a welcome from the dda chief executive matthew isom · • metronidazole 200mg price increase 622%...

DDA 2014 Conference Update

Quality in dispensing practice –why bother?

Supported byan educationalgrant from

Look out for the final emails and printed invitations to the Dispensing Doctors’ Association 2014 annual conference, whichare being mailed this week to practices.

Moving the comprehensive conference marketing campaign into top gear, the DDAand event organiser Closer Still Media willbe contacting practices from this week in afinal effort to secure practices’ free placesat the DDA conference and Best Practiceevent. Practices should look out for the invitation email, and also for the conferenceflyer appearing in GP press until the conference on October 22-23, and takingplace at the Birmingham NEC alongside theBest Practice show.

According to CSM, event registration is up a massive 412 per cent compared to thistime last year, with dispensing practiceteam members representing over 5 per centof the current registrant base.

A programme of expert presentations are scheduled to take place at the DDA Conference.

force in England is the Electronic Prescription Service.

Dispensing practice today has a clearbusiness objective to prioritise patient satisfaction and encourage best possibleuse of NHS resources. The DDA 2014 conference programme has been createdto help everyone in dispensing practice to deliver a quality offering that benefits theNHS, the patient and the practice. The keyfocus of the event is on making quality count for you.

www.dispensingdoctor.org

Welcome to the latest in our series of educational modules brought to you in association with Actavis.

1st September marked the second anniversary of my appointment as Chief Executive of the DDA. Time does flywhen you are having fun!

A lot has happened in those two years andthere is more still to do, principally in relation to reimbursement system for dispensing practices. It simply is not rightthat more and more items are beingdispensed at a loss and that the NHS continues to allow this to happen. I hadhoped that we would have made moreprogress in changing this by now and I amgenuinely sorry that we have not. It is not for the want of trying, I can assure you. As we move towards another GeneralElection, politicians will have to answer totheir constituents why rural practices continue to be disadvantaged in this way.

Dispensing practices are the bedrock of theNHS in rural areas providing both a medicaland a pharmaceutical service. When will theNHS and politicians wake up and realisewhat excellent value you provide for patientsand taxpayers, and how much more it wouldcost us all if your service was not there? I advise you to put this question to all of thecandidates standing for election in your constituency next May, not just the incumbent MP.

Matthew Isom

Chief ExecutiveDispensing Doctors’ Association

e. [email protected]. 0330 333 6323www.dispensingdoctor.org

Among the confirmed presentations are:• Workshops on controlled drugs and

monitored dosage systems• Case studies on improving the quality

of PPD returns and practical dispensing matters

• The latest news on funding for dispensing services

• Up-to-date information about changesto NHS general practice contracts

The DDA 2014 annual conference will also offer dispensing GPs, practice and dispensary managers, and dispensers the chance to network with importantcommercial stakeholders.

For a very good reason ‘Quality counts’ is the theme of the 2014 DDA Conference,taking place this year for the first timealongside the Best Practice show. Dispensing practice remains under pressureand it is only by demonstrating quality practice that dispensing practices will secure their future, and the quality servicesthat dispensing patients have come to expect.

From NHS funding, rural diseconomies of scale, unfair Government policy and theageing population with increasingly complex healthcare needs, dispensing practice is under unprecedented stress. Asrural populations grow, so previously secure‘GP dispensing only’ areas are becoming attractive to pharmacy applications. During2013-14 even very rural areas of Scotland –the outer Hebrides, for example - have seenpharmacy applications . Another competitive

To register your place, visit the 2014conference registration website, whichcan be accessed via DDA Online. http://www.dispensingdoctor.org/listing.php?cid=142

A welcome from theDDA Chief ExecutiveMatthew Isom

Benbecula Medical Practice in the Outer Hebrides hasbeen subject to its first predatory pharmacy application

THE

DDA CONFERENCE

PROGRAMM

E IS NOW LIVE

SECURE YOUR FREEPLACE TO ATTEND NOW

Finance update

2 www.dispensingdoctor.org

Category M Quarter 3 sees large rises in reimbursement prices following the conclusion of the 2014/15 pharmacy contract settlement.

Under the new deal, Category M will be adjusted to add £10 million per month to pharmacy retained purchase margin for the next six months (until March, 2015).

Dispensing doctors account for just under 6% of dispensing by cost of pharmacy, so dispensing doctors can expect £581,400 extra in Category M purchase margins per month for the next six months; for the average sized practice with 3,085 dispensing patients thisequates to an extra £550 a month, or £2.14 per patient per year.

Wavedata price trend analysisExclusive DDAprice analysisfor Augustshows ongoing increases

in the averagegeneric prices

paid by dispensingdoctors.

In the latest price analysis brought toyou exclusively by the DDA, Wavedata reports that average generic prices paid by dispensing doctors and retail pharmacists have equalised, and during August, continued the longer term increases seen over the past year.

The analysis also shows that dispensingdoctor prices for parallel imports also flattened out in July.

Fallers

The monthly data analysis, available exclusively to DDA members and only on DDAOnline, highlights price reductions on threepacks of paracetamol, due to Teva price reductions. Beta Pharmaceuticals, the onlycompany advertising ketoprofen caps 100mgx56 in July and August, reduced prices to £1.49 for stock expiring in January.

Prices offered to dispensing doctors forsenna tabs 7.5mgx60 also fell in August asAAH and Teva reduced prices.

RisersPrices for trandolapril caps 1mg x28 increased as the Drug Tariff rose from£5.81 to £11.81. Alliance Healthcare, however, bucked the trend and decreasedits prices.

Dispensing doctor prices for allopurinoltabs 100mgx28 rose in August as Actavisand Beta increased prices. Prices of fenofibrate micro caps 200mgx28 alsorose, with increases visible from both Tevaand Actavis. Similar trends were experienced by retail pharmacists andgood offers were hard to find.

Be the first to see it! Full analysis of pricing trends during September will be available to DDA members in the first week of October – only on DDA Online.

The full August price analysis data is now available to DDA members on DDA Online at: http://www.dispensingdoctor.org/comments.php?id=3368

Size Jun-14 Jul-14Price % price

Change ChangeAdditions

Wavedata (see below) analysis of purchase prices suggests that dispensing doctors are subject to similar purchase prices as pharmacies.

In this Category M adjustment there are several significant reimbursement price changes including:

• Valsartan prices increase by 300-500%• Metronidazole 200mg price increase 622%• Senna 7.5mg tablets fall by 45%• Trazodone 50mg/5ml oral solution sugar free

price reduction of £9.17 (-25%)

• Modafinil 200mg tablets price falls by £17.46Other points to note include:• 484 products will rise in reimbursement price• 73 products will fall in reimbursement price.• Eight stay the same.

Chlorphenamine 2mg/5ml oral solution 150ml £2.49 £1.66 -£0.83 -33%

Escitalopram 10mg tablets 28 £14.91 £1.98 -£12.93 -87%



Nystatin 100,000units/ml oral suspension 30ml £20.46 £2.42 -£18.04 -88%

Paracetamol 120mg/5ml oral suspension paediatric sugar free 100ml £0.66 £1.29 £0.63 95%

Rivastigmine 9.5mg/24hours transdermal patches 30 patch £77.97 £55.54 -£22.43 -29%

Removals - The two products to be removed from Category M this quarter have only spent one quarter in Category M:• Calcium and Ergocalciferol tablets; pack size 28 • Flucloxacillin 250mg/5ml oral solution; pack size 100ml

E

X C L U S

IVE!ON

LINE

£6.98m Category M Q3 adds £6.98mto GPs’ retained purchase margin

The Department of Health continues its recent behaviour of slashing the price on drugs entering Category M.

For the full analysis of this latest Category M adjustment, please visitDDA Online at:

http://www.dispensingdoctor.org/comments.php?id=3393

Brought to you exclusively by theDispensing Doctors’ Association

Supply chain update

www.dispensingdoctor.org 3

The main purpose of the EFMD is to introduce measures to prevent the entry offalsified medicines into the legal supplychain. Scanning any unregistered code willimmediately alert the dispensary to the possibility of a falsified product, or it couldindicate that a product has been dispensedelsewhere previously and re-entered backinto the supply chain.

Among the benefits of the verification system is that it will allow better product recall as the dispensary system will knowwhich patients received the affected product.It can also be used to help manage stock rotation, identifying expired products andproducts that are soon to expire.

Who will pay for it?

Funding presents another challenge. The IT behind the EFMD, a barcode verification system designed by Solidsoft, is being funded at a European level. As for equipping dispensaries with scanning

Look out for the results of the DDA/NPAwholesaler standards survey, which will bepublished during October.

The survey, in association with the NPA,

has polled views on the standards of service dispensing practices and pharmacies receive from wholesalers.Practices were urged to share their viewson wholesaler services in general and howyou are responding to the problem of medicines shortages until September 30.

technology, “the mechanisms for paying forthis have not yet been decided - that is a decision for politicians,” says Garth Pickup,Solidsoft's CEO.

Practices currently without scanningequipment will need to acquire it – and at thesame time may want to future-proof for theElectronic Prescription Service (inclusion inwhich is a key part of the DDA’s currentlobby agenda). Note, though, that it will beup to each country to decide if the Unique Identifier (UI) code should link toother aspects, such as e-prescriptionrecords. “There is no dependency on eachother. It does not require the existence of anyother system,” says Mr Pickup.

What needs to happen now?

Professional bodies, led by the Royal Pharmaceutical Society, and including theDDA, are concerned about an apparent lackof engagement by the Department of Healthand the MHRA. The August announcement

of the ‘white list’ consultation is one of onlytwo EFMD related announcements from theMHRA during 2014.

This consultation will inform the exact listof medicines covered by the EFMD. Other details such as the characteristics and thetechnical specifications of the unique identifier of the safety features will be decided by the European Commission in separate legislation (a delegated act).

The survey is based on a set of 22 standards that the DDA, in line with independent pharmacies, believe should bereasonable for all dispensing contractorsto expect from wholesalers.

Questions cover the five areas set out inthe standards:• fairness, for example over proportionate

surcharges and stock allocations; • responsiveness to queries and

complaints;

• timely communications, for exampleabout stock availability;

• efficiency, for example in invoicing and refunds, and responding to allocation requests;

• and transparency, for example in detailing why a quota had been set at acertain level.

The European Falsified MedicinesDirective: who’s going to pay?

DDA assesses wholesaler service standards

For more information and the latestfindings, keep an eye on DDA Online,www.dispensingdoctor.org

Are you ready for barcode scanning?

The European Falsified Medicines Directive is going to affect your dispensary at some point in the next four years – and when it does dispensing practices need to know who is going to foot the bill.

At its most basic level, packaging of anyprescription item that is dispensed willhave to be scanned so that a unique identifier (UI) code can be checked againsta data hub using the internet ‘cloud’.

The UI will be a 2D data matrix (the chequered version of the barcode) and isunique for each individual package. The manufacturer will print the UI ontothe pack before it leaves the factory, andupload the details to the cloud-held European Hub.

The UI has four elements: the productnumber; batch number; expiry data and arandom serial number. If necessary the UI number can be keyed in manually without scanning, but the strength of the system will depend on how reliable internet access is.

For rural practices, internet speed will bea key question.

This system will be used to verify the authenticity of all 10 billion or more prescription items dispensed each year in 27 EU countries, and will need to be interoperable between countries and be in place by 2018, the technological challenge should not be underestimated.

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How does the EFMDwork in practice?

The full version of this article is availableon DDA Online at: http://www.dispensingdoctor.org/comments.php?id=3337

“

”

the mechanisms forpaying for this have not

yet been decided - that is a decision for

politicians,”

looks at rheumatoid arthritis, the mostcommon form of arthritis in the UK afterosteoarthritis.

Unlike osteoarthritis (OA), which is primarily caused by wear and tear on thebody’s joints, rheumatoid arthritis (RA) is a lifelong, chronic and progressive autoimmune disorder. The reason why the immune system attacks the joints is not certain, although viral infection is implicated as a trigger. Often the smalljoints are affected first, such as the fingersand toes, becoming swollen, sore, hot totouch and stiff (particularly in the morning),and making the sufferer feel very tired.However, RA affects different people in different ways, and some may first noticeswelling in one or more larger joints, whichthen spreads to the smaller ones. To somepatients, it may appear as if the inflammation ‘flits around’ different joints.

The condition may suddenly flare, duringwhich time symptoms become markedlyworse. This is sometimes called an exacerbation, and subsides after a period of time. Because RA is an autoimmune

Rheumatoid Arthritis Module 5


Dispenser Education Modules: Test your knowledgeDDA Dispenser Education Module (DEM) training is designed to provide practice dispensary staff with information to improve the way patients manage their conditions. Available free and exclusively to DDA members, each DDA DEM includes various activities and multiplechoice questions to help dispensers put the theory of their learning into practice, and to help staff identify any areas needing a quickrecap. Activities and questions relating to this DEM on rheumatoid arthritis can be found on the DDA Website, DDA Online at:http://www.dispensingdoctor.org/listing.php?cid=96

ManagingRheumatoid Arthritis

While rheumatoid arthritis (RA) is nowherenear as prevalent as osteoarthritis (OA), it isstill thought to affect nearly 700,000 peoplein the UK. RA centres on an autoimmune inflammation, rather than the physicaldamage and wastage to the cartilage between bones that is seen in OA. Thismeans it is managed in a very different way to osteoarthritis.

Aims

By the end of this article, you will:• understand the cause of rheumatoid

arthritis and the groups of people it ismore likely to affect

• appreciate how the condition is diagnosed

• know the aims of RA management, andhave an understanding of the maindrugs and treatment approaches used.

What is arthritis?

Arthritis, which means inflammation of thejoints, is an umbrella term for more than100 forms of the condition. This article

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condition, other parts of the body can become inflamed, such as the tear glands,salivary glands, the lining of the lungs andthe heart, and the blood vessels. Nodules,which are also caused by inflammation,may appear around parts of the body.

People with RA suffer from more thanjust joint pain because in the conditionwhite blood cells accumulate in the inflamed joints. These produce large numbers of chemicals, and when these release into the blood stream they causelocal effects such as swelling and pain, aswell as tiredness and a general feeling ofbeing unwell. Over time, RA sufferers mayexperience mobility problems that may prevent normal daily activities such asgoing to work or mobility around the house,and this can take its toll on their mentalhealth, causing illnesses such as anxietyand depression.

Although arthritis is often associated withageing, RA can affect people of any age,though it usually presents at some point between the ages of 40 and 70 years. It is

Dispenser EducationModule 5:

three times more common in women thanmen, and certain lifestyle choices – smoking, a diet rich in red meat, drinkinglarge quantities of coffee – seem to increase the risk of RA developing. Genetics certainly play a part, but they are not an absolute predictor of the condition occurring.

DiagnosisWhereas OA is usually diagnosed by the patient’s GP, RA is usually confirmed by aspecialist, following referral by the patient’sGP. However, RA is not always easy to diagnose and although some people willseek medical advice because of a flare up,more commonly the initial symptoms arenon-specific such as joint pain, stiffness,appetite and weight loss and tiredness – all of which have a multitude of causes.

Some of the blood tests that are performed to confirm the diagnosis of RAinclude erythrocyte sedimentation rate(ESR) and C-reactive protein (CRP) to detect inflammation, analysis of rheumatoid factor(RF, an antibody present in many peoplewith RA), and a full blood count (FBC) to seeif the patient is anaemic (as is the case forthe majority of RA patients). Imaging techniques such as x-ray, ultrasound ormagnetic resonance imaging (MRI) may beundertaken to assess the extent and severity of the disease throughout the body,as these will influence management.

Management

In common with other forms of arthritis,two of the treatment goals of RA management are relieving pain and maintaining mobility. Drugs like paracetamol,either on its own or in combination with anopioid such as codeine to enhance the analgesic effect, and non-steroidal anti-inflammatory drugs (NSAIDs) have aplace in RA management.

Physical therapy is often recommended for patients with RA. Sufferers may be reluctant to exercise, fearing the toll it willtake on their joints, but keeping mobile iscrucial – many patients find the stiffnessand the subsequent reduced mobility of RAas problematic as the pain. Gentle walkingor swimming are good ways of keeping fitwithout putting undue stress on the joints,and taking part in Pilates or Tai Chi classescan help stretch the muscles to reducestiffness and improve balance. Someone experiencing a flare up should seek physiotherapy guidance on how and when to exercise.

Because the feet and ankles may be affected by RA, appropriate footwear is vital.

A podiatrist is the best person to consult foradvice on what to wear for everyday activities and exercise. If everyday activitiesare a struggle, an occupational therapistcan provide advice on ways to make thingseasier, for example, using splints to supportthe wrists or attaching levers to taps tomake them easier to turn on and off. They may also be able to suggest ways ofovercoming the fatigue that can feel overwhelming to an RA patient.

Corticosteroids have a role in RA for theirability to reduce inflammation quickly andeffectively, so high doses may be used during a flare up. A lesser effect – but by no means less significant to some patients – is the feeling of wellbeing that many peopleexperience when taking corticosteroids,though patients should be warned thatsleep may become elusive. Low dose corticosteroids may be prescribed to try and control the joint destruction associated with RA, but the duration for which thesedrugs should be taken is made on an individual basis.

There are also drugs that can slow theprogression of RA itself. These are knownas disease modifying anti-rheumatic drugs(DMARDs) and as their use requires carefulmanagement, they present dispensers with a role in helping to support adherence.Some of the more commonly used medicines in this class are methotrexate,hydroxychloroquine, sulfasalazine andleflunomide. Usually one drug on its own(monotherapy) will be tried first, and thepatient should be advised to give the medication several months to see whetherthey feel any benefit. If there is no apparentimprovement, patients should be referredback to their specialist who may prescribeanother single agent, or two or more drugsat the same time.

Patients should be advised that it willtake time to work out the best regimen to

give the greatest chance of efficacy whilereducing the risk of toxicity or nasty side effects. Once a regimen has been deemedbeneficial, patients should be aware that itwill need to be taken long term. Patientsmay also need to be reminded of the importance of having regular DMARD blood tests.

Biological treatments such as the TNF-alpha inhibitors (for example, etanercept and infliximab) are sometimesprescribed for RA patients who have tried a couple of DMARDs and still find that theirsymptoms are quite severe. These agentsare injected, and work by stopping the immune system from attacking the lining of the joints. The most common side effectis skin reactions at the site of the injection,but occasionally past illnesses such as tuberculosis may be reactivated, so theymust be used under the supervision of aspecialist.

Surgery is sometimes performed for RA,to either correct deformities that have developed or restore a patient’s ability touse a joint. Examples include releasing tendons in fingers that have become bentout of shape, removing inflamed tissue inthe joints, and – in severe cases – joint replacement.

One of the most important aspects of RA management is monitoring. The toolmost commonly used – and that recommended by the National Institute forHealth and Clinical Excellence (Nice) – isthe DAS28 scoring system, which involveslooking at the joints most commonly affected by RA. Nice recommends doingthis at least once a year, alongside an assessment of functional ability and acheck for the development of other conditions such as depression, cardiacproblems and osteoporosis, as a way of evaluating how well the RA is being controlled.

Module 5 Rheumatoid Arthritis


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NormalRheumatoid

Arthritis

the estimated glomerular filtration rate (eGFR).

Other tests that may be conducted when assessing whether a person has CKD include urine analysis (for blood orprotein, which can indicate that the kidneys aren’t working as well as theycould be), scanning the kidneys (to checkurine flow and the shape of the organs),and a biopsy of the tissue so the cells can be examined under a microscope.

Who gets CKD?

Certain conditions, such as hypertensionand diabetes, can put a strain on the kidneys if they are not well controlled, andas such are the most common causes ofCKD. Therefore, people who are at higherrisk for these conditions are more likely todevelop CKD. There are certain risk factorsthat cannot be controlled, such as age, afamily history of diabetes or hypertension,and being of African-Caribbean or southAsian origin, but there are also manylifestyle risk factors, for example, smoking,being obese, drinking excessive alcohol,having a diet that is high in salt or fat, notexercising, and being very stressed.

Chronic Kidney Disease Module 6


Dispenser Education Modules: Test your knowledgeEach DDA DEM includes various activities and multiple choice questions to help dispensers put the theory of their learning into practice,and to help staff identify any areas needing a quick recap.Activities and questions relating to this DEM on Chronic Kidney Disease can be found on the DDA Website, DDA Online at:http://www.dispensingdoctor.org/listing.php?cid=96

If you imagine someone with chronic kidney disease (CKD), you may think of anolder person lying in a hospital bed hookedup to a gently whirring dialysis machine.But the reality is that this is a worst casescenario – and it is one that less than 10per cent of CKD patients will require. Infact, CKD is remarkably common – affecting around half of those aged over 75 years – and with careful management,most patients are able to lead normal lives.

Aims

By the end of this article, you will:• know what chronic kidney disease is,

including how it usually presents and is diagnosed

• understand the causes of CKD and whois likely to suffer from the condition

• be equipped to help patients understand how CKD can be managed,including lifestyle measures, medication, dialysis and transplantation.

What is chronic kidneydisease?In chronic kidney disease (sometimescalled chronic renal disease) the kidneys

do not work as well as they should. The kidneys have many functions, the mostobvious of which is filtering waste productsfrom the bloodstream and converting theminto urine. Other roles range from helping tomaintain blood pressure and stimulate production of red blood cells, to producingvitamin D to keep the bones healthy.

Because CKD develops gradually overmany years, the symptoms tend to not beobvious until the condition becomes advanced. At this stage, the patient mayfeel very tired, complain of water retentionthat causes their hands, feet or ankles tobecome swollen, need to urinate more thanusual (particularly at night) and notice bloodin their urine, experience shortness ofbreath, itchy skin, muscle cramps or erectile dysfunction, or feel nauseous.

Because these symptoms are quite non-specific, it usually isn’t obvious thatsomething is amiss with the kidneys. Thankfully, most people don’t even get this far, because CKD is generally picked up at an early stage during a blood test for something else. The measurements that indicate how well the kidneys are functioning are creatinine level and

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Chronic Kidney Disease

Module 6:Dispenser Education

• eat a diet that is low in fat and salt• stick to recommended alcohol intakes• maintain a healthy weight• take regular exercise• avoid the use of NSAIDs, both bought

over the counter and prescribed.

Medication also has a place in controllingdiseases that may also be present, such ashypertension and diabetes, and which canincrease the risk of CKD progressing. Aspirin is commonly used to reduce therisk of cardiovascular disease, as this is increased in patients with CKD, and astatin may be prescribed to reduce cholesterol levels. If water retention is aproblem, for example causing puffy ankles,diuretics such as furosemide may be necessary, and vitamin D supplementsmay be prescribed if the kidneys are notworking well enough to convert theamount taken in from sunlight and foodinto a form that can be used by the body to avoid bone damage.

At stages three and above, CKD cannotbe ‘reversed’ and patients will need tocome to terms with the diagnosis of a longterm condition or the need for long-termmedication, particularly if they do not experience any tangible benefit from themedication they are prescribed. If a patientseems to be struggling with their diagnosisor management plan, dispensers shouldoffer reassurance and consider referringthe patient back to the doctor for furtheradvice.

Anaemia often becomes a problem atCKD stages 3 and higher. Iron supplementsare usually tried first, but many patients goon to require erythropoietin, a hormonethat boosts the body’s red blood cell production. These drugs are sometimescalled erythropoiesis stimulating agents(ESAs).

At CKD stages 4 and 5 – at which point patients should be under specialist care –phosphate accumulates in the body because the kidneys aren’t working wellenough to get rid of it. This needs treatingotherwise it can cause other chemicals inthe body to become unbalanced, mostcommonly calcium, which can lead to thebones become weak. For this reason, patients with this level of CKD need to limittheir phosphate intake by reducing theamount of red meat, fish, eggs and dairyproducts they consume, usually under thesupervision of a dietician. If this doesn’tprove effective, phosphate binders may beprescribed to be taken before meals.

Patients who are at CKD stage 4 or 5need to prepare themselves and their close friends and family for the very real

possibility that they will need dialysis. This process may take place weekly ormore frequently in hospital or specialistunit, or several times a day or overnight at home and will involve using a specialmachine to filter the blood, replacing thelost kidney function. Problems can occur,such as infections, or side effects such asmuscle cramps or itching, and many people find it very draining.

A kidney transplant is the only cure forstage 5 CKD, but is a major operation so isonly suitable for patients who are fitenough to cope with the surgery. Suitablecandidates must undergo tissue typing, soa good match can be found, and will needto go on a waiting list unless a compatiblelive donor (usually a close family member)comes forward. Anyone who has a kidneytransplant must be regularly monitored toensure the organ is working as it shouldbe, and need to take medication for life toreduce the chance of the donated kidneybeing rejected by the body.

What is acute kidney failure?

Unlike CKD, acute kidney failure happensrapidly, over a matter of days or weeks. Itusually happens as a result of another illness or following major surgery, so patients are often already in hospital whenit occurs. Dialysis is usually required whilethe kidneys recover, but the condition isoften short-lived and reversible unlesspermanent kidney damage has occurred.

Module 6 Chronic Kidney Disease


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Other conditions can also causes CKD,though not as commonly as hypertensionand diabetes, including certain kidney conditions (glomerulonephritis,pyelonephritis, polycystic kidney disease,kidney stones), and long term use of certain medicines, such as non-steroidalanti-inflammatory drugs (NSAIDs), eg. ibuprofen.

What causes CKD?

CKD is thought to affect over three millionpeople in the UK and each year an estimated 13,000 people die as a result.Both these figures are expected to rise asthe population gets older. The disease isage-related, so while it is rare in youngadults (around one in every 50 is affected),in the 65-75 year age range, one in fivemen and one in four women has CKD. Inthose aged over 75 years, the figure maybe as high as 50 per cent.

Individuals who are considered to be athigh risk of developing CKD should undergo regular screening. The GP is thebest person to decide whether someone is a suitable candidate.

What are the classifications of CKD?

Once CKD has been diagnosed, it is classified according to how advanced thecondition is:

• At stage 1, the eGFR is at the normallevel, but other tests reveal that thekidneys are mildly damaged.

• At stage 2, the eGFR is in the range60-90ml/min, so lower than normal.Stage 1 and 2 are usually asymptomatic, and it may be possible to slow down the progress of CKD, oreven stop or reverse the decline inkidney function.

• At stage 3 (eGFR 30-59ml/min), thepatient’s kidney function is moderately reduced. Anaemia oftenbecomes apparent.

• At stage 4 (eGFR 15-29ml/min), thereis a severe reduction in kidney failure,and the patient will usually start toshow symptoms.

• Stage 5 (eGFR< 15ml/min) is alsoknown as established (or end stage)kidney failure, and usually requiresdialysis or a kidney transplant.

How is CKD managed?

The way in which CKD is managed dependson the stage the patient is at. Stages 1 to 3are usually monitored by the GP, with thepatient urged to make lifestyle changes,such as:• stop smoking

will be used as a key determinant in setting the boundary for the controlled locality.The controlled locality will be subject to routine review everythree years, although provisionsexist for earlier review followingsubstantial change to the locality.

Prejudice test

In the new prejudice test, to be appliedwhen considering pharmacy applications in a controlled locality an application will berefused if the granting of the applicationwould adversely impact on the security and sustainable provision of existing NHSprimary medical and pharmaceutical services in the locality concerned. Where anapplication is refused on the grounds ofprejudice, the health board will not considerany further applications from any applicantin that controlled locality neighbourhooduntil the controlled locality status is reviewed by the health board, or in the eventthat new evidence comes to light of substantial change.

The prejudice test is in addition to the necessary or desirable test, which will beexpanded to include the likely long term

sustainability of the proposed pharmaceutical services.

Other key changes implemented by the2014 amendment regulation

• A pre-application stage attempts tomake health board involvement in thepharmacy application more proactive

• For the first time, community representatives will have ‘interestedparty status’, which creates a right tobe involved at key stages in the pharmacy application

• There will be statutory timeframes for decisions

• Dispensing GP practices will be required to receive the support of anappropriately qualified pharmacist independent prescriber.

Political Update


To view the full DDA/GPC statement,visit DDA Online.http://www.dispensingdoctor.org/comments.php?id=3194

The National Health Service (Pharmaceutical Services) (Wales)Regulations 2013.http://tinyurl.com/kghcj6g

Prejudice and controlled localities secured in Scotland

Dispensing practice matters

New regulations offer some protection to rural Scottish practices

For more information The National Health Service (Pharmaceutical Services) (Scotland) (Miscellaneous Amendments) Regulations 2014.http://www.legislation.gov.uk/ssi/2014/148/contents/made

The DDA has joined forces with the GPC in Wales to respond to the Welsh control ofentry consultation announced recently inthe White Paper "Listening to you: Yourhealth matters".

holistically, alongside itsrole and relationship toall other components in the patient pathway."

Included in this consideration must be the cross-subsidy ofGMS services providedby dispensing income,which has become avital stream of funding for the provision of primary care services in many rural areas.There are also the challenges of recruitment and retention of doctors inrural areas and low GP morale.

Rural Scottish GPs have secured beneficialchanges to the pharmacy control of entryregulations. The new regulations, the National Health Service (PharmaceuticalServices) (Scotland) (Miscellaneous Amendments) Regulations 2014, came intoeffect from June 28, 2014, and make the following changes:

• A new definition for ‘controlled localities’in remote and rural areas

• A new ‘prejudice test’ when consideringpharmacy applications in controlled localities

• A new ‘pre-application’ stage and jointconsultation by the applicant and thehealth board.

Controlled localities

Controlled localities are defined as an areawithin a health board which is remote orrural in character and which is served by a GP dispensing practice. To define a ruralarea, health boards are advised to referencethe Scottish Government urban/rural classifications.

Under the terms of the regulations, theGP dispensing practice/s area (including itsbranch surgeries/practices) within an area

This consultation, which closed before the Welsh Assembly summer recess, proposes to basepharmacy control of entry in Waleson a Pharmaceutical Needs Assessment.

In the joint response the DDA andthe GPC reaffirm the need to considerthe effect of a pharmacy opening onthe long-term future of the servicesprovided by GP practices in controlled localities.

The statement from the DDA andthe GPC in Wales makes clear GPs' supportfor the integration of pharmaceutical andmedical services, "wherever possible andappropriate in order to maximise patientbenefit and convenience".

But the organisations warn that pharmacy provision must be considered

The Senedd, home to the National Assembly for Wales

a welcome from the dda chief executive matthew isom · • metronidazole 200mg price increase 622%...

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