In Analysis

Follow this topic

Bookmark

Record learning outcomes

Are specials in danger of being viewed as expensive luxury items and not what they really are – essential medicines?

In 2014, money is tight. Individuals, families, businesses and institutions are all looking for ways to cut costs in the hope that, over time, the books will balance. The NHS is no different and one area that has come under scrutiny in recent years is specials.

Accounting for around 1 per cent of prescription costs in the UK, some number crunchers have suggested that specials are an expensive luxury. Pressure has been put on prescribers to steer away from these unlicensed medicines that have to be manufactured in small quantities on demand and alternatives, such as emptying capsules or crushing tablets, have been suggested. To pharmacists, such ideas are ludicrous. The work of specials manufacturers is appreciated for what it is – necessary and desirable.

The finance gurus might view specials as an unnecessary expense but there is little doubt that the cost to the NHS would be much higher if the patients who need these unlicensed medicines didn’t receive them. Without specials, many patients would end up needing hospital care, some for prolonged periods.

Using a series of case studies, a white paper published by the Association of Pharmaceutical Specials Manufacturers (APSM) explores the importance of maintaining safe manufacturing practice in order to prepare essential and effective medicines for the patients who need them and ultimately provide value for the NHS.

“We wanted to put a document out about the importance of the specials industry because of the many misconceptions that exist,” says APSM’s David Clough. “Specials manufacturers make medicines to a very high quality that keep patients out of hospital, help them get better and therefore reduce the cost to the NHS. The paper aims to attribute an economic value to this.

“What seems to be getting lost is that specials manufacturers can make medicines to the same or similar pharmaceutical standards that apply to other companies that make licensed medicinal products, yet there is huge downward pressure on the cost of unlicensed medicines. We believe that APSM members should be seen as providing value for money for and to the NHS – not just expensive medicines,” says Clough, who is sales and marketing director at Eaststone Specials.

The full APSM document can be viewed at www.apsm-uk.com.

The Specials Tariff

A determination to control the costs associated with specials led in 2011 to the introduction of a dedicated section of the Drug Tariff in England and Wales. “An alternative mechanism was needed to price these lines because specials, by their very nature, are procured on a named patient basis, which is different to conventional licensed products,” says Komal George, head of dispensing and supply at PSNC.

“The aim was to increase transparency and link reimbursement to the actual cost of specials, not only to provide value for money for the NHS but also to make sure pharmacists were sufficiently incentivised when sourcing specials.”

In the three years that the specials tariff has been in place, it has grown from 58 lines to over 250 thanks to a regular update cycle conducted by the Department of Health with input from specials manufacturers. “PSNC looks out for specials tariff products unavailable at the set price,” says George. “So far, there haven’t been any problems as contactors have become familiar with the reimbursement of these products.”

The effectiveness of the specials tariff is clear from the most basic data analysis, says David Francis, sales and marketing director at IPS Specials. “The market is reasonably stable in terms of prescription numbers – it is not really going up or down – but the value of the market has decreased because the Department of Health is getting to grips with it.”

The tariff has also helped to make pricing clearer in pharmacy, he adds. “Pharmacists now understand that a special isn’t just a high price solution, it’s a sensibly priced solution for a patient who needs a personalised medicine.”

In Northern Ireland there is no specials tariff and reimbursement remains based on the price of the product as endorsed by the dispensing contractor, but a similar arrangement to England and Wales has been in place in Scotland since February 2013. “There is a different mechanism and structure as to what products go in and the price that is charged,” explains Brian Fisher, group commercial director at the Quantum Pharmaceutical Group.

“In England, if a product is not in the tariff, the contractor is reimbursed the price they paid. If the same situation occurs in Scotland, the contractor has to have the reimbursement price authorised by their health board prior to submitting the prescription for payment.” While this means that all specials are controlled in Scotland, the tariffs used both north and south of the border have been effective in providing “structure, robustness and consistency”, he says.

One side-effect of the establishment of the specials tariffs has been the removal of price as a factor for pharmacists looking for a specials supplier, suggests Fisher. Instead, contractors can concentrate on looking for a credible supplier who has a good reputation and provides a good service.

David Francis of IPS agrees, adding: “Next day delivery is important as this is something the pharmacist can pass onto their patients. Ordering options also come into play, particularly for repeat orders, when using a supplier that keeps detailed records can be an advantage.”

Too tight a squeeze?

When something is working, there can be a temptation to do more to make it quicker, better or – as is often the case these days – cheaper, but David Clough is concerned that continued efforts to cut the cost of specials could be detrimental. “If pricing is squeezed further, businesses, contractors, prescribers and providers could start to compromise on quality. The impact on patient safety could be large and lead to the cost to the NHS going up.”

An APSM survey of 200 GPs conducted last year discovered that more than half had been asked to reduce their prescribing of specials, he says. “There seems to be a trend towards prescribing standard formulations with instructions to crush tablets or split capsules. This is happening despite there being a system in place to avoid people with no expertise crushing tablets because it can be dangerous and put patients in hospital. It shows how there is too much pressure on the cost of specials from on high and not enough emphasis on patient safety.”

Quantum’s Brian Fisher sums up both sides of the debate most succinctly. “Every participant in the healthcare sector should be mindful of the need to get value for money given the economic pressures that the whole country, and particularly the NHS, is under. But the products supplied by specials companies are essential, they make people better, keep them well and keep them out of hospital.” It really is that simple.

Dementia Medicines Adherence programme

The Quantum Pharmaceutical Group is joining forces with the South West Yorkshire Partnership NHS Foundation Trust and Rowlands Pharmacy to evaluate the Biodose Connect medicines delivery system. A tailored education programme has been devised to help people with dementia to independently adhere to their treatment regimen and to understand more about their medication.

The evaluation will be undertaken by Professor Stephen Curran, consultant in old age psychiatry and Richard Clibbens, nurse consultant, from the South West Yorkshire Partnership NHS Foundation Trust in Wakefield. Rowlands Pharmacy will provide an integrated Biodose Connect dispensing service with individual tailored reviews, pharmacist advice and interventions to support patients and their carers participating in the evaluation.

Biodose Connect enables live, remote monitoring and management of patient adherence, making it possible to quickly identify potential lapses in drug treatment regimens and deploy the appropriate intervention promptly.

“Poor medicines adherence for people experiencing dementia can lead to a range of difficulties. Patients can accidentally overdose, miss doses or discontinue treatment without any consultation with their GP, all of which can be highly detrimental to their health and well-being and costly to the NHS and social care budgets,” explains Professor Curran. “In a community setting Biodose Connect could significantly reduce these issues of poor adherence, preventing unnecessary, distressing and costly hospital admissions by providing better and safer outcomes for patients.” It is hoped that the study will start in January 2015 with an initial recruitment of 60 patients.