Photo credit: APSM
More than £77 million was spent on specials in 2017 in England, but this was down 11 per cent from £87 million in 2016. The total net ingredient cost (NIC) of the top 500 most commonly prescribed specials for the quarter ending December 2017 in England was £16.5 million out of a total NIC of £18.2 million for all specials (NHS BSA data).
Of this, the top 10 most commonly prescribed products accounted for £4.7 million, or 28 per cent, but only half of them appear in the Drug Tariff part VIIIB. The drugs that do not appear in the DT had an NIC of £3 million – 64 per cent of the total cost of the top 10 items.
The largest outlay for specials was on co-proxamol tablets at a cost of nearly £1.4 million (7,430 items), while the most commonly prescribed product was melatonin oral solution 5mg/5ml prescribed 13,702 times and costing £664,000.
When looking at specials by number of items prescribed, about 50 per cent of the top 500 appear in the DT. However, when looking at the top 500 by total NIC, only 39 per cent of them are in the Drug Tariff.
Indeed, the top 10 specials (by total NIC) account for 35 per cent of the cost of the top 500, with an NIC of £6 million out of a total of £17 million, but only two appear in the DT.
So, on the surface, it looks like there is more room to squeeze suppliers.
Occasionally, it can be unclear if a prescription is for a special, or whether a licensed product is available. However, PSNC recommends following the MHRA guidance on the hierarchy for the use of unlicensed medicines to see if a licensed product is available and to notify the prescriber if this is the case.
In order to check the licensing status of a product against the description of the prescribed product, PSNC recommends using the NHS Dictionary of Medicines and Devices (dm+d).
Pharmacist Mike Edge, from specials manufacturer Nova Laboratories, highlights another option. “Pharmacists can also speak to our customer service team who have resolved many formulation issues and technical problems over the past 20 years,” he says.
The Association of Pharmaceutical Specials Manufacturers (APSM) agrees: “A special can only be supplied when and if a licensed alternative is not available and so the very first thing a specials manufacturer will do is to check this.”
Sharon Clift of The Specials Laboratory adds that “the value of a strong, reliable and technically proficient partner will save you lots of time and ensure your patient gets the right medication.”
Once identified as a special, the order can then be placed with a manufacturer.
For further information on how to use dm+d, visit psnc.org.uk/dmd. Pharmacy staff can also check their invoices to determine if an item is to be treated as a special, for example by checking for an MHRA specials/importer’s licence number.
Mr Edge has the following tips for managing and procuring specials to help eliminate risk and save time. “It’s essential to trust your specials supplier because speed is often of the essence, so be sure to work with a supplier you can rely on,” he says. “Always utilise the technical support available from your specials supplier and speak to their expert customer service teams and in-house pharmacists for advice and guidance.
“Keep a record of manufacturers that are able to fulfil certain prescriptions to avoid having to contact multiple manufacturers each time. Try to use a supplier who can cover all bases to save on admin.”
He also advises asking about the end-to-end process and checking whether the product is made and tested in-house. “Ask for evidence that the product meets appropriate standards,” he says. “This will help assure you and the patient that the special is compliant and made to the highest quality. While some specials manufacturers outsource testing and production, Nova manufactures and tests all specials in-house in its state-of-the-art facility.”
The pharmacy must also stamp, date, initial and endorse the Certificate of Analysis (CoA)/ Certificate of Conformity (CoC) with the invoice price and prescriber’s details. At the end of the month, the pharmacy must then send a copy of the CoA/CoC to the local NHS England team of the prescriber along with the prescriber’s details.
When preparing the end-of-month submission bundle, prescriptions for unlicensed specials should be separated and placed in the red separator. This ensures they are seen by an exception handler. It is advisable to keep a record of the specials prescriptions dispensed and to reconcile it with the monthly P34 Schedule of Payments.
The SP fees paid are displayed in the Prescription Fees section on page 1 and the total value of these fees is displayed under “Additional fees – 2A unlicensed medicines”. If an unlicensed special has an item value of £100 or more, it will be listed in the summary of expensive items.
Specials are essential for some patients, but they can be an extra inconvenience for busy community pharmacy teams to identify, order and record. Choosing the right supplier and ensuring that prescription endorsements are accurate (see the box to the left for current guidance) are two important steps in ensuring the procurement process runs smoothly.
With significant costs involved, correct endorsement is essential to avoid reimbursement problems. According to PSNC, incomplete endorsements are the most common type of error when it comes to specials, particularly the omission of the SP endorsement, and the topic was recently the subject of a PSNC webinar.
Another common error is the incorrect use of XP or OOP endorsement for out-of-pocket expenses instead of SP and vice versa. In addition, PSNC is keen to remind contractors that “broken bulk” cannot be claimed on any specials.
A PSNC factsheet with worked examples is available to support the correct endorsement of unlicensed specials. This can be found at psnc.org.uk/specialsfactsheet.
1. For items listed in Part VIIIB of the Drug Tariff:
The pharmacy will be paid as per the Part VIIIB listing. The only endorsement required is SP to claim the fixed fee of £20 per item for costs incurred when obtaining the special.
2. For items not listed in Part VIIIB, the following endorsements are required: