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“Promoting the interests of Dispensing Doctors and the excellence of doctor dispensing for the benefit of patients”. Dr David Baker. Chief executive DDA since 2002 Former Dispensing GP in Bassingham Jobbing locum (very occasionally) A bit of occupational health. WARNING.

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    1. “Promoting the interests of Dispensing Doctors and the excellence of doctor dispensing for the benefit of patients” Devon LMC 12/09/2008

    2. Dr David Baker • Chief executive DDA since 2002 • Former Dispensing GP in Bassingham • Jobbing locum (very occasionally) • A bit of occupational health. Devon LMC 12/09/2008

    3. WARNING This presentation is not the DDA definitive response. Our response will be developed in the light of information from members, listening events and other meetings prior to the closing date of 20th November. Use the slides to help you formulate your own response to the consultation – widespread copying and pasting will not be helpful; individually crafted responses will be much more effective. Devon LMC 12/09/2008

    4. Consultation Questions DDA View • Do you agree the current market entry system should be changed to one based on pharmaceutical needs assessments (PNAs)? • What safeguards may be appropriate to ensure transparent, fair and unbiased consideration of applications? Devon LMC 12/09/2008 NoBecause PCTs are not yet sufficiently experienced to carry out this duty without significant risk of legal action. Pharmaceutical needs should not be equated with the provision of a pharmacist. A set of national minimum standards. Patient choice should be paramount.

    5. Questions • Do you agree that specific additional factors, as identified in this Chapter, should also be introduced to help PCTs determine applications? • Should decisions be appealable and, if so, to whom? Devon LMC 12/09/2008 DDA View: • Patient choice should be paramount in all cases. There will be problems as different PCTs will make different decisions in identical cases, further adding to the postcode lottery in health service provision • Yes, appeals should be made to the NHS Litigation Authority

    6. Questions • If introduced, do you agree such an approach should be piloted and evaluated before introduction? DDA View:Yes, to allow new models to develop e.g. internet pharmacy and to facilitate joint working. -Results of any pilot should include patients’ views, must be published and be the main driver for change. • Do you agree exceptions to this new system may be necessary and, if so, what might these exceptions be? DDA View: Technological developments may necessitate further exemptions, introduced after further consultation Devon LMC 12/09/2008

    7. Quality • Proposed new PCT powers to: Take action against contractors for inadequate quality of service • Proposed regulatory standards on Premises Qualifications of staff Training programmes Minimum service delivery standards Devon LMC 12/09/2008

    8. Chapter 3 100 Hour pharmacies Supplementary lists • Proposes changes to the current arrangements for pharmacies opening at least 100 hours per week. • Proposes ‘supplementary lists’ for individual pharmacists and discusses compliance with the Safeguarding Vulnerable Groups Act 2006 Devon LMC 12/09/2008

    9. The options (100 hour) • A distance restriction on new 100 hours per week pharmacies of 1.6 km or 2 km.(DH preferred option – with option 4) • Impose a requirement to justify the need • Allow the exemption to continue but use Local Pharmaceutical Services (LPS) contract terms. • Strengthen the requirements for specific services a 100 hours per week pharmacy provides.(used either alone or in conjunction with the other options) Devon LMC 12/09/2008

    10. Government view At the time of publication, the Government’s preferred approach was to combine the first and fourth options Devon LMC 12/09/2008

    11. DDA View • 100 hour pharmacies – Option 4 onlyIllogical to have a distance criterion. E.g. either side of a river • Supplementary lists - We agreeThis proposal brings pharmacists into line with GPs and their performers’ lists. Devon LMC 12/09/2008

    12. Chapter 5: Appliance Contractors Discusses market entry proposals for dispensing appliance contractors and a system for appliance contractors comparable to pharmacists’ supplementary lists. DDA view: We have no difficulty with this proposal Devon LMC 12/09/2008

    13. The options – appliance contractors • Replace the existing regulatory structure with a national scheme where applications are made to a central registering body • Introduce a new exemption to the current market entry arrangements using the existing regulatory structure. (Preferred Option) • Remove market entry arrangements for appliance contractors and adopt an ‘any willing provider’ approach. • A lead PCT or aregional NHS body to handle applications on behalf of all PCTs in their area using the existing regulatory test. Devon LMC 12/09/2008

    14. Chapter 6 - other legislative reforms Necessary and “expedient ” (?already changed) Permitting inducements that encourage “healthy living” e.g. item of fruit or exercise DVD-DDA View: We feel that no inducement of any kind should be offered. E.g.. Loyalty points No inducement to be offered to other NHS providers No hidden arrangements between pharmacies and other providers Minor changes to LPS Devon LMC 12/09/2008

    15. Chapter 4Dispensing by Doctors Devon LMC 12/09/2008 AZ

    16. What is the perceived problem? The sustainability of some primary medical services (care from a GP). Some dispensing doctors have expressed concern that without their dispensing income they would be unable to maintain full medical services. The Department does not consider that funding arrangements for medical services are such as to usually require a further cross-subsidy from dispensing income. Devon LMC 12/09/2008

    17. The problem as seen by PWP Current regulatory arrangements can lead to anomalies Costs: Dispensing doctors more expensive. Devon LMC 12/09/2008

    18. Feedback from the national listening events Serious concern about changing the current arrangements, as patients liked the convenience offered by the GP dispensing service, which also offered opportunities to strengthen GP/patient relationships and continuity of care. Concern about the capacity of the existing pharmacy network to absorb increased volumes of dispensing if this service were to be withdrawn from GPs altogether An equitable system should apply to both GPs and pharmacists There were benefits in making better use of all available health professional skills to develop and extend service provision – through, for example, pharmacists working with GPs in practices. Devon LMC 12/09/2008

    19. Options on dispensing doctors • No change. • PCTs to determine the rural localities where GP dispensing is appropriate on the basis of their PNA.(1.6Km rule goes, controlled locality stays) • Change distance criterion to:The distance between the dispensing surgery and the nearest community pharmacy. (Such a distance could be put at less than the current 1.6 km, for example, at 500 m or at 1000 m.) • A variation of Option 3. It would mean that a GP would not dispense where there is a pharmacy within 500 m or 1000 m of the GP practice and a second pharmacy within 1500 m. Devon LMC 12/09/2008

    20. Department View • It is important to stress that the Department has no preferred option at this stage nor has it come to a view as to whether any reform of these particular arrangements is necessary. However, the Department considers there are a number of related implications to be considered as part of this consultation for: • the treatment of branch surgeries; • maintaining services; and • how any move to new arrangements, if a decision were taken on any particular option for reform, might be achieved. Devon LMC 12/09/2008

    21. Questions for consultation The Department has identified four possible options to reform the current arrangements regarding dispensing by doctors. Is the Department right in believing that there are inequities and anomalies within the current procedures under which patients can obtain their medicines and appliances directly from their surgery rather than from a community pharmacist? Have you any personal experience of any such inequities and anomalies? If so, please briefly set them out. Do you believe that having a local choice between two or more local dispensers when having a prescription dispensed is important to you? Could you quantify how important this is for you on a scale of 1-5 where 1 is exceptionally important and 5 is of no importance? Is it right for the Department to publish a national set of rules setting out when a doctor can provide dispensing services or should the local NHS, for example your PCT, consulting with others, have more say? Devon LMC 12/09/2008

    22. “Doctors prescribe and Pharmacists dispense” DDA View: This mantra is outdated and, if taken at face value, negates most of the premise on which the White Paper is based. When pharmacists prescribe will they need a doctor on hand to check their diagnosis and a second pharmacist to dispense the prescription? Of course not! Both professions, properly trained, can and do perform both tasks safely. Devon LMC 12/09/2008

    23. Is the Department right in believing that there are inequities and anomalies within the current procedures under which patients can obtain their medicines and appliances directly from their surgery rather than from a community pharmacist? DDA view: Yes, but removing the option most patients prefer, cannot be the right way forward.The question incorrectly assumes dispensing patients currently have no choice, which they do. It is non-dispensing patients who have no choice, and this is the underlying anomaly Devon LMC 12/09/2008

    24. Have you any personal experience of any such inequities and anomalies? If so, please briefly set them out. DDA View: The majority of all patients (dispensing and non-dispensing) asked would like to have the choice of getting their medicines dispensed at their surgery. Devon LMC 12/09/2008

    25. Do you believe that having a local choice between two or more local dispensers when having a prescription dispensed is important to you? Could you quantify how important this is for you on a scale of 1-5 where 1 is exceptionally important and 5 is of no importance? DDA View: Genuine choice that includes doctor dispensing is to be welcomed Artificial limitation of choice is to be deplored Devon LMC 12/09/2008

    26. Is it right for the Department to publish a national set of rules setting out when a doctor can provide dispensing services or should the local NHS, for example your PCT, consulting with others, have more say? DDA view: National rules should allow patients free choice as to where and by whom their prescriptions are dispensed. Local NHS should have a say, but only if they reflect patients wishes. Devon LMC 12/09/2008

    27. Questions for consultation Do you agree that the four options set out in this consultation document relating to dispensing by GPs are appropriate options for consideration? Are there others that should be considered? If you have a preference between Options 1-4, please indicate which is your preferred option and why. If there were to be change, what issues do you believe the Department should take into account when implementing any new system? Are there other factors to take into account – for example, how well do these options or your preferred option link to the proposals below for a common regulatory route for all applications? Devon LMC 12/09/2008

    28. Do you agree that the four options set out in this consultation document relating to dispensing by GPs are appropriate options for consideration? Are there others that should be considered? A further possible option would be to consider the benefits of pharmacist placement (not necessarily a pharmacy) in every surgery – making the pharmacist part of the primary health care team. The ‘any willing provider’ option could be given consideration. Devon LMC 12/09/2008

    29. If you have a preference between Options 1-4, please indicate which is your preferred option and why. DDA view: Option 1 is the only acceptable way forward Devon LMC 12/09/2008

    30. If there were to be change, what issues do you believe the Department should take into account when implementing any new system? DDA View: • Patients’ views and choices should be paramount • Regard must be taken of the long term effect on medical and pharmaceutical services • Joint working between pharmacists and doctors must be encouraged [destabilisation of current services and loss of professional co-operation if any other choice but option 1] • Compensation for loss of business and redundancies must be made available. • [Refer to the practice survey on job losses] • Rural aspects of GMS funding will need revisiting to ensure maintenance of patient services • There will be a disproportionate effect on older and disabled patients Devon LMC 12/09/2008

    31. Numbers affected 1135 Practices 5335 Doctors 5000+ Dispensary staff 3.51M Dispensing patients 8.9M Patients of dispensing doctors Devon LMC 12/09/2008

    32. Numbers affected 1135 Practices 5335 Doctors 5000+ Dispensary staff 3.51M Dispensing patients 8.9M Patients of dispensing doctors Devon LMC 12/09/2008

    33. Actual results (120 practices, rounded up WTE) 469 Dispensers 12 Reception Staff 18 Nurses 40 Doctors 12 Managers 39 Support Staff Estimated for England (1135 practices) 4436 Dispensers 114 Reception Staff 170 Nurses 376 Doctors 109 Managers 369 Support Staff Staff at risk of redundancySurvey results Devon LMC 12/09/2008

    34. Are there other factors to take into account – for example, how well do these options or your preferred option link to the proposals below for a common regulatory route for all applications? DDA View: As there are so few new applications for doctor dispensing and the current regulations preclude many more, it seems unnecessarily complicated to change to current application process. Option one allows incremental change to take place and maintains stability in rural health provision Devon LMC 12/09/2008

    35. A common regulatory route for all applications Do you agree: • the proposal to align the regulatory route for dispensing doctor applications with those of pharmacies and appliance contractors? • dispensing by doctors should, as now, apply to those patients who live in designated rural areas? • the approval of doctors’ dispensing premises should continue? • the ‘serious difficulty’ rule should be retained to enable a PCT to authorise dispensing for any patient who has serious difficulty getting to a pharmacy? Are there other factors which need to be taken into consideration? Devon LMC 12/09/2008 AZ

    36. Question the proposal to align the regulatory route for dispensing doctor applications with those of pharmacies and appliance contractors? dispensing by doctors should, as now, apply to those patients who live in designated rural areas? the approval of doctors’ dispensing premises should continue? DDA view Agreed as fair As a general rule, yes. Yes A common regulatory route for all applications:Do you agree: Devon LMC 12/09/2008

    37. Question the ‘serious difficulty’ rule should be retained to enable a PCT to authorise dispensing for any patient who has serious difficulty getting to a pharmacy? Are there other factors which need to be taken into consideration? DDA View Yes, it is essential that the procedure is there, although patients rarely need it Patient choice must be paramount. A common regulatory route for all applications:Do you agree: Devon LMC 12/09/2008

    38. The sale of over the counter medicines by dispensing doctors As an initial step, the MHRA plans to conduct an informal review and consultation with industry and external stakeholders starting in the autumn of 2008 to seek input on potential areas for reform. Devon LMC 12/09/2008

    39. Questions Do you believe that it would be beneficial for patients and consumers if dispensing doctors were able to sell general sale list (GSL) medicines to their patients where there is no convenient alternative? Do you believe that it would be beneficial for patients and consumers if dispensing doctors were able to sell pharmacy (P) medicines to their patients where there is no convenient alternative? How might the term ‘convenient alternative’ best be defined? For example, should a distance limit of, say 500 m, be set, or should this be left to local determination? If dispensing doctors were to sell P medicines, do you agree there should be safety provisions regarding such supply - for example, similar or equivalent to those that govern the sale and supply of P medicines through pharmacies? Are there any risks not identified here in permitting a dispensing practice to make a profit from selling medicines to their patients? Devon LMC 12/09/2008 AZ

    40. Chapter 7 Chapter 7 sets out the questions arising from these proposals on which the Department welcomes views. Devon LMC 12/09/2008 AZ

    41. Do you believe that it would be beneficial for patients and consumers if dispensing doctors were able to sell general sale list (GSL) medicines to their patients where there is no convenient alternative? DDA View: Permitting dispensing practices to supply any GSL products to their patients rather than being limited, as at present, to supplying products blacklisted by the NHS is a logical change but it will in fact be a very small market. Devon LMC 12/09/2008

    42. Do you believe that it would be beneficial for patients and consumers if dispensing doctors were able to sell pharmacy (P) medicines to their patients where there is no convenient alternative? DDA View: The sale of (P) medicines only benefits patients if: They would otherwise pay a prescription charge, and the drugs cost less than that charge NOTE: Dispensing doctors can only supply medicines to their patients, not ,as in a pharmacy, to members of the public – we do not see a need for that to change Devon LMC 12/09/2008

    43. How might the term ‘convenient alternative’ best be defined? For example, should a distance limit of, say 500 m, be set, or should this be left to local determination? DDA View: Any fixed distance criterion will create confusion as far as GSL is concerned. How can one justify a garage next door to a pharmacy selling GSL but not the surgery on the other side? (P) Medicines are different; we suggest the right might be restricted to dispensing surgery premises which are themselves situated in a controlled locality. Devon LMC 12/09/2008

    44. If dispensing doctors were to sell P medicines, do you agree there should be safety provisions regarding such supply - for example, similar or equivalent to those that govern the sale and supply of P medicines through pharmacies? DDA View: Yes, when medicines are provided otherwise than by prescription or NHS supply, the safety provisions should be equivalent to those governing the sale or supply through pharmacies Devon LMC 12/09/2008

    45. Are there any risks not identified here in permitting a dispensing practice to make a profit from selling medicines to their patients? DDA View: Dispensing doctors will in fact make far less “profit” from the sale of P or GSL items than they would if they were to provide them through the usual NHS route. Thus we see no risk. Devon LMC 12/09/2008

    46. The Department welcomes comments on the impact on small businesses How serious is the problem the proposals seek to address in relation to smaller firms? What changes will smaller firms have to make to the way their business operates? Is there likely to be a greater impact on the operations and performance of smaller business than others? What are the likely approximate costs and benefits of the proposals for small business? Devon LMC 12/09/2008 AZ

    47. How serious is the problem the proposals seek to address in relation to smaller firms? Nearly all dispensing practices would be classed as small businesses. The effect of Options 3 or 4 (and possibly 2) would be devastating. 5000+ redundancies are predicted. Reduction in patient services is inevitable Devon LMC 12/09/2008

    48. The consultation,its associated Impact Assessments and other documents accompanying the consultation are available at: http://www.dh.gov.uk/en/Consultations/Liveconsultations/DH_087324 Devon LMC 12/09/2008

    49. What should I do? Respond to the consultation using the proforma at:http://www.dh.gov.uk/en/Consultations/Liveconsultations/DH_087321Email the completed form to: PWPCONS@dh.gsi.gov.uk Copy your response to your MP with a personal covering letter explaining how it will affect his constituents Ask your patients to respond to DH and copy to MP Devon LMC 12/09/2008

    50. Responses - reprise Responses should be sent no later than Thursday 20th November 2008 to: PWPCONS@dh.gsi.gov.uk. Alternatively, copies can be sent by post to: Gillian Farnfield Department of Health Medicines Pharmacy and Industry Group Area 453D, Skipton House 80 London Road London SE1 6LH Devon LMC 12/09/2008