June 2020 CPN

CPN

Community Pharmacy News – June 2020

Review into pharmacy representation

Findings and recommendations to improve the efficiency of PSNC and LPCs are published

Pharmacy Advice Audit | NHS Test and Trace launches | Special containers factsheet

PSNC’S WORK

FUNDING AND STATISTICS

CONTRACT AND IT

Chief Executive’s blog PSNC Chief Executive Simon Dukes describes how his team are starting to look towards important negotiations for the autumn and winter of 2020/21.

Simon Dukes

PSNC Chief Executive As business and social restrictions are gradually lifted, many of us are starting to pick-up things we had been working on before the pandemic. NHSE&I and DHSC is no different, and in previous blogs I have mentioned our work with them on what they call ‘restoration and recovery.’ PSNC and the community pharmacy sector are also no exceptions to this. This month has seen the delayed publication of Professor David Wright’s independent review; the launch of our pharmacy advice audit – which we began talking about much earlier this year – and now that some of the immediate COVID19-related negotiations have passed, we are embarking on important wider funding work and negotiations.

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We will be fighting for pharmacies to remain central to vaccination efforts

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Our immediate priority is to negotiate a COVID-19 funding settlement for 2020/21.

This needs to include a write-off or full reconciliation of the total of £370m advance payments that HM Government has made to contractors. We also want to see all contractors’ costs related to the pandemic covered. As soon as we hear back from HM Treasury and DHSC on 2 Community Pharmacy News – June 2020

our funding bid – which we expect to do soon – we will be able to take forward the negotiations. Our ambitions, as ever, are to gain as much financial support and security for contractors as we can. This has been a tortuous process thus far, and we can expect protracted negotiations over the summer as HM Government tries to argue that the words of the Secretary of State for Health at the start of the pandemic promising that it would ‘do whatever it takes … do all that we can’ to get through coronavirus do not apply to us.

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I hope as many contractors as possible will take part in the Pharmacy Advice Audit

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This work will take place alongside the ongoing discussions about outstanding COVID-19 matters, including about funding temporary pharmacy closures and the local Emergency Supply service, and about the delayed elements of the CPCF such as the Pharmacy Quality Scheme and the Discharge Medicines Services. All of these are matters that pharmacies need answers on as quickly as possible and on which PSNC has pressed repeatedly.

The summer will also be also be a time of preparation. We have already begun negotiations ahead of the Flu Vaccination Service: there will be many challenges this year and we will once again be dependent on wider healthcare policy decisions being made by the Cabinet, but we know we will be fighting for pharmacies to remain central to the vaccination efforts, and to be fairly remunerated for doing so. Later in the summer we also expect to begin the annual review of the CPCF, which is our chance, every year, to reflect on the progress of the five-year CPCF deal and to make the case for more investment. We will be looking at ways to gather evidence

for this process, and of course this will be closely linked to our work on restoration and recovery with the other pharmacy bodies and NHSEI and DHSC. The evidence collation has already begun, and I hope as many contractors as possible will take part in the Pharmacy Advice Audit which we launched this month. To take part in the audit, which involves recording all the informal consultations you have with patients over a single day, please visit: psnc.org.uk/adviceaudit The data we capture will help us to track pharmacy workload as well as demonstrating how much local communities value their pharmacies.

Finally, alongside this work, PSNC will be reflecting further on how we and the LPCs can make ourselves fit for the future.

Following the Independent Review of Contractor Representation and Support which I kicked off last year, Professor Wright has set out 33 recommendations for change which we now need to consider carefully as a sector. That process will begin with a PSNC and LPC event on July 8th, and I hope to be able to give contractors an update, including details on how they can be involved, over the summer.

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It’s vital that we use these summer months to make progress

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Nobody could have anticipated that a global pandemic would impact on pharmacies and on the sector’s work so much as it has in 2020. But as all parts of the NHS start to prepare for what could be the most challenging period yet, it’s vital that we use these summer months to make progress too: progress on funding; progress on representative change for contractors; and progress on a realistic roadmap for the next 12 months and beyond.

DISPENSING AND SUPPLY

SERVICES AND COMMISSIONING

THE HEALTHCARE LANDSCAPE

Findings of Pharmacy Representation Review Independent review of community pharmacy representation recommends overhaul of LPC/PSNC structure with a new, separate governing body.

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LPCS

Next Steps PSNC is keen to engage community pharmacy contractors in the outcome of the review, whilst also recognising the need for LPCs to come together with PSNC to plan the next steps. Here is how we are doing it.

Summary of the report

New Council of LPC Chairs recommended by independent review

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The findings and recommendations of the independent review into community pharmacy representation and support have now been published.

The review was commissioned jointly by PSNC and LPCs last year to look for ways in which they could work more effectively together, and to ensure that the representation and support network for contractors – both local and national – is fit for the future.

The review was led by Professor David Wright, Professor of Pharmacy Practice at the University of East Anglia (UEA), working with a team of UEA researchers and taking evidence through focus groups, interviews and surveys from people across the community pharmacy sector and beyond.

The report acknowledges the selflessness and commitment of PSNC members over the years and recommends a new integrated LPC/PSNC structure for the future.

The main change recommended is that the elected PSNC Committee should be replaced by a Council of LPC Chairs, with all local and national representation overseen by a separate governing body in a new organisation called Community Pharmacy England.

Other recommendations include measures to bring local and national representation functions closer together, such as through better networks, more centralised functions (e.g. HR provision) and improved systems to capture and take forward innovative services.

PSNC and LPC Members will meet early in July to consider how to start taking the recommendations forward, whilst contractors are invited to attend a webinar being hosted by Professor Wright (see details in side column).

Professor Wright’s report (which is available as a short or long version) is available to read via his website at: pharmacy-review.org

PSNC secures £20m cash injection for 1st July A further £20m of advance funding will be paid to community pharmacies at the end of June to help with the cashflow problems facing many contractors as a consequence of the COVID-19 pandemic. The advance this time is smaller than in previous months because the reported COVID-19 related costs are less now than those experienced through the initial peak of the pandemic.

This money will be paid at the same time as the 1st July payment and comes as DHSC has also announced that it will maintain the £15m uplift to reimbursement prices first seen in June. PSNC’s strong view is that contractors must not have to pay back the advance funding payments made this year, but our bid for additional funding sector is still being considered by HM Treasury and DHSC.

PSNC’s Communications Team has produced a summary briefing of the findings of Professor Wright’s independent review, including an explanation of how his proposals would change the current system. It has been written primarily for community pharmacy contractors and their teams, but it may also be of interest to LPC Members.

Read the summary: ow.ly/dqQM30qRr3K

Contractor webinar Professor Wright will host a webinar for contractors to enable them to learn more about his review.

At 7pm on Monday 29th June, the Professor will talk through the recommendations that he has made following his review, explaining why he made them. He will also answer your questions live. An on-demand version will be made available following the event.

Register or watch on-demand via: psnc.org.uk/webinars

Virtual meeting of LPCs and PSNC PSNC and LPC Members will meet digitally on Wednesday 8th July both to question Professor Wright on his findings and to consider ways to take forward his recommendations. This is likely to be followed by working group activity over the summer and further engagement with contractors.

LPC Members should have received a separate email with information about the virtual event along with a request to submit initial questions to Professor Wright. Any LPC requiring further information should email commsteam@psnc.org.uk

psnc.org.uk 3

PSNC’S WORK

Secretary of State visits pharmacy The Rt Hon Matt Hancock, Secretary of State for Health and Social Care, visited a community pharmacy in June to thank the team and wider sector for all the work they have been doing through the COVID-19 pandemic.

On a visit to Market Chemist in London, Mr Hancock heard from Shiraz Mohamed, an independent community pharmacy contractor, about how his pharmacy has been helping the local community throughout the pandemic. Ensuring that patients have access to the medicines they need has been critical and pharmacies have had to find new ways of working to cope with increased demand for medicines and advice. Learn more at: ow.ly/1X3730qSUjC Changes to Shielding From Saturday 1st August 2020, Government guidance will be relaxed so clinically extremely vulnerable people will no longer be advised to shield, but support will remain available from NHS volunteers and local councils.

PSNC expects that NHS England and NHS Improvement (NHSE&I) will write to pharmacy contractors in the next few days to confirm that the provisions for the pandemic delivery service (the Terms of Service requirements and the Advanced service) will remain in place until 31st July 2020. Please check the PSNC website for further updates.

Flu Vaccination Service update Plans are underway for the 2020/21 flu vaccination programme, including consideration of whether the programme could be expanded to include a wider group of patients than normal, as was highlighted in the Annual flu letter for 2020/21.

PSNC has started discussions with NHSE&I on potential changes to support provision of the community pharmacy service in a COVID-safe way.

We have also asked for clear guidance on the appropriate personal protective equipment to be used when vaccinating patients; in the meantime, it would be safe to assume that the use of fluid resistant surgical masks will be a minimum requirement.

4 Community Pharmacy News – June 2020

FUNDING AND STATISTICS

CONTRACT AND IT

PSNC Pharmacy Advice Audit Pharmacy teams asked to take part in an audit about the advice they give to visitors to their pharmacy to inform future funding negotiations.

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Help demonstrate community pharmacy’s value in w/c 29th June

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PSNC is asking community pharmacy teams to take part in an audit that will capture information about all of the advice that pharmacies are giving to patients and local communities.

The audit has been tested by a small group of pharmacies to ensure it is easy to carry out, and it can be carried out as one of pharmacies’ contractual (clinical) audits for 2020/21. Pharmacies will be asked to carry out the audit on a single day in the week commencing Monday 29th June.

Apart from referrals via the Community Pharmacist Consultation Service (CPCS) – which has now surpassed 300,000 referrals – patient consultations are not recorded anywhere, but from anecdotal reports we know that they are having a significant beneficial impact on local communities, patients and the wider NHS. The audit will help us to assess how many of these informal consultations are happening and their positive impact on the patient and wider health care system, and this evidence will be used to support the ongoing funding negotiations, including PSNC’s ask for more investment in the sector.

Led by Richard Brown, working at PSNC but also an LPC Chief Officer, the audit has been designed to be as straightforward as possible for pharmacy teams to carry out and tested with a small number of pharmacies in the south west of England.

How to partcipate To successfully complete the audit, pharmacy teams will need to: 1. R ecord patient/customer interactions where advice was given by either a nonpharmacist team member and/or a pharmacist.

2. C arry this out for one whole day recording all consultations (to be valid, you must continue until you achieve at least 20 consultations).

3. E stimate the percentage of consultations that were recorded during that time period (as some may be missed).

4. R ate your confidence in the advice given to help identify areas for improvement to reflect on post-audit.

5. Enter the data on PharmOutcomes.

Find more information and resources at: psnc.org.uk/adviceaudit

DISPENSING AND SUPPLY

SERVICES AND COMMISSIONING

THE HEALTHCARE LANDSCAPE

NHS Test and Trace is launched PSNC provides information on the implications of the Test and Trace Service for pharmacies, including offering some advice on patient and staff contacts.

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Flow diagram setting out the Test and Trace procedure

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Since the launch of the Government’s NHS Test and Trace programme, a number of pharmacy teams across England have been asked to self-isolate in accordance with the service. PSNC has written this article to support contractors in understanding how the programme applies to community pharmacy and the relevant mitigations that may help to avoid the need for whole pharmacy teams to self-isolate if one member tests positive for COVID-19.

1. Close contacts: A close contact broadly means spending 15 minutes or more within 2 metres of an infected person, or a very close specified personal interaction for a shorter period of time e.g. skin to skin physical contact or travel in the same small vehicle, and applies to those who spend significant time with an infected person within the same household.

2. Patient contacts: A pharmacy team member’s contacts with patients will not be close contacts if the appropriate mitigation has been used, for example, 2m social distancing, an appropriate Perspex screen or the safe use of appropriate PPE (see psnc.org.uk/PPE for guidance).

3. Staff contacts: If a pharmacy team member is determined by a contract tracer to be a recent close contact of another staff member who has tested positive for COVID-19, they will be asked to self-isolate. Mitigations which may help to avoid the whole pharmacy team needing to self-isolate include: 2m social distancing; safe and appropriate use of PPE; and working practices that reduce transmission, e.g. the use of separate staff teams.

4. Further mitigation of risks: Pharmacies should review the steps taken so far to reduce the risks of patient to staff and staff to staff transmission, as additional measures may be necessary to minimise close contacts. Risks should be considered on a pharmacy basis and an individual staff member basis, particularly when considering those most at risk including BAME pharmacy staff.

5. NHS coronavirus app: The NHS coronavirus app is currently being trialled on the Isle of Wight. The government has announced the next phase of development in building an app will bring together the work done so far on the NHS COVID-19 app and the new Google/Apple framework. When this is rolled out across England the app will supplement the other forms of contact tracing now in place.

6. Pharmacies that have to close: A community pharmacy that has to close should follow its business continuity plan and may also find helpful advice in PSNC’s emergency closure checklist.

LPCS

Test and Trace clarifications PSNC is continuing to seek guidance on Test and Trace and the potential impact on community pharmacy. This includes whether pharmacy team members asked to self-isolate will be eligible for a coronavirus test before they develop symptoms.

Alongside seeking these clarifications, PSNC will also be having urgent discussions with the Department of Health and Social Care (DHSC) about financial support for pharmacies that have to close temporarily if the whole pharmacy team has had to self-isolate.

Minimising spread of infection NHS England and NHS Improvement (NHSE&I) have written to healthcare providers to outline the plans put in place to minimise nosocomial infections (e.g. COVID-19), including through the NHS Test and Trace programme and the management of outbreaks.

See: ow.ly/8EBk30qRenZ The letter asks all primary care contractors to review their existing business continuity plans and states that the recent recommendation for hospital staff to wear facemasks will also apply to primary care settings.

Please see PSNC’s advice on page 6.

Risk assessment template updated Contractors need to consider COVIDrelated risks to staff and patients and put in mitigations, and may wish to refer to PSNC’s Social Distancing and Infection Control Risk Review Template.

An updated version (version 2) of this risk assessment template has recently been published.

The template aims to help pharmacy teams to identify potential changes which could be made to their pharmacy environment or procedures during the pandemic to increase the safety of staff and patients. Download the risk assessment template from: psnc.org.uk/PPE Note, NHSE&I are requesting that NHS providers complete individual risk assessments for at least staff in at-risk groups (including BAME staff) by 24th July 2020. psnc.org.uk 5

PSNC’S WORK

Updated PHE posters Public Health England (PHE) has updated the set of COVID-19 public information posters for use in pharmacies. These can be downloaded from the PHE campaign resources hub. Additional promotional material is also available at: coronavirusresources.phe.gov.uk

Face covering poster As part of risk management, PSNC had designed a poster template that contractors can use, if they deem it appropriate, to encourage patients to wear face coverings when in the pharmacy. Download the template from: psnc.org.uk/COVID19publicinfo

Advice for smokers and vapers Public Health England (PHE) has released advice for smokers and vapers that could be used by healthcare professionals to encourage patients to quit smoking in light of the COVID-19 outbreak.

Based on mixed and developing evidence, PHE released the advice which could be used as part of Very Brief Advice (VBA) approaches to support patients. PHE advises that stopping smoking benefits both the patient and can take pressure off the NHS especially in the current pandemic, but also notes that the current effects of vaping on susceptibility to severe disease if a patient contracts COVID-19 are unknown. Read PHE’s advice: ow.ly/AJRR30qSes2

Supporting carers Whilst pharmacy teams will already be supporting carers during the COVID-19 pandemic, the Carers Trust – in partnership with the Royal Pharmaceutical Society and PSNC – are asking pharmacy teams to also consider: • allowing 2 people into the premises when the carer has the person being cared for with them; • prioritising carers of vulnerable people for medicine delivery slots; and • recognising that, for some families, young carers are the only people able to collect medicines in the household.

A guide has also been published which sets out helpful hints and tips to support unpaid carers to make the most out of their pharmacy team. Learn more: ow.ly/VDdS30qSUzk 6 Community Pharmacy News – June 2020

FUNDING AND STATISTICS

CONTRACT AND IT

Facemasks and face coverings Advice on the recommended appropriate use of facemasks and face coverings by staff and members of the public in community pharmacies.

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Assess when to use facemasks in your pharmacy

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Since the start of the outbreak, community pharmacy contractors have been taking steps to ensure their pharmacies are COVID-secure, including considering the use of facemasks.

Whilst there is clear advice for pharmacy staff to wear a Type IIR facemask for patient interactions, the official Public Health England position for staff interactions is to follow advice for ‘shops and branches’ and other retail outlets. However, the use of facemasks in pharmacy is complicated by the way in which staff routinely move from patient interactions on the medicines counter to non-patient interactions, working in the dispensary.

NHS England and NHS Improvement (NHSE&I) has indicated that new primary care guidance will be issued shortly but, until then, pharmacy contractors are asked to consider whether to follow the guidance issued to hospital staff in non-clinical situations, as well as the advice for visitors to wear face coverings, as follows.

Interaction

Circumstances

Facemask/face covering

Working in an area with possible or confirmed case(s) and unable to maintain 2 metres social distance should wear a surgical facemask – fluid resistant (Type IIR) surgical facemask – for sessional use. One session could be a half day period of time on the medicines counter.

Sessional use of facemasks (Type IIR) – personal protective equipment (PPE) recommended.

Staff to staff working (e.g. staff working in the dispensary)

In all settings that are unable to be delivered as COVID-secure, all staff (both in clinical and non-clinical roles), when not otherwise required to use personal protective equipment (PPE), should wear a facemask; worn to prevent the spread of infection from the wearer*

*The recommendation is for a Type I or Type II facemask worn to prevent the spread of infection from the wearer. If Type IIR facemasks are more readily available, and there are no local supply issues for their use as personal protective equipment, then these can be used as an alternative to Type I or Type II masks.

Patient/public in the pharmacy

Patients and the public should be encouraged to wear a form of face covering, to prevent the spread of infection from the wearer.

Face covering encouraged.

Staff interactions with patients

(Full guidance at: ow.ly/cgaY30qSnil)

(Full guidance at: ow.ly/hh3W30qSnjW)

(See information on PSNC poster template in side column.)

Visors also offer protection against COVID-19 infection or transmission.

Disclaimer: The token and prescription illustrations are reproduced here with permission from the Department of Health and Social Care. Subject to Crown copyright. They were the correct version as at the date of publication (April 2020), but medical professionals should check which versions are valid and in use at any given time and should not assume the versions printed are still valid.

Read more (including tips and FAQs) at: psnc.org.uk/tokens, psnc.org.uk/phase4 and within the EPS-related forms and tokens factsheet.

(with an electronic prescription message)

Release 1 (R1) barcoded paper prescription

THE HEALTHCARE LANDSCAPE

EPS tokens: Signature box includes the wording “PRESCRIPTION TOKEN – Not to be used as a prescription, even if signed by an authorised prescriber“.

R1 barcoded paper prescriptions: Must include an ink signature.

EPS token: Short 18character token number.

Release 1 (R1) barcoded paper prescription: The barcode is twice as long on a R1 compared to the EPS token.

e.g. Phase 4 non-nominated paper tokens

(issued in parallel with a legal electronic NHS prescription)

Prescription token

SERVICES AND COMMISSIONING

The image comparison below sets out the key differences to look out for. Phase 4 tokens may look identical to other EPS prescription tokens.

Both types of these forms are printed by prescribers onto green FP10SS stationery and both include barcodes and barcode numbers on the right.

Depending on the type of form, these will be processed differently by pharmacy teams.

Community pharmacy teams should familiarise themselves with the various prescription forms and tokens they will encounter. This factsheet compares the differences between Release 1 (R1) barcoded paper prescriptions and EPS Phase 4 non-nominated paper tokens.

Identifying the differences: EPS Phase 4 token v. bar-coded paper prescription

DISPENSING AND SUPPLY LPCS

psnc.org.uk 7

PSNC’S WORK

FUNDING AND STATISTICS

New reporting form for quota restrictions Is your pharmacy facing challenges obtaining stock due to quota restrictions? Then we want to hear from you.

PSNC is urging community pharmacy teams to report issues obtaining stock due to drug quota restrictions applied by wholesalers or manufacturers to assist with our representation of these issues to the Department of Health and Social Care (DHSC), the Healthcare Distribution Association (HDA) and the Association of the British Pharmaceutical Industry (ABPI).

The PSNC Dispensing and Supply Team has become aware that drug quota allocations applied by manufacturers and wholesalers are an increasing problem for many pharmacies.

Pharmacy contractors are reporting difficulties in sourcing stock of many products (including of life-saving drugs) and are having to spend an inconsiderable amount of time and staff resource daily to obtain supplies, often to no avail.

To support pharmacy teams PSNC have released an updated reporting form to allow pharmacy teams to report quota issues, which will support our representation of issues in the supply chain.

Report a medicine shortage

PSNC received nearly 150 individual reports since the reporting form went live on the 1st June. Reports may be shared with DHSC, HDA, ABPI and the respective manufacturers/ wholesalers of the drug(s), where appropriate, to help with investigation of a reported quota issue(s). The information may also be used as evidence in discussions with manufacturers, for example to highlight problems within their distribution and contingency arrangements.

You can find our reporting form here: ow.ly/K1Gu30qRgBI

Report problem obtaining an appliance

CONTRACT AND IT

May Ranitidine price concession Following further representations from PSNC, the Department of Health and Social Care (DHSC) has re-determined a price concession for Ranitidine 150mg tablets (60 tablets) for May 2020 at £7.32. The revised price will automatically apply to any prescriptions for Ranitidine 150mg tablets submitted in May prescription bundles.

Initially, no concessionary price was granted by DHSC for Ranitidine 150mg tablets in May. However, following reports received from contractors regarding their purchases, PSNC submitted an application to DHSC requesting a redetermination of the price, which was accepted.

Report product over Drug Tariff price

NHS IT COVID-19 developments Here we bring together a number of recent NHS IT changes implemented in response to the COVID-19 pandemic that community pharmacy teams should be aware of.

Temporary changes to eRD consent model Patient consent requirements for electronic Repeat Dispensing (eRD) have been temporarily suspended to encourage wider use of the system during the COVID-19 pandemic.

NHS England and NHS Improvement (NHSE&I) has confirmed that these changes to the consent model for eRD are currently due to remain in place until 30th June 2020, at which point they will be reviewed.

New SCR COVID-19 codes GPs have been instructed to record whether a patient is assumed to have had COVID-19, whether a patient has been tested, and whether the patient is at risk of medical complications should they contract the virus. When GP practices use these new COVID-19 SNOMED CT codes on their clinical systems, this will also be visible within SCR Additional Information.

8 Community Pharmacy News – June 2020

Smartcard multi-site code NHS Digital has added the multi-site FFFFF Smartcard code to Smartcards with the pharmacist or technician role, for the duration of the pandemic. The initiative has been supported

by PSNC and NHSE&I. This greater flexibility will help pharmacy staff if they unexpectedly find themselves working at their nonusual pharmacy – e.g. because of staff shortages.

Can you help? Case studies requested SCR and Smartcard changes are scheduled to last during the pandemic (including SCR with Additional Information as the default SCR). PSNC is requesting pharmacy teams email it@psnc.org.uk with experiences about why the changes are necessary even were it not for the pandemic. Please share experiences and case studies about how wider SCR access supports your ability to care for your patients.

Learn more at: psnc.org.uk/smartcards and psnc.org.uk/SCR

DISPENSING AND SUPPLY

SERVICES AND COMMISSIONING

THE HEALTHCARE LANDSCAPE

LPCS

All you need to know about: Special containers and products requiring reconstitution There are special requirements and reimbursement arrangements for dispensing products which are recognised as being packaged in special containers or those requiring reconstitution. This factsheet will take you through what these special requirements are and how your payment can be affected. form with the number and size of those containers. Where the quantity ordered falls exactly between two containers, contractors should round down, and supply the nearest complete container.

Payment for the nearest complete pack or number of packs also applies to antibacterial, antiviral or antifungal preparations listed in 5.1, 5.2 and 5.3 (except 5.3.1) of the British National Formulary (BNF), which are for oral administration and requires reconstitution from granules or powder. Part II Clause 13 of the Drug Tariff states that:

Special container status A product is granted special container status in cases where it is not practical to split a pack, for example where the product is sterile or hygroscopic. A product can be classed as special container in its complete original pack size or in its sub-pack size (for example a tablet blister strip).

Where the quantity of a product ordered by the prescriber does not coincide with that of an original pack size and the product is considered a special container (as a complete pack or sub-pack size), contractors are required to supply the special container or combination of containers nearest to the quantity ordered and endorse the prescription form with the number and size of these containers. Where the quantity ordered falls exactly between two containers, contractors should round down, and supply the nearest complete container.

Criteria of special containers and products requiring reconstitution Part II Clause 10 B of the Drug Tariff outlines the following criteria which needs to be met for a product to be granted special container status. Where the quantity ordered by the prescriber does not coincide with the of an original pack and the drug or chemical reagent is: • Sterile • Effervescent or hygroscopic, or • a. Liquid preparations for addition to bath water b. Coal Tar preparations c. Viscous external preparations • Packed in a castor, collapsible tube, drop-bottle, pressurised aerosol, puffer pack, roll-on-bottle, sachet, shaker, spray, squeeze pack, container with an integral means of applications or any other container form which it is not practicable to dispense the exact quantity: the contractor shall supply in the special container or containers the quantity nearest to that ordered and endorse the prescription

“when the quantity reconstituted from an original pack or packs is unavoidably greater than the quantity ordered and it has not been possible for the contractor to use the remainder for or towards supplying against another prescription, payment will be calculated from the Basic Price of the preparation and will be based on the nearest pack or number of packs necessary to cover the quantity ordered”.

Please note that the phrase “necessary to cover” is interpreted as the amount dispensed must allow the patient to complete the full course of medication prescribed. Therefore, if a product matching the above description is required to be reconstituted, contractors will be paid based on number of packs required to cover the quantity prescribed.

Difference between Part II Clause 13 (RECONSTITUTION OF CERTAIN ORAL LIQUIDS) and special container rules Where the quantity ordered falls exactly between two containers, the rounding down rules do not apply to eligible oral anti-infective products which require reconstitution. This is because where the quantity of a liquid antibiotic, for example, reconstituted from granules or powder, is unavoidably greater than the quantity ordered and it is not possible for the contractor to use the remainder of the reconstituted product to fill another prescription, the contractor should supply enough packs necessary to cover the quantity ordered and will be reimbursed based on the nearest pack or number of packs necessary to cover the quantity ordered. psnc.org.uk 9

PSNC’S WORK

FUNDING AND STATISTICS

CONTRACT AND IT

Identifying products which havebeen marked as special containers Products classed as special containers in Part VIII of the Drug Tariff are marked with a small black square (◼) next to the drug name, for example:

◼

Perindopril arginine 10mg tablets

30

1065

C

Coversyl Arginine

Eligible products for oral administration which require reconstitution from granules or powder are marked with a small black circle ( ) next to the drug name in the Drug Tariff, for example:

•

Amoxicillin 125mg/5ml oral suspension sugar free

•

100 ml

156

M

examples taken from June2020 Drug Tariff’

To confirm the status of a product not listed in the Drug Tariff, you can check the NHS Dictionary of Medicines and Devices browser (dm+d) browser which is updated weekly (every Thursday) by the NHSBSA. Alternatively, dispensing system supplier should automatically prompt users as to which products which are classed as special container and indicate the number of packs (or sub-packs) to dispense. Check with your system supplier on the frequency of dm+d system updates which should ideally be done weekly in line with NHSBSA’s scheduled weekly update. PSNC also maintains a special container database which is updated on a monthly basis and can be found at: psnc.org.uk/SCdatabase.

Dispensing the exact prescribed quantity if it is different to the special container pack size Where the quantity ordered does not coincide with that of the special container pack size you are required to supply the nearest complete pack or sub-pack(s) nearest to the quantity ordered.

Exceptions to the rules around quantity to supply for special containers In a small number of cases, where there is an over-riding clinical requirement to dispense the exact quantity ordered rather than the nearest complete pack or sub-pack size (for example, if the drug is required to be packaged into a weekly compliance aid of if there is a risk that the patient may misuse the drug), pharmacists would need to assess the clinical appropriateness of splitting the pack to dispense the exact quantity bearing in mind the impact on the stability of the drug once removed from its original packaging. There may be patient safety issues to consider if a pharmacist decides to dispense the exact quantity ordered (if not a multiple of the sub-pack size).

For example, if a hygroscopic drug is not stored and used correctly, exposure to moisture could affect the integrity of the drug by potentially decreasing its stability and/or efficacy.

Special container endorsements For products classed as special containers, pharmacy teams are required to endorse the prescription form with the number and size of the containers used to dispense from.

10 Community Pharmacy News – June 2020

Products requiring reconstitution endorsements With regards to items requiring reconstitution, NHSBSA will automatically flag any eligible items as special containers and therefore reimbursement will be calculated automatically based on the nearest number of packs required to cover the quantity ordered. This will occur even if resulting liquid is not of limited stability as the stability of the liquid does not affect the quantity to be reimbursed.

Pharmacy teams are advised to endorse the amount of packs supplied to enable the patient to complete the full course of medication prescribed.

In cases where there is a clinical requirement to dispense the exact quantity of a product ordered rather than the nearest pack size, to protect against any suggestion of fraud, the contractor should dispense the prescribed quantity and endorse the prescription form clearly with the quantity supplied and the pack size used.

Special container status updates Following a review, DHSC has re-determined a number of products now meet the special container criteria as set out in Part II Clause 10B of the Drug Tariff. To assist pharmacy teams and provide full visibility, monthly changes to special container status of products will be listed on PSNC’s new page: psnc.org.uk/SCupdates If you identify any particular product(s) which are not currently classed as special containers but you believe satisfy the criteria, please notify PSNC via info@psnc.org.uk who will investigate.

DISPENSING AND SUPPLY

SERVICES AND COMMISSIONING

THE HEALTHCARE LANDSCAPE

LPCS

Ask PSNC PSNC’s Dispensing and Supply Team answer some common queries about Special Containers: Q. What quantity would I be reimbursed for supplying against a prescription ordering ‘Epilim 100mg crushable tablets x 28’?

A. Epilim 100mg crushable tablets have been re-classified as a special container in sub-packs of 10. If a prescription calls for 28 tablets, you would dispense and be reimbursed for 30 tablets (3 x 10 sub-packs).

Q. What quantity would I be reimbursed for supplying against a prescription ordering 112 x Epilim 200mg gastro-resistant tablets?

Q. Why have all tablet formulations of Epilim been reclassified as special containers?

A. Drugs that are hygroscopic are granted special container status as part of the criteria listed in Part II Clause 10 of the Drug Tariff.

All tablet formulations (gastro-resistant, modified-release and crushable) of Epilim have been re-classified as special containers as the SPC’s of these products clearly state that ‘Epilim is hygroscopic. The tablets should not be removed from their foil until immediately before they are taken. Where possible, blister strips should not be cut.’

Q. What quantity would I be reimbursed for supplying against a prescription ordering 15 x Epilim 100mg crushable tablets?

A. Epilim 100mg crushable tablets are widely available in packs of 30 and are classed as a special container in sub-packs of 10. Where the quantity ordered falls exactly between two special container pack sizes, the contractor should round down the quantity dispensed to the nearest complete special container pack size. In this case, if a prescription calls for 15 tablets, you would round down to dispense and be reimbursed for 10 tablets (1 x 10 sub-pack).

A. Epilim 200mg gastro-resistant tablets have been re-classified as a special container in sub-packs of 10.

If a prescription calls for 112 tablets, you would dispense and be reimbursed for 110 tablets (11 x 10 sub-packs).

Q. Can Epilim tablets be dispensed in a Monitored Dosage System (MDS)?

A. Pharmacists dispensing small but frequent quantities (e.g. weekly) of Epilim tablets will need to assess the clinical appropriateness of cutting the blister to dispense the exact quantity bearing in mind the impact on the stability of the drug once removed from its original packaging. As Epilim tablets are hygroscopic and therefore sensitive to the effects of moisture, any water ingress may result in the chemical and/or physical stability of the drug being compromised. Given the nature of these products and the special precautions for storage as outlined in the SPC, it may be advisable for prescribers to review the prescribing of these products away from split packs, where clinically appropriate.

For further guidance on stability of drugs in Monitored Dosage Systems (MDS) please refer to the Specialist Pharmacy Service guidance on Usage of Medicines in Compliance Aids: ow.ly/wC7O30qRgqW

For more information on Special Containers see our factsheet on page 9 If you would like more information on special container or any other topic, the PSNC Dispensing and Supply Team will be happy to help (0203 1220 810 or email info@psnc.org.uk). psnc.org.uk 11

PSNC’S WORK

FUNDING AND STATISTICS

CONTRACT AND IT

KEY:  Special container • I tems requiring reconstitution * This pack only (others already available)

Drug Tariff Watch Below is a quick summary of the changes due to take place from 1st August 2020.

Part VIIIA additions Category C: • Adapalene 0.3% / Benzoyl peroxide 2.5% gel ◼ (45g) - Epiduo • Alendronic acid 70mg / Colecalciferol 140microgram tablets ◼ (4) Bentexo • Estramustine 140mg capsules (100) - Estracyt • Estriol 30microgram pessaries (24) - Imvaggis • Hydroxycarbamide 500mg/5ml oral solution sugar free ◼ (150ml) Xromi • Mercaptamine 25mg gastro-resistant capsules ◼ (60) - Procysbi • Nortriptyline 10mg/5ml oral solution sugar free (250ml) - Colonis Pharma Ltd • Olodaterol 2.5micrograms/dose inhalation solution cartridge CFC free ◼ (60 dose) - Striverdi Respimat • Povidone-Iodine 5% eye drops 0.4ml unit dose preservative free (20) - Minims

• *Pseudoephedrine hydrochloride 60mg tablets (12) - Sudafed Decongestant • *Pseudoephedrine hydrochloride 60mg tablets (24) - Galpseud • *Sodium valproate 100mg tablets (30 (3x◼10)) - Epilim • *Sodium valproate 200mg modified-release tablets (30(3x◼10)) Epilim Chrono • *Sodium valproate 300mg modified-release tablets (30(3x◼10)) Epilim Chrono • *Sodium valproate 500mg modified-release tablets (30(3x◼10)) Epilim Chrono Part VIIIA deletions *Pseudoephedrine hydrochloride 60mg tablets (100) - Galpseud

Part IX deletions Product

Additional information (e.g. size, product code, etc.)

CATHETERS, ACCESSORIES – Cath-Fix

630M, all sizes

DRESSINGS – WOUND MANAGEMENT DRESSINGS – Algosteril

All sizes

DRESSINGS – WOUND MANAGEMENT DRESSINGS – Algosteril Rope

30cm/2g

EMOLLIENT AND BARRIER PREPARATIONS – Aquamol

All sizes

Supply Updates Stanek® and Sastravi® (levodopa/carbidopa/entacapone) tablets: anticipated re-supply dates between June 2020 and August 2020 – strength dependent.

Phenelzine Sulphate 15mg tablets (Nardil®): re-supply end of 2021, at the earliest. Unlicensed imports/specials available.

SSP05 Fluoxetine 10mg tablets extended On 12th March 2020 it was announced that the Secretary of State had authorised a Serious Shortage Protocol (SSP) to help manage the supply of Fluoxetine 10mg tablets. This SSP was put in place to manage stock and to try to ensure that fewer patients need to return to their prescriber.

Isoniazid 50mg tablets: re-supply late July 2020.

Mirtazapine 15mg and 45mg orodispersible tablets: out of stock until late July 2020.

Imipramine 25mg tablets: out of stock until August 2020.

SSP05 Fluoxetine 10mg tablets has been extended (previous end date was 12th June 2020) and will now end on 11th September 2020.

Phenytoin Sodium NRIM 100mg capsules (Accord): stock remains unavailable with no confirmed date of re-supply.

Pharmacists should ensure they are using the current version of an SSP before supplying an alternative product. The SSP provides that the capsule formulation of Fluoxetine may be supplied against prescriptions for Fluoxetine 10mg tablets as follows:

H2-antagonists (Cimetidine, Famotidine and Nizatidine): various re-supply dates.

For prescriptions (NHS or private) requesting:

Supply permitted under SSP04:

Evorel Conti: available mid-June 2020. Possible intermittent supply shortages throughout June.

Fluoxetine 10mg tablets

Fluoxetine 10mg capsules

Current versions of SSPs can be found at: ow.ly/ZFWM30qRgFA

12 Community Pharmacy News – June 2020