White Paper - Executive Summary

In July 2007, the Minister of State for Public Health, the Rt Hon Dawn Primarolo, MP announced that the Department of Health would publish a pharmacy White Paper.

Pharmacy in England: Building on strengths - delivering the future was accordingly published on 3 April 2008. It builds on A Vision for Pharmacy in the new NHS launched in July 2003 and Our health, our care, our say: a new direction for community services published in January 2006.

The White Paper set out the Government’s programme for a 21stcentury pharmaceutical service and identified practical, achievable ways in which pharmacists and their teams can contribute to improving patient care through delivering personalised pharmaceutical services in the coming years. A series of consultation events were held in May to consider the proposals in more detail and a summary report of those is now available at http://www.dh.gov.uk/en/Publicationsandstatistics/index.htm

The White Paper was developed to align closely with the NHS Next Stage Review led by Lord Darzi and the development of a new primary and community care strategy. High Quality Care for All - the NHS Next Stage Review final report - was published on 30 June 2008 and Our Vision for primary and community care was published on 3 July 2008.

The White Paper also provided the Government’s response to the Review of NHS pharmaceutical contractual arrangements commissioned in 2007 and conducted by Anne Galbraith. Her report was published alongside the White Paper. In addition, the White Paper took account of recommendations of the All Party Pharmacy Group’ report, The Future of Pharmacy published in June 2007.

The pharmacy White Paper stated at paragraphs 1.7 and 1.8: ‘As part of the development work to align pharmacy with the primary and community care strategy, the Government intends to publish, for consultation later in 2008, fuller information on a number of proposals for structural change. That consultation will comprise both actions to be taken in the medium term – including any necessary revisions to primary legislation – and actions to reform the current regulatory system pending those revisions’.

This consultation fulfils that commitment. In compliance with the Cabinet Office Code of Practice on Consultation, it discusses a number of changes and levers which the Department believes are needed to transform delivery and to align pharmaceutical services within the wider reform programme. Where a change in legislation is indicated, this will apply in England.

Content

• Chapter 1 provides background information about pharmacy as part of the vision for delivering High Quality Care for All and Our vision for primary and community care.
• Chapter 2 proposes changes to the current NHS market entry system called ‘control of entry’ to one based on PCTs’ assessments of local needs to commission services which promotes choice and competition in the delivery of clinical care and ensures high standards, quality and good patient outcomes for the investment made. It also sets out proposals to enable PCTs to take effective action on quality grounds where contractors are not achieving acceptable performance standards.
• Chapter 3 proposes changes to the current arrangements for pharmacies opening at least 100 hours per week. It also proposes introducing ‘supplementary lists’ for individual pharmacists and discusses compliance with the Safeguarding Vulnerable Groups Act 2006.
• Chapter 4 sets out proposals for possible reform of arrangements where doctors provide dispensing services, mainly in rural areas, together with a single regulatory entry system for pharmacies and dispensing doctors
• Chapter 5 discusses market entry proposals for dispensing appliance contractors and a system for appliance contractors comparable to pharmacists’ supplementary lists.
• Chapter 6 presents proposals for reforming the NHS (Pharmaceutical Services) Regulations 2005 and current legislation relating to Local Pharmaceutical Services.
• Chapter 7 sets out the questions arising from these proposals on which the Department welcomes views.

A list of those organisations being consulted is at Annex A. Background information to the current market entry and contractual arrangements for community pharmaceutical services is at Annex B.

Partial impact assessments are published alongside this consultation document and can be found at http://www.dh.gov.uk/en/Consultations/index.htm together with an Equality Impact Assessment.

A template for consultation responses is also included and published separately at http://www.dh.gov.uk/en/Consultations/index.htm.

Chapter 4: Dispensing by Doctors (Page 33) - Questions for consultation...

The Department has identified four options on which they are seeking views.

1. Option 1 is no change. This has the advantage of maintaining the status quo, does not remove services from patients and does not put any jobs at risk. It does not, however, address the financial issues or the inequities within the current system identified earlier and in particular, whether GP dispensing can be justified when there is a pharmacy in close proximity.
2. Option 2 is that whilst continuing with current arrangements where GP dispensing applies in controlled localities, the existing specific distance criteria would be removed. This would allow PCTs to determine the rural localities where GP dispensing is appropriate on the basis of their PNA. This option could address the current anomalies of a rigid national scheme and empowers local communities to make decisions appropriate to their needs. It aligns with the longer-term strategic direction for commissioning and pharmaceutical services generally, based on PNAs.
3. Option 3 would mean that, instead of the distance between the patient’s home and the pharmacy, the determining factor should be a 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. This removes the anomaly of a doctor dispensing to some of his/her patients where there is a community pharmacist in close proximity and also removes the question of a practice having dispensing and non-dispensing patients. Such a `cliff edge’ effect is less pronounced than under the current arrangements although there may still be such cut-offs where there are nearby practice boundaries.
4. Option 4 is 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. Those who are permitted to dispense may do so to all their registered patients regardless of the distance between their home and the surgery or pharmacy. This option maintains an element of choice for patients when having their drugs dispensed and has a less pronounced effect on GP dispensing.

(P36) The Department has identified four possible options to reform the current arrangements regarding dispensing by doctors.

1. 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?
2. Have you any personal experience of any such inequities and anomalies? If so, please briefly set them out.
3. 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?
4. 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?

• 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?

(P39) The Department proposes to amend the 2005 Regulations (and associated primary medical legislation) to introduce a single regulatory route to authorise dispensing by doctors for patients in rural areas. 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?

(P42) The Department proposes to allow, where there is no convenient alternative, dispensing doctors to supply over the counter medicines to all of their patients, subject to the MHRA’s review and forthcoming informal consultation on the current medicines legislation.

• 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

Documentation and Links

The main DH White Paper Consultation was released on the 27 Aug 08
DH Source

The original paperwork DH - White Paper - Pharmacy in England: building on strengths - delivering the future was released back on 3 Apr '08
DH Source

DH - Press Release - Millions to benefit from improved access to treatment , check-ups and health advice from pharmacists White Paper Outlines Bigger Role for Pharmacists in Treating Sickness and Promoting Good Health 3 April '08
DH Source

BMA

Pharmacy White Paper Response Toolkit for LMCs

Useful Information for Patients

Options Regarding GP Dispensing Proposed by the Department of Health in its Consulation Document

Pharmacy White Paper - Response Form

Presentations from Devon LMC

Devon LMC - Event briefing paper

Presentation by Dr Russell Walshaw, GPC lead for Rural Practice and Dispensing

Presentation by Dr David Baker, Chief Executive DDA

LMC Commentary by Dr Barry Moyse

This document has this to be said for it: it is clearly written and unambiguous in its intent. The great majority of the White Paper deals with a vision of the future of pharmacies as part of the wider provision of health care, advice, preventative measures and screening in line with government thinking as originally expressed in the Wanless Report. The underlying principles are that there is a demographic "time bomb ticking" with an ageing, more obese, alcohol-abusing fit population incubating chronic diseases which the NHS will not be able to tackle using its present traditional structures and systems. Therefore every effort must be made to encourage wider and more accessible opportunities for members of the public to engage with aspects of their own health before disease becomes apparent. Various examples of pilot schemes are given in the by now time honoured text boxes within the paper. Many seem to have resulted in large proportions of those taking part having been referred to their GP for further assessment.

There are also assessments of current programmes, such as pharmacist medication use reviews which are thought not to have delivered uniform value for money, repeat dispensing and electronic transmission of prescriptions from practices to pharmacists. Uptake of both of these is judged to have been disappointing so far especially, the author points out, considering how much general practitioners complain about the time taken to generate and sign repeat prescriptions.

The largest area of contention however is undoubtedly the small section (eight out of 77 paragraphs) in Chapter Eight "Structural enablers and levers" concerning dispensing doctors which, if implemented will have major implications for the provision of general medical services in rural areas of Somerset where a third of the 76 practices dispense to at least some of their patients. It will also have wider implications for rural communities who are losing amenities including post offices, schools, shops and public houses. A report from Oxford University this month found that 45 per cent of the neighbourhoods in England - 14,493 out of 32,439 are more "geographically deprived" than in 2004.

The relevant section (8.67) begins by saying that PCTs are currently not capable of full commissioning and so a control of entry regime will continue for pharmacies and dispensing doctors. The government believes that there are two concerns about dispensing consent for doctors. The first arises because of the condition that it is where the patient resides that determines whether a patient is able to receive "convenient dispensing services" from their GP. The White Paper sensibly acknowledges for the first time that this leads to inequity where patients living on opposite sides of the same street are treated differently and also that the "one mile" (inevitably these days "1.6km") takes no account of how far patients might actually have to travel to collect their medicines. The second concern is "the proximity of dispensing practices to community pharmacies. Some people who receive dispensing services from their GP surgery walk past a community pharmacy...especially in market towns." A "logical solution" is offered to take the form of new control of entry rules for dispensing practices - a single condition relating to the distance from the surgery to the nearest pharmacy instead of where the patient resides. If this rule were satisfied then the surgery could dispense to all the patients on its list and a dispensing practice would also be allowed to sell over-the-counter medicines in order to improve the availability of these products in areas without a convenient local pharmacy.

At first reading it is possible to conclude that this new regulation might be for new applications but section 8.72 makes it clear that this is not the case. "Transitional rules would be required and these would need to consider the financial impact on the GP practice of losing the right to dispense as well as the impact on pharmacy provision. Practices meeting the new criteria could find they dispense to more patients but...those who do not...will have to accept that they will need to wind down their dispensing role." We are reminded that provision for the removal of consent to dispense all ready exist, for example when a pharmacy opens in the vicinity of some a dispensing surgery's patients and these "could provide a model for such a phased approach."

This crucial section concludes by saying that the government recognises that although the present market entry arrangements are the "inconsistent" it recognises that they are the result of previous agreements between representatives of pharmacists and doctors. Therefore it states that "any changes...should be part of a wider consultation on elements of the control of entry itself..." It is also hoped that such a consultation will result in a "streamlining" so that in future consent to dispense is sought under a single regulatory route.

This consultation exercise will be held in the summer of this year and there is a "listening event" in Bristol on May 8th where Somerset LMC and dispensing practices will be represented. It is vital that the impact of these plans on provision of medical services in rural areas of Somerset is widely advertised. The government will undoubtedly point out that dispensing doctors in larger practices are amongst the highest earners in the profession and seek to traduce their position as one of naked self-interest. However, with the government's expressed intention to removed the minimum practice income guarantee it seems that all practices - and remember the high proportion of Somerset practices that dispense - will be seeing considerable reduction of income to provide services over the next few years. The tragedy is that the current administration is unlikely to be moved by predictions of "traditional general practices" becoming financially unviable as this will simply serve to advance their plans to increase the proportion of services purchased from the alternative providers and delivered by employees rather than independent contractors. Therefore the wider implications for all ready beleaguered rural communities must be the main thrust of our arguments and forums wider than internal NHS "consultations" must be engaged at once.

LMC Newsletter Article from September 2008

PHARMACY IN ENGLAND: BUILDING ON STRENGTHS – DELIVERING THE FUTURE
A WHITE PAPER APRIL 2008 – A THREAT TO ONE IN THREE PRACTICES IN SOMERSET.

The consultation period on this document has now opened and the LMC urges all practices to look at the Pharmacy White Paper and to submit comments. It may have grave consequences for up to a third of all practices in Somerset. The greatest part deals with a vision of the future of pharmacies as part of the wider provision of health care, advice, preventative measures and screening in line with government thinking as originally expressed in the Wanless Report. There are also assessments of current programmes, such as pharmacist medication use reviews which are not thought to have delivered value for money, repeat dispensing and electronic transmission of prescriptions from practices to pharmacists.

The largest area of contention is the small section (eight out of 77 paragraphs) in Chapter Eight “Structural enablers and levers” concerning dispensing doctors which, if implemented will have major impact for the provision of general medical services in rural areas of Somerset where a third of the 76 practices dispense to at least some of their patients.

The government has two concerns. The first is that, because of the “one mile rule,” it is where the patient lives that determines whether he can receive “convenient dispensing services” from his GP. The White Paper acknowledges for the first time that this leads to inequity where patients living on opposite sides of the same street are treated differently and also that this rule takes no account of how far patients might actually have to travel to collect their medicines.

The second is about the proximity of dispensing practices to community pharmacies. “Some people who receive dispensing services from their GP surgery walk past a community pharmacy...especially in market towns.” A “logical solution” is new control of entry rules for dispensing practices – a single condition relating to the distance from the surgery to the nearest pharmacy instead of where the patient resides. If this rule were satisfied then the surgery could dispense to all the patients on its list and a dispensing practice would also be allowed to sell over-the-counter medicines in order to improve the availability of these products in areas without a convenient local pharmacy. It might appear that this might be only for new applications but it is not. “Transitional rules would be required … to consider the financial impact on the GP practice of losing the right to dispense as well as the impact on pharmacy provision. Practices meeting the new criteria could find they dispense to more patients but...those who do not...will have to accept that they will need to wind down their dispensing role.”

The LMC believes it is vital that the potential impact of these plans on rural areas of Somerset is acknowledged and resisted. The national LMC conference this year unanimously backed a call that all practices be able to dispense to their patients if they chose to, thus providing the opportunity to “level up” services to patients as well as allowing real competition in this field which might even be really made into the proverbial “level playing” one. Dispensing practices in Somerset rely on dispensing income to employ staff and not just in the Dispensary. Reduced practice income will have grave implications for rural communities who are rapidly losing amenities including post offices, schools, shops and pubs. The general practice and certainly the branch surgery, could be next.