Transcript Homecare - Guild of Healthcare Pharmacists

PROCUREMENT &
DISTRIBUTION INTEREST
GROUP
Autumn Symposium 2007
http://www.pdig.org.uk/
Medicines Homecare
Andrew Alldred
Director of Pharmacy and Medicines Management
Harrogate District NHS Foundation Trust
Chair Yorkshire and Humber NHS Pharmaceutical
Purchasing Consortia
PDIG November 2007 Symposia
Introduction - Brief
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When should we use homecare for
medicines
What are the key issues
How can the market be developed
safely
What is Homecare?
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Homecare is the provision of medical
supplies and/or clinical services to
patients in the community.
Clinical homecare typically involves the
provision of medication, medical
supplies, nursing support and clinical
waste collection to patients at home.
Medicines Homecare in the
UK – Size of the Market ?
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Difficult to assess
Significant growth over last 10 years
Healthcare at Home (2006)
– £347million sales
– 75,000 patient visits
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Nationally
– over 100,000 patients
– ~ value of £500 million for medicines
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Yorkshire and Humber
– Conservative estimate £40 - £50 million
What does Medicines
Homecare involve?
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Aim to support patients with chronic and
acute illnesses in the community.
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Compounding of a Medicinal Product
Supply and product monitoring
Administration
Collection of waste
Patient and Family education and support.
Data management and support
What are the drivers for
medicines homecare?
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Policy
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– Treating patients closer
to home
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Patients
– Choice
– Convenience
– Quality of Life
Pharma Industry
– Novel distribution route
– Clinical service provision
NHS Constraints
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Capacity
Waiting times
Bed occupancy
Admission rates
LOS
Financial
– Infrastructure
– Product costs
– (PbR)
VAT and Medicines
Homecare
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Medicines dispensed to individuals for their personal use,
dispensed by a registered pharmacist against a prescription
issued by a registered doctor (or nurse for administration) in
their own home (or residential home) are zero-rated.
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Pharmacy dispensing services provided by a registered
pharmacist are exempt from VAT
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Delivery services are subject to VAT at the standard rate
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Where two or more of the above elements form part of a composite
supply, the predominant element will determine the VAT liability of
the whole.
NHS Policy and Structural
Reform
Pharmacy Policy and
Structural Reform
Medicines Homecare in the
UK – The Services
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Low Tech
– Dispensing and Delivery
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Renal replacement therapy
Enteral feeds
Anti Retrovirals
Transplant drugs
EPO
Isotretinoin
Anti TNF agents
Oral anti cancer agents eg imatinib
Medicines Homecare in the
UK – The Services
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High Tech
– Compounding and Nurse Support
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TPN
IV antibiotics in CF
Desferral
Iloprost
IV and SC Immunoglobulins
Growth Hormone
Infertility drugs
Subcutaneous methotrexate
Medicines Homecare in the
UK – The Services
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Future Developments
– Delivery of chemotherapy regimens
– Delivery of biological therapies
– IV antibiotics for cellulitis
– Management of PE and DVT
– Blood Transfusions
– Clinical Trials
Medicines Homecare in the
UK – The Providers
What are the benefits of
Medicines Homecare
Organisation Patient
Discharge patients
sooner
 Reduce nonessential admissions
 Reduce
readmissions
 Single point of
contact
 Capacity gains
 Reduced waiting
times
 Financial
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Patient
centred
 Closer to
home
 Choice
 Time saving
 Reduced travel
 Convenience
 Quality of life
 Less risk of
HCAI
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Pharmacy
Capacity gains
 Refocus skill mix
and clinical priorities
 Reduced waiting
times
 Patient focused
care
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Primary
care
Time
 Capacity
 Efficiency
 Control
 Patient
centred
 Financial
 Policy
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The Procurement Framework
and Contracting Models
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Host Trust Tender
– Trust selects the service
– Specification developed and tendered
– Trusts selects a preferred provider
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Pharma Company
– Pharma tender or selection
– New distribution route
– No NHS involvement
The Genzyme Case
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Genzyme vs. Healthcare at Home (2003)
– OFT upheld HCAH complaint that Genzyme infringed UK
Competition act
– Complex case around bundling of drug price with the
homecare services delivery and applying a margin squeeze
on competing firms
– Genzyme in a monopoly situation with Cerezyme (90% of
Gauchers disease market)
– Would only sell Cerezyme at the bundled price and
adjudged to thus be anti competitive
– More likely that companies will offer a drug at an
unbundled product price
The Governance and Quality Issues
- with outsourcing comes risk
– Clinical and Technical
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Responsibilities and
liabilities of each party
Prescription validation
Ongoing Monitoring
Product Quality
(especially unlicensed
medicines including
specials)
Quality of advice
Training of staff
Quality systems
Error monitoring
Performance standards
Transport and delivery
– Financial
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Product and service
costs
Tendering
Compliance with SFI’s
and SO’s
Invoice matching
Order generation
Data management and
reporting
The Governance and Quality Issues
- with outsourcing comes risk
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Robust Contracts
Provider Quality status
– MHRA licensed
– RPS registered
– NHS QA audits
– ISO 9000
– Professional standards
Best Practice in setting up
Homecare
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Maintain control
Pharmacy led approach
Tender when appropriate
Understand the risks and
manage them
Ensure appropriate
resources
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Define key processes under
SLA / contract
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service description
Training
Patient registration
Prescription process
Delivery of medicines
Communication chains
Performance standards
Procurement
Invoicing and payments
Audit
Liability / legal issues
Homecare – Example
Process
Patient reviewed
by clinician
Patient signs
delivery note
Invoice and
delivery note
to pharmacy
Patient registered
/ Consented
Patient Choice
Medicine / service
delivered to patient
Order
generated
Prescription
written
Prescription
prepared
by Homecare
provider
Invoice
matched
with
delivery note
Prescription
validated
Rx sent
to Homecare
provider
Passed
for Payment
Other issues to be
resolved / managed
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Transparency
– Unbundling of costs
– Cost of services and
products
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Data
– Quality
– Provision
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Quality
– Services
– Audit
– Performance standards
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The workforce
– Training
– NHS “Drain”
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Control
– Keep it!
Summary
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Medicines Homecare
– Significant benefits to stakeholders
– Significant risks
– Issues to be resolved in the market
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Undertaken robustly will deliver
effective and efficient patient care
Useful resources
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National Clinical Homecare Association
– www.nchamedical.co.uk
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National Homecare Medicines
Committee
– Homecare medicines eLibrary/documents
– http://www.pasa.nhs.uk