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
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
What is the market sizeWhat is the market size
Market characteristicsMarket characteristics
Models of Distribution Models of Distribution
Governance arrangements Governance arrangements
Outstanding issuesOutstanding issues
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
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
What is the market sizeWhat is the market size
Market characteristicsMarket characteristics
Models of Distribution Models of Distribution
Governance arrangements Governance arrangements
Outstanding issuesOutstanding issues
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
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
What is the market sizeWhat is the market size
Market characteristicsMarket characteristics
Models of Distribution Models of Distribution
Governance arrangements Governance arrangements
Outstanding issuesOutstanding issues
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
Pharmaceutical Manufacturers
Homecare Supplies
Hospitals/PCT’s/CPH’s
Tendering
Relationship? No Tendering
Models of DistributionModels of Distribution
Hospitals/PCTs/CPH’s
Pharmaceutical Manufacturers
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??
Description of the serviceDescription of the service
What is the market sizeWhat is the market size
Market characteristicsMarket characteristics
Models of DistributionModels of Distribution
Governance arrangements Governance arrangements
Outstanding issuesOutstanding issues
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
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
What is the market sizeWhat is the market size
Market characteristicsMarket characteristics
Models of DistributionModels of Distribution
Governance arrangementsGovernance arrangements
Outstanding issuesOutstanding issues
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