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The
dum-dum DDA
(Contract
details at the end of this piece)
The dispensing doctors’ new contract will be revealed to the world on
Wednesday in all its stupid ghastliness.
There is little reason for optimism when it is considered who
negotiated on behalf of dispensing doctors; Dr Malcolm Ward of the DDA
and a chum and the GPC. A
rag-bag of the timid, the sycophantic and the ignorant.
None of whom, judging by past actions have the dedication, the
gumption or the leadership to press the case for their dispensing
colleagues.
Remember, it was this group that brought you into the thrall of the
chemists with their recent dispensing regulations fiasco.
They told you that you were safe – but you are not.
They told the small practices they were particularly safe through
reserved area status but that’s a sword of Damocles just waiting for a
chemist to release on your head.
They brought you category-M generics and failed to emulate the chemists
by getting you compensation.
They got you VAT – with no choice
but with a great deal of work.
And
they are failing to take any advantage of the vast open door for the
extension of doctor dispensing presented by the abandonment of on-site
supervision by chemists, and by chemist prescribing both of which shoot
the chemist truly in both feet. Not to mention the other chemists'
objection that the prescriber should not profit from his prescribing.
Hardly sizzling successes so far for your £100 sub!
Now they are going to give you a new contract – so, watch out.
None of us actually know what they have been negotiating on your behalf.
None of us have even been asked for an opinion.
Before the DDA was formed there may have been an excuse for that.
The GMSC was institutionally secretive and nannyish and there was
no way for dispensing doctors to be kept informed.
But since 1984 there has been a quarterly DDA magazine.
I know, I edited it from 1984 to 1997 and it was a damn good mag
and kept dispensing doctors well in the political picture, with articles
and regular referenda, as did the Conference but now we have the DDA Ltd
with an equally obsessive institutional secrecy attitude.
Result is, you know damn all what’s going to happen in your
name because they say nothing in the magazine and nothing gets debated
at Conference.
To my mind that is the height of complacent arrogance
They are working for you not the other way round.
Anything they agree will affect you.
How dare they exclude you from the discussions!
Dr Ward was recently asked why this was so and apparently he replied
that GPC wanted things to be kept secret until it was all over.
That about sums up his leadership.
Apparently he cares more for his relationship with GPC than about
you, the members of the DDA Ltd.
There are two very good vehicles for the DDA Ltd to use to get
dispensers’ opinions but the dum-dum-DDA Ltd is too frightened to use
them for fear that it will have to stand up to the GPC for once.
What a group of pitifully dangerous poseurs they are.
What is the point of having am independent dispensing organisation that
brown-noses chemists and GPC?
No doubt it is very flattering to the DDA Ltd Board members
to be wined and dined around the place, though, but they should give
some thought as to why they are being buttered up by those groups.
It doesn’t take a rocket scientist to work it out.
One of the reasons will be revealed on Wednesday 22 Feb 2006
when the triumph of their new dispensing contract negotiations is
revealed.
They have already given away “on-cost” but it remains to be
demonstrated at what cost!
Quick, back of the envelope calculations show that the enhanced
dispensing fee, which I have opposed for 10 years, needs to be about or
above £2.50 per item just to equate to “on-cost”.
However, a little bird told me this weekend that the DDA Ltd and
GPC had settled for around £2.00.
As the DDA Executive Officer (get him!) and GPC stalwart, Dr David Baker
said about another matter, there will be winners and losers.
No doubt. No doubt.
But how many losers?
Dodd and Co (Accountants) recently estimated that the result of current
financial negotiations are likely to cost dispensing practices £24,000
per annum. Add on a loss of
around 50p per item and you are talking of a very substantial sum –
and it’s only cost you £100 for the DDA Ltd to lose it for you.
As
for the rest of the contract, the very thought makes me shudder!
Oh, and unlike the GMS contract, you don’t get a vote.
It’s enough to make you weep.
Nay, it’s almost enough to bring me out of retirement to re-join the
DDA Ltd. After all Dr Ward
is retiring in Spring….
(18/2/06)
AMENDED
CONTRACT INFORMATION - Thursday afternoon 1.
PCTs are to be given a lump sum of £143, ring fenced for containers,
VAT etc.
This figure equates to the figure they were given in 2004/5 in other
words it's a cut and there will have been no inflation rise for at least
2 years by the time it is reviewed. The figure is immutably fixed
"to keep costs down". There is no uplift for VAT
(cost to DDs is £20M), no uplift for Category-M (cost £30M), no uplift
for increase in volume used. 2.
QOF sum will be fixed at £8million and will involve standards, service and
training
There are no grades, as for other QOF targets. It's all or
nothing and the PCT will decide. Each dispensing practice must
nominate a GP accountable for the dispensing. Some of
the work may be delegated to the practice manager or other dispensing
staff member. 3.
Fees
These were not announced as they are still under negotiation (God
help you!) but they will be lower than anticipated, said the chairman,
to allow for past increases. In other words, there is going to be
an effective clawback. PCTs will have a fixed amount of
£71million to cover all claims for fees. If there's more
claims then it is likely that DDs will lose in other ways. The fee
will cover "on-cost", container allowance and the current
dispensing fee. It is likely to be fixed at £2 where
it should be around £2.50 if it were to accurately and properly cover
the above items. It is expected that dispensing doctors
will switch from 84 or 56 days to 28 day prescribing. More work
for no increase in pay. The
£71million will be distributed equally amongst all PC0s. The
effect will be that the rural, dispensing practices will once again
subsidise non-dispensing practices. 4.
Discount
There is to be a new discount enquiry system. It will be
more thorough this time so as to get the most back for the DH.
Also it is intended to demonstrate once and for all that dispensing
doctors are more expensive prescribers than non-dispensers.
As that is an out and out lie, at least some good should come from the
enquiry if it's not rigged. 5.
Drug expenditure is to be rigidly controlled
There will, in effect, be an approved list of drugs for all GPs
and GPs can only prescribe out of the list if they can give a sound
clinical reason. DDs are to be especially watched to prevent
them gaining by the back door. This
marks the end of freedom of prescribing for all UK GPs. 6.
The BMA
The BMA have agreed to all this - well, would you expect anything
else? - and the DDA Ltd were party to the discussions and agreed to the
secrecy. 7.
"on-cost"
This is, of course, abolished in favour of the above.
LMC Conference voted for that as GPC Policy several years ago, would you
believe. The
overall effect of all these will be that the government will have its rural
dispensing done for peanuts. Well, after all, monkeys were doing
the negotiating. --------------------- COMMENT The
one good thing which may come out of this, if anybody (GPC or DDA td)
pushes for it, would be that dispensing by doctors will be so much
cheaper than by chemists that dispensing could be expanded especially
bearing in mind the chemists' own rejection of it (see above).
However, would it be worth it? However,
my
advice to you in the meantime, is to maximise your dispensing income
whilst you can because it could be your last opportunity and you are a business after
all. Pity there's not much time. And,
of course, you should consider resigning from the DDA Ltd which has done
very little for you -
and demand your share capital back from them. They are a Limited
Company, the DDA Ltd. If they won't give it, complain
to Companies House. Far
from pontificating at his meeting in Corby Glen next month, David Baker,
if he had any decency should resign from the DDA if not in disgrace
then in protest at the way his dispensing colleagues have been
treated. I have absolutely no doubt that the impact adhesive on
his pants will keep him in office. The same applies to all
the board members who, one assumes, were fully informed by Ward et al. Alternatively,
members (you are all shareholders) are free, under the Companies Act, to
call a Special General Meeting of the DDA Ltd to call upon the Board to
resign. A new board could then be elected. But,
please do not sit on your hands and do nothing. This is a crisis
for dispensing doctors. You colleagues need your
support. More
details: The
following is the GPC slant on all this as my colleague has yet to send
me full details from the meeting. As I said elsewhere, I will be
attending a briefing meeting for PCT Chairs next week.
If my colleague hasn't come through with details before then I will
write it all up when I get back. You
will note that the GPC slant is light on figures. Enjoy
your reading! ---------
Removal
of the link between pay and drug costs
4.1 A new system for the remuneration of dispensing doctors has been
developed. Under the new system, the on-cost allowance has been
abolished. This removes the direct link between drug costs and
remuneration. Dispensing doctors will receive a fee for each item that
they dispense. The new fee scale is calculated by dividing the
dispensing doctors’ remuneration envelope by the number of items
expected to be dispensed in 2006/07.
4.2 The Prescription Pricing Authority (PPA) in England (which will be
known from April 2006 as the Prescription Pricing Division of the
Business Services Authority) and the Prescribing Services Unit (PSU) in
Wales will continue to calculate the amounts due to doctors in fees and
allowances for dispensing and personal administration and these are paid
through the Exeter system. The PPA system will be changed to implement
the new fees from
1 April 2006
onwards. The new calculations will be applied
to prescriptions submitted to the PPA for April 2006 (these will be
submitted by 5 May). The PPA will calculate an interim payment which is
due on 1 June and the actual entitlement (less interim payment) will be
due on 1 July.
Calculating the envelope
for dispensing doctors’ remuneration for 2006/07
4.3 The remuneration envelope is based on the actual payments made to
dispensing doctors for both fees and on-cost allowance, appropriately
adjusted to reflect anticipated payment levels for 2006/07.
4.4 In calculating the remuneration envelope for 2006/07:
- it
was also agreed that the container cost allowance of 3.8p per
dispensed item was longer appropriate as most drugs are now
pre-packed by suppliers. Instead, 10% of the current container cost
allowance envelope was included in the overall remuneration envelope
- £1.4m
was included to support dispensing practices in meeting their
responsibilities under the Disability Discrimination Act 1995.
Support
for people with disabilities
4.5 Under the Disability Discrimination Act 1995 (DDA), dispensing
doctors as service providers have a duty to make reasonable adjustments
to enable someone with a disability to utilise the service. Reasonable
adjustment may include the provision of an auxiliary or compliance aid
to enable a person who is disabled to obtain and take their medicines.
In determining what is reasonable, consideration needs to be given to
the individual circumstances of the patient and the dispensing practice,
and a judgement made by the specific provider, the dispensing practice.
Discount enquiry and full
pay review
4.6 The Technical Steering Committee has been asked to oversee a full
pay review covering dispensing doctors and a review of the discount
factor applied to the drug tariff when reimbursing dispensing doctors
for the purchase of drugs dispensed.
VAT reimbursement
4.7 In
England
and Wales From 1 April 2006 the Department of
Health will not pay a VAT allowance on dispensed items. This means that
practices will need to register for VAT purposes with HM Revenue and
Customs (HMRC) if they require VAT reimbursement after
31 March 2006
.
4.8 From
1 April 2006
the Department of Health will pay a VAT
allowance on personally administered items for all practices, as
these are an exempt supply for VAT purposes and are therefore not
re-claimable from HMRC. Previously, the Department of Health had
excluded VAT-registered practices from this re-imbursement.
4.9 The PPA system will be changed to implement the changes in VAT
allowances for all items dispensed and personally administered from
1 April 2006
onwards. This means that practices which are
not currently registered for VAT will be able to claim VAT allowance on
dispensed items through the PPA system for all items dispensed up to and
including
31 March 2006
. These prescriptions should be submitted by 5
April. The PPA will calculate an interim payment due on 1 May and actual
entitlement (less interim payment) due on 1 June.
4.10 Assuming that a practice registers for VAT with HM Revenue and
Customs (HMRC) with an effective date of
1 April 2006
, VAT can be reclaimed from HMRC on items
purchased on or after
1 April 2006
which the practice intends to dispense.
4.11 Practices will be able to audit stock in hand on 1 April in order
to reclaim VAT on items purchased before 1 April but not dispensed until
that date or later. Entitlement to VAT recovery will be governed by the
intent to make taxable supplies with the goods in question, once VAT
registration has been effected.
4.12 An information sheet about the VAT registration process for
dispensing practices has been developed by HMRC and is available via the
GPC and NHS Employers websites. This information sheet provides:
- advice
about how practices can register for VAT
- information
about the VAT treatment for goods and services
- advice
about how much VAT can be recovered on purchases.
4.13
For general information practices should contact HMRC on 0845 010 9000
or look on the HMRC
website - go there now.
4.14 Primary Care Organisations (PCOs) need to be aware that all
dispensing practices are likely to register with HM Revenue and Customs
for VAT from
1 April 2006
. This may have implications for any
reimbursement provided by PCOs to contractors for premises and IT if the
reimbursement is gross of VAT. If contractors are registered for VAT
they may be able to claim reimbursement of some of the VAT costs of
capital expenditure from HMRC. PCOs therefore need to be aware of the
VAT status of practices and what sums they can reclaim from HMRC in
order to avoid double payments of VAT costs.
Dispensary Quality
Payments Scheme
4.15 Dispensing practices will be paid for providing a high quality of
dispensary services under a new Dispensing Quality Payments scheme.
Details about this scheme are still being negotiated and will be
published as soon as possible.
Maintaining clinically
cost effective prescribing
4.16 Guidance which outlines what might be considered to be excessive or
inappropriate prescribing has been developed for PCOs and health
professionals.
Excessive
or inappropriate prescribing - guidance for health professionals on
prescribing NHS medicines
Improving
the quality, cost effectiveness and affordability of prescribing in the
context of the overall use of NHS resources is of benefit to patients.
The guidance provided here is designed to support those objectives and
to guide all health professionals who prescribe and/or dispense
NHS medicines, or who have responsibilities in practices, services,
clinics etc and in Primary Care Organisations (PCOs) for promoting
appropriate, effective and efficient prescribing.
Comments on this guidance and suggestions for amendment should be
addressed to NHS Employers or the General Practitioners Committee (GPC)
of the British Medical Association.
1. Introduction
1.1 The aim of this Guidance is to outline and provide examples of what
might be considered to be excessive or inappropriate prescribing.
1.2 It has been developed by NHS Employers and the GPC. It will be
subject to subsequent discussion with the bodies representing the other
professions who have or are being given prescribing rights through
changes in legislation.
1.3 “Excessive Prescribing” is defined within contractual
regulations for GPs. GP practices can be in breach of their contract by
“prescribing drugs, medicine or appliance whose cost or quantity, in
relation to any patient, is, by reason of the character of the drug,
medicine or appliance in question in excess of that which is reasonably
necessary for the proper treatment of that patient (NHS General Medical
Services Contracts Regulations 2004, Schedule 6, Part 6, Paragraph 46).
1.4 Any health professional believed to be prescribing excessively may
be subject to challenge by their PCO and required to justify their
prescribing behaviour. PCOs are authorised to manage excessive
prescribing under paragraph 46 of Schedule 6 to The NHS (General Medical
Services contracts) Regulations 2004, paragraph 44 of Schedule 5 to The
NHS (Personal Medical Services Agreements) Regulations 2004 and Schedule
1 Part 4 of the Terms of Service of Pharmacists in the NHS
(Pharmaceutical Services Regulations) 2005.
1.5 It is possible that potentially excessive prescribing will be
identified in the first instance by the local PCO prescribing adviser.
In the interests of developing good prescribing practice it is
recommended that the initial approach to health professionals who are
perceived to prescribe excessively should be by way of education.
Appropriate remedial action should be instituted if the practice agrees
that such action is warranted.
1.6 In the absence of an agreed course of action the PCO will need to
consider whether there is sufficient evidence to demonstrate that the
contractor’s prescribing practice constitutes a breach of their
contractual requirement (see paragraph 1.3 above). If there has been a
breach of contract then the PCO will need to consider what action it
wishes to take against the contractor. This might involve issuing a
breach or remedial notice or invoking a contract sanction. If the
contractor does not accept that they have breached their contract or
that the PCO’s action is appropriate it can challenge the PCO action
by invoking the dispute resolution mechanism. The local medical
committee (LMC) may be involved as appropriate and must be involved
where this is a requirement of the contract.
2. Principles
2.1 NHS cash for prescribing is part of the wider resource available for
the care of patients.
2.2 Professional guidance on standards of practice states that it is the
responsibility of every prescriber to make efficient uses of the
resources available (eg General Medical Committee (GMC) Good Medical
Practice). The GMC advises doctors that they have a responsibility to
consider the impact of their actions, such as prescribing, on resources
available to other patients; it also states that doctors must not
deliberately withhold appropriate treatment. Judgement of excessive or
inappropriate prescribing by any health professional will need to
reflect the balance between these duties.
2.3 As a guiding principle it is appropriate to prescribe the most cost
effective medication for a patient. It follows that switching patients
to less expensive drugs usually within a therapeutic class is generally
appropriate where there is no contra-indication and where there is
evidence of equal or greater efficacy. This may release cash within the
system that can be invested in additional and different care for
patients. Patients should be informed of the rationale for these
changes, for example via patient information handouts.
2.4 Switching significant numbers of patients’ drugs within a
therapeutic class (eg either by changing to brand or by changing the
drug) should only be undertaken where the predicted NHS savings is
expected to be sustained and provided there is no clinical disadvantage
for the patient.
2.5 There may be occasions where switching patients may be clinically
inappropriate eg in line with the British National Formularly (BNF) or
Medicines and Healthcare Products Regulatory Agency (MHRA) guidance
certain drugs should be prescribed by brand to ensure continuity with
regard to bio-availability.
2.6 It is appropriate that doctors and health professionals have the
clinical freedom to switch individual patients to higher priced drugs
(branded or otherwise), or to alternative drugs, for clinical reasons.
3. Due Process
3.1 PCOs are recommended to demonstrate due process eg that the
development of prescribing incentive or improvement schemes are
supported by appropriate processes involving local clinicians, and that
the process of developing and implementing such schemes is
evidence-based and appropriately documented. Where practices are
expected by PCOs to change prescribing practice to improve the quality
and/or cost-effectiveness of prescribing, or to make prescribing budget
savings, PCOs are recommended that information about the rationale
behind such prescribing changes should usually be available for
patients, eg from the PCO prescribing advisory group.
3.2 Similarly, prescribers and dispensers should also demonstrate due
process eg it is reasonable and appropriate for health professionals to
exercise wise buying in the purchase of drugs from wholesalers and
manufacturers. This acts as a driver for manufacturers and suppliers to
reduce prices which in turn reduces the NHS drugs bill via the discount
claw back systems that apply to dispensing doctors and community
pharmacy.
3.3 However, other than as outlined in 3.2, substantial sponsorship or
financial deals that could reasonably be perceived to affect the choice
of treatment in a way that is financially beneficial to the prescriber
but significantly increases NHS costs, other than where there is clear
evidence of clinical benefit to patients, should be recorded in a
register of "Gifts and Hospitality".
4. Examples that may be judged
to indicate excessive prescribing
4.1 The following examples illustrate behaviours that may be judged to
indicate excessive or inappropriate prescribing, particularly where this
has been done for a significant proportion of patients and/or in a
systematic manner by health professionals or their staff:
- prescriptions
where the drug is initiated or switched, eg within a therapeutic
class/indication, with the effect that reimbursement is based on a
product that provides a larger purchase margin for the prescriber(s)
and the product(s) selected cost the NHS more, unless there is good
clinical evidence to support the switch or the exceptions noted in
paragraphs 2.5 or 2.6 apply
- prescribing
that is varied according to the impact on reimbursement to the
practice, eg differences between patients to whom the practice
directly supplies medicines (including personally administered drugs
and through NHS dispensing) and those to whom they supply
prescriptions for dispensing elsewhere, and where the prescriber(s)
is/are unable to provide a reasonable explanation
- profligate
prescribing may be considered to exist where the prescriber(s)
consistently prescribes excessive amounts of high cost products or
inappropriate, high quantities of medicines that are significantly
at variance with comparable clinical scenarios and where the
prescriber(s) is/are unable to provide a reasonable explanation
- it
may also be appropriate for a PCO to investigate a prescriber that
consistently significantly under-prescribes where there is evidence
to suggest that there is a failure to adhere to good clinical
prescribing practice.
(23/2/06) |
