Ensuring a supply of specialist drugs — a universal challenge for commissioners

Ailsa Colquhoun spoke to a specialist medicines pharmacist to discuss medicines optimisation

By Ailsa Colquhoun

Ailsa Colquhoun spoke to a specialist medicines pharmacist to discuss medicines optimisation

Last December’s Hackett report on clinical homecare embodies the challenge facing specialised medicines pharmacists like Yorkshire and the Humber’s Paul McManus. 

Writing his report — “Homecare medicines: towards a vision for the future” — on the emerging clinical homecare market last December, Mark Hackett, the chief executive of University Hospital Southampton NHS Foundation Trust, concluded that there is no simple way to ensure specialist or high cost medicines are delivered in a robust way. His recommendations for the £1bn and rising clinical homecare market call on the NHS to implement a range of measures. The recommendations that enable high-quality suppliers to flourish and providers to benefit from effective leadership, governance and monitoring, and allow commissioners to work in a more collaborative manner, aim to ensure that patients and the taxpayer receive services that are cost-effective, evidence-based and accountable.


The findings will resonate with Mr McManus, the lead pharmacy adviser for the Yorkshire and the Humber office of the North of England Specialised Commissioning Group. Working in one of only four SCGs in England, Mr McManus is part of a small clinical advisory team charged with ensuring the cost-effective, robust and fully accountable commissioning of high cost medicines used within specialised services and excluded from the national hospital payment by results (PbR) tariff.

With up to 60 per cent of medicines expenditure in secondary care already accounted for by non-Tariff medicines, according to the National Prescribing Centre, this already significant challenge is made all the more complex by influences such as increasing use of home delivery and other outpatient settings involving high-tech and high-cost medicines.  He concedes: “As long as there are QIPP opportunities to be realised, these models of care are not going to go away. Our challenge is to ensure that patients receive the right support, at the right time, and delivered in the right place.”


During a 22-year career spanning pharmacy practice in primary and secondary care, and positions involving the provision of general and specialised drug information, Mr McManus has seen primary care trusts become much more questioning about their expenditure on non-Tariff medicines. He says: “PCTs have realised that this is not simply a financial exchange, that they are being billed for hospital drug costs that could run in to tens of millions without any input into the claim. They felt it was time to take back some control.”

With cost-effective service development in mind, one of the roles of an SCG is to feed in local expertise and experience in specialised drug use into new national commissioning policies for specialist drugs currently under development for use by the new National Commissioning Board. Among the 30- clinical areas forming this work are fields such as pulmonary hypertension, cystic fibrosis and renal transplantation. The aim is to have a set of core priority policies in place by April 2013, with others following by April 2014.

However, the relevance of specialised drug optimisation is not just limited to the NCB. Although the NCB will directly commission many high-cost, specialist medicines, clinical commissioning groups also need to consider the issue — specifically, how they plan to commission high-cost, non-Tariff medicines used within their remit of responsibility, and manage the use and cost of the drugs involved therein. (An example could be ophthalmology and the use of intravitreal injections for diabetic macular oedema.) From his current role and experience integrating clinical home care provision into patient care pathways, Mr McManus is only too aware of the chasm in patient care that can open up when one care pathway works in a silo, and without consideration of the impact on, or implications for, other service providers.

For this reason, he urges CCGs to think now about how they will manage commissioning of high-cost medicines, and how specialist medicines management advice will be funded. As with other CCG commissioning roles demanding pharmaceutical advice provision, the funding situation is far from clear. Nor is it certain how the small pool of specialised pharmacists involved in this area of care will find themselves employed as the new NHS structures emerge. He says: “At the moment, we don’t know who is going to pay for that specialist post, how much is available, or where the money comes from. All this needs to be worked out.
“What is certain, however, is that CCGs need to wake up to the fact that there’s a whole chunk of non-Tariff medicines that will fall on CCGs to manage. They will need to know how to control that expenditure, as they will have to account for it.”

Citation: The Salvadore URI: 11100511

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