Andrew Platten MSc, MRPharmS, DipM, MCIM, Head of Consultancy at HealthGain Solutions
Introduction The pace of change within the NHS has shown no sign of abating during 2003 with new contracts of employment agreed with hospital consultants and GPs and negotiations underway on a new pharmacy contract. The pharmaceutical industry has not escaped the winds of change either with the Pharmaceutical Price Regulation Scheme (PPRS) due for renewal in April 2004 initial discussions are being held on its successor and proposed changes to the reimbursement of generic medicines have also been consulted on.
January January finally saw the publication of the much delayed Delivery Strategy for the Diabetes National Service Framework and, unlike earlier NSFs, it gave flexibility for local NHS organisations to set their own targets within a national framework. The key elements proposed in the Delivery Strategy are that Primary Care Trusts (PCTs) should consider:
• setting up a local diabetes network, or similarly robust mechanism, which involves identifying local leaders and appointing and resourcing network managers, clinical champions and a person(s) with diabetes to champion the views of local people
• reviewing the local baseline assessment, establishing and promulgating local implementation arrangements with a trajectory to reach the standards
• participating in comparative local and national audit
• undertaking a local workforce skills profile of staff involved in the care of people with diabetes and developing education and training programmes with the local Workforce Development Confederation
January also saw many pharmacists sit up and take note as the Office of Fair Trading issued its report on community pharmacy and recommended a liberalisation of the market to enable more pharmacists to obtain NHS contracts. This drew support from many of the large multiple pharmacy chains who would be in a position to take advantage of this new arrangement but the majority of independent pharmacies were opposed to the changes as they feared it would force them to close and thus reduce patient choice. The government acknowledged the report and said that it would issue a response later in the year.
February February saw the announcement from the British Medical Association and the NHS Confederation that after 18 months of negotiation an agreement had been reached on the new GMS contract for GPs. Unfortunately when GPs studied the small print many of them realised that they would be worse off financially under the new contract and thus it was not voted in.
The Department of Health also issued guidance on supplementary prescribing for nurses and pharmacists this month and this will undoubtedly have a long term impact on the pharmaceutical industry. The NHS aims to have 10,000 nurses and 1,000 pharmacists trained as Supplementary Prescribers by the end of 2004 with this the historical precedent of the GP or Hospital Consultant holding all of the power when making prescribing decisions will cease. Marketers and sales teams will need to develop new skills and materials to enable them to engage and influence these new prescribers.
March March ended with the publication of the final Performance Indicator Set for PCTs for 2003/4 and these provide some opportunities for the pharmaceutical industry to work in partnership with PCTs and help them achieve some of their targets. The indicators that are of particular interest to the pharmaceutical industry include:
• Prescribing of atypical antipsychotics
• Death rates from circulatory diseases, aged under 75
(change in rate)
• Death rates from cancer, aged under 75 (change in rate)
• Teenage Pregnancy: Conceptions below age 18 (change in rate)
• Diabetes services baseline assessment
• CHD Audit
• Prescribing rates of antibacterial drugs
• Prescribing rates for drugs acting on benzodiazepine receptors
• Generic prescribing
A full breakdown of the performance indicator set is available from the Commission for Health Improvement website at www.chi.org.uk
April
Details of a potentially new important customer group appeared in April as the Department of Health published ‘Liberating the Talents – Implementing a scheme for Nurses with Special Interests in Primary Care’. The document describes examples of many nurses with special interests including:
• Colorectal Nurse Specialist
• Sexual Health Development Nurse
• Heart Failure Nurse
• Epilepsy Specialist Nurse
• Clinical Nurse Specialist, Pain Management
In the foreword to the document Dr David Colin-Thome, National Director for Primary Care, noted that ‘the work of GPs with special interests has been widely adopted as a way to maximise the wealth of skills and knowledge in the primary care medical workforce.’ He went on to state that ‘doctors are only part of the team’ and ‘the successful development of any practitioner in a specialist role will depend on their effective integration within the team. PCTs should ensure that the expansion of primary care services takes a whole system approach, maximising the potential of all primary care staff to take on new roles and recognising their interdependency.’
May
In May, 29 hospitals were invited to form the first wave of applications to become Foundation Trusts. In order to be eligible to apply for foundation status the NHS trusts must:
• Hold a ‘three star’ rating in the annual NHS performance ratings and maintain this throughout the application process
• Prove that they have strong leadership and a commitment to modernising services for the benefit of patients and local communities
• Have the support of staff and other local stakeholders for their vision for reform
The successful applicants will become Foundation Trusts from April 2004 and full details on this new type of hospital can be found at www.doh.gov.uk/nhsfoundationtrusts. The rules governing foundation trusts allow members of the local community to become ‘members’ of the trust and have a say in the direction and planning of the hospitals services. Foundation Trusts are free to set their own terms and condition of employment as well as raise additional capital, within a pre-determined limit, from any source to develop the services they offer. It is possible in the future that Foundation Trusts could form partnerships with the pharmaceutical industry to enhance the development of services in defined clinical areas where they have a mutual interest. June June 12th saw the departure of Alan Milburn from the cabinet to ‘spend more time with his family’ and the subsequent appointment of Dr John Reid as the Secretary of State for Health. Although bringing with him a reputation as a hard negotiator one of the first things Dr Reid did was to re-open discussions with hospital consultants on their new contract and break the deadlock that had existed since Alan Milburn had tried to impose the contract after it had been voted out. June also saw movement on contract negotiations with another group of doctors, GPs, with the new GMS contract being voted in on 20th June with nearly 80% of those GPs who voted agreeing to the contract. The new GMS contract now means that PCTs will contract with the GP practice and not individual GPs as before and it is focused on three key elements:
The successful applicants will become Foundation Trusts from April 2004 and full details on this new type of hospital can be found at www.doh.gov.uk/nhsfoundationtrusts. The rules governing foundation trusts allow members of the local community to become ‘members’ of the trust and have a say in the direction and planning of the hospitals services. Foundation Trusts are free to set their own terms and condition of employment as well as raise additional capital, within a pre-determined limit, from any source to develop the services they offer. It is possible in the future that Foundation Trusts could form partnerships with the pharmaceutical industry to enhance the development of services in defined clinical areas where they have a mutual interest.
June June 12th saw the departure of Alan Milburn from the cabinet to ‘spend more time with his family’ and the subsequent appointment of Dr John Reid as the Secretary of State for Health. Although bringing with him a reputation as a hard negotiator one of the first things Dr Reid did was to re-open discussions with hospital consultants on their new contract and break the deadlock that had existed since Alan Milburn had tried to impose the contract after it had been voted out.
June also saw movement on contract negotiations with another group of doctors, GPs, with the new GMS contract being voted in on 20th June with nearly 80% of those GPs who voted agreeing to the contract. The new GMS contract now means that PCTs will contract with the GP practice and not individual GPs as before and it is focused on three key elements:
• Essential services – these are the ‘must do’ services which are defined as ‘Management of patients who are ill or believe themselves to be ill … for the duration of that condition, and … patients that are terminally ill
• Enhanced services – these are additional voluntary services that GPs can provide in agreement with the PCT. They are split into national enhanced services e.g. services to the homeless which have a nationally agreed set of criteria and local enhanced services which enable PCTs to set local criteria based on the needs of their population and negotiate locally with GPs on the terms and conditions for delivery.
• Quality payments – Annex A of the new GMS contract lists a set of standards for improving the quality of services in key areas e.g. CHD, diabetes. Each disease area has a set of points that can be achieved and for each point achieved the GP practice will receive a payment of £75 in 2003/4 rising to £105 in 2004/5. There are a possible 1050 points to be achieved and it is likely that this element of the contract could account for between 30-50% of a GPs total remuneration.
The new GMS contract provides a myriad of opportunities for the pharmaceutical industry to help GPs achieve increases in their income whilst also showing the positive health outcomes of their products in the disease areas linked to the quality payments.
July On July 17th the government issued it’s response to the OFT Report on the de-regulation of community pharmacy services. Whilst accepting that the OFT had made a strong case that the current control of entry rules impeded competition the government stated that a complete de-regulation of the existing system was not viable at the moment. Instead a compromise arrangement was made with those pharmacies that met the following criteria being given exemption from the existing regulations:
August August 29th heralded yet more pharmacy focused NHS policy with the publication of a consultation paper entitled ‘Proposals to reform and modernise the NHS (Pharmaceutical Services) Regulations 1992’ which invited formal feedback on the proposals outlined in ‘A Vision for Pharmacy in the New NHS’.
September September saw the publication of two discussion/consultation papers that will impact the pharmaceutical industry in 2004 and beyond.
1. The Pharmaceutical Price Regulation Scheme – A Discussion Paper. This document invited views from the NHS, the pharmaceutical industry and other interested bodies on the possible structure of the agreement to replace the PPRS in April 2004. Views were sought on the following suggestions by the end of October:
• Rolling forward the 1999 PPRS agreement without change
• Amending certain parts of the current agreement through negotiation
• The potential for complete deregulation
• Any alternate proposals
At the time of writing it is unclear how these discussions will develop but whatever the outcome it will have an impact on the future promotion of pharmaceuticals and thus the role of the medical representative.
2. Arrangements for the Future Supply and Reimbursement of Generic Medicines for the NHS. This consultation document sought views on the UK generics market and once the final arrangements have been agreed they will replace the current ‘Maximum Price Scheme’ for generic medicines that has been in place since 2001. Any future system will have to be based on the following principles:
• Maintain and improve the current quality of service to patients
• Reimburse community pharmacists , overall, as closely as possible to what they actually pay for the medicines they dispense under the NHS
• Have transparent prices
• Support a competitive pharmaceutical market
• Secure value for money for the NHS
• Ensure arrangements for the future reflect the current supply chain and future developments
The outcome of these discussions will have a big impact on many community pharmacists who currently secure a proportion of their income from successfully negotiating generic prices below those in the drug tariff. It will be important to ensure that these pharmacies are fairly remunerated under any new pharmacy contract and able to maintain a viable level of income from alternative sources.
September also saw the publication of ‘Choice, responsiveness and equity in the NHS and social care’ which was a national consultation paper aimed at identifying the best way of ensuring patients and carers views are heard within the NHS. The consultation ran until the middle of November and it’s findings will have a major impact on how PCTs and other NHS organisations plan services in the future.
October The new consultant contract was agreed on October 20th with 60.7% voting in favour. It has secured the services of consultants for the NHS for a minimum of 40 hours per week before any private work is undertaken and in return the consultants gained concessions on evening and weekend work and the starting salary for a new consultant has risen from £54,000 to over £65,000.
Conclusion 2003 has been a very busy yeaAugust August 29th heralded yet more pharmacy focused NHS policy with the publication of a consultation paper entitled ‘Proposals to reform and modernise the NHS (Pharmaceutical Services) Regulations 1992’ which invited formal feedback on the proposals outlined in ‘A Vision for Pharmacy in the New NHS’.
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