Moreover, says the DDA, the National Health Service Business Services Authority (NHSBSA) Prescription Pricing Division (PPD)’s latest monthly data show that reimbursement per item for dispensing doctors fell from £9.70 to £8.50 (12.4%) from first-half 2006 to first-half 2008, while for pharmacy the drop was 9.7%, from £10.83 to £9.78.

The DDA pointed to these figures in its initial response to the Department of Health’s recently-published consultation document on proposals for reform of market entry arrangements for dispensing doctors.

The reforms have been proposed because of “concerns,” says the Department, that “existing arrangements by which doctors may dispense to their patients may result in arbitrary decisions regarding which patients are eligible to receive NHS dispensing services from their general practitioners (GPs). There is also some indication that dispensing doctors may be costlier to the NHS than non-dispensing doctors.”

There are currently 3,510,895 dispensing patients and 50,542,505 NHS patients in England. 5,664 dispensing doctors, located at 1,147 (mostly rural) dispensing practices, account for 7% of all prescriptions in England.

The current market entry rules state that, where patients have difficulty in accessing their medicines through a pharmacy, Primary Care Trusts (PCTs) are able to approve GP practices in “controlled” rural localities to offer dispensing services to certain of their patients.

“While dispensing doctors provide a valuable service to patients who otherwise might not have been easily able to access pharmaceutical services, a number of concerns have arisen relating to the appropriateness of the existing regime, in particular the equality of access for patients, relative cost-effectiveness to the NHS and the alignment of prescribing incentives,” says the consultation document.

For example, it notes that in March, the Information Centre GP Earnings and Expenses Enquiry reported that dispensing doctors earn more on average than non-dispensing GPs and that, on average, a dispensing doctor’s annual net profit is £127,061, against £106,681 for a non-dispensing doctor.

Moreover, dispensing doctors may be prescribing more items per patient, and they also perform less well than prescribing doctors against some of the Better Care Better Value indicators of prescribing, it adds. For example, according to the PPD data, dispensing doctors prescribe fewer (3.8%) generic statins as a percentage of all statins, compared with non-dispensing doctors. Dispensing fees per prescription dispensed are higher for dispensing doctors for pharmacies, which makes each prescription dispensed more expensive than it is at pharmacies, the document adds.

Other than keeping the existing arrangements as they are (Option 1), the government is considering the following options for change:
- Option 2: retain the controlled localities and allow PCTs to determine dispensing rights based on pharmaceutical needs assessments;
- Option 3: retain controlled localities and replace the existing “patient-to-pharmacy” distance criterion with a “practice-to-pharmacy” distance criterion and allow dispensing practices to dispense to full list; or
- Option 4: as Option 3, but ensuring that there is a second pharmacy in close proximity.

Yesterday, the DDA declared that Option 1 is the only one which it would find acceptable – “that is, to maintain the status quo and so protect services to patients.” However, it adds that a special meeting of the Association’s Board has been arranged for September 11 to discuss the proposals, and it urges all members to respond to the government’s proposals by the deadline of November 20.

The Association also tells its members that the consultation document “contains many apparent errors of fact, especially in the area of costs, and these can and will be refuted comprehensively.”