The New Arrangements for Dispensing Doctors

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The New Arrangements for Dispensing Doctors
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The New Arrangements for Dispensing Doctors

• Philip Grant
• Director of Finance Advisor
• Core Negotiator
• NHS Employers

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Roadshow Agenda

• Welcome and overview
• Finance
• New fee structure
• VAT implications for practices
• Impact on PCT finances
• Dispensing Quality Payments Scheme
• Guidance prescribing NHS medicines
• Workshop sessions
• Reflection
• Messages for stage 2
• Questions and panel discussion

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Overview

• New fee scale resource neutral
• 90 container allowance scrapped
• Support for implementation of Disability
  Discrimination Act
• Changes to VAT
• Costs of Beynon funded
• Discount enquiry and pay review
• Joint guidance on excessive prescribing
• Dispensing Quality Payments Scheme

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Finance

• Philip Grant
• Director of Finance Advisor
• Core Negotiator
• NHS Employers

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Background

• Number of dispensing doctors 4,947
• Number of dispensing practices 1,248
• Number of dispensing patients 3.1m

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04/05 Dispensing Spend
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Principles

• Dispensing income should not be used to subsidise
  rural general practice.
• The remuneration system for dispensing doctors
  should be transparent and equitable, and the link
  between drug costs and remuneration should be
  broken.
• The system of VAT reimbursement should be
  rationalised, particularly for personally
  administered items, and the reimbursement should
  equal the VAT actually paid.

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Remuneration envelope

• Fees plus on-costs adjusted to 06/07 level
• plus
• 10 of container cost allowance
• plus
• 1.4m for Disability Discrimination Act
• Balancing mechanism

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Feescales

• Remuneration will now be on a fully fee per item
  basis
• Redistributes on-cost allowance will be some
  winners/losers
• Remuneration envelope divided by forecast number
  of items to develop feescale

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VAT Allowance

• Currently
• If you are not VAT-registered
• then VAT allowance from DH
• (based on Drug Tariff prices)
• If you are VAT-registered
• then reclaim input VAT from HMRC
• (based on actual cost of drugs)

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Beynon

• This case confirmed that personally administered
  items are an exempt supply for VAT purposes
• ie. VAT-registered practices cannot reclaim
  input VAT on personally administered items from
  HMRC, nor do they receive VAT allowance from DH
• Existing system is therefore unfair to
  VAT-registered practices

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DAmbrumenil

• ECJ ruling will increase the range of services
  subject to the full rate of VAT
• HMRC are reviewing the scope of the exemption for
  medical services
• When implemented, practices may find themselves
  above the threshold where VAT registration
  becomes mandatory

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VAT allowance changes

• From 1 April 2006
• There will be a VAT allowance on personally
  administered items for all practices ie. even if
  VAT-registered
• BUT
• There will be no VAT allowance on dispensed items

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VAT implications

• Expect all dispensing practices to register for
  VAT from 1 April 2006 (so they can reclaim VAT
  incurred on drugs purchased for dispensing)
• All PCTs will benefit from savings on VAT (est.
  71m for 06/07) NB. cost of VAT allowance
  currently allocated across PCTs on basis of drugs
  spend

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Quality Scheme

• 8m for extending the range and quality of
  dispensary services
• Equates to 2.58 per dispensing patient
• Funded by PCTs from unified budget

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Net impact on PCTs

• All PCTs have share of VAT savings (est. 1.34
  per patient), but PCTs with dispensing patients
  must cover cost of quality scheme (est. 2.58 per
  dispensing patient)
• All PCTs (bar 2!) should be net gainers

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Impact on practices

• Remuneration changes are effectively cost neutral
• Reimbursement is subject to market forces (and
  Drug Tariff)
• Discount enquiry and pay review to better
  understand dispensing income and costs to
  inform development of a fair pay system

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12.30 1.30 Lunch
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Dispensing Quality Payments Scheme

• Sue Ashwell
• Director of Medicines Management
• Huntingdonshire PCT

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Introduction

• What the Scheme is designed to deliver for
  patients, practices and PCTs
• Payment
• Service specification and indicators of service
  delivery
• Monitoring
• Future developments of the scheme

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Background and Principles

• What the NHS wants to see delivered CONSISTENTLY
  by doctors dispensaries
• Arrangements for the supply of medicines need
  to provide patients with safe, appropriate and
  timely access to medicines, irrespective of how
  and by whom the supply is made
• Standards
• Governance
• Consistency and structure

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Payment

• Does not override GMS, PMS, PhS
• Does not affect PA items and OOH or bag supplies
• Payment based on number of dispensing patients
  (not total list size)
• Based on indicators to demonstrate that service
  specification is delivered

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Service specification and indicators

• Dispensing evidence is required that dispensary
  services provided by the practice can reasonably
  be expected to support the safe, effective and
  appropriate supply and use of medicines
• (1) Systems and processes
• storage, checks, systems and SOPs in use
• Record keeping
• Advice to patients/carers on medicines use
• Reviews with patients their compliance and
  concordance with prescribed medicines - face to
  face
• Written information for patients

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Service specification and indicators

• Dispensing evidence is required that dispensary
  services provided by the practice can reasonably
  be expected to support the safe, effective and
  appropriate supply and use of medicines
• (2) Staffing
• Supported CPD and competence assessment annually
• Training standards
• Qualifications and/or accreditation of competence
• Staff hours dedicated to dispensing

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Service specification and indicators

• Governance of Dispensary Services evidence is
  required that dispensary services provided by the
  practice can reasonably be expected to ensure
  that service quality and safety is monitored and
  improved by the practice wherever possible
• Named, accountable GP for dispensary services
• Audits of dispensing services including advice to
  patients/carers and using these for service
  improvement
• Using SOPs for quality improvement and in
  training
• Staff appraisal and ongoing development/training
• Confidentiality
• Incident reporting and learning from incidents

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Guidance and Monitoring

• Guidance
• To assist practices and PCTs
• To supplement the published SFE
• Monitoring
• To assess compliance with the specification
• To assist practices with quality improvements
• To support and protect dispensing staff
• To protect GPs
• To protect patients

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Future development of the scheme

• Development of the staff specifications
• Ensuring fitness for purpose
• Building on experience
• To maintain and improve standards in dispensing
  in dispensing doctors premises,in line with
  standards for community pharmacists, whilst
  recognising the differences in terms of service
  and professional regulation
• Acknowledgements GPC, DDA, RCGP

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Guidance on excessive or inappropriate
prescribing

• Sue Ashwell
• Director of Medicines Management
• Huntingdonshire PCT

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Introduction

• Who is the guidance for?
• Principles
• Due process
• How it supplements current arrangements
• Examples

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• NHS cash for prescribing is part of the wider
  resource available for the care of patients
• therefore
• improving the quality, cost effectiveness and
  affordability of prescribing in the context of
  the overall use of NHS resources is of benefit to
  patients

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Who is the guidance for?

• Health professionals and those who have
  responsibilities in practices, services, clinics
  etc and in PCOs for promoting effective and
  efficient prescribing
• Agreed with GPC of BMA

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Principles

• Outlines and provides examples of what might be
  considered excessive or inappropriate
• Professional guidance requires efficient use of
  the resources available and the impact on other
  patients to be considered
• Changes in prescribing should take account of
  these criteria as well as clinical
  appropriateness and patient need at practice and
  PCO level

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Due process

• Prescribing incentive or improvement schemes
  improving quality and/or cost effectiveness or to
  make savings to invest elsewhere
• Practice formularies and/or prescribing and
  purchasing policies
• Sponsorship or financial deals that could be
  perceived to affect choice of treatment in a way
  that might be beneficial to the prescriber but
  not the wider NHS
• Information for patients

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Current arrangements

• GMS and PMS contractual regulations
• Subject to challenge and required to justify
• To agree change and/or action by PCO and/or
  consider whether there is a breach of contract
• GP practices can be in reach of their contract by
  prescribing drugs, medicines or appliances
  whose cost or quantity, in relation to any
  patient, is, by reason of the character of the
  drug in question in excess of that which is
  reasonably necessary for the proper treatment of
  that patient

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Examples

• Particularly where this has been done for a
  significant proportion of patients and/or in a
  systematic manner and a reasonable explanation
  is not provided
• Under prescribing linked to possible poor
  clinical practice
• A greater purchase margin and costs the NHS more
• Varied according to the impact on practice income
• Excessive amounts of high-cost products
• High quantities not consistent with other
  practitioners

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• Improving the
• quality, cost effectiveness and affordability of
  prescribing in the context of the overall use of
  NHS resources is of benefit to patients

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Workshop Session

• Reflection
• Messages for Stage 2

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Questions and Panel Discussion

• Philip Grant, NHS Employers Core Negotiator
• Mark Wilson, Department of Health
• Sue Ashwell, Director of Medicines Management,
  Huntingdonshire PCT
• Taryn Harding, NHS Employers Project Manager

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Further Information

• www.nhsemployers.org
• www.primarycarecontracting.nhs.uk
• Guidance details www.nhsemployers.org/primary/pr
  imary-632.cfm
• Primary Care Contracting Support, email
  pcc.contact_at_pcc.nhs.uk
• Primary Care Contracting AdvisorsDetails
  available on the PCC website under
  ../Resources/Contacts