Not Dispensed Pharmacy Partnership Scheme
(Leics County &Rutland PCT Financial Recovery)
Proposal & Business Case
Background: The growth in the average number of prescription items per annum per head of population is driving up drug budget costs as much as price inflation per se. In 1995 the average was 9.8 items per head of population, rising to 14.3 in 2005/6, which is a rise of 46%. Notably, elderly patients average 38.4 items and patients with LTC’s typically have over 50 items per annum. National Service Frameworks and NICE guidance contribute to this item growth.
Point of Information: Prescription items to be taken or used as required account for a considerable number of these additional items. Examples of these ‘variable use’ items include reliever inhalers, blood testing strips, & analgesics. Importantly, these items tend to accumulate, expire and ultimately are wasted.
SERVICE CONCEPT – Pharmacists to discuss such repeat prescription items with the patient, and to check if they need to be dispensed & supplied that month.
If not needed, because they have sufficient at home, they are NOT DISPENSED.
NB: Prescribing rationale is not being questioned here. Most of these items are quite appropriately prescribed for ‘as required’ use. Nevertheless, a prescription is effectively a financial commitment to the PCT which this service can help mitigate.
Pilot Studies: This innovative concept was tested in Coventry, Rugby, and presently in Hinckley & Bosworth PCTs. Whilst it has been proven to be operationally expedient and worthwhile, considerably less than half of community pharmacists in Coventry have engaged with it. In Hinckley & Bosworth PCT it has been piloted as a Collaborative Project with the support of the LPC. Some anticipated issues are becoming evident. More lower value items are being ‘not dispensing’ by independent pharmacists, with fewer claims being made for higher value items not dispensed. Financial analysis of the piloted model has since demonstrated an inherent financial disincentive that explains these findings. Thus this learning from the pilot can usefully inform & improve service commissioning.
ENSURING ENGAGEMENT of pharmacists (WIN / WIN Commissioning) – The financial disincentive to pharmacy contractors is mitigated in this revised reimbursement model. It builds upon an understanding of how reimbursement works within the new pharmacy contract. Further the scheme is marginally weighted above cost-neutral (+3.7%) to the contractor. Thus they will be more inclined (commercially) to not dispense. However this increment is relatively insignificant and will not create an untoward professional/commercial dilemma.
Importantly it does recognise the goodwill that the PCT will expect from pharmacists in making this recovery concept work. (Pharmacists will be aware that PCTs will retain several 100% more in savings than they will be paid in fees.)
A spreadsheet detailing the business model is appended.
A flat rate of £3.00 per unit of service continues to be offered in consideration of the extra paperwork and processing. It is also noted that the net time required to not dispense a prescription item is often greater than the time to dispense it, because discussions with the patient can get protracted, venturing into Medicines Use Review-type issues, etc.
Key to this proposal is the fact that Community pharmacists handle over 95% of prescribed medicines. They are the last healthcare professionals in the medicines supply chain. Thus they are well placed to intervene where such cost savings can be made. But it is crucial that they are fully engaged, both professionally and in the detail of the business case.
The Department of Health explicitly recognises the potential of community pharmacists as detailed in Pharmacy in the Future – Implementing the NHS Plan.
PCTs are required to develop Medicines Management programmes and not dispensed schemes can constitute a very useful, inclusive and cost-effective starting point from which more sophisticated concepts can be developed.
Outcomes: The not dispensed scheme piloted in Coventry PCT netted savings of £28, 336.73 after £6,296.00 in payments to pharmacists.
On analysis, this flat fee service model, which is cash positive to contractors for not dispensing cheaper prescription items, tends very quickly towards cost neutral and then into cash negative as the cost of the not dispensed prescribed item increases – which crucially are the ones which the PCT could save most money on. (see red figures on model) In this case 60% of the Coventry pharmacists did not participate.
The revised proposal converts these marginal contractor loses into marginal gains.
Profile of Savings(revised model)
Number of LCR Pharmacies Participating / Net savings in 6 months to PCT, based on the following number of drugs not dispensed @ £12.03 each (NIC)2 per week / 4 per week / 6 per week
50 (41.%) / £19,550 / £ 39,100 / £ 58,650
100 (82%) / £39,100 / £78,200 / £117,300
Based on the evidence from other schemes, the LPC would advise that a saving of 5 items per week via 80% of community pharmacists is a reasonable projection for savings in the next 6 months under the revised proposal.
It is therefore suggested that the scheme could save £97,750 in 2006/7 if implemented on the 1 November 2006.
Pump-Priming? - None required for this service. Fees are paid retrospectively out of reduced cash-flow obligations. ie the PCTs bill from the Prescription Pricing Authority will be less, equivalent to the gross savings. Pharmacists are then paid locally by the PCT. (not via the PPA)
Financial Risk of 10% additional payment? – Evidence suggests none. The percentage factor in this simple revised formula mitigates risk to the PCT in absolute terms across the prescription item cost (NIC) spectrum.
Eg If a cheap 50 pence item is not dispensed, the additional risk over and above the £3.00 flat fee is just 5p. But if a £50 item is not dispensed there is a more significant additional £5.00 obligation (but to save £45.00)
Conversely that £50 item in the Coventry PCT model, (see spreadsheet appended) would precipitate a £1.48 loss to the pharmacy contractor if it were not dispensed.
Crucially, the revised pharmacy business case avoids such dilemmas, so providing an alternative win/win scenario.
Clinical Risk – none. There are no changes to the choice or doses of medicines taken by the patient. Patients may actually learn more about how such variable use items should be appropriately taken, and how to reorder them more thoughtfully.
Clinical Governance - The service is designed to review and make direct interventions regarding the supply of prescribed medicines and as such embodies the principles of good clinical governance. It also follows a methodology which is auditable and will be used to monitor outcomes. (Service Level Agreement)
Pharmacy Access (PCT Coverage)
All pharmacists will be invited to deliver this service. Thus the scheme can support all GP practices in the PCT. Additional training is not necessary.
Primary Care Relations (GP Acceptability?)
a)The proposed scheme does not challenge or query original GP prescribing choices. The medicine does not change as a result of the pharmacy activity.
b)The scheme will help GPs to achieve their prescribing cost containment objectives. Thus there is a mutual benefit to be gained from working with pharmacists in this scheme.
Partnerships and Compounded Savings - The LPC would wish to see 50% of savings accrued by this route ring fenced, and used, pending appropriate business cases, for the commissioning of further medicines management service concepts.
END