Contract conference details

The NHS Primary Care Contracting organisation held its New Arrangements for Dispensing Doctors Conference on 1 March 2006 at the rather splendid Haycock Hotel, Wansford, near Peterborough .   In excess of 100 delegates attended including a smattering of dispensing doctors and/or their staff.

Some of the following has already been reported on countrydoctor but most has not.

The NHS speakers were:  Philip Grant (a drafted in professional negotiator) and Sue Ashwell, pharmacist.    The first out-gunned the dispensing doctors’ representatives and the second was like letting a fox into a hen house.

These are the demands of the NHS employers – in brief.

Everything has been agreed on your behalf by both the DDA and GPC.  Both were party to the negotiations

For the sake of payments “dispensary services” does not include personal administration, out of hours provision or branch surgery dispensing.

The dispensing quality payments scheme

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”

To provide this dispensing practices will be paid a flat fee of £2.58/dispensing patient.

Practices will have to provide evidence to the PCT examiner that services provided “can reasonably be expected to support the safe, effective and appropriate supply and use of medicines”

It is expected that staff will attain the NVQ2 standard or, if without this when they join the practice they will be expected to enrol on a course within 3 months of joining.    Existing staff coming to retirement will be allowed “grandparenting” rights.   It is assumed that GPs will be at least up to NVQ2 standard to be able to supervise. They will not be expected to take the exam.

Governance of dispensing

Each practice must have an “accountable” GP and he may delegate  to suitable staff.
Dispensing must be audited.
Standard operating procedures must be in place and used.
The aim is to bring dispensing standards into line with those of pharmacy  (Ed: surely that means we will have to lower standards?)

Excessive prescribing

This session was conducted by pharmacist Sue Ashwell of Huntingdonshire PCT.

The NHS Employers call this “Guidance” but let there be no doubt about it that it is damn well compulsory for all GPs on pain of extreme penalties.

One questioner asked what penalties and how could they “deal” with a recalcitrant practice of 16,000 patients?  M/s Ashwell replied, with some evidence of glee, that things were different now.   When I pressed her about what she meant by that, she replied that any practice could have its contract removed and be replaced by a private contractor.  I suggested to the meeting that, considering that would mean that the doctors would lose their liveliehood, that was blackmail.  This did not go down well with M/s Ashwell and was denied.   In fact, she is wrong.  Any action which can only be attained by threats and menaces is, indeed, blackmail.

Secondly, all the emphasis was on using approved (by whom?) drugs and penalising or disciplining doctors and practices who dissent without good reason.    I asked when this would lead to a national approved drug register.  M/s Ashwell denied that it would.    Oh, yes?

All this was agreed with the GPC – and Dr Russell Walshaw, who was present, did not deny it and, instead, came to the aid of the NHS employers and was frequently asked his opinion.

The strict “guidelines” will surface later.

“Sponsorship or financial deals that could be perceived to affect choice of treatment in a way which might be beneficial to the prescriber but not the wider NHS”  will be dealt with by the PCO.

It is now (hidden) in the GP contract that:

“GP practices can be in breach 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 the patient”.

(Note that the word “character” implies the use of the compulsory, local, so far, drug list)

If this has been done for a “significant” number of patients without a “reasonable” explanation penalties will follow.  
The reason is to prevent excess discount deals which may benefit the practice not the NHS.  

You may have thought that that was what the Discount Redistribution Scale was about but there is to another, tighter one of those, anyway.  So, they’ll force your income down one way or another.

And don’t forget the final sanction that, should you dissent they can take away your contract and liveliehood.    Dr Walshaw, God bless him, seems to believe this will rarely be used but I don’t trust this government, if the sanction is there, it will be used.  If only to encourage les autres.

Finances and fees
The principle agreed by DDA Ltd and GPC is that dispensing should not subsidise rural practice.   All very well, so long as the new arrangement pays doctors appropriately for the dispensing service they provide but I don’t believe the new scale is intended to do that.   And who but a fool trusts governments to up-rate scales appropriately?  GPC and DDA!

There will be a scale – still being negotiated.  The scale will fall according to the increasing number of items dispensed. 

There will be winners and losers.  Some losing practices could suffer a drop of £50,000, others will lose upwards of £10,000/year.

Dispensing doctors are expected to “howl” but the NHS Employers and the GPC and DDA have agreed to "spin" it to persuade you that it’s not bad.   

So, you can expect a farago of lies and half-truths just as you did over nGMS.   Be very, very cynical especially if they have a go at countrydoctor.

The fee has been based on 2004-05 figures:  
Remuneration £143million:     fees £72million and on-cost £71million);
Reimbursement £710million:  Drugs £612, VAT £96, containers £2M.

Total £853million

The sum represented by these will be up-rated to 2005-6 but not later.   It has been accepted by all parties that there will be a loss to practices.

The fee will be £2.30 per item not the £2.50 which accounts calculate will be needed to stand still.

VAT
There is no compulsion to register but if you don’t then neither customs nor DoH will reimburse your VAT.   

Apparently some VAT advisers have told practices they can back-date registering several years to make a windfall.   However, if you do then the NHS will demand back payment of their VAT reimbursement, at the higher rate, for the same period of time.

The un-reimbursed VAT will save the NHS £71million and this will be distributed around ALL PCTs – dispensing or not, so you will subsidise non-dispensers.

Other VAT advice is on Customs web-site.

Questions
Most of these were answered by pharmacist Sue Ashwell.

What do we do about expensive proprietary drugs prescribed by hospitals affecting our figures?
Talk to the hospital pharmacist.

Who negotiated for dispensing doctors?
One from the GPC and one from the DDA.   (NB: names were not given)

How are we to get the message over to dispensing doctors?
The DDA and the GPC have agreed to put the message positively on their web-sites etc.   (i.e.  “spin” it.)

When will the QOF details be announced?
They are effective on April first but will be a supplement to the July SFE.

How will communication with practices about VAT be made?
Through the web-sites of the DDA, GPC and customs.

What about zero discount items?
An allowance has been made but there is no list.

Is waste disposal a “quality” item?
No.

What about staff training costs?
It comes out of the allowance (???)

Will thousands of bird-flu injections affect figures.
Personally administered, so NO.

Is the dispensing QOF compulsory?
No, but no work no fee. (and you will depend on that fee for a large part of your income.   It''s an offer you cannot refuse, as they say!)

Is there a compulsion to use monitored dosage systems?
Yes, where appropriate under the Disability Discrimination Act.

Is there a list of personally administered items?
Yes, the PPA have one and you must keep checking it.

Pharmacies may have drug deals and dispense branded against a generic script by endorsing, thus adversely affecting our figures.  What can we do.
If you find out about it, have a word with them  (!!!!!!) or come to some agreement beforehand.

That, together with the earlier country doctor item ends, for now, the announcement of your new dispensing contract.

You may, like me, believe that you have been badly done by.   Whatever, do let me know – not necessarily for publication.

David Roberts

PS.  It was good to see some old faces there, today

(1/3/06)