PSNC update Hampshire and IoW LPC Dorset LPC 14 September 2016 - - PowerPoint PPT Presentation

PSNC update

Hampshire and IoW LPC Dorset LPC 14 September 2016

Mike Dent Director of Pharmacy Funding Gordon Hockey Director of Operations and Support

Overview

• The 17th December letter

– Context – Funding issues – Regulatory issues – The campaign

• Community Pharmacy Forward View
• PwC report on the value of community

pharmacy

A reminder of the current environmental context

• The NHS has a massive financial crisis

– hospital trusts overspent last year – GP recruitment and retention crisis – challenge of providing 7 day services – wage pressures and workforce unrest (e.g. junior doctors)

• Demands on the service and resource are seen as unmanageable
• Still needs to save £22bn per annum by 2020

17th December 2015 letter

• Open letter to PSNC
• Announces funding for community pharmacy in 2016/17 will

be cut by £170m (from £2.8bn to no higher than £2.63bn)

• A reduction of more than 6% in cash terms
• Was planned to take effect from October 2016; David Mowat

announced this will not be implemented in October

17th December 2015 letter - premise

• Government believes efficiencies can be made within

community pharmacy without comprising the quality of services or public access

– more pharmacies than are necessary to maintain good access – 40% of pharmacies are in a cluster where there are three or more pharmacies within 10 mins walk – large-scale automated dispensing provide opportunities for efficiencies

17th December 2015 letter – key elements

• Funding cuts
• Pharmacy Access Scheme (PhAS)
• Modern services
• Hub and spoke
• Pharmacy at the heart of the NHS
• Pharmacy Integration Fund (PhIF)

PSNC’s proposed service developments

• PSNC’s proposals set out how the CPCF

could develop in order to meet DH and NHS England’s stated aims

• They were presented to DH and NHS

England as outline proposals to prompt further discussions with PSNC

• Set out in three phases – focussed on a

care plan service

PSNC’s counterproposals

• Focus was on creating cash releasing cost savings for the NHS

– Short term focus; service development proposals still valid – Not dispensed scheme, therapeutic and generic substitution, care homes, unwanted medicines campaign

• But also included proposals on service development

– Emergency supply service

• And a proposal for a Quality Payment/Framework

Quality payment

• Having a consultation room that meets MUR/NMS requirements;
• Provision of Advanced Services (MUR, NMS and flu vaccination);
• Maintenance of an up to date NHS Choices profile and NHS 111 Directory of

Services listing;

• Having a programme for the provision of public health interventions to meet

local population needs

• Training staff as health champions;
• Making interventions on prescriptions as part of the therapeutic substitution and

not-dispensed services (described above);

• Participation in available locally commissioned services;
• Access to the Summary Care Record; and
• Participation in an annual medicines waste campaign and audit

Where have we got to in discussions?

• DH and NHS England are interested in

– Emergency supply (low fat version) – Quality payments

• Clinical services review (chair - Richard Murray)

– Independent community pharmacy services review to advise the CPhO – Threat to current services?

• Pharmacy First/MAS

– No interest nationally – needs a local push…

Where have we got to in discussions?

• Post-Brexit - new PM, Cabinet and DH ministerial team
• David Mowat – announcement of non-implementation in

October (5th Sept)

• But that means keeping going with the Campaign is even more

important

• Further discussions with DH and NHS England underway

Funding issues

• December letter

– Funding cut of £170m for 2016/17 – Establishment Payment to be phased out – Single Activity Fee to be introduced – Some reimbursement mechanisms to be changed

• Other

– Margins and Category M

Funding cut

• ‘Community pharmacy also has to play its part in delivering the

efficiencies required by the Government’s recently published Spending Review’

• Letter indicated a cut of £170m for 2016/17
• This was to be taken in the second half of the year – a 12%

reduction on the first half income

• PSNC’s response: Service developments, Counter proposals to

save NHS wasting money

Establishment Payment

• ‘Funding arrangements promote and reward an efficient community

pharmacy sector rather than sustain pharmacies dispensing small volumes

• f prescriptions’
• ‘This incentivises pharmacy business to open more NHS funded pharmacies,

adding costs to the taxpayer’

• Proposal: Reduce Establishment Payment over several years
• PSNC’s response: Logic is ridiculous. Introduce fixed payment for quality

Single Activity Fee

• Proposal:

– Pay a Single Activity Fee, which will be a flat fee per item dispensed – Abolish repeat dispensing fees, EPS payments, establishment payments and practice payments – Retain the additional fees linked to particular types of prescriptions (for example unlicensed medicines, controlled drugs and expensive items)

• PSNC’s response: Totally wrong incentives; will only serve to

increase focus on volume

Reimbursement

• Seeking to complete the work introduced as part of 2014/15

settlement – ‘changes to the Drug Tariff to equalise access to margin’

– Discount deduction scale – Category A reimbursement – Concession price setting – Non Part VIII reimbursement – Specials reimbursement

• PSNC’s response: Making progress as appropriate

Margins

• Margins are measured using a survey of independents’ actual

purchase prices

• Inevitably lagged - 2015/16 survey is nearly complete
• 2015/16 will see a significant over-delivery
• DH reduced DT from June by £12m pcm to start to recover

Impact

• Expected H2 2016/17 impact was huge if cuts had been

implemented given margins reductions

• There was an expected bounce back in 2017/18 as margin recovery

unwinds and the half year effect softened BUT:

• Minister has announced a ‘pause and reflect’

Impact

Alistair Burt (@AlistairBurtMP)

05/09/2016, 17:39

V pleased to see this. Apologies for uncertainty

• f which I was part. But now a great
• pportunity for pharmacy.

Impact

• PSNC will produce illustrative income tables and a cash flow

model to help contractors understand and plan, when we know what’s happening

• Meantime we have been busy…

What else is going on?

• PSNC has agreed to undertake a significant piece of work

examining the needs of the NHS and how they would want pharmacy to work with them

• CPFV published and work on developing the care plan service

concept is ongoing

• Challenging Falsified Medicines Directive post-Brexit
• PwC work

Community Pharmacy Forward View

• Workshop of pharmacists, LPCs and other

stakeholders to scope out the vision

• Worked with Pharmacy Voice to develop a shared

narrative on the future community pharmacy service

• Endorsed by RPS English Pharmacy Board
• Submitted to DH and NHS England as part of our final

consultation response

• Published 30th August 2016
• psnc.org.uk/forwardview

#futureofpharmacy

PwC report

• Assesses the value of community pharmacy
• Published 7th September 2016
• psnc.org.uk/valueofpharmacy

#valueofpharmacy

PwC

We have assessed the net value of 12 community pharmacy services – but some important aspects are out of scope

Pharmaceutical manufacture and distribution Community pharmacy Healthcare system (e.g. GPs and A&E) Patient/service users Wider society Scope of community pharmacy services  Public health services  Support for self-care  Medicines support services (e.g. enhancing access to medicine and delivering patient management services)  Standard dispensing of medicines activities & all

• ther essential services

 Advanced services (other than MUR and NMS)  Other locally commissioned services  All other type of services that pharmacies provide at their own discretion as part of their business model  Economic and fiscal value  Developing specialist pharmacist skills  Economic and fiscal value of supply chain – indirect and induced impacts Excluded Included Key: Healthcare system  NHS efficiency benefits  Other avoided NHS costs  Wasted drugs  Compensation payments Other public sector bodies  Avoided costs Patient / carer  Wellbeing  Time savings Wider society  Value of life  Avoided lost economic output  Supporting the viability of local communities

PwC

Our approach to assessing the value of minor ailment advice is similar to other services

Patient identifies potential symptom Patient goes to CP to seek minor ailments advice Counterfactual patient pathway Patient identifies potential symptom Patient does nothing Patient goes to another area of health system e.g. GP, GPOOH, A&E, walk-in-centre Patient purchases product over the counter Outcomes compared to current pathway Increased cost to NHS

• Cost of corrective treatment/drugs
• Increased cost from more expensive points of

delivery Increased costs to patients

• Diminished wellbeing from being ill for a

longer period of time due to less effective treatment Increased costs to society

• Delayed return to work
• Time off work to attend appointments

Our approach

• Develop patient pathways and logic models
• Define parameters in each model & associated data

requirements

• Identify potential data sources: pharmacy survey &

secondary data

• Design and deliver pharmacy survey
• Review relevant literature and gather secondary

data

• Integrate data and undertake analysis

PwC

The estimated value of different community pharmacy services in England in 2015 varies considerably

[CELLRANGE] [CELLRANGE] [CELLRANGE] [CELLRANGE] [CELLRANGE] [CELLRANGE] [CELLRANGE] [CELLRANGE] [CELLRANGE] [CELLRANGE] [CELLRANGE] [CELLRANGE]

£0 £1 £10 £100 £1,000 £10,000 £100,000 1 10 100 Social value per transaction/user Number of transactions/users

Self-care support Medicines support Public health

PwC

The 12 community pharmacy services assessed contributed a net value of £3.0 billion in 2015 across different elements of society

The biggest beneficiary of community pharmacy services is the NHS

NHS, £1,352m Other public sector, £452m Wider society, £575m Patient benefits, £612m

Estimated distribution of the value of community pharmacy (England, 2015)

PwC

We have assessed the impact of the 12 community pharmacy services on the public finances over both the short and long term

Theme Avoided costs for the NHS (gross) Avoided costs for

• ther parts of the

public sector (gross) Funding by DH Funding by local commissioners

Public health £467.8m £1,122.3m £64.6m Self-care support £615.2m n/r £3.8m Medicines support £688.5m £124.3m £66.6m Total £1.8 bn £1.2 bn £2.8 bn £0.1 bn

n/r = Impact not materially relevant

What you can do…

• Keep in touch with developments
• Work with and support the LPC
• Review business performance and opportunities
• Plan for funding changes
• Keep participating in the campaign

Regulatory Issues

Letter of 17 December 2015 from Will Cavendish and Keith Ridge

• Consultation with PSNC and others
• Potential for CP and pharmacists
• Initiative - clinical pharmacists in GP practices
• Making efficiencies
• clustering of CPs (Market Entry 4)
• development large-scale automated dispensing (DSP 3)
• Maintain patient access (Pharmacy access scheme 2)
• Hub and spoke (1) separate consultation

Information available

• Public domain

17 December 2015 letter March Consultation (hub and spoke) April Stakeholder meeting (shared with PSNC in Feb) May PSNC response

• Confidential
• Department of Health and PSNC discussions or negotiations

Hub and spoke consultation 1

• Hub and spoke dispensing by spoke pharmacies not part of the

same business as the hub pharmacy

• Permit dispensing label to include indicative cost of medicine

and statement as to how cost is met

• Clarify labelling requirements for MDS
• Redesign section 10 of the Medicines Act 1968, the exemption

for pharmacists

Hub and spoke models

• Patient – spoke – hub – spoke – patient
• Patient – spoke – hub – delivery Ltd. - patient
• Patient – spoke – hub – patient
• DH proposing no restriction on the models?
• Abcur judgment - section 10 of the Medicines Act
• Reference to pharmacy hubs and hospital pharmacies

Draft regulations wholly different to the narrative of the consultation

• Spokes may be any relevant clinical setting – registered

pharmacy, hospital, health centre and it is proposed NHS doctor’s surgery

• Hubs – probably any relevant clinical setting
• Pharmacist supervision of dispensing
• Unrestricted wholesale dealing

… leads to a different legislative framework for the retail supply of medicines

Hub and spoke issues 1

• Level playing field between ‘independents’ and ‘multiples’ – but,

inherent risks with third party hubs e.g. sharing your patient list

• Economic efficiency (DH) – not evidenced (NPA report) – minimal

benefit, likely burden and risks high – increased vertical integration leading to loss of competition – particularly with generics

• Safety (DH) – not evidenced – human errors even with automation

– two businesses - likelihood / significance not considered

Hub and spoke issues 2

• Falsified Medicines Directive – is this possible?
• Professional accountability - confused
• Changing the emphasis from pharmacy to pharmacist – in

surgeries there is a loss of superintendents and structure

• Unrestricted wholesale dealing – but what about European

rules

• Abcur judgment – does not warrant change to s10

Indicative price and explanation >£20

• Not supported by report quoted in the

consultation:

• patients worried about cost, encourage

selling on of costlier medicines, those who need to be targeted will not care

• problems when clear that Rx charge greater

than cost

• Label already crowded – a second label could
• bscure clinical and safety info. and will be

additional cost to NHS

Department of Health Pharmacy Commons 38588

• To ask the Secretary of State for Health, if he will re-open the

consultation on pharmacy dispensing models and displaying prices on medicines that closed on 17 May 2016 in order to allow respondents to take into account revised information on the safety profile of hub and spoke dispensing models.

Answered by: Alistair Burt

• The consultation on changes to medicines legislation including on ‘hub and

spoke’ dispensing did not rely on any specific safety profile of hub and spoke dispensing. Instead, the consultation document specifically asked consultees to provide evidence on the issue. Nevertheless, the responses to the consultation have raised issues around removing the bar on ‘hub and spoke’ dispensing between retail pharmacies that are not part of the same business that the Department would like to explore in more detail with stakeholders’ representatives before progressing any legislation. It does not now envisage changes to the legislation on this issue commencing on 1 October 2016

September 2016 DH stakeholder meeting

• PSNC and NPA robust in comments
• Many around the table unable of the detail of the draft

regulations

• DH still seeking to progress but will consider its position
• Our view remains - consultation flawed - because issues not

discussed and draft regulations wholly different from narrative

• f consultation

Pharmacy access scheme (Phas) 2

• Phase out the establishment payment – approx. £25K for all >2,500

Rx per month

• DH aim to ensure community pharmacies upon which people

depend continue to thrive

• Introduce a Phas to provide more NHS funds to certain pharmacies

compared with others, considering factors such as location and the health needs of the population

• Gov. expects 3,000 pharmacies to close
• Discussions described here are historic

Phas - background

• Access to the 11,600 pharmacies in England is excellent
• 99% of population 20 minutes by car
• 96% by walking or using public transport
• Access greater in areas of highest deprivation
• Changes could put some pharmacies under financial pressure
• Particularly so if heavily reliant on NHS income and have a low

prescription volume

Phas – details (old)

• National formula
• Identify those most geographically important for patient access
• Isolation criteria based on travel times or distances, population

size and needs

• Then need to determine qualification threshold
• Funding from global sum - top up minus 3%

Isolation criteria

• Two travel time components - time to walk to the nearest

pharmacy in each output area and time to walk to the second nearest (to be refined by public and private transport)

• Weighted by population of output area
• Population need – including deprivation, age, mortality ratios,

age-sex standardised limiting long term illness

• Continue to develop during consultation

Concerns

• Complex and difficult to understand assessment
• Ranking – what is the objective – misused?
• Distance from population based on the centre of the output

area, which varies in geographical size

• No account of the topography of the area or mobility of

patients

• Arbitrary and statistical rather than real world
• Numbers affected and thus funding required

PSNC response

• Despite repeated PSNC requests, partial explanation

received May 13th, eleven days before consultation closed

• Various sums put forward, some large – is this a cull of

pharmacies – post office style

• Use an application process against published criteria
• Isolation measured by distance between pharmacies or

populations served

• Exclude very low volume Rx and only for those

unviable without Phas

• Flexibility of opening hours according to local need
• Include quality as an eligibility criteria
• For how long (memories of ESPLPS)

Distance selling pharmacies 3

• Differentiate between DSPs and bricks and mortar pharmacies
• In respect of terms of service and fees
• Reduce fees for DSPs because they do not need patient-facing

premises and provide in a different way

• DH expect initial reduction in fees to be outweighed by

increase in volume

DSPs – response/issues

• Patient choice

a) patients like consultation rooms, home delivery and flexible opening hours – meets the needs of consumers b) Patients are positive about pharmacies – trust pharmacist and think they could take pressure off family doctors (Healthwatch England)

• CPCF recognises value of face-to-face services
• Direction of prescriptions – ineffective action
• Potential issues if fees to be apportioned to CCGs

Market entry 4

• 40% of pharmacies in a cluster where 3 or more pharmacies

within 10 minutes walk

• In early 2015 PSNC proposed market entry changes to support

reduction of pharmacies in clusters

• June 2015 rejected by DH as unnecessary
• Regs changes to ‘enable rational planning and mergers or

market exit without fear of speculative and potentially predatory applications’ (April Stakeholder meeting)

Market entry changes likely

• Application accepted by NHS England and protection only if no gap

created – patients needs cannot be left unaddressed

• HWB carries out Pharmaceutical Needs Assessment (PNA) and

additional statements, so agreement of HWB required

• Mechanism to refuse unforeseen applications
• Protection must be time limited not indefinite – next PNA?
• Protection limited by patients needs and only if new application a

result of merger/closure

The Campaign for community pharmacy

The Campaign:

• PSNC, RPS, PV, NPA, AIMp and CCA co-ordinating

activities

• Luther Pendragon offering strategic advice and

practical support with Parliamentary work

• Key messages have adjusted over time
• Local campaigning vital to support national work
• A long-term campaign – two years, not months

The Campaign:

• Key work at national level has included:

– Parliamentary briefing documents – Individual meetings and events with MPs – lots

• f PQs asked and two pharmacy debates

– Paper petition (>2m signatures) – One-to-one advice for LPCs – Media work – radio and national papers – Research – NPA, Dispensing Health, PwC – Local templates eg for media use – MP briefing event (60 MPs)

May 24th Activity: consultation closing day

• 60 MPs/researchers at Parliamentary

speed briefing event

• Key question from MPs: what does

pharmacy want instead?

• Petition delivered to Downing Street
• Local press releases and coverage
• Articles in Daily Telegraph, Express and

Mirror – all supportive of the campaign

Campaigning since the consultation

• Conservative MPs event in June
• Continued pushing key messages: backbenchers and

Health Select Committee members really important

• Patient groups letter to Jeremy Hunt
• CPFV and PwC report shared with MPs and minister
• PSNC meetings with target MPs – supported by LPCs
• Updated briefings and guidance on local events
• Online petition push and NPA template MP letters
• Support from All-Party Pharmacy Group

What Next: Our Key Messages

• Minister has announced a pause; we must use this time to

continue the political pressure

• We still need MPs to feel concerned about constituents and

political consequences

• New minister must be encouraged to think again
• Use PwC data to highlight the strengths of pharmacy and the

risks

• Promote Forward View and PSNC counter proposals as

credible alternatives – press Government to consider these

• Give local examples of care and support that could be lost

What Next: Party Conferences

• Key lobbying opportunity at a crucial time
• Pharmacy organisations working together
• Community pharmacy exhibition stand
• Roundtable events on the future of community

pharmacy

• Sponsored fringe events highlighting the role of

pharmacists

• Joint resources for MPs plus social media activity
• Pharmacy contractors present to ensure pharmacy is
• n the agenda across health events

What Next: Other Parliamentary Work

• Summaries of PwC work circulated to key MPs
• Follow-up after conferences with key messages
• Suggested PQs on PwC and CPFV
• Labour MPs seeking debate on pharmacy
• Possible Parliamentary events for November
• APPG meeting with other All-Party Group Chairs to

discuss community pharmacy

• APPG seeking meeting with David Mowat MP
• Ongoing support for local events

What Next: Other Work

• Patient groups – engaging on CPFV
• Ask Your Pharmacist Week as key chance to

continue promoting pharmacy to the public

• Case studies – please feed these in as PSNC

still looking at video edit

• Ongoing work with national media – recent

Daily Telegraph coverage

• Still hopeful that we will have pan-

pharmacy advertising campaign

How LPCs Can Help: Next Steps

• Follow up with local MPs – thank them for support

and ask them to write to the new minister

• MP infographic on PwC report available shortly
• Share the new briefing with councillors and others
• Use the template tweets – see

psnc.org.uk/campaign for the latest

• Use guidance to plan a local lobbying event
• Start planning Ask Your Pharmacist Week activities
• Help available – Luther Pendragon can give insight
• n individual MPs
• Continue to seek positive local media coverage

How LPCs Can Help: Ongoing Jobs

• Keeping contractors updated
• Gathering and collating case studies of local

practice and the impact on patients

• Responding to and giving information to the

local media

• Engaging local politicians, councillors and

patient representatives on social media

• Guidance and support will continue to be

posted on website and sent via LPC Emails

How Pharmacy Teams Can Help

• Social media – keep sharing how you have

helped patients using #lovemypharmacy and use the template tweets on the PwC research

• Offer to help the LPC with a local MP meeting
• Continue any dialogue with the local MP
• Talk to patients – look out for Ask Your

Pharmacist Week resources

• Direct patients to supportyourlocalpharmacy.org
• Send case studies to the LPC (guidance on the

PSNC website)

Questions and discussion