Building the case for offering anticoagulant monitoring

Anticoagulant monitoring has been taking place in a small number of community pharmacies since the early 1990s.

From March 2008, East and Coastal Kent Primary Care Trust, one of the most progressive PCTs for moving this service into community pharmacies, is changing the way it funds the service to provide a fairer reflection of running costs.

Whether or not other PCTs choose to follow suit, community pharmacies are perfectly placed to provide a convenient anticoagulant monitoring service and pharmacists have the expertise to deliver it.

The time is right for pharmacists to consider the financial case for adopting this service.

Establishing a service

“First, you must let the PCT know that you are interested,” says Michael Eakins, a community pharmacist from Hythe, Kent, who has run an anticoagulant monitoring service for the past 10 years. The service that he offers is explained in Panel 1.

“You won’t be able to compete with hospitals purely on a cost basis,” says Roger Kirkbride, a pharmacy consultant from Nottingham. “The process in hospital is very slick, and gets through a large number of patients in a short period of time.”

However, running the service in a hospital does incur considerable transport costs. These costs are borne by the NHS if the patients need to travel by ambulance. PCTs that have set up this service in the community have generated a £5–£15 saving per test, says Mr Eakins.

Other patients may need to pay for parking or take time off work to attend appointments, adds Mr Kirkbride. Although not paid for by the NHS, the costs to the patient must be considered.

If the PCT is not convinced by the cost saving, Mr Eakins suggests that other benefits should be emphasised. These include:

• Reduced hospital admissions

• Less distance to travel for testing

• Close liaison with GPs

• Increased therapeutic options — GPs can prescribe medicines that interact with the anticoagulant more freely because additional INR tests are easy to organise

• A list of the patient’s current medication available at the site of testing

Initial costs

During the first year, the only set up cost to bear is that of registering with a quality assurance programme, says Mr Eakins. Once you have successfully tendered for the service, most of the set up costs are normally paid for by the PCT.

However, some PCTs may not be quite so benevolent, warns John Hall, a director of Dixon and Hall Ltd, a community pharmacy chain in County Durham. John Hall and Noel Dixon have run an anticoagulant service since 1991. Mr Hall suggests that pharmacies need to be prepared to pay for other set up costs, such as:

• Device and test strips — see Panel 2 (below)

• Computer upgrades and software for dose calculations

• Training

Quality assurance To ensure accuracy of results, pharmacies can join the National External Qualification Assurance Scheme (organised by the Quality Assurance Laboratory which is part of the Health Protection Agency) for £120 per machine per year, for which they will receive a test sample every three months. This sample is run through each machine and the results are returned to a central laboratory for validation.

Training Pharmacists will require training to run the service. “This might be provided and paid for by the PCT. You may even negotiate for the PCT to pay for locum cover while you take the course,” says Mr Eakins. If the PCT will not offer such training, a course can be taken at the University of Birmingham (three-day course, £1,350). University of Sunderland also offers a course.

Computer software Specialist software is available that stores INR results and calculates suitable dose adjustments. Such software includes:

• Dawn AC (4S Dawn Clinical Software)

• INR Star (Sullivan Cuff Software Ltd)

Software will cost an annual fee of £3–£4 per patient, per year. Some PCTs may be able to link the pharmacy computer system into the one currently used at the hospital or PCT.

Service fees

Pharmacies that currently offer anticoagulation monitoring, and have based their fee on that offered in the general medical services contract to GPs, are paid approximately £120 per patient, per year — regardless of the number of INR tests that are conducted.

“This fee becomes less profitable when patients require more regular testing, such as when they are being loaded with warfarin,” says Mr Hall. “A recent increase in the number of patients who undergo warfarin loading in the community has meant that this fee structure has become quite tight.”

Under the current system, some service providers only receive £5 for each domiciliary visit. This level of remuneration does not reflect the true cost of providing this facility, adds Mr Hall.

From this month, East and Coastal Kent PCT has changed the way it pays for anticoagulant monitoring. The previous arrangement, based on the national benchmark, has been replaced by a fee per test. A spokesman from the PCT told Retail Round-up that service providers will now be paid £31.25 per test.

Although there has not been a change in the national benchmark, the new payment is “in line with national policy for payment by results”, according to the spokesman. The service provider must agree to undertake domiciliary visits when necessary, but the test fee will be paid regardless of whether a test is carried out in the patient’s home or in the pharmacy.

A national service specification for anticoagulant monitoring will be published by the Pharmaceutical Services Negotiating Committee in 2008.

Training staff

Mr Eakins has trained some of his counter staff to be phlebotomists, so that the pharmacist does not have to perform every test. This training can be funded by the PCT, although once the pharmacist has been accredited, he or she would be capable of training other staff members.

“The PCT insists on at least three people being trained to take blood, so there is no chance of service interruption during staff holidays or absence,” he says. “Having two additional trained assistants has meant that we don’t need to hire an extra pharmacist — even when the shop is busy.”

Mr Dixon and Mr Hall have taken a different approach. At their pharmacies, the pharmacist carries out the blood test while interviewing the patient. “We believe that by separating the blood test from the patient interview, the whole process takes more time,” says Mr Hall.

Other considerations

The service produces sharps waste, so this will require additional disposal arrangements. “Because the service is funded by the PCT, they are happy to add us to the waste collection service for GPs, at no extra cost,” said Mr Hall.

Extra members of clerical staff may be required to answer telephones, organise clinic lists, file paperwork and send letters to patients and GPs — depending on the number of patients using the service.

Members of staff who carry out the tests should be offered vaccination against hepatitis B. Although the NHS does not provide this automatically, the PCT will often write to a GP to ask for service providers to be vaccinated free of charge.

A profitable service?

“Several PCTs have realised that there would need to be at least 100 patients recruited for a service to make it financially viable,” says Mr Eakins.

“However, they can offer assistance by writing to patients in the area who take anticoagulants, and asking if they would prefer to have their INR checked in the pharmacy.”

However, he warns that pharmacists must be prepared to undertake domiciliary visits, because the PCT will expect this level of service.

An example of the turnover that can be generated, using figures provided by Dixon and Hall Ltd, is shown in Panel 3.

However, both Mr Eakins and Mr Hall agree that providing the service is not just about the money.

“Although the service has been profitable, we originally took it on to raise the profile of the pharmacy and get the pharmacist involved in delivering a new and interesting service,” says Mr Hall.

“It has certainly done that.”