Specials system in English primary care no longer delivers best care or value for money

We are writing in response to the news story ‘Pharmacy negotiators say centralised system for specials procurement could “drive down quality”’ (The Pharmaceutical Journal online, 15 May 2019).

The current system for specials’ prescription and supply in NHS primary care in England could be improved for all. The system has not changed for many years, but the nature of the medicines concerned, and the context of their use, has changed dramatically. In our view, the system no longer delivers the best possible quality of care for patients or value for NHS money owing to:

• Lack of specialist knowledge among prescribers and pharmacists, and poor access to timely specialist advice;
• Prescription of a variety of formulations, many of which lack supporting clinical evidence;
• Lack of support for patients to plan continuing supplies, leading to last minute submission of repeat prescriptions. As a result, a high proportion of products are extemporaneously dispensed or ‘bespoke manufactured’ and requested for ‘urgent’ supply, both of which inflate costs;
• A fragmented and uncoordinated supply chain, which often involves several parties, all of whom charge for their service, further inflating costs;
• Lack of incentives for stakeholders in primary care to invest time and effort in improving this system.

We are not aware of any formal recommendation for centralised product procurement, but we do not believe that it would threaten product quality. The system could be adopted to promote better informed prescribing decisions and product choice via a formulary-type approach, which would lead to demand for a narrower range of clinically justified and pharmaceutically validated products. The change should facilitate greater reliance on products that are batch manufactured to agreed quality specifications and good manufacturing practice (GMP) standards. This would, in turn, help to ensure consistently higher product quality, improved supply chain efficiency, more timely access for patients, and better value for NHS money.

Pharmacists have a professional responsibility to ensure that product quality specifications are in place and that specials are purchased from sources that work to GMP standards. Best practice principles are described in the Royal Pharmaceutical Society’s 2015 ‘Professional Guidance for the Procurement and Supply of Specials’. If these principles are followed, the procurement model alone will not adversely impact product quality, whether managed centrally or not.

Specials remain an essential element of medical care for many patients of all ages. As pharmacists, we should seize the opportunity to take control of improving access to and management of specials in primary care. We should work with others in the NHS to propose a way of working that will benefit patients and the public purse, and we welcome the chance to work with the Pharmaceutical Services Negiotiating Committee and other relevant professional stakeholders to get started.

Tim Root, assistant head, NHS Specialist Pharmacy Service;

Mark Santillo, regional quality assurance officer, South Devon Healthcare NHS Trust;

Mark Jackson, director, NHS Quality Control North West;

Andrew Lowey, lead clinician, Clinical Pharmacy and Preparative Services, Leeds Teaching Hospitals NHS Trust;

Kay Pollock, pharmacy production unit manager; joint head of radiopharmacy, NHS Greater Glasgow and Clyde.