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Thursday 29 September 2016
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Dispensing debate drums up drama – is battle about to commence?

Premises & Facilities

Ailsa Colquhoun

Freelance journalist specialising in pharmacy

The recent conference of the Dispensing Doctors' Association (DDA) has been described as the "most important ever". Falling just three weeks shy of the 20 November closing date of the Department of Health (DH) consultation on, among other things, the "one-mile" rule, it has certainly been timely.(1)

The conference heard the DDA set out its alarm at the prospect of more than 5,400 sector job losses – including at practice manager level – if government plans to change the control of entry rules for dispensing practices go ahead.

Doctors, dispensing or otherwise, will also be watching with interest how any changes to the dispensing rules damage already fragile relations with pharmacy. New proposals enabling the pharmacist's absence from a pharmacy are seen by the DH as critical to enabling pharmacists to take on new clinical roles.(2)

But it is feared that delivering these services could also have the potential to remove important Quality and Outcomes Framework (QOF) information from the GP surgery. So, are the battle lines between pharmacists and GPs about to be redrawn?

Rural rumblings
Until 2005, feelings between pharmacists and dispensing doctors ran pretty high. Legal loopholes created by the 1992 pharmaceutical services regulations allowed controversial dispensing application decisions involving significant numbers of prescriptions.

Tensions between pharmacists and dispensing doctors were commonplace, and there was often disturbance and a sometimes unwelcome and forcible change to the way in which patients received pharmaceutical services. Pharmacists and dispensing doctors then entered into long and careful negotiation and, in 2005, new regulations were introduced.(3)

The NHS (Pharmaceutical Services) Regulations 2005 were based on the overriding principle of improving access to, and quality of, pharmaceutical services for patients in rural areas, while retaining the existing choice of rural patients to receive medicines from their GPs.(4) With these regulations, the one-mile rule was born.

Three years on, the feeling is still that the 2005 regulations have served both sets of professionals and their patients well, and there is little support for the changes now being outlined in the control of entry (rural dispensing) regulations consultation. The British Medical Association (BMA) backs the status quo. A spokesman said: "Reviewing how rural patients can best get their medicines is a worthwhile exercise, as it is crucial that dispensing procedures meet the evolving demands of the population.

"However, the BMA believes that current arrangements provide an efficient, well-tested process, and we will be arguing in this consultation that the principles of the current system are maintained."

The DDA, as you might expect, has come out firmly against any change. As chief executive Dr David Baker says: "We worked long and hard to get to the 2005 agreement. We now have in place a good, stable system, where patients can enjoy the services that both sets of professionals can give."

Importantly, pharmacists are also singing from this same hymn sheet, albeit, possibly, with certain caveats. Contract negotiators the Pharmaceutical Services Negotiating Committee (PSNC) recently qualified their previous support for the status quo by saying: "We need to decide what is best for community pharmacy, particularly for [those] in dispensing doctor areas. The consultation paper identifies a range of options. We need to look at the likely outcome of each of the options. We have to make judgments based on our future ambitions for
community pharmacy."

An equally guarded position statement has been issued by the Royal Pharmaceutical Society, which states that the overriding considerations in the debate must be patient access and safety. President Steve Churton believes that community pharmacy is essential to addressing these.

What is interesting, though, is that at grassroots level, there is little appetite for battle. As Tony Dean, executive officer for Norfolk Local Pharmaceutical Committee, says: "Over the past few years things have got better. We have got better at recognising each other's professional strengths. In Norfolk, we are working together and the priority is patients. When you go to war, patients suffer."

Proposed changes to rural dispensing
The consultation on proposed changes to the rural dispensing rules identifies four options:

  • Option 1. No change.
  • Option 2. The one-mile rule is removed. Instead, primary care trusts (PCTs) determine the appropriateness of GP dispensing on the basis of a Pharmaceutical Needs Assessment (PNA).
  • Option 3. Criteria for enabling GP dispensing should become the distance between the dispensing surgery and the nearest community pharmacy. Such a distance could be put at less than the current 1.6km – for example, at 500m or at 1,000m.
  • Option 4. GPs should not be allowed to dispense where there is a pharmacy within 500m or 1,000m of the GP practice and a second pharmacy within 1,500m. Those who are permitted to dispense may do so to all their registered patients, regardless of the distance between their home.

Explaining the rationale for change, the DH believes that the current regulatory arrangements are anomalous, lacking in transparency and, in some cases, actually unfair to patients. Ministers also consider that there is, perhaps, the potential for cost savings, noting the increased pharmaceutical costs of dispensing via general practice. With its hand firmly on NHS purse strings, the DH clearly wants to dismiss the argument that the funding arrangements for medical services in smaller practices should require cross-subsidy from dispensing income.

However, dispensing doctors dispute that savings are possible, and, in fact, argue that any moves to reduce doctor dispensing could actually increase costs.

Staff at the Gipping Valley Practice, in Barham, Suffolk, believe it is likely to be among those most affected by any changes to the dispensing rules. According to Dr Paul Thomas, the practice would close, making five fulltime and three part-time staff redundant.

As part of his argument for no change, Dr Thomas has given his local MP figures suggesting that pharmacy dispensing costs at least 3% more than dispensing by doctors. He also stresses the danger that, by forcing dispensing doctors to close, "money formerly employed on rural NHS services will in future serve only to benefit pharmacy corporations".

Most importantly, though, he argues that closing rural dispensing practices threatens patient care. He said: "Income from dispensing subsidises the provision of other medical services here, which includes practice nursing, blood tests and the treatment of minor injuries.

"The implications for the constituency are that it will leave the 5,000 or so local residents without any quality local NHS medical services … or forced to travel significant distances in order to obtain any form of NHS treatment. It seems very odd indeed for me to learn that a government that advocates patient choice and service quality should propose any measure that denies choice and local access to qualified medical advice and treatment."

PNAs – problems not answers?
The DDA describes options 3 or 4 as "a disaster for dispensing doctors". Yet option 2, where PCTs use PNAs to regulate dispensing applications, is also ringing alarm bells. Solicitors specialising in the control of entry regulations believe it is a recipe for chaos.

PCTs are widely felt to have had a mixed track record on service commissioning and administering the current control of entry regulations. As David Reissner, head of healthcare at specialist law firm Charles Russell, says: "In theory, all PCTs should already have a PNA. In practice, few PCTs have a PNA that is of any use."

He says that even if PCTs identify with great precision the pharmaceutical needs in every housing estate, and then express these needs clearly on paper, there are a number of difficulties with PNAs:

  • PNAs are only a snapshot of the position at the time they are written. How often will they be republished?
  • What if a PCT fails to identify a need that an applicant believes exists, or identifies a need that existing pharmacies believe is already adequately met?

Mr Reissner concludes: "The DH's proposals regarding PNAs will create problems, not answers to the flaws it perceives in the current system."

The DDA adds that a local rather than national system also creates the potential for a "postcode lottery". As DDA chairman Dr David Baker questioned: "Patients living close to PCT borders won't know whether they are entitled to GP dispensing services or not. It's a daft suggestion."

Until the government responds to the white paper consultation, it is hard to know how the land lies. But a clue, perhaps, lies in health minister Ben Bradshaw's answer to a parliamentary question on primary care access. He said: "We recognise the value in [dispensing doctors]. At the same time, we want pharmacies and pharmacists to play a greater role in the provision of primary care, and we need to address some of the distortions that have been in the market for rather too long."

Pharmacy service development
Public listening events held in the run-up to the launch of the control of entry consultation also raised interesting questions about pharmacy capacity. In the context of the control of entry consultation, delegates at these events raised concerns about the capacity of the existing pharmacy network to absorb increased volumes of dispensing if this service were to be withdrawn from GPs altogether.

However, pharmacy capacity issues also affect pharmacists' abilities to take on new roles, as outlined by Darzi in his NHS review. These include: screening for vascular disease in the over-40s and for sexually transmitted infections, minor ailment services and providing more support to people with long-term conditions – with routine check-ups and monitoring available on a drop-in basis.

Rising dispensing volumes in primary care are not a new concept, and pharmacy leaders have been wrestling for years with the question of how pharmacy can be redesigned to cope with the increasing workload.

Support staff regulation and training has already been instigated, with a view to maximising the value of the skill mix in pharmacy. New legislation enshrining in law the pharmacist's ability to delegate to trained staff activities such as medicines supply, and to be absent from the pharmacy for a limited period during the working day, has just been drafted. Independent prescribing by pharmacists is a reality.

Pharmacy should be pleased. Making better use of pharmacists' clinical skills is at the heart of the pharmacy contract, established in 2005. Getting away from the "pick, lick and stick" of dispensing is what pharmacists have said they have wanted for years.

Yet pharmacy service development raises several important questions. First, are there enough pharmacists to do the extra services?

According to employee pharmacist trade union the Pharmacists' Defence Association, there is a "fundamental assumption [at DH level] that there may be insufficient pharmacists to fully discharge clinical and supervision duties, and perhaps also to develop the role of the pharmacist in the future".

Second: do pharmacists and their staff want to take on the new roles?

As recent debate within pharmacy over the concept of the "absent pharmacist" shows, it is not at all clear whether pharmacists want to take on new roles that may make them less accessible to walk-in customers. Anecdotally, multiples and independents are said to be equally mixed in their evaluation of the opportunities.

Pharmacy technicians are most commonly mentioned in the context of taking on pharmacy supervision in the absence of the pharmacist, but representatives admit that not all technicians will want to step up to the plate.

Fiona Price, community sector employment relations officer at the Association of Pharmacy Technicians UK, says: "Not all technicians are going to want to step up to the new role. If they are, we would also argue that they will have to be remunerated accordingly."

Finally, it is not clear yet how patients and other purchasers of pharmacy services feel about the concept of new roles for pharmacists that may make them less accessible to the public – a debate that will, no doubt, be fuelled by recent Which? and Daily Mail exposures of substandard medicines supply in pharmacies.

Technological advance and support staff role development are rapidly making obsolete traditional pharmacist roles in making up medicines. Hence it is of little surprise that pharmacists are now lobbying hard to develop a genuine future role.

From the point-of-view of the DDA's Dr Baker, this is best done "within the primary care team" and, ideally, by pharmacists even based at the doctors' surgery, whether as partners or employees of medical practices.

Until that happens, it is possible that many GP practices will see pharmacy service development only as competitive. According to Steve Donlan, practice manager at The Endeavour Practice in Middlesborough, practices based in deprived areas find it challenging enough already to get patients to come to clinics, with no-shows sometimes running as high as 50%.

Mr Donlan states: "If pharmacists take a greater role in this area then at best there is a risk of duplication of effort, and at worst the chance that we won't see patients at all, and that would be frustrating."

References
1. Department of Health. Pharmacy in England: Building on strengths – delivering the future – proposals for legislative change. London: DH; 2008. Available from: http://www.dh.gov.uk/en/consultations/Liveconsultations/DH_087324
2. Public Consultation on the Responsible Pharmacist Regulations made under Section 72A of the Medicines Act 1968.
3. Pharmaceutical Services Negotiating Committee. Pharmaceutical Services in Rural Areas. Guidance for LMCs and LPCs by the GPC/DDA/PSNC. Available from: http://www.psnc.org.uk/pages/rural_issues.html
4. Department of Health. The NHS (Pharmaceutical Services) Regulations 2005: information for primary care trusts (control of entry). London: DH; 2005. Available from: http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati...