I would concur that few enhanced services have been commissioned by PCTs, I don’t think that at this point we should throw the whole new contract out. I think we should be working to increase opportunities to commission new services.”

Glenn Miller (East Riding and Hull) warned that the DoH has just “faced down” GPs, one of the most powerful lobby groups, over opening hours. “Are they going to consider a new contract at this moment in time?” he asked, adding that contractors could end up with a worse deal than they have now.

Mr Miller believes that the profession needs to prove it can deliver on existing advanced services before it starts asking for more.

Rekha Shah (City and Hackney) argued that the new contract has delivered clinical benefits for patients, citing medicines use reviews as an example.

Mrs Sharpe asked whether the resolution should be amended to state that the conference calls on the PSNC and the DoH to review the contract in the light of experience and improve commissioning of pharmacy services.

This amendment was proposed by Bindu Bhatt (North Cheshire, St Helens and Knowsley) and the motion was carried.

Call to end clawback

Pharmacies should not have to dispense any medicine at a loss, Kamal Mahasuria (Berkshire) told the conference.

The discount clawback was greater than the discount available from suppliers for more and more medicines, Mr Mahasuria said. If purchase profit was part of the contract, then why was the discount clawback still there, he wanted to know. Any system based on national averages was unfair because it could not take account of local prescribing variations, primary care trust policies on prescribing branded generics or centralised systems for supplying dressings.

“I’m subsidising both the NHS and the industry”, Mr Mahasuria asserted.” He warned that contractors might start refusing to supply certain items.

Responding, Mike Dent, head of finance at the PSNC, said that reducing the discount scale would increase the margin on branded medicines, but it would also increase the margin on generics, leading to surplus profit that would have to be recovered by reducing Category M prices in the Drug Tariff.

Contract renegotiation called for

Retiring PSNC member Steven Williams said that the forthcoming White Paper on pharmacy should trigger a new pharmacy contract.

“We’re after a renegotiation and the introduction of an entirely new contract,” he said in a short debate.

The White Paper will have to decide between a regulated market/planned service and a deregulated free-for-all, he told the conference. There was pressure on the Government and the Department of Health for deregulation, but primary care trusts wanted to be able to control the system without having to manage complex regulations. It was his view that service planning would lead to service development, while deregulation would favour basic dispensing services. In either case, the four exemptions from control of entry requirements would have to change.

“I think the pendulum has swung to a planned service,” Mr Williams said. “I think we have made progress over the past months to persuade the DoH that the best future is a planned service so that PCTs are able to plan services to meet local needs, but with an acceptance that some services will be provided nationally.”

But he warned that, if PCTs were to buy services, there was little evidence that pharmacies were the best providers and that there would be competition from other potential providers.

Ash Soni (Lambeth, Southwark and Lewisham) expressed concern at the ability of PCTs to do the necessary planning and commissioning. He said that there would need to be an arbitration system to deal with any shortcomings.

Hopkin Maddock (Cornwall and Isles of Scilly) said that there was potential for hundreds of new pharmacies to be set up by dispensing doctors because doctor dispensing was expected to become uneconomic.

“They are being told how to set up pharmacies,” Dr Maddock said.“What PCT will be able to refuse a contract to a pharmacy next to a surgery?”

EPS prompts differing views

Conflicting views on the electronic prescription service were voiced at the conference.

Michael Holden (Hampshire and Isle of Wight) was concerned at a lack of funding for pharmacies to buy the equipment needed to use EPS, while GPs were fully funded by the NHS. All Isle of Wight GP surgeries used the same system, while pharmacies were using nine different systems that were in different stages of development. Some pharmacies were having to spend five times their NHS IT allowance on new systems. Too many unknowns meant that pharmacy could not move ahead with EPS.

Problems with the system identified by Michael Keen (Kent) included: difficulties caused when patients nominated pharmacies to which their prescriptions should be sent, but then decided to collect their medicines from a different pharmacy; the time taken to download some prescriptions; printing the paper tokens needed for patients to claim exemption from the prescription charge; and how to check that someone who wanted to collect dispensed medicines was who they said they were.

Another delegate raised the issue of GPs who printed out barcoded prescriptions and then added handwritten amendments.

Richard Wells (Doncaster LPC) asked why anyone from NHS Connecting for Health would listen to concerns with EPS release 2 when the profession was not engaging with EPS release 1. Mark Collins (East Lancashire) agreed, adding that pharmacy was a small part of the system.

Fin McCaul (East Lancashire) said that EPS 1 was working well in his pharmacy, but that he had major reservations about EPS 2. These included concern over the correct mapping of the dm+d dictionary of medicines and devices between GP and pharmacy systems, and workload.

“You either have to invest heavily in IT, with four or five systems per pharmacy, or you have to print out every prescription,” he said. Plus, he was concerned about the implication of system crashes.

“[EPS 2] is being foisted on pharmacy without enough forethought,” Mr McCaul said. Despite this, he believed that the profession should support the concept, but say no to the current process.

A delegate from Nottinghamshire said that the EPS and paper prescriptions should operate in parallel for two to three years so that contractors who were able to implement EPS quickly woulod not be able to take over the dispensing of pharmacies that could not move so quickly.

Patrick Leppard (Hampshire and the Isle of Wight) said that much of the criticism of EPS was unfounded. Engagement with EPS was the only way pharmacy could be connected to the primary care team. In the future, pharmacists would need access to health records and that would only be possible if they first embraced EPS.

Concluding the discussion, Sue Sharpe, chief executive of the PSNC, said that the overwhelming message was that CfH had not engaged with pharmacy enough to make sure that the system was built and developed to work for community pharmacy. The PSNC had experienced real problems getting effective communication with NHS CfH.

MDS contract wanted

Pharmacists want to supply monitored dosage systems under a funded national service specification for an advanced service.

Successfully proposing this as a solution to demands from care homes and carers for medicines to be supplied in MDSs, Michael Holden (Hampshire and Isle of Wight) described MDSs as an inappropriate, high-risk solution to perceived compliance problems. They were seen as a solution by untrained carers and ill-informed professionals to facilitate home care and speedy discharge rather than to meet the needs of patients.

There was little or no evidence that MDSs improved adherence to prescribed regimens and some evidence that they worsened it. Nevertheless, he called for a national advanced service based on appropriate assessment and medicines use reviews.

Delegates also carried a motion of no confidence in the prescription pricing system.

Patrick Leppard (Hampshire and Isle of Wight) said that significant errors were being made since the system had been largely computerised.

Lyndsay McClure, head of information services at the PSNC, said that the Prescription Pricing Division had failed to consult contractors over what it called its capacity improvement programme. There had been insufficient testing and too little staff training. Things had started to improve since the PSNC raised the matter with senior officials at the DoH and with the NHS Business Services Authority’s chief executive.

Alison Kidner (Swindon) successfully called for manufacturers to be fined when they could not supply products promptly.