Procurement and Distribution Interest Group and the National Homecare Medicines Committee Jointly presents: Medicines & Homecare Symposium Thursday the

Procurement and Distribution Interest GroupProcurement and Distribution Interest Groupand the National Homecare Medicines Committeeand the National Homecare Medicines Committee

Jointly presents: Jointly presents:

Medicines & Homecare Medicines & Homecare SymposiumSymposium

Thursday the 15Thursday the 15thth January 2009 January 2009at “The National Motorcycle Museum”, Birmingham at “The National Motorcycle Museum”, Birmingham

Allan Karr, Allan Karr, MRPharmS, DipM, MBA.MRPharmS, DipM, MBA.Chairman, National Medicines Homecare Committee Chairman, National Medicines Homecare Committee and PDIGand PDIG

What are “Medicines What are “Medicines Homecare Services” Homecare Services” and why have these and why have these services expanded?services expanded?

What are “Medicines What are “Medicines Homecare Services” Homecare Services” and why have these and why have these services expanded?services expanded?

Myths of the Homecare Myths of the Homecare Medicines Supply Medicines Supply ServiceService

““Like politics and religion……e.g. Like politics and religion……e.g. variations around UK.” variations around UK.”

““A simple process…….….just fax a A simple process…….….just fax a prescription to the homecare prescription to the homecare provider…….”provider…….”

What are “Medicines What are “Medicines Homecare Services” and Homecare Services” and why have the services why have the services expanded?expanded?

Description of the serviceDescription of the service and and benefitsbenefits

What is the market size?What is the market size?

What are the market characteristics?What are the market characteristics?

Models of Distribution Models of Distribution

Governance arrangements Governance arrangements

Outstanding issuesOutstanding issues

Aim is Aim is to :to :

Medicine Homecare Medicine Homecare ServicesServices

“Support patients with chronic and acute

illnesses in the community.”

Description of ServiceDescription of Service

Supplier perspective

Technology/ Intervention perspective

Clinical risk perspective

What is Homecare?What is Homecare?

Homecare is the provision of medical Homecare is the provision of medical supplies and/or clinical services to supplies and/or clinical services to patients in the community. patients in the community.

Clinical homecare typically involves Clinical homecare typically involves the provision of medication, medical the provision of medication, medical supplies, nursing support and clinical supplies, nursing support and clinical waste collection to patients at home. waste collection to patients at home.

Medicines Homecare – Medicines Homecare – Technical ViewTechnical View

High TechHigh Tech– Compounding and Nurse SupportCompounding and Nurse Support

TPNTPN

IV Cancer treatmentsIV Cancer treatments

Desferrioxamine InfusorsDesferrioxamine Infusors

Lyposomal storage disorderLyposomal storage disorder

Medicines Homecare – Medicines Homecare – Technical ViewTechnical View

Low TechLow Tech - - Dispensing and DeliveryDispensing and Delivery

Renal replacement therapyRenal replacement therapy

Enteral feedsEnteral feeds

Anti RetroviralsAnti Retrovirals

EPOEPO

Oral anti cancer agents Oral anti cancer agents

Increasing value added service

Delivery Process

Nurse Administration

Increasing

Risk

+

Increasing

Cost

+

Increasing

Complexity

Dispensing Process

Delivery Process

Dispensing Process

Delivery Process

Delivery Process

Dispensing Process

Nurse Administration

Preparation Aseptic

Risk Management Potential

Existing Therapeutic AreasExisting Therapeutic Areas

CardiologyCardiologyOncologyOncologyCystic fibrosisCystic fibrosisDermatology Dermatology GastroenterologyGastroenterologyHaematology Haematology Haemophilia Haemophilia HIVHIVHypopituitarismHypopituitarismLyposomal storage Lyposomal storage disordersdisordersMultiple SclerosisMultiple Sclerosis

Post-menopausal Post-menopausal Osteoporosis Osteoporosis Primary Primary Immunodeficiency Immunodeficiency Disease Disease Renal dialysis and Renal dialysis and transplanttransplantSchizophreniaSchizophreniaRespiratory diseaseRespiratory diseaseRheumatoid Rheumatoid arthritisarthritisRheumatologyRheumatologyThalassaemia Thalassaemia

Current medicinal products Current medicinal products supplied via Homecare Servicessupplied via Homecare Services

Home parental nutritionHome parental nutritionIVF TreatmentsIVF TreatmentsAdult growth hormoneAdult growth hormoneMilrinoneMilrinoneTrastuzumabTrastuzumabEpoetinEpoetinAnitbioticsAnitbioticsEtanerceptEtanerceptEfalizumamEfalizumamMethotrexateMethotrexateAdalimumabAdalimumabImigluceraseImigluceraseEpoetin Epoetin Blood coagulation factor VIII & Blood coagulation factor VIII & IXIXAnti-retroviralsAnti-retroviralsSomatropin(human growth Somatropin(human growth hormone)hormone)

DesferrioxamineDesferrioxamineInterferonInterferonBeta-interferonBeta-interferonTopotecan Topotecan TeraparatideTeraparatideIV/SC immunoglobulin IV/SC immunoglobulin Darbepoetin Darbepoetin Immunosuppressants for Immunosuppressants for renal transplant renal transplant Clozapine Clozapine TerbutalineTerbutalineAdalimumabAdalimumabInfliximabInfliximabTeraparatideTeraparatideMethotrexate Methotrexate DesferrioxamineDesferrioxamineHerceptinHerceptin

Medicines Homecare - The Medicines Homecare - The ServicesServices

Future Developments?Future Developments?

Delivery of chemotherapy

regimens

Delivery of more

biological therapies

Clinical Trials

Blood Transfusions

Homecare Service ProcessHomecare Service Process

1.1. Consider product and type of serviceConsider product and type of service

2.2. Methodology for recruiting/registering patients Methodology for recruiting/registering patients

3.3. Prescription process e.g. clinical check, chasing RxPrescription process e.g. clinical check, chasing Rx

4.4. Contract with Homecare providerContract with Homecare provider

5.5. Communication process between all parties Communication process between all parties

6.6. Medicine purchasedMedicine purchased

7.7. Delivery and preparation/administration of medicines Delivery and preparation/administration of medicines e.g. signed D/N.e.g. signed D/N.

8.8. Agree performance standardsAgree performance standards

9.9. Invoicing and PaymentInvoicing and Payment

10.10. General/Value added e.g. General/Value added e.g. Collection of waste, education and Collection of waste, education and support. Data management, Training, Clinical Governance & Auditsupport. Data management, Training, Clinical Governance & Audit

What are the benefits of What are the benefits of Medicines Homecare?Medicines Homecare?

OrganisatioOrganisationn

Discharge patients sooner Discharge patients sooner

Reduce non-essential OPD appointments & admissions Reduce non-essential OPD appointments & admissions

Moves workload from dispensary to administrationMoves workload from dispensary to administration

Reduced waiting times Reduced waiting times

Financial?Financial?

PatientPatient Increased choiceIncreased choice

Time saving - no waiting in OPDTime saving - no waiting in OPD

Reduced travelReduced travel

ConvenienceConvenience

Quality of life – less hassleQuality of life – less hassle

Less risk of HCAILess risk of HCAI

PharmacyPharmacy Capacity gainsCapacity gains

Reduces stress in the dispensaryReduces stress in the dispensary

Refocuses skill mix and clinical prioritiesRefocuses skill mix and clinical priorities

Reduced waiting times for non-home care patients. Reduced waiting times for non-home care patients.

Primary Primary carecare

PolicyPolicy

CapacityCapacity

EfficiencyEfficiency

ControlControl

Patient choice Patient choice

FinancialFinancial

Benefits/Drivers Pharma Benefits/Drivers Pharma Industry PerspectiveIndustry Perspective

Company is closer to the patientCompany is closer to the patientAbility to offer reduced prices to Ability to offer reduced prices to customers without loss of profit customers without loss of profit

(a) Increased competitive advantage(a) Increased competitive advantage (b) Increased use of high cost medicines(b) Increased use of high cost medicines

Fewer control systems? Fewer control systems? Increased opportunity for DTC Increased opportunity for DTC marketing?marketing?More control over the supply chainMore control over the supply chain


Description of the serviceDescription of the service

What is the market sizeWhat is the market size

Market characteristicsMarket characteristics




What is the size of the What is the size of the Medicines Homecare Medicines Homecare

Market ?Market ?

Difficult to assess – lack of data. Difficult to assess – lack of data. Significant growth in market Significant growth in market (products, services, purchasers (products, services, purchasers and suppliers) over last 10 years and suppliers) over last 10 years which is continuing further.which is continuing further.Approx £500 million sales Approx £500 million sales Nationally over 100,000 patientsNationally over 100,000 patientsOver 150,000 patient visitsOver 150,000 patient visits








LOCALISEDLOCALISED COMMERCIALISED COMMERCIALISED

11 Provision by community Provision by community pharmacist pharmacist

Provision by a commercial home care Provision by a commercial home care company. company.

22 Medicine prescribed by G.P.’s. Medicine prescribed by G.P.’s. Medicines often prescribed by hospitals Medicines often prescribed by hospitals only only

33 Ad hoc value added serviceAd hoc value added service Service planned and requires Service planned and requires managementmanagement

44 Patient selects service providerPatient selects service provider Organisation selects service providerOrganisation selects service provider

55 Wide range of medicines Wide range of medicines involvedinvolved

Specific medicine(s) involvedSpecific medicine(s) involved

66 Oral, low cost, less technicalOral, low cost, less technical High technology medicine with high High technology medicine with high costcost

77 Low cost service – often Low cost service – often provided free of chargeprovided free of charge

High cost service – service fee from High cost service – service fee from homecare provider homecare provider

88 No detailed legal contract No detailed legal contract requiredrequired

Legal Contract requiredLegal Contract required

99 Consumer driven marketConsumer driven market Industrial/commercially driven marketIndustrial/commercially driven market

1010 Medicine dispensed as a single Medicine dispensed as a single processprocess

Medicine could be dispensed as part of Medicine could be dispensed as part of a batcha batch

1111 Delivery tends to be the only Delivery tends to be the only additional service offered.additional service offered.

Multiple services can be offered e.g. Multiple services can be offered e.g. nurse administration, aseptic nurse administration, aseptic preparation, diagnostic testing.preparation, diagnostic testing.

Characteristics of the Homecare Characteristics of the Homecare MarketMarket

Current list of Homecare Current list of Homecare ProvidersProviders

Air productsAir products Calea UkCalea Uk CareologyCareology

Central Home Care Central Home Care (Unichem)(Unichem)

Flexible Home CareFlexible Home Care Health Care at Health Care at Home/ADSHome/ADS

Evolution (AAH/Celesio)Evolution (AAH/Celesio) IntercareIntercare Nutricia Clinical CareNutricia Clinical Care

Bupa (ex Clinovia)Bupa (ex Clinovia) PolarspeedPolarspeed Mawdsley BrooksMawdsley Brooks

WillowWillow

Movianto UK Movianto UK

(Rebrand from (Rebrand from Healthcare Logistics)Healthcare Logistics)

Lloyds Pharmacy Lloyds Pharmacy

(taken over Pharmagen)(taken over Pharmagen)

Vertically Integrated Vertically Integrated SuppliersSuppliers

Air Products

BOC

Baxters

Fresenius

Gambro

Merzpharma

Homecare Suppliers








Key Players in the Key Players in the Pharmaceutical Chess GamePharmaceutical Chess Game

Chief Pharmacist

MHRA

Dispensary managerHCC & CSCI

Procurement PCT’s

Commissioners

Home care providersHome care providers

Wholesalers

Formulary Pharmacist

Patient Services

RPSGB

Production manager

Channels of DistributionChannels of Distribution

WholesalersWholesalers

RetailersRetailers

DistributorsDistributors

InternetInternet

and now Homecare….a new channel? and now Homecare….a new channel?

Medicines Supply Medicines Supply ChainChain

Hospital pharmacy

Production unit

Production unit

R&DManufacturer

Original patent holder

Specials Manufacturer

Generic Supplier

PI Supplier

DISTRIBUTOR

WHOLESALER

&

Patient

Production

unit

Community pharmacy

Dispensing doctor

Homecare delivery service

Ward

ME

DIC

INE

S M

AN

AG

EM

EN

T

EMEA

MHRA

EMEA

MHRA

The Procurement The Procurement Framework and Contracting Framework and Contracting

ModelsModels(1) Host Trust Tender Model(1) Host Trust Tender Model

Trust selects the serviceTrust selects the serviceSpecification developed and Specification developed and tenderedtenderedTrusts selects a preferred providerTrusts selects a preferred provider

(2) Pharma Company Model(2) Pharma Company ModelPharma tender or selectionPharma tender or selectionNew distribution routeNew distribution routeNo NHS involvementNo NHS involvement

Pharmaceutical Manufacturers

Homecare Supplies

Hospitals/PCT’s/CPH’s

Tendering

Relationship? No Tendering


Homecare Supplies

Hospitals/PCT’s/CPH’s

Tendering

Relationship? No Tendering

Models of DistributionModels of Distribution

Hospitals/PCTs/CPH’s


Home CareSupplies

Role of the National medicines Homecare

Committee

What are “Medicines What are “Medicines Homecare Services” and Homecare Services” and why have the services why have the services expandedexpanded??







The Governance and Quality The Governance and Quality Issues - with outsourcing Issues - with outsourcing comes riskcomes risk

Services are Services are notnot the same as the same as products e.g.products e.g.

Absence of inventory from trust Absence of inventory from trust perspectiveperspectivePeople as part of the servicePeople as part of the serviceGreater involvement of customersGreater involvement of customersGreater difficulties in maintaining Greater difficulties in maintaining quality standardsquality standardsImportance of time factorImportance of time factor

The Clinical Governance The Clinical Governance FrameworkFramework

Establishment of quality systems and Establishment of quality systems and performance standards performance standards Risk management e.g. assessment and Risk management e.g. assessment and risk reduction techniquesrisk reduction techniquesInclusion in Trust Clinical Governance Inclusion in Trust Clinical Governance procedures procedures

The Governance and Quality The Governance and Quality Issues – Issues –

with outsourcing comes riskwith outsourcing comes risk

Prescription checking and validation Prescription checking and validation

Aseptic preparation and administration Aseptic preparation and administration Technical and clinical adviceTechnical and clinical advice

Responsibilities and liabilities of each Responsibilities and liabilities of each partyparty

Performance standards Performance standards

Error and complaint monitoringError and complaint monitoring

What guidance is there?What guidance is there? Disease Management EL(94)94Disease Management EL(94)94

Finance IssuesFinance Issues

Community PharmacyCommunity Pharmacy

Patient ConfidentialityPatient Confidentiality

Medical Ethics and Patient careMedical Ethics and Patient care

Impact on PPRSImpact on PPRS

The Governance and Quality The Governance and Quality Issues – Managing the riskIssues – Managing the risk

Robust and effective contractsRobust and effective contractsExamples of how do you ensure the Examples of how do you ensure the quality status of the provider? quality status of the provider? – MHRA licensedMHRA licensed– RPS registeredRPS registered– NHS QA auditsNHS QA audits– ISO 9000ISO 9000– Professional standardsProfessional standards

Emergence of the National

Medicines Home care Committee

and the National Clinical

Homecare Association

National Medicines National Medicines Homecare Committee – Homecare Committee –

Aims and ObjectivesAims and Objectives1.1. Development of effective service level Development of effective service level

agreements and contracts agreements and contracts 2.2. Monitor adherence to principles of EL94(94)- Monitor adherence to principles of EL94(94)-

Disease Management and effective Clinical Disease Management and effective Clinical Governance Governance

3.3. Encourage competition in the market placeEncourage competition in the market place4.4. Promote improvements to in-house pharmacy Promote improvements to in-house pharmacy

and home care supplier systemsand home care supplier systems5.5. Provide useful information and documentationProvide useful information and documentation6.6. Develop performance standardsDevelop performance standards7.7. Encourage audit, through Regional QC Encourage audit, through Regional QC

network, according to agreed home care network, according to agreed home care service standards service standards

Documents Being Developed by the Documents Being Developed by the National Medicines Homecare National Medicines Homecare

CommitteeCommittee

1.1. List of homecare suppliersList of homecare suppliers2.2. List of products and therapeutic areasList of products and therapeutic areas3.3. Definition of types of home care Definition of types of home care

serviceservice4.4. Summary of processSummary of process5.5. SWOT – posting versus deliverySWOT – posting versus delivery6.6. Policy on home care Policy on home care 7.7. VAT positionVAT position8.8. National contract – core delivery and National contract – core delivery and

dispensingdispensing9.9. Invoicing ProcessesInvoicing Processes

Documents Being Developed by the Documents Being Developed by the National Medicines Homecare National Medicines Homecare

CommitteeCommittee

Home care contract specificationsHome care contract specificationsContract Adjudication – Decision Analysis Contract Adjudication – Decision Analysis documentdocumentImplementation tasksImplementation tasksList of organisations/individuals List of organisations/individuals responsibilitiesresponsibilitiesPerformance standardsPerformance standardsAudit processAudit processHome care services reportsHome care services reports






Governance arrangementsGovernance arrangements


Outstanding Issues Outstanding Issues

NHS strategy e.g. private sector or do-NHS strategy e.g. private sector or do-it- yourself, don’t do it all. it- yourself, don’t do it all. Confirmation/clarity on VAT position Confirmation/clarity on VAT position Agreed product list for home careAgreed product list for home careEnsure adherence to principles of Ensure adherence to principles of EL94(94) and Clinical Governance.EL94(94) and Clinical Governance.Operational systems need improving Operational systems need improving e.g. employing home care co-e.g. employing home care co-ordinators, electronic links with home ordinators, electronic links with home care suppliers.care suppliers.Data management Data management

Outstanding Issues Outstanding Issues

Clarification of PCT/GP/Commissioners roleClarification of PCT/GP/Commissioners roleFit in new financial structure e.g.TariffsFit in new financial structure e.g.TariffsRelationship between home care service Relationship between home care service provider and manufacturer provider and manufacturer Managing a contracted service effectivelyManaging a contracted service effectivelyDevelopment of common contractsDevelopment of common contractsDevelopment of performance standardsDevelopment of performance standardsWhat should be the audit arrangements? What should be the audit arrangements? Unbundling of costsUnbundling of costs

Summary Medicines Summary Medicines HomecareHomecare

• Significant benefits to Significant benefits to stakeholdersstakeholders

• Significant risks – need to be Significant risks – need to be managedmanaged

• Issues to be resolved in the Issues to be resolved in the marketmarket

• Undertaken robustly and Undertaken robustly and efficiently will deliver effective and efficiently will deliver effective and efficient patient careefficient patient care

Procurement and Distribution Interest GroupProcurement and Distribution Interest Groupand the National Homecare Medicines Committeeand the National Homecare Medicines Committee

Jointly presents: Jointly presents:

Medicines & Homecare Medicines & Homecare SymposiumSymposium

Thursday the 15Thursday the 15thth January 2009 January 2009at “The National Motorcycle Museum”, Birmingham at “The National Motorcycle Museum”, Birmingham