Introduction

This is the response of the National Pharmacy Association (NPA) to the Department of Health’s (DH) ‘Arrangements under Part IX of the Drug Tariff for the provision of stoma and incontinence appliances – and related services – to Primary Care’.

The NPA represents the owners of virtually all community pharmacies in the UK. We have, in voluntary membership, virtually all pharmacy owners. The overwhelming majority of our members contract with the NHS for the provision of NHS pharmaceutical services

A fee of 90p per Part IX prescription item dispensed should be paid to dispensing appliance contractors?

The NPA accepts that based on the principle of a ‘level playing field’ between pharmacy and appliance contractors that the 90p fee should apply to both. However, the NPA would like the issue of discount deduction to be addressed by the Department of Health (DH). Pharmacy contractors will in the proposed new arrangements be subject to discount deduction on Part IX products whilst appliance contractors will not be subject to this. The NPA would like Part IX products to be removed from discount deduction calculations for pharmacy contractors. This would represent a consistent and fair approach being applied between appliance and pharmacy contractors.

Extend the additional dispensing fee to all Part IXA (catheter) and Part IXB (incontinence related) prescription items, as well as Part IXC (stoma); set the additional dispensing fee at £3.23 for those prescription items

The NPA has previously stated that we believe it is unfair that patients using Part IXA and IXB products may be deprived of funded delivery services from contractors. Therefore, the NPA is pleased that the DH has now extended the additional dispensing fee to cover both Part IXA and IXB products.

The £2.77 figure used to calculate the additional dispensing fee has been taken from the current Royal Mail packet tariff. The NPA is pleased that the DH has recognised the cost has increased since their last proposals – however it is still important that this figure is reviewed periodically to ensure potential increases by Royal Mail are reflected in the revised figure.

The NPA still believes that the figure of £3.23 is still too low based on the fact that posting by first class does not guarantee next working day delivery. According to the Royal Mail website[1] the phrase used is ‘Delivery Aim 1 Day’ – therefore to ensure the product reaches the patient with ‘reasonable promptness’ it is essential the delivery option used can guarantee next working day delivery. The tariff available from Royal Mail for this type of delivery is the ‘Special Next Day’ option. The current tariff available[2] for this option for a 1kg package is £6.00 with other prices available for different weights.

By using the Royal Mail Special Next Day option you are also guaranteeing the product gets to the patient by 1pm the next working day. Also the parcel is tracked therefore the risk of the parcel getting lost is minimised. Royal Mail has admitted that more than 14 million letters and parcels were lost, stolen, damaged or tampered with last year[3].

Taking the above points into account the use of another postage route may be more beneficial as some couriers are able to collect directly from the contractor and guarantee next day delivery. Therefore, the NPA strongly suggests that the proposed additional dispensing figure is revised upwards in light of the above comments.

A fee for stoma customisation of £3 per Part IXC (stoma) prescription item subject to cap of 25,000 Part IXC (stoma) items per month

The NPA is happy with the proposal that a fee is paid per Part IXC prescription item dispensed. However, the NPA is strongly opposed to the level of the fee being proposed. The NPA is concerned that the £3 fee has been calculated without adequate provision for the training costs required for contractors to be able to offer stoma customisation.

In addition, there will no doubt be waste issues to consider, for example, if errors are made such as cutting a hole to the wrong size or puncturing a bag, the contractor undertaking the customisation would bear the cost of the replacement product. Therefore the NPA would like DH to re-consider the proposed £3 fee – as this needs to be revised upwards.

Extend specialist nurse home visits to all Part IXA (catheter) and Part IXB (incontinence related) prescription items, as well as Part IXC (stoma)

The NPA stated in its previous submission that patient choice and equity of care are being compromised if patients with incontinence needs are not able to receive visits from a specialist nurse. Patients who require incontinence products may well require and benefit substantially from a specialist nurse visit. If such patients are not able to receive a visit under the proposed funding structure the danger is that they will not receive a visit due to lack of funding in other areas of primary and secondary care. Therefore the NPA supports the extension of specialist nurse visits to all Part IX prescription items.

Dispensing appliance contractors and pharmacy contractors should be paid £40 for each specialist nurse visit declared - but that the number of visits declared in any financial year (April to March) must not be greater than one for every 70 Part IXA (catheter), Part IXB (incontinence related) or Part IXC (stoma) prescription items dispensed in that year

The proposed £40 fee for specialist nurse visits is totally inadequate – as it will not ensure that all contractors are able to offer this type of service. The NPA would like to see all the costs associated with providing a specialist nurse visit taken into account when calculating the fee. Costs incurred will include: the cost of the specialist nurse, travel costs, administrative costs in booking the nurse and the appointment for the patient and ensuring that a record of the visit is maintained. These costs will be on top of the financial incentive that a contractor will need in order to carry out the service. Currently the NPA can only see the costs of a nurse’s time in the DH calculating the £40 fee.

The NPA would like to mention an alternative to the proposed mechanism for specialist nurse visits – PCTs should be allowed to make local decisions on the commissioning of nurse visits for patients living with incontinence and stoma needs in their areas. A key advantage of empowering PCTs to commission nurse visits is that in making local commissioning decisions, PCTs could consider the number and needs of patients who require visits. This supports the DH agenda of ensuring NHS service providers work in partnership with health professionals directly employed by the NHS locally, maximising quality and continuity of care in a way that is cost effective for the NHS.

The NPA feels that the number of visits should be determined by patient need and the professional judgement of an appropriate professional – rather than placing a cap on the number of visits. It is wholly inappropriate to suggest that where a patient has chosen to request services from a particular provider but the contractor’s limit has been exceeded, that the patient should be denied this support and referred to another provider. This would restrict access, does not support continuity of care and could lead to delays in patient care.

The proposal that the infrastructure payment for dispensing appliance contractors should be banded at 10 levels rather than the six previously proposed

Amend Part VIA paragraph 6 of the Drug Tariff to include dispensing appliance contractors.

Proposals regarding Service Specifications and Regulatory Terms of Service

Whether you agree that the proposed amendments to the Regulations and the revised Directions capture what the Department is trying to achieve in relation to the services provided by dispensing appliance contractors and pharmacy contractors in relation to the dispensing of Part IXA (catheter), Part IXB (incontinence related ) and Part IXC (stoma) prescription items.

Dispensing appliance and pharmacy contractors should be able to pass a prescription form to another organisation, including another dispensing contractor, with the patient’s consent if they cannot dispense the prescription item - provided that they do not receive either a gift or a reward from the other organisation. However, if the patient does not consent to the prescription form being passed, the dispensing contractor should recommend two alternative contractors - if details are known to them

The NPA was strongly opposed to the abolishment of the ‘Agency Agreements’ in its previous submission to the DH - Arrangements for the remuneration of services relating to appliances within Part IX of the Drug Tariff (Apr 07). Therefore the NPA is pleased that the above proposed amendment to the regulations and the revised regulations will allow dispensing appliance and pharmacy contractors to pass a prescription form to another organisation, including another dispensing contractor, with the patient’s consent.

However, the NPA recommends for clarity, that verbal patient consent be allowed in order for contractors to pass on the prescription form to another contractor. If a contractor needs to obtain written consent - it is not practical to obtain this written consent every time the patient presents themselves to the same pharmacy. Therefore, similarly to the patient sign up process for prescription collection services, the NPA recommends that when a patient presents themselves initially the sign up process need only occur once.

Dispensing appliance and pharmacy contractors should provide as an essential service home delivery plus complimentary supply of disposal bags and wipes in relation to the dispensing of Part IXA (catheter) and Part IXB (incontinence related) prescription items, in addition to originally proposed Part IXC (stoma) prescription items

Currently the vast majority of Part IX manufacturers provide disposal wipes and bags free of charge to contractors - this is an attempt to build patient loyalty for their brand of product. With the proposed reduction in drug tariff prices of Part IX products it is highly unlikely that manufacturers will be able to continue this and the likelihood of wholesalers further down the supply chain being able to offer competitive pricing on wipes and bags is even more unlikely. Therefore, the NPA would like to seek reassurances that the current benchmark figures (based on industry data) take into account the likelihood of contractors purchasing bags and wipes at the stated reimbursement levels.

The NPA would also like to seek reassurances from the DH that the additional dispensing fee takes into account fully the costs of supplying disposal bags and wipes. More importantly the reimbursement levels need to be reviewed regularly to ensure the cost of bags and wipes do not go above the reimbursement level for contractors.

Dispensing appliance and pharmacy contractors should provide if they so choose as an advanced service, specialist nurse home visits to users of Part IXA (catheter) and Part IXB (incontinence related) appliances, in addition to originally proposed Part IXC (stoma) appliances

Dispensing appliance and pharmacy contractors should have, subject to the agreement of the PCT, greater flexibility as to where the customisation of a stoma appliance takes place

The withdrawal of the requirement for two previous failed stoma customisation attempts in order to refer patients to the prescriber

The withdrawal of the requirement to limit the annual number of specialist nurse home visit per patient to one

An implementation date of 1 May 2008for both the proposed levels of service remuneration and the amendments to terms of service for dispensing and pharmacy contractors. Plus, the proposal to allow a six-month transition period for all dispensing appliance and pharmacy contractors to comply with their new terms of service

The NPA would like to see a minimum of three month’s notice given before new prices are implemented for Part IX products. This transitional period will allow contractors to manage their existing stock of Part IX products more effectively, prior to any price reductions. More importantly this transitional period will negate any problems with de-listing of products by manufacturers and any problems with changes in GP prescribing patterns for Part IX products. The NPA would also like to seek reassurances from the DH that once the new prices have been agreed for Part IX products that these are published to all stakeholders (including contractors) at the same time.

The Department’s proposal to limit the price adjustments and each of the proposed options for doing so:

o applying the pricing model to the revised product classification and capping reductions at 35%

o applying a uniform 12% reduction in current reimbursement prices for all Part IXA (catheter), Part IXB (incontinence related) and Part IXC (stoma) prescription items; pricing model not applied

The proposed implementation date of 1 June 2008for the proposed new levels of reimbursement

The NPA notes that both options being proposed equate to an overall reduction of £25 million in Drug Tariff prices for Part IX products. No matter what option is decided upon by the DH, the NPA would like to make the following comments in relation to reduction of prices for Part IX products:

Do you have any other comments you would like to make in relation to this consultation

The NPA is still disappointed that only pharmacy and appliance contractors are being considered in this consultation and that doctor dispensing contractors are outside the scope of this consultation. The argument being that doctor dispensing contractors only dispense a small number of Part IX products. Doctor dispensing contractors do in fact supply a significant number of Part IX products via the use of ‘agency schemes’. Therefore although actual dispensing volumes may be low amongst doctor dispensing contractors, when you consider the use of the agency agreements the volumes may in actual fact be a lot higher. It is therefore unacceptable for doctor dispensing contractors to be outside the scope of this consultation.

The NPA would like to mention the area of discount deduction. Pharmacy contractors in these proposed arrangements seem to be subjected to discount deduction on Part IX products whilst appliance contractors will not be subject to this. The NPA would like Part IX products to be removed from discount deduction calculations for pharmacy contractors. This would represent a consistent and fair approach being applied between appliance and pharmacy contractors. This would also mean pharmacy contractors will not be penalised unfairly as often they are not able to obtain discounts on Part IX products.

The NPA remains continually concerned that the issue of sponsored nursing posts is not being addressed in this consultation. This is totally unacceptable as the impact of sponsored nursing posts in particular on the supply chain (e.g. loss leading, supply of free product in secondary care etc.) can dramatically impact on prescribing patterns in primary care. This point was extensively covered in the NPA’s original response in Jan 2006 and to the consultations issued in October 2006 and April 2007. Therefore, the NPA would again like to see the development of service standards for sponsored nurses and the running of patient clinics.

[1]Available from URL http://sg.royalmail.com/portal/rm/PriceFinderResults?pageId=pc_sltc_rm_product&productCarrier=RM&catId=23500532&keyname=14&index=5

[2] Available from URL

http://www.royalmail.com/portal/rm/content1?catId=400026&mediaId=22700554

[3] BBC News Available from URL

http://news.bbc.co.uk/1/hi/business/4700190.stm