Dr RUSSELL WALSHAW

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Dr RUSSELL WALSHAW

• GPC representative for
• East Yorkshire
• Northern Lincolnshire and
• Lincolnshire
• and
• GPC lead for Rural Practice and Dispensing

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Pharmacy in EnglandBuilding on strengths
delivering the futureThe Pharmacy White
Paper3rd April 2008
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• White Paper
• noun (in the UK) a government report giving
  information or proposals on an issue.
• Green Paper
• noun (in the UK) a preliminary report of
  government proposals published to stimulate
  discussion.

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Implications for all GPs

• Current Government Policy
• 1½ years of GP bashing
• Helped by the press
• No let up
• Stimulate Choice
• ?Privatisation?

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Government Policy

• Farming out medical tasks to others
• Health care assistants
• Paramedics
• ECPs
• Physicians Assistants
• Nurses
• Pharmacists (including prescribing)

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Government Policy

• To disrupt practices
• Darzi centres (wanted or unwanted)
• GP-led health centres (PCT driven)
• Terminate contracts
• On partnership splits
• Via draconian remedial notices
• Move to 5 year APMS contracts
• Stimulates competition

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PHARMACISTS

• Are highly trained
• Have a university degree
• Do not utilise all their skills
• Independent prescribers
• Hospital V Community
• Community
• Business
• Profit
• Dispensing

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Anne Galbraith

• White Paper
• Result of review of pharmaceutical contractual
  arrangements
• GPC involved
• DDA involved
• Uncle Tom Cobleigh.
• Never published

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HMGs commitment to Pharmacy

• Its place as a leading clinical profession
• Puts Pharmacy in front line
• Promoting health
• Not just treatment

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HMGs AIMS

• Shift emphasis from dispensing to provision of
  clinical services
• Wide range of services available through pharmacy
• Convenient locations
• Extended opening times
• Use of Pharmacists clinical skills
• (including prescribing Crown Reports)

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HMGs AIMS

• Pharmacies will
• Become healthy living centre
• Supply common medicines
• Be first port of call for minor ailments
• saving GPs one hour per day or 57 million
  consultations a year
• Provide support for people with LTCs

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GPC Statement

• Issued 8th May with M Letter
• LMCs to distribute it to practices
• The GPC is totally committed to defending the
  rights of dispensing doctors
• This is the stated policy of the Annual
  Conference of LMCs

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DoH Listening Events

• Messages
• PCTs, Pharmacists, Dispensing Doctors want the
  status quo
• GPC/DDA/PSNC met DoH and gave a strong message
  which they heard!!!
• Consensus Message IIABDFI

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Medicines Act

• Section 52 53
• Allows doctors to sell medicines to their
  patients
• P POM GSL
• Cannot sell to the public
• NHS regulations preclude this
• Reg 24 (GMS) Reg 15 (PMS)
• Separate company can sell GSL medicines to public

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Dispensing Doctors and OTCs

• 3.48 The Government believes that there
• are sufficient grounds to reform
• arrangements for selling OTC medicines
• where the GP practice has consent to
• dispense. This needs to be linked to
• the broader reforms of dispensing by
• doctors see Chapter 8.

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QUALITY

• 8.47 The Government will also work with the NHS
  and professional bodies to develop a set of
  pragmatic, easily measurable metrics or
  indicators that will serve to demonstrate the
  quality and outcomes of pharmacy service
  provision.

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QUALITY

• 8.51 The lack of defined quality markers in both
  the regulations and the SFE in relation to
  dispensing doctors might also contribute to
  differing standards and quality of service
  delivery

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QUALITY

• 8.52 A Dispensary Services Quality Scheme was
  introduced as part of the 2006/07 contract
  changes. It introduces standards around
  governance, training and patient reviews.
• It is a voluntary scheme.

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QUALITY

• 8.53 The Government will therefore ask NHS
  Employers to work with the GPC and the DDA to
  look at the development of further quality
  standards in dispensing practices and to examine
  any resource implications from this work.

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Consent (market entry) for dispensingdoctors

• 8.67 Given the Governments conclusion
• that commissioning development
• within PCTs is not yet at a stage
• where PCTs can be charged with full
• contractual responsibilities, there will
• remain a control of entry regime

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CONCERNS

• Two principal concerns in relation to
• dispensing consent for doctors.
• 8.68 Peoples perceptions and expectations
• 8.69 Proximity of dispensing practices to
  community pharmacies.

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FIRST CONCERN 8.68

• Eligibility to receive GP dispensing based on
  distance between home and the nearest pharmacy
  leads to the inequitable situation where a
  patient who lives on one side of a road is a
  dispensing patient whereas a patient on the other
  side of the road is not

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FIRST CONCERN

• This test can also fail to identify the actual
  distance a person has to travel when going from
  home to the GP and on to the nearest pharmacy.
• If the surgery and the pharmacy are in opposite
  directions, the distance travelled can
  considerably exceed the 1.6 km stipulated in the
  regulations.

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SECOND CONCERN 8.69

• Some people who receive dispensing
• services from their GP surgery walk past a
  community pharmacy on their way to and from the
  surgery, particularly in market towns.

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How to resolve them!

• 8.70 Both issues could be resolved by considering
  new control of entry equivalent rules for
  dispensing practices.
• What does this mean?

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• 8.71 If a dispensing practice met the new single
  criteria (sic), then dispensing to all the
  practices patients would be allowed.
• This would allow patients to buy OTC medicines
  from their dispensing practices
• No patient would be forced to have their
  medicines dispensed by their practice (the choice
  to go elsewhere must reside with the patient).

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Transition

• 8.72 Transitional rules would be required and
  these would need to consider the financial impact
  on the GP practice of losing the right to
  dispense as well as the impact on pharmacy
  provision

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The GREEN BIT

• Green Paper
• noun (in the UK) a preliminary report of
  government proposals published to stimulate
  discussion.

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The GREEN BIT

• 8.74 The Government considers that the current
  process has significant inconsistencies but is
  aware that the current market entry arrangements
  in rural areas reflect previous agreements
  between representative bodies of pharmacists and
  doctors. 10 years of hard grind and
  bridge-building!

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The GREEN BIT

• Therefore, the Government proposes that any
  changes to dispensing doctor market entry
  arrangements should be part of a wider
  consultation on elements of the control of
  entry system itself, as proposed here.

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The GREEN BIT

• The consultation will also consider whether
  current regulatory arrangements can be
  streamlined so that dispensing consent in future
  is sought under a single regulatory route.

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Parliamentary Statements

• Minister of State 17th July
• Graham Stewart 22nd July
• Sir Paul Beresford 22nd July
• No intention to abolish doctor dispensing!

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The CONSULTATION

• Published on the web 27th August 2008
• Three month consultation until 20th November
• 68 page document
• Eight Impact Assessments
• More National Listening Events
• www.pcc.nhs.uk/events/ NONE IN THE SOUTH WEST
• GPC Road Shows
• Cambridge Leeds West Midlands

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Chapter 1

• Refers to possible reforms which would enable
• Revisions to current regulatory criteria for DDs
• A common regulatory route for their applications
• The sale of OTCs by dispensing doctors

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Chapter 2

• DH proposals
• replacement of current market entry test with one
  determined by reference to local
• Pharmaceutical Needs Assessment PNA
• PNAs
• 2005 regulations
• Varying quality
• Would become part of PCTs
• strategic planning
• Commissioning
• Implementation

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PNAs

• PCTs would consider
• the level of access
• the choice and diversity of providers or of
  services
• innovation in service delivery
• the services available to specific populations or
  to meet specific health conditions or disease
  needs and
• the overall longer-term impact of approving new
  applications.

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Chapter 4Dispensing by doctors

• It has been a long established general precept
  one that all Governments have endorsed since the
  NHS came into being that doctors prescribe
  medicines and pharmacists dispense them. Good
  practice requires, wherever possible, the
  separation of the prescribing and supply
  functions. In this way, patients receive the
  benefit of both professions expert advice,
  intervention and care.

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What is the problem?

• 100 year old regulation
• Sustainability of medical services
• Anomalies
• Costs

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100 year old regulation

• No reason, in itself, for review but changes in
• Countrys infrastructure
• Population
• Health
• Healthcare delivery structure
• Pharmaceutical services transformed
• Medical pharmaceutical services development

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Sustainability of medical services

• Dispensing income subsidises medical services
• DH disagrees with this concept
• No problem in small urban practices
• Cross subsidisation is uncompetitive
• Cross subsidisation can only be exceptional
• Professions view
• Utilisation of services inversely proportional to
  distance from service
• Rural GPs provide extra services pro bono

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Anomalies

• Distance
• One mile rule
• Proximity of pharmacy to surgery
• Pharmacy next door to surgery Market Town
  agreement
• Or pharmacy one mile the other way
• Patient has double journey
• Fairness between neighbours
• One mile rule cut-off

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Costs

• Impact Assessment
• GP dispensing costs more than pharmacy
  dispensing
• Ignores historical costs
• Dispensing income part of pre 2004 GP
  remuneration
• Ignores clawback
• Historically part of GP remuneration
• Ignores differences in Pharmacy/GP contracts
• Payment mechanisms always different
• Dispensing Fee calculated differently
• Two rates for GP dispensing
• PA v Rural Dispensing

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The four options to determine dispensing rights

• 1 No Change
• 2 Removal of specific distance criteria and use
  of PNA
• 3 Distance between surgery and pharmacy
• 4 Distance from surgery to two pharmacies
• 5
• 6

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1 No Change

• GPC favoured option
• Supported by all dispensing GPs
• Supported by DDA
• Supported by PSNC
• Supported by PCTs
• Supported by YOU
• Gives patients choice
• Does not address financial issues
• Does not address inequities

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2 Removal of specific distance criteria and
use of PNA

• Continue dispensing in controlled areas
• Remove specific distance criteria
• PCT to use PNA to determine
• Allows local communities to determine needs
• Allows long-term commissioning strategy
• RESULT PCT can dictate local policy
• No uniformity
• No national consistency
• Patronage
• Disaster

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3 Distance - surgery to pharmacy

• Remove one mile rule
• Remove market town agreement
• If distance is less than 1000m or 500m
• RESULT Practice cannot dispense
• Disaster
• Income ?
• Staff job losses and redundany
• ? Doctor job loss
• Angry patients
• Pharmacist/Doctor relationship ?

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4 Distance surgery to two pharmacies

• No dispensing where
• Pharmacy within 500m or 100m AND
• Second pharmacy within 1500m
• RESULT Practice cannot dispense
• Disaster
• Income ?
• Staff job losses and redundany
• ? Doctor job loss
• Angry patients
• Pharmacist/Doctor relationship ?

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Retrospective or Prospective

• How do you read the documents?
• Different interpretations
• No mention of Transition in Consultation
• Your interpretations needed

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Department of HealthNo preferred option

• DH has no preferred option
• DH has not come to a view as to whether any
  reform of these particular arrangements is
  necessary.

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Related implications

• DH - Related implications to be considered as
  part of this consultation for
• Treatment of branch surgeries
• Not discussed
• Lots of ramifications and loopholes
• Maintaining services (transition?)
• How move to new arrangements might be achieved.

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Common regulatory route

• Currently different regulatory tests in rural
  areas
• Doctors
• Has to show no prejudice to medical, dispensing,
  pharmaceutical services or LPS locally
• Pharmacists
• Has to pass Control of Entry test (desirable
  necessary)
• Has to pass prejudice test

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Number of dispensing outlets
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All Applications to PCTs
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What needs to change

• Same requirements for all
• GPC would want a level playing field
• A dispensing practice should not be required to
  cease should a pharmacy application succeed
• Introduce a Control of Entry test for all
• Include necessary or Expedient (new term)
• expedient
• 1 convenient and practical although possibly
  improper or immoral.
• 2 suitable or appropriate

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Sale of OTCs

• Proposal to allow DDs to sell OTCs to their
  patients
• P
• GSL
• POM
• Is this a major issue?
• Pharmacists not keen
• Local determination depending on distance?

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The DH Questions

• A series of Questions to be answered
• OK to answer them
• Does not cover the issues of interest to us
• Advise write an essay on each subject
• Do not refer to profit but rather a resource put
  into other services in a rural environment
• Dispensing is a separate business reasonable to
  run it as a business as do pharmacists

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Should I open a pharmacy?

• YES
• DDA view
• NO
• DDA view

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What to do

• LMCs must distribute Consultation document to all
  dispensing practices - email
• Every dispensing doctor must
• Read it
• Respond personally

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Response Emphasis

• Responses should emphasise
• Convenience of the one-stop shop
• Services to patients
• Patient choice
• Cheapness of DD
• PPD report

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(No Transcript)
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What will I do?

• Ensure all LMCs have copies of the Consultation
• Encourage all LMCs to mobilise their DDs
• Keep sending emails to LMCs reminding them to
  chivvy their DDs to respond we need 100 DD
  response

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What will I do?

• Act at national level to ensure that the DoH is
  apprised of the views of DDs and the profession
• Write the GPC response
• Unite with the DDA and PSNC to prevent any change
  to the current arrangements

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What if?

• Government
• still has a large majority
• Can act on a whim
• GPC will negotiate the best deal possible in the
  event of the DoH and Government not heeding the
  views of a substantial majority of professionals

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J J J J

• FIN

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Dr RUSSELL WALSHAW

• GPC representative for
• East Yorkshire
• Northern Lincolnshire and
• Lincolnshire
• and
• GPC lead for Rural Practice and Dispensing