Rural Dispensing Practices Threatened by New Pharmacy Contract
The new Pharmaceutical Care Services Plans being rolled out in Scotland will have serious effects on many remote and rural communities. With increased funding available to Community Pharmacists under the new contract, many communities are being targeted by opportunistic applications for new Pharmacy licences in areas where medications have traditionally been dispensed by the patient’s GP. When a new pharmacy opens, the local GP practice loses the right to dispense medicines, and the loss of income results in reduced service provided by that practice to the local community.
Number of Dispensing Practices per Health Board Area
In Scotland, dispensing practices represent 12% of the total number of practices, but look after only 3% of patients. This reflects the remote and rural nature of mostdispensing GPs operating with small list sizes.
Patients registered with a dispensing practice are older, on average, than those from non dispensing practices, and 85% of these patients live in areas classed as rural
.
What is the Problem ?
Where there is no community pharmacy provision close to patients, GPs are required to provide dispensing services by the Health Board. However if a Health Board receives an application from a pharmacist to set up a community pharmacy a formal process is followed. Pharmacy applications are heard by a committee consisting only of Health Board officials and pharmacists. This process is seriously flawed in that it does not recognise the dispensing GP as an interested party. This effectively bars dispensing GPs from the consultation process. Patients’ representatives and community councils from the affected area also have no statutory rights within this consultationto express an opinion on the proposed change – contrary to the NHS (Scotland) Reform Act 2004.
If the Health Board decides to grant the pharmacy application ( they can only consider “eligible evidence”), then the dispensing doctor is instructed to stop dispensing. This results in a loss of practice income, disruption to staffing levels within the affected GP practice, a subsequent reduction in GP services and a poorer service to patients.
Value for Money
Dispensing practices dispense items which are on average £2 cheaper than community pharmacists, but tend to dispense more items. This may be explained by the fact that dispensing practices are not allowed to sell over the counter (OTC) items, and thus some items are prescribed which otherwise might be purchased. The older population of dispensing GPs are likely to be prescribed more medication and the current system rewards monthly prescribing. Despite the higher number of prescriptions, the average cost to the taxpayer per patient, is less than that for patients served by community pharmacies.
Current drug pricing structures are complex, as community pharmacy payments are set up in a very different way to those earned by dispensing doctors. However, over the past 3 years, community pharmacy costs have risen sharply, while payments to dispensing practices have fallen. Currently most dispensing practices are not VAT registered and the NHS is required to pay the VAT on their behalf. If dispensing practices were to register for VATthis cost to the NHS would be removed, then fees paid to dispensing practices would be even lower thanthose paid to community pharmacists.
Quality of Service
Patients like having medicines dispensed at their general practice - satisfaction surveys consistently show that this personal service is valued. Many of these patients are elderly or have significant disability. The ability to collect medication in the same place that they have consulted their GP is their preferred option. In rural communities public transport is limited or unavailable and long, single track roads and ferry crossings may be involved in making a separate trip to collect medication from a pharmacy. It is clear that elderly, sick and disabled patients would be further disadvantaged by losing their local dispensing GP services.
GPs already provide most of the ‘essential’ services listed under the new pharmacy contract :- Minor Ailments Service, Acute Medication Service, Public Health Service and Chronic Medication service, but under current regulations, because they are not registered pharmacists – they are not funded for this work. They also provide, without charge, many of the “additional” pharmacy services being suggested within the new pharmacy contract e.g. emergency contraception, palliative care medication service, smoking cessation services.
Many of these rural areas are visited by significant numbers of tourists, who appreciate being able to have one-stop-shop medical care, without recourse to long double journeys to collect forgotten medication.
Lack of Consultation
Last year all Health Boards were required to draw up Pharmaceutical Care Services Plans on how they will implement the new pharmacy contract in their area. Dispensing GPs are not pharmacy contractors, and are therefore not classed as ‘interested parties ‘, they were therefore unable to participate in the process.
There is similar lack of public consultation when a pharmacy application is made within an area currently served by a dispensing GP. There is no statutory requirement to consult the public on a change in service delivery, and once again, only registered pharmacists can participate in the discussions around provision of pharmaceutical services.
Loss of Medical Services and Branch Surgeries
The Scottish Government Health Department has consistently said that general medical services are self funding and are not dependent on a subsidy from dispensing income. However for many practices, dispensing forms a significant part of practice income used to employ additional staff, or to provide additional services to patients. Where a practice loses the right to dispense for patients, there will be a reduction in staffing with direct effects on service to patients.
There are real risks that loss of dispensing services from remote and rural general practice will destabilise current medical services.
Our main message is that dispensing GPs provide excellent value for money, by ensuring a regular, safe supply of medication to their patients, and large numbers of visitors. The service is popular with patients, and very cost effective.
Key points
- Dispensing costs per patient are lower for dispensing practices than for community pharmacy
- Dispensing income is part of a rural practice income and is used to provide additional patient services
- Approval to open a pharmacy means loss of GP dispensing and a reduction in practice services
Key Questions
- Why are dispensing practices not considered within the Health Board Pharmaceutical Services Care Plans?
- Why is the public not given a chance to express a view when the Health Board Pharmacy Practices Committee (PPC)considers a pharmacy application? This is in contravention of the requirements of the Reform Act (Scotland) 2004 for a community to be consulted when a significant change in service could result.
- Why are dispensing practices not allowed to provide the additional patient services that pharmacies can such as selling OTCmedication?
The Solution
- Amend the NHS Pharmaceutical Regulations
- To allow dispensing practices to be regarded as ‘interested parties’ when a pharmacy application is made in an area in which patients are currently served by a dispensing practice. The services that they provide will then be taken into account by Health Boards when considering whether or not to grant the new pharmacy application.
- To require PPCs to consider representations made to them by a community subject to a pharmacy application.
- Allow dispensing GPs the same rights as pharmacy contractors to supply OTC (over the counter) medication to their patients
- Allow a general medical practitioner to be a member of the National Pharmacy Appeals Panel
Report from Remote Practitioners Association of Scotland
Dr Susan Taylor, Morvern Medical Centre, Lochaline, Morvern PA34 5UY. 9/1/2009