Alcock P (Phil) This has been received from an external party and has been swept for the presence of computer viruses.

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1 Page 1 of 1 Alcock P (Phil) From: Andrew Power [Andrew.Power@gartnavel.glacomen.scot.nhs.uk] Sent: 05 September :08 To: Cc: Appliance Contractors Consultation iain.bishop@fvpc.scot.nhs.uk; lorna scahill; Audrey Thompson; mary.struthers@hpct.scot.nhs.uk Subject: Response from SPAA This has been received from an external party and has been swept for the presence of computer viruses. Dear Mr. White, Please find attached the response from the Scottish Prescribing Advisers Association (SPAA) on the Appliance Contractors Consultation. Regards Andrew Power Dr. A. Power Chairman, SPAA Greater Glasgow PCT Trust HQ 1055 Great Western Road Glasgow 612 OXH Tel: Fax: /10/2003

2 Are the objectives which SEHD is trying to achieve the right ones? Yes Are the standards of service & the type of appliance appropriate? Background Para 11 - There is therefore an incentive to 'oversupply' or recommend 'expensive' products. It seems unreasonable that there is such a large difference in remuneration for different suppliers. We would like to see 'on cost' abolished. We also fail to see why appliance contractors are not subject to the same discount claw back as community pharmacists. This calls into question why the NHS pay VAT on services and products supplied by appliance contractors? Para 13: This suggests that GPs are influenced by appliance contractors. There is no doubt this is true in view of the complicated system that this consultation is seeking to simplify. There should be a professional input into assessing the appropriateness of the product for a patient. Point 14 - Such services are also provided from most community pharmacies, although the community pharmacist might not have such an in-depth knowledge of types and range of appliances. Point 15 - 'but in return '. Appliance Contractors 'sponsor' nurses and in return most business is directed to the Contractor. As has been stated in paragraphs 7 and 8, there is significant funding available for Contractor's providing a supply service. We do not believe that sponsorship is a reasonable way of providing patient care within NHS Scotland. If there is a clear clinical need for such services, these posts should be wholly funded by the NHS. Patients n\ay not be aware they have a choice as to where they can get their appliance prescription dispensed. In most practices the request for appliance prescriptions are

3 received directly from the appliance contractor, rather than from the patient. Some patients are unaware that the system for ordering appliances is exactly the same as that for drugs. There is no incentive for contractors or 'sponsored nurses' to contain or reduce costs - indeed the opposite may apply. Direct promotion to patients, including direct mailing of samples, should be avoided at all costs. Para. 17 -If withdrawal of company-sponsored nurses would lead to NHS having to make up deficit, this is a wider NHS issue and needs to be addressed accordingly. Removal of 'sponsored nurses' may result in a decrease in dispensing costs. Objectives Para Provisioning arrangements should be initiated by impartial personnel to avoid bias. All contractors, both pharmaceutical and appliance, should be allowed a reasonable return and should expect a level playing field. A further objective should be to ensure that budgetary and clinical accountability lies with the person recommending appliances and / or providing professional care for the patient. Para 21. We would be in favour of a central monitoring service similar to that of payment verification. Para 22: The Service Standards seem reasonable. If disposal bags and wipes are deemed to be a vital part of the service they should be added to the Drug Tariff thus allowing them also to be prescribed by SPs or nurses and dispensed by community pharmacies. Some doubt was expressed that in rural areas that any supplier could guarantee home delivery within two working days. Next day delivery is only guaranteed within two days by most of the national carriers. There may be security issues for contractors providing measuring and fitting in the patient's home. Para 23: Community pharmacists providing the same level of service should be remunerated in the same fashion. They may, however, be expected to carry more stock in order to deliver this service. Para 26: Concerns have been raised by GPs about inappropriate ordering of prescription on behalf of patients by appliance contractors. Often several months supply have been

4 provided without prescription and the GP is then asked to prescribe vast quantities. The plans to streamline repeat dispensing should include this area. Where the standards are met, should payment continue to be a flat rate of on-cost or would tendering provide a more cost-effective service? Para. 27. We agree with the ethos of paying the same for a product regardless of route of supply. Para Doing nothing does not remove this exploitation for cross Border differences in remuneration. Para This point needs clarification. Does this mean that appliances can be ordered and supplied from dispensing points other than the contractors registered address? Is the registered address used as a collection point for the paper prescriptions before submission to PPD? Does this not therefore encourage the cross border exploitation? Para We would support the introduction of a global sum. It seems unreasonable to have this arrangement for community pharmacy and not appliance contractors. If the legitimate cross Border traffic in prescriptions to specialist providers is a barrier to the introduction of a global sum, remove the incentives to do this. Para 39: The central supply of continence products has been successful and has allowed input by specialist practitioners who remain employed by the local healthcare provider. It seems appropriate to consider this method of supply for appliances. Tendering has been successful in securing the following for two major areas in Glasgow; incontinence products and Nicotine Replacement Therapy patches: 1. A discount on the cost of the product. 2. additional services over the product itself. E.g. Support for novel ways of delivering smoking cessation services through community pharmacies Tendering would also make the 'appliance contractors...signifleant cash and service contributions' referred to in paragraph 15 explicit. A national tendering scheme would seem more realistic as profitability will be reduced in rural areas where travelling distances are higher. Tendering should not lead to a situation

5 where patients have to be changed to different products if the tender is awarded subsequently to a different supplier. Should there be a global sum? A global sum for appliance contractors would a sensible and equitable option.the problems of differentials with the general pharmacy global sum should not exclude this option. Should reimbursement of appliance contractors be subject to the same discount deduction as for community pharmacies? Para 28: Appliance contractors should be subject to discount clawback schemes. Should agency arrangements be banned? Para 29: The outlawing of agency arrangements is reasonable. Para 30: Agree with the method for banning agency arrangements. How cases of urgency would be defined is challenging. Option B - Tendering should be done by impartial committee. Any conflicts of interest should be declared. Para. 40 -It is probable that community pharmacists would be unable to tender for these contracts. Creating monopolies is a definite risk and limiting patient choice is also an issue. Option C - What would happen at locality boundaries, especially where there were differences in supply arrangements? If one locality area operates a "formulary" with a limited range of appliances and a neighbouring area has considerably more freedom of choice, would this not result in the complaint of postcode prescribing?

6 Option E - Community pharmacists should be offered the opportunity to extend their role, and be remunerated in exactly the same way as appliance contractors. It is anomalous that it takes longer to order an appliance via a pharmacy than via an appliance contractor given that most pharmacies have at least twice daily deliveries from at least one wholesaler. Should a telephone help-line be a service standard when operated by a company? The advantages of community pharmacy supply include medicines and appliances can be ordered together. Community pharmacists know their patients and are best placed to offer personalised service and identify any causes for concern. Option F - This may encourage a race to register patients. This would be unfair if sponsored colorectal nurses direct patients to a particular contractor. An option worth exploring may be to set up a global sum and remuneration via fees similar to the system under which community pharmacies are currently paid? Issues such as differential fees for bags and accessories could be resolved, and a system of extra fees for services over and above supply could be introduced for example for measuring and fitting, and flange cutting.