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Implications of the White Paper

Dr Phipps ponders the reforms and whether the sun is rising or setting on dispensing practices.

The recent White Paper lacked detail on the implications of proposed reforms for dispensing practices (Photograph: SPL)
The recent White Paper lacked detail on the implications of proposed reforms for dispensing practices (Photograph: SPL)

Following the release of the White Paper Liberating the NHS, we now know some of the intentions of the coalition government.

Of particular interest for dispensing practices is how the proposed reforms will help or hinder the dispensing of medicines to our patients. The White Paper lacked such detail, and there is no sign so far of realigning the promised increase in the dispensing fee following last year's reduction.

This White Paper covers England only, but it could indicate likely developments across the UK.

Effects on all GPs
Many of the implications for GPs have been summarised elsewhere, particularly the increased role of GPs in managing NHS spending through the development of consortia.

While many dispensing practices may wish to form consortia with other dispensing practices with whom they have a lot in common, there are restrictions that could prevent this.

These new GP consortia should have an accent on groupings of users of similar locality based services, and formation across old PCT boundaries should be made possible.

While the announced increase in spending in real terms on health annually is welcome, the £20 billion efficiency savings with reductions in spending on NHS management by 45 per cent could prove difficult for GPs.

Pharmaceutical services
The new consortia will control purchasing of services by GPs for their patients. Some of the work formerly undertaken by PCTs - dentistry, ophthalmic services and community pharmacies - will transfer to a separate NHS Commissioning Board however. One difficulty for dispensing practices is that it is likely to include medical dispensing, so there will be two different responsible bodies.

Closer working ties between GPs and pharmacies are envisaged by the White Paper with the development of excellence. The promotion of this may encourage those practices not undertaking the dispensing service quality scheme (DSQS) to reconsider their decision.

If excellence is to be encouraged, failure of a practice to participate in DSQS may become difficult to defend, and could lead to redistribution of a contract for provision of services.

The White Paper also seeks greater transparency in the provision of and remuneration for pharmaceutical services. As I believe we have always shown good value for money, I do not think dispensing GPs need feel threatened.

Since another stated aim is to 'strip out activities that do not have appreciable benefits for patient's health', there may be greater targeting of pharmacists' services in terms of medication use reviews (MURs). These reviews may be focused on patients with multiple medical problems or medications.

Choice of provider
With increased choice for patients and the development of 'any willing provider' contracts, there could be a significant rise in the number of patients we dispense to. Taken to its logical conclusion, patients would have a choice over where their prescriptions were dispensed, allowing our non-dispensing patients to be supplied with medication directly from our dispensing practices.

I will be responding to the White Paper consultation to suggest the DoH allows unrestricted choice for patients over where their prescriptions are dispensed.

The other proposal that has received national publicity is to allow patients to register with practices outside the locality of their permanent residence.

Although details are not yet available, I suspect the impact on dispensing practices would be negligible.

The greatest need for medicines is in the elderly and those with long-term illnesses. The groups of patients most likely to exercise their right to register away from their home are those who are mobile and commute a significant distance.

In general, it is the elderly and those with long-term illness who appreciate the personal service and expert knowledge that their GP can provide. I believe this relationship will dissuade many such from patients from registering elsewhere.

Prescribing budgets
With consortia, many commentators believe, will come even greater pressure on GPs to prescribe cost-effectively. These pressures already exist and possibly there will be a wider emphasis on cost-effective treatments that will benefit dispensing doctors.

Many dispensing practices have more limited access to secondary care due to their rural nature and take greater financial responsibility for the whole care of their patients. This can sometimes be associated with higher prescribing costs for the practice.

Currently, prescribing is closely monitored since it is the area in primary care with the most robust data. With consortia being responsible for large parts of the NHS budget, greater clarity in spending on referrals and secondary care will be necessary with greater emphasis on the total cost of patient care.

Treatment of diabetes complications is a major cost to the NHS and increased spending on newer, more expensive medications may reduce overall NHS costs while increasing prescribing costs.

Similar scenarios exist for many other disease areas.

Development of budget-holding consortia may stop criticism of practices that have high prescribing costs but lower secondary care costs, a move likely to benefit dispensing practices.

The future for dispensing still looks rosy. While the White Paper will not be a huge boost for dispensing practices, it does not contain the dangers inherent in the previous pharmacy White Paper.

  • Dr Phipps is a dispensing GP in Lincolnshire
Action plan
  • Consider signing up to the dispensing service quality scheme.
  • Ensure continuation of cost-effective prescribing.
  • Sound out local dispensing practices on forming a consortium.
  • Lobby the DoH for choice in pharmaceutical services provision - the White Paper consultation period runs to 11 October.

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