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CCG claims stopping pharmacy managed repeats saved £2m

Bedfordshire LPC say full facts of the scheme’s impact have not been published

The first clinical commissioning group (CCG) to block pharmacies from managing repeat prescriptions says the scheme has saved £2 million over two years and given patients “considerable benefits”.

Luton CCG calculated that “in broad terms” rolling out the scheme across the whole country could save “the entire NHS over £500m”, in an evaluation published in September.

A spokesperson told C+D last week (October 27) that it has already scheduled discussions with NHS England, as part of its recommendation for “a national programme of work” to maximise the savings.

Since Luton first reported successful savings from its initiative– initially of £400,000 in the four months to October 2015 – other CCGs have rushed to implement similar schemes.

Last month, a C+D investigation found almost four in 10 CCGs in England plan to stop pharmacies from ordering repeat prescriptions on behalf of patients. A similar proportion either have, or are considering, instructing patients to order repeat prescriptions directly from their GP.

These CCGs estimate their schemes will make average savings of £1.4m, C+D’s investigation found.

In its evaluation, Luton CCG concluded that its scheme had “shown that transformational change can have [a] significant impact”.

LPC not convinced

But Bedfordshire local pharmaceutical committee (LPC) chair Coll Michaels told C+D the savings “were down to many variables” the CCG had worked on, such as changing prescriptions from seven to 28 days, better GP education, and initiatives to increase the uptake of the electronic prescription service.

The reduction in managed repeats is also affecting his profits, as the number of items his pharmacy dispenses is down around 4% compared with before the scheme was introduced.

Bedfordshire LPC chief officer Gerald Zeidman told C+D: “It’s worrying that the scheme has spread without the full facts being published.”

“The report talks about cost, but not about the good practice in pharmacies and the help they provide to GP practices,” he said last week (October 26). “There’s nothing positive [in the report about pharmacies].”

“All of the pharmacies in Luton have been tarred with a similar brush. We did everything we could as an LPC to improve practices – regrettably they closed the door. The impression I have is that they had their idea and wanted to run with it.”

No benefits for pharmacies

The 45 pharmacies in the Luton area are yet to gain any benefits from the scheme, said Mr Zeidman, who added that relationships between contractors, GPs and the CCG had soured.

Luton CCG told C+D it will review the impact of the scheme on community pharmacy services, such as the new medicine service and medicines use reviews. But the CCG stood by its scheme, adding it is “confident the savings are attributable to the change in third party requests”.

“Prior to implementing these changes, there was high annual growth in spend in Luton on medicines. Following this change, benchmarking against national prescribing trends has identified Luton as an outlier with lower growth in medicines spend,” it said.

“There have been significant financial savings, and safety improvements for patients,” the CCG added.

What did the Luton evaluation find?

An audit in 18 practices in Luton between October 2013 and January 2014 found 29% of items ordered by community pharmacies were found to be “over-ordered”, which cost a “conservative estimate” of more than £2m a year.

The CCG also claims there were safety concerns with items ordered by pharmacies. However, the LPC challenges these findings.

The CCG says its “bold step” resulted in estimated savings of £2m over two years (equal to 7% of its annual primary care prescribing budget), and “evidence of considerable benefits to patients”.

Applying the Luton figures at a national level could amount to more than £500m in savings to the entire NHS, so “warrants serious consideration by NHS leadership”.

The CCG received 13 complaints and 69 queries from concerned patients – and a quarter of the 250 calls to a patient helpline were about repeat prescriptions.

Source: Repeat prescription services, final report, Luton CCG, September 2016

53 Comments
Question: 
What do you think about blocking pharmacies from managing repeats?

Dave Downham, Manager

Interestingly, I contacted Luton CCG with a couple of queries:

"You have feedback from patients and GPs – was there any from pharmacies? E.g., the page 18 on the report has “…GPs felt it improved their relationship with patients and community pharmacies” - was that view reciprocated by the community pharmacies?" Response: "We did not evaluate this. "

Also: "You refer to “…evidence of considerable benefits to patients.” – Could you please point me in the direction of where this is assessed?" Response: "Greater contact with GPs, signposted to community pharmacy services and greater IT utilisation"

Conclusive evidence...

Valentine Trodd, Community pharmacist

As with a lot of things the devil is in the detail. The terms 'auto-ordering', 'managed repeats' and 'ordering repeat prescriptions on behalf of patients' are being bandied around and used interchangeably. There is a world of difference between a computer system/careless human auto-ordering every item for a patient every month and a diligent dispenser either taking an order from a patient over the phone or carefully ordering items for a blister pack. The LPC should be digging into the details with the relevant CCG to find out what is going wrong and educating them on the different kinds of ordering done by pharmacies - not whinging that their members profits are being impacted.

David Sarabowski, Locum pharmacist

Stockport CCG has been trying to enforce a no auto repeats from pharmacy rule for about 2 years now. We have received several essentially threatening letters from the CCG and surgeries that if we auto repeat for patients then we will be banned from ordering repeats at all, despite the fact that we have only ever ordered automatically for our 40ish MDS patients. Everybody else must initiate the request by popping in or 'phoning. However, the 3 big multiples, Boots, Lloyds and Superdrug, all auto order routinely, and when doing locum work I find their staff are unaware that the practise is banned in Stockport. This has caused us to lose customers who want the service and say they can get it from Boots/Lloyds/etc. (I do not know if Well still do it). I am not commenting on the pros or cons of stopping auto ordering, but the unfairness of the independents being pressured while the big multiples crack on without interference, placing us at a clear disadvantage.

Dax Trader, Finance

In my experience when patients do their own ordering they tend to underorder due to forgetfullness and even laziness and will often go without their meds for a few days until they get round to doing something about it.  So the savings have probably come about not from cutting down on over ordering but by patients under ordering.  In my view the money 'saved' today will not be enough to pay for problems caused tomorrow by people not adhering to their medication regimen.

Anne Butler, Locum pharmacist

I hope that when the patients come in for their  medication orders from the Pharmacy, when there is no prescription, wrong items, wrong quantity etc, that they refer the patient back to the doctors, not spend hours on the phone trying to sort it out for them. A standard form of " The doctors will not let us do any ordering any more, you have to do it yourself. " Of course that will mean the surgery will have to sort out those who are housebound, don't know the name of the tablets.." you know, its the pink ones for my heart"and all the rest. Patients will suffer, I hope all pharmacies involved will make sure the patients  know the cause.

A Long Serving Pharmacist, Community pharmacist

So, when we complete an MUR and realise that the patient's medicines are all out of synch e.g. some on 28 days, some on 56 days, different items due at different times etc.etc and we instigate a repeat request to balance everything up the GP will only accept this request IF the patient orders it. How, I ask, would the patient understand how to sort this all out? Not every patient has the skill to order their own medication correctly and just 'order everything' every month in case the GP takes it off their repeat list. Medication changes mid month cause havoc and you suggest that only the patient can order their Rxs. Some patients would be at the surgery every week, or more frequently, unless they have help from the pharmacy to sort things out. I'm all for 'empowering' the patient (and incidentally taking pressure of the pharmacy staff to organise repeat orders) but a blanket ban is not the way forward.

Alchemist 1948, Locum pharmacist

A couple of years ago the then East Lancashire PCT did detailed work on this much to the chagrin of the LPC who felt this would be bias. The conclusion was that a well managed pharmacy repeat service worked well. Interestingly the analysis of the "overordering" demonstrated   that roughly 33% of the problems were caused by pharmacies, 33% by patients and (unsurprisingly) 33% by GP surgeries. So we all have to work together for NHS  benefit.  

Jupo Patel, Production & Technical

Contractors still pretending it's about 'patient safety' when real concern is not being able to wring the most money from the NHS.

David Holdsworth, Community pharmacist

Surely the NIC is the same for a drug prescribed 4x7 day Rx or 1x28 day Rx.As fees come from global sum how does 28 day Rx save CCG money?

 

 

 

 

 

Bal Singh, Locum pharmacist

Dispensing fee. (4) vs. (1)

Farm Assistant, Community pharmacist

Let's be honest, everyone knows managed repeats are a racket as otherwise why would the multiples be so keen on them. I remember an area manager who used to ask how many patients we had helped today with an mur (nothing to do with the money of course). Until pharmacy faces a few home truths there is no hope for its future......oh hang on a minute there is no hope for it anyway.

Farmer Cyst, Community pharmacist

When I first heard about this plan I thought it was doomed to failure, and couldn't understand why other CCGs were so quick to take the idea on board. As a locum I had worked across a number of different contractors, and would have said that the issue of Pharmacists overordering was 'not a problem' and in fact, it was one of the better free services we provided - the stress and hassle of dealing with patients and their ordering habits was something Pharmacists soaked up for the NHS.

So I went in expecting inconsequential savings. However this was not the case. Leads me to believe that a significant number of contractors ARE overordering, or that the level of scrutiny that is not being applied to patient requests is far greater than was being done in the pharmacy. Whether this is due to the conflict of interest in not ordering items resulting in lower item counts, or because the CCG staff had a computer with the record in front of them (a luxury I've never seen in community) we as a profession can't deny that a CCG has made a substantial saving by taking this off us.

It reinforces the attitude that we can't be trusted as a profession.

Shaun Steren, Pharmaceutical Adviser

A perfect summation in my opinion

Shaun Steren, Pharmaceutical Adviser

So the trial 'report' doesn't elucidate the mechanism by which the savings are being made. However, savings are savings and if this can be reproduced in other areas then it can supported on the basis of 'if it works - it works'

Meanwhile the response of the community pharmacy is one of conspiracy theories and complaints about loss of profit. The latter can at least be respected for its honesty. The former being a product of those who cannot be honest about the latter. 

Dilip Shah, Community pharmacist

Interesting evaluation but it seems that suggested over ordering is one side of the point of view. It should be noted that when repeats are managed well issues regarding non compliance etc does not happen and saves NHS  monies long term.I would like to see data on non compliance and by patients when thay order and no one is present to check and remind them especial the elderly as GP surgeries will not be able to carry out this function.From experience I can see more elderly and vunerable being admitted to hospitals on the long run.I personally favour patients managing their repeats as it saves a lot of management and staff time so that we can concentrate on quality work.

 

 

 

 

 

 

 

Nat Mitchell, Community pharmacist

It's more the insinuation that I'm doing anything dangerous that I'm offended by. This report is very prejudiced. 

Anyone ever received a script for two different calcium channel blockers? Lisinopril and Candesartan? New strength of furosemide without cancelling the old strength?  I have many, many times. What did I do? I solved the problem rather than using the incidents as proof that repeat prescribing is dangerous. 

Valentine Trodd, Community pharmacist

If they're saving this kind of money, it should be rolled out IMMEDIATELY to every CCG in the land.

Dave Downham, Manager

Key word is "if".

Valentine Trodd, Community pharmacist

True. But what have the CCG got to gain by making it up? I'm sure the surgeries won't be very happy when they hear they have to deal with all the ordering - they'd probably just as soon go along with the status quo. Incidentally, my local CCG has come up with a hare-brained scheme based around eRD, where you cajole the GP into signing patients up on Pharmaoutcomes, get a years worth of repeats (not including PRNs), quiz the patient everytime he needs a PRN, enter it all on Pharmaoutcomes and get paid one pound something for every PRN dispensed. I don't think they're having much luck with it, as I can't even get GPs in my area to respond to calls about urgent medication queries!

Olukunmi Popoola, Community pharmacist

We have just been informed by the surgery next to us that we cant order repeats for our patients anymore. I will let you know the full effects after 3 months

How High?, Community pharmacist

Fantastic news!!

Let's hope every CCG rolls this out, then we can concentrate on patients, services and being pharmacists instead of trying to hit yet another pointless corporate KPI. It was just a way of trapping repeat business anyway, which decent teams and great pharmacists can get through great customer service. It's not like the scripts are actually going to disappear is it?

 

John Dow, Advertising

Yes Indeed fantastic.

 It seems from the use of certain terminology( KPI, great customer service ) that you work for Boots. I can fully understand anyone wanting to abandon this with the crap they load on their staff and I hope it completely disappears.

What's Your-Agenda?, Pharmacy

Agreed.  We're the only pharmacy in the area NOT offering managed repeats and from the publicly available Rx volume data we're growing at 3 times the national average and the surrounding pharmacies have falling script volumes (one increasing below average).

I've only knowingly encountered one patient who left us.  He was adamant I should know when his script was due and have it ready (despite his multiple PRN items).  However, I've lost count of the number of new patients who have come to us because they're fed up with getting extra items or the managed repeat system at their old pharmacy failing miserably. 

Manged repeats, as much as I hate it, made some logical business sense before EPS to lock in customers.  With most patient's nominations being locked in, those screaming for managed repeats for anyone but patients with difficulties, are just asking to do more work for nothing...unless they ARE getting something extra out of it...

A Hussain, Senior Management

From the report:

Repeat prescription ordering services can be defined as a service to patients that has been agreed primarily between the community pharmacy and an individual patient where the community pharmacy is empowered by the patient to order and collect their repeat prescription. 

Sounds like managed repeats to me.

86% of items were ordered by community pharmacies on behalf of patients, patients ordered 11% of items and 3% were ordered by carers 

Does anybody else find this stat unbelievable? How would they know if the patient or a pharmacy had ticked the order sheet?

This report seems to have had its results already decided.

A Hussain, Senior Management

So 'massive changes to prescribing habits reduces wastage' should have been the  story here.

I'm still waiting to find out just how handing a slip into a pharmacy (acting responsibly) ends up wasting more money than if it is handed into a surgery.  Stop managed repeats by all means, but banning us from handing in requests is draconian.

 

 

Oliver Carter, Locum pharmacist

The evaluation of this initiative bases the estimated savings on a set of assumptions that need closer scrutiny.  For example, the reduction in items prescribed might not be those at which a £8 AIC is valid (e.g. 7 day to 28 day switches).  There also needs to be consideration of the reduction in prescribing for items and the effect of such on adherence and ultimately upon the longer term health of the population and the consumption of health resources subsequent to this.  The assessment of patient experience also needs to be explored further through PPGs in more detail, rather than looking primarily at PALS complaints as a proxy for patient experience.

S Pessina, Pharmacist Director

Olive, you are making it too complicated.   The multiples have been winning every time and indoctrinating everyone as to how good this is. Well it ain't and its hard work and its a gravy train.

max falconer, Superintendent Pharmacist

I think the CCGs are confusing 2 completely different processes. 

Auto ordering whereby the PMR system determines when a repeat should automatically be requested from the surgery is one thing, ordering on behalf of a request initiated by the patient is a completely different thing.

The former in my view can easily lead to abuse by pharmacies and is potentially highly wasteful. Our local CCG conducted an audit and generally it was the large multiples ordering items patients didn't want and generally the independents were behaving more responsibly.

The latter service of ordering as requested by patients, on each occasion, is essential and highly beneficial to pharmacies, patients and GP practices. 

Do CCGs really want every request for repeat meds to go via their offices rather than pharmacies doing most of the donkey work for them? I suspect not, but that's what they could easily end up with. I estimate in our area pharmacies are dealing with 60-70% of all repeat requests saving huge amounts of time at practices.

Gerry Diamond, Primary care pharmacist

electronic repeat dispensing should only be chosen when you have had a full review with the patient, and other options such as online ordering, bringinig or posting in their repeat slip have been explored. That is, you have established their regular repeat meds, if they use regular inhaler and are compliant then it can be on eps RD too, such as a regular preventer or insulin pens are discussed with the patient. I intend to make a point with local pharmacies that they will implement asking the appropriate questions to the patient. The danger is that is a free for all, and such pharmacists should be struck off and jailed for fraud.

John Urwin, Community pharmacist

"electronic repeat dispensing should only be chosen when you have had a full review with the patient, and other options such as online ordering, bringinig or posting in their repeat slip have been explored."

Rubbish. This implies that eRD is somehow inferior to online ordering etc.. eRD can make the repeat process easy for patient while reducing workload for GP and surgery staff.

If the patient has been cleared to receive several months worth of repeats under the old system prior to review, what possible justification is there for requiring an extra review before starting eRD. There is no "loss of GP control" with eRD, if anything it can be greater. The notion that GPs carefully scrutinise each and every script they sign is fanciful.

I would feel insulted if a practice pharmacist reminded me to ask the appropriate questions. That is part of the service specification. Yes, I agree, fraudulent practice should be punished.

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