Stoma Appliance Service in the Community: Stoma Care Quality and Cost Effectiveness Review 2015

7. Cost Effectiveness

7.1 This strand of the review focused on the existing commercial arrangements and what if any changes may be appropriate. The evaluation of responses to the quality audit and other relevant engagement with interested parties helped to inform the outcome of the work in this area. The views of interest parties such as dispensers and manufacturers through the BHTA were taken into account.

7.2 The cost effectiveness group also took into account the principles of effective prescribing when exploring key themes identified for the supply of stoma appliances in the community. The principles include:

• To provide patients with appropriate products at the best possible cost;
• For prescribers to have control over expenditure with monitoring and feedback arrangements to support decision making;
• Reducing variation by using formularies/guidelines;
• Reducing spend on products less suitable for prescribing;
• Reducing wastage by ensuring appropriate quantities dispensed;
• Importance of good information and appropriate interpretation of this data;
• Regular reviews to ensure consistency /appropriateness of prescribing.

7.3 The group explored the following 3 Areas through the course of its work;

1. The level of expenditure on Stoma products in Primary Care.

2. The arrangement for fees (dispensing, customisation and delivery).

3. Potential areas for further investigation and discussion include:

• Establishment of National Protocols Guidelines.
• Review of current spend and potential outlier for review.
• Role of stoma teams in Prescribing and Review.
• Alternative Models (Rotherham Model).

Exploration of Themes of Review

7.4 Expenditure on Stoma products in Primary Care

7.4.1 The expenditure on stoma products in Scotland has been analysed by review of BNF Chapter 23 from PRISMS.

7.4.2 This analysis may include items that are not exclusively used in stoma care but it was the groups best approximation of spend on stoma products. Expenditure has increased over time to a level of just over £21m in 2014-15. This primary care spend is significantly larger than the c£1m spend covering arrangements up until discharge from hospital.

7.4.3 The prescriptions are issued primarily by GPs with a small element of around 1% attributable to nurse prescribing. The prescriptions are dispensed and supplied to patients either through local community pharmacy or Dispensing Appliance Contractor (DAC). The DACs are spread throughout the country and provide the majority of dispensing.

7.4.4 80% of the spend is on the 4 types of ostomy bags (Colostomy, Ileostomy, Urostomy and Two Piece Ostomy Systems). There has been a decrease in two piece ostomy system reflecting change in clinical preference to products which provide more mobility and more discretion. Growth has been highest in ileostomy which now comprises a similar spend and volume to colostomy.

7.4.5 The average cost per item has been relatively consistent and growth is mainly determined by higher volumes and additional patients but there has more growth in the volume of non-bags or accessories. The range of products available in Primary Care is wider than those for hospital use and new products have been introduced over time.

7.5 Fees

7.5.1 The stoma appliance service is currently supported by a system of fees paid to appliance contractors (DACs and community pharmacies) for dispensing, delivery and customisation of products for patients. Specific rates are set for each component. Delivery is a flat fee regardless of volume, but there are volume related tiers for dispensing and customisation and the fee decreases at higher volumes. The fees are adjusted quarterly to ensure the fixed global sum is delivered and not exceed.

7.5.2 A fixed global sum ensures that NHS Boards are aware of the potential exposure in terms of spend. A fixed global sum is also a feature of the overall community pharmacy remuneration arrangements for NHS pharmaceutical services.

7.5.3 In 2015-16 the global sum for stoma fees was uplifted in line with that applied to the overall community pharmacy remuneration arrangements (1.44%) and it now stands at £3.8m. Dispensing covers 70% of the total with customisation and delivery accounting for 7% and 23% respectively.

7.5.4 There are specific volumes applied to each fee component with dispensing fees paid on all items and customisation and delivery at lower volumes reflecting the level of service provided.

7.5.5 It is proposed that main elements of current fee arrangement will continue i.e. a fixed global sum, and reviewed quarterly to determine any required rate adjustment to deliver the total global sum.

7.5.6 It is noted that under a fixed global sum that increases in volumes means that rates have to be reduced to deliver the fixed global sum. The group recognised the concerns from appliance contractors that increasing volumes are not directly compensated in the current structure.

7.5.7 It is the intention to work within current funding levels to address equity concerns. Replacing the current system would be administratively complex and would be difficult to deliver within available resources.

7.6 National Guidelines

7.6.1 National Guidelines could establish a policy for the prescribing of stoma products and appliances. They could be developed from existing guidelines in place in England covering, for example:

• Policies to reduce cost by reducing variation, waste and inappropriate prescribing.
• Awareness of normal usage rates and prescribing of stoma appliance at appropriate quantities.
• Role of local Stoma Teams in monitoring response to treatment and advise GPs of any changes to prescriptions.
• Policies for active review of prescribing by establishing expected duration of treatment and if long term set a date for review.
• Annual Review of Stoma prescriptions.
• Strategies to maintaining patient independence and avoiding unintended admissions.
• Allow product initiation and give patients appliances which enable them to better lead independent lives.
• Monitor closely those patients with high usage.
• Procedures for responsibility for stoma prescriptions and repeats (both administrative and clinical). Eliminate retrospective prescriptions (i.e. matching quantities already dispensed and re-establishing control with the prescriber).
• Only accept requests for prescriptions including initiation of and changes to prescription after clinical review.

7.7 Trigger Tools /Alerts

7.7.1 It is proposed that the development of reports is considered to help identify outliers and high cost prescriptions. Establishing a process of trigger tools give direction to potential reviews and would help achieve the twin aims of cost minimisation and also maximising patient care and quality of care by allowing a greater focus on patient centred product selection from these reviews.

7.7.2 While outliers can be established against guidelines as a desk top exercise, it is important that these outliers are clinically reviewed. It is recognised that Stoma Teams may require some changes to infrastructure to deliver benefits from the following areas:

1. Potential Over prescribing. Indicative volumes for normal usage can be determined and exception to these levels highlighted for investigation and potential corrective action.

2. Prescribing of non-recommended accessories. Guidelines or standards can be implemented to help the service identify and focus expenditure on clinically appropriate products. In Stoma / Ostomy it appears that approximately 5% of spend is on products that are currently not part of English protocols.

3. High Annual Costs of Prescribing. A further trigger or alert can come from highlighting high total cost or patient treatment and to review outliers.

7.7.3 It is acknowledged that there must be great care when using information at patient level.

7.7.4 From detailed work for one NHS Board area it was determined that approximately 10% of patients would be in a category that would benefit from review, and extrapolation to a national level suggested a potential £2.5-£3m saving from corrective action (Appendix 1 shows this in detail). These savings could be potentially reinvested in the introduction of new cost effective products which would be more beneficial to patients.

7.8 Rotherham Model

7.8.1 One area that arose during the review into alternative arrangements is the model developed by the Rotherham NHS Foundation Trust. This approach moves away from the standard GP route for prescriptions for stoma supplies to a centralised prescription service, under the control of stoma care teams. Background on the model is shown below. As it would be a significant redesign and largely determined by local circumstances it is not part of recommendations but has been included for awareness.

7.8.2 Savings were achieved by the improved management of prescriptions. There was greater control of prescribing due to involvement of clinical specialists. The project did not restrict product choice but aimed to provide the most suitable products, using the knowledge of the specialist nurses, reducing waste and potentially inappropriate prescribing.

7.8.3 The new service is declared to deliver a higher quality, more cost efficient service and better care for patients. It is similar to the centralisation of Continence Service that has been undertaken by some NHS Boards in Scotland, although dispensing and delivery remain with community pharmacy and Dispensing Appliance Contractors.

Recommendations of the Group

(23) NHS Boards should maximise effective prescribing through a system of review of Stoma prescriptions to ensure that expenditure is appropriate and thus ensure that resources available to patient care can be maximised.

(24) NHS Boards should develop a system of 'Trigger Tools' in line with protocols in England to ensure there is no oversupply and to minimise potential wastage.

(25) NHS National Services Scotland NP and NHS Boards should bring the provision of non-bag products or accessories into line with standard protocols established in the NHS in England:

• There is potentially a cost saving to boards from more rigorous reviews of outliers.
• While desktop Non clinical Review has some use it is more appropriate that the review should involve Stoma Nurses although it is recognised that these resources are limited.
• It is possible that locally NHS Boards could consider investment in Stoma Teams to facilitate this work. These reviews would not be purely financially driven and would give a route into developing patient centred approaches.
• It is noted that Manufacturers were keen to explore ways in which they could assist in future arrangements, including the introduction of new cost effective products which would be more beneficial to patients. This needs to be considered.

(26) NHS National Services Scotland NP and the Scottish Government, in consultation with NHS Boards, should maintain the fees for dispensing, delivery and customisation. Fees need to ensure that all providers of all sizes get a fair share of the remuneration global sum. It is proposed that the current quarterly review continues to ensure the total funding for fees is distributed equitable and not overcommitted. The fees should remain as a fixed total and be adjusted to take account of volume changes on a quarterly basis. The fees should remain capped with discretion to uplift in line with the community pharmacy funding uplifts where these apply.