DISPENSING Back to Basics A whistlestop tour of

DISPENSING Back to Basics A whistle-stop tour of how to ensure maximum efficiency within your dispensary and make your practice more resilient Dr Philip Koopowitz

DISPENSING Back to Basics Dr Philip Koopowitz

DISPENSING Back to Basics PROFIT PAs and VAT Inhalers D/NOACs Gliflozins Gliptins

DISPENSING PROFIT

DISPENSING PROFIT The vast majority of Dispensing GPs plough their profits back into their practices to provide care and ensure practice resilience. Without Dispensing Profit, Rural General Practice is in danger!

DISPENSING PROFIT =

DISPENSING PROFIT Profit/Loss = Reimbursement – Cost

DISPENSING PROFIT Reimbursement = Basic Price -Discount Abatement(11. 18% Basic Price) + Dispensing Fee (Independent of product prescribed) + VAT (if Personally Administered Item) + £ 20 – if Special and endorsed correctly

DISPENSING PROFIT Cost = Cost price of product (Not always the same as Basic Price) Minus Discount (- Wholesalers Discount (0 -12%) - Additional Discount (endangered species)) Ignore VAT as it is reclaimed from HMRC (unless it is a PA)

DISPENSING PROFIT Assumptions Ignore VAT Discount Abatement = 11. 18% Exclude Dispensing Fee (~£ 2. 00)

DISPENSING PROFIT Non-PA(Personally Administered)

DISPENSING PROFIT Reimbursement Non-PA Reimbursement = Basic Price (BP) Minus Discount Abatement(DA)

DISPENSING PROFIT Costs Non-PA Cost = Cost price (CP) Minus Discount(D) Cost price is not always the same as BP

DISPENSING PROFIT Reimbursement- Non PA - £ 10 Reimbursement = BP-DA = £ 10 - £ 1. 12 =£ 8. 88 = BP x 88, 82%

DISPENSING PROFIT Costs - Non-PA - £ 10 Cost = Cost price (CP)– Discount = £ 10 - £ 0 = £ 10

DISPENSING PROFIT Profit - Non-PA - £ 10 (no discount) Profit =Reimbursement –Cost = £ 8. 88 - £ 10 = Loss of £ 1. 12

DISPENSING PROFIT Profit Non-PA - £ 20 (no discount) Profit =BP –DA –CP -D = £ 20 -£ 2. 24 - £ 20 = Loss of £ 2. 24 Not offset by the Dispensing Fee !!

DISPENSING PROFIT Controllable factors which affect profit • Cost Price • Discount

DISPENSING PROFIT Controllable factors • Wholesalers Discount In danger of extinction! Full Wholesalers discount – now applies to very few products Average RWM discount ~ 5%

DISPENSING PROFIT No Additional Discount On: • • • Generics (but not all!) Parallel Imports Fridge Items CDs ZD products Food supplements

DISPENSING PROFIT • Additional Discount MDS – Manufacturers Discount Scheme Check to see whether MDS includes basic Wholesalers Discount Is the headline discount hiding something ? ? ?

DISPENSING PROFIT PAs and VAT Unravelling the complexities

DISPENSING PROFIT VAT and PAs NHSBSA List Injectables, but not Implants Local anaesthetics, Sutures Vaccinations, Ring pessaries NHSBSA dm+d Browser https: //apps. nhsbsa. nhs. uk/DMDBrowser/DMD Browser. do#product

DISPENSING PROFIT NHSBSA dm+d Browser Attributes Product Information Prescribing Information Clexane 100 mg/1 ml solution for injection pre-filled syringes (DE Pharmaceuticals) 10 pre-filled disposable injection Attribute Name Attribute Value Description PADM Ind 0001 Attracts an administration fee

DISPENSING PROFIT NHSBSA List PA - YES Will receive VAT back

DISPENSING PROFIT VAT and PAs HMRC If it is applied or injected at the surgery Not a PA if able to take it away in a bag

DISPENSING PROFIT HMRC PA –YES Will not be able to claim VAT back ie. Pay Full VAT on cost price

DISPENSING PROFIT VAT and PAs 1. NHSBSA –PA : HMRC –PA 2. NHSBSA –PA : HMRC –Non-PA 3. NHSBSA –Non-PA : HMRC -PA

DISPENSING PROFIT VAT and PAs 1. NHSBSA –PA : HMRC –PA Most fall into this category eg. Flu jabs, Steroid injections

DISPENSING PROFIT Reimbursement PA (Personally Administered) Reimbursement =BP-DA+VAT(on 88, 82% of BP)

DISPENSING PROFIT Reimbursement : PA : £ 10 Reimbursement = BP-DA+(VAT on 88, 82% of BP) = £ 10 - £ 1. 12 + (20% x £ 8. 88) =£ 8. 88 + £ 1. 78 = £ 10. 66 = BP x 106. 6%

DISPENSING PROFIT Costs PA Cost = CP – D + VAT(on CP-D) Cost price is not always the same as BP

DISPENSING PROFIT Costs – PA- £ 10 Cost = CP– D+ VAT (on CP-D) = £ 10 - £ 0 + £ 2 = £ 12

DISPENSING PROFIT Profit – PA- £ 10 (no discount) Profit =BP x 106. 6% minus CP –D – VAT(on CP-D) = £ 10. 66 - £ 12 = Loss of £ 1. 34

DISPENSING PROFIT Reimbursement : PA : £ 20 Reimbursement = BP x 106. 6% = £ 20 x 106. 6% =£ 21. 32

DISPENSING PROFIT Costs – PA- £ 20 Cost = CP– D+ VAT (on CP-D) = £ 20 - £ 0 + £ 4 = £ 24

DISPENSING PROFIT Profit – PA- £ 20 (no discount) Profit = £ 21. 32 - £ 24 = Loss of £ 2. 68 Not offset by the Dispensing Fee !!

DISPENSING PROFIT Lack of Discount is a Killer

DISPENSING PROFIT Decent Discounts can lead to HAPPINESS

DISPENSING PROFIT Gn. RH Analogues Basic Price Profit Lutrate £ 191. 86 £ 24. 14 Prostap £ 225. 72 £ 28. 40 Zoladex £ 235. 00 £ 21. 35 Decapeptyl £ 207. 00 £ 3. 28*

DISPENSING PROFIT VAT and PAs 2. NHSBSA –PA : HMRC –Non-PA This includes Insulins, Clexane, Metoject, etc. Can claim full VAT back from HMRC

DISPENSING PROFIT Reimbursement : PA Clexane 40 mg x 10 =£ 30. 27 Reimbursement = BP x 106. 6% = £ 30. 27 x 106. 6% =£ 32. 27

DISPENSING PROFIT Costs – -Non PA Clexane 40 mg x 10 =£ 30. 27 Cost = CP–D (Can claim full VAT back on CP) = £ 30. 27 - £ 0 = £ 30. 27

DISPENSING PROFIT Profit – Clexane 40 mg x 10 =£ 30. 27 Profit = £ 32, 27 - £ 30. 27 = £ 2. 00 PROFIT

DISPENSING PROFIT VAT and PAs 3. NHSBSA –Non-PA: HMRC –PA Nexplanon – No VAT paid by NHSBSA, but unable to claim VAT back from HMRC

DISPENSING PROFIT Reimbursement : Non-PA Nexplanon - £ 83. 42 Reimbursement = BP -DA = £ 83. 42 - £ 9. 33 =£ 74. 09

DISPENSING PROFIT Costs –PA Nexplanon - £ 83. 42 -7% Discount Cost = CP– D+ VAT (on CP-D) (Cannot claim VAT back from HMRC) = £ 83. 42 - £ 5. 84 + (£ 77. 58 x 20%) = £ 93. 10

DISPENSING PROFIT Nexplanon - £ 83. 42 Profit/Loss = £ 74. 09 - £ 93. 10 = £ 19. 01 LOSS

DISPENSING Back to Basics ? ? Questions? ?

Dispensing Inhalers Patient First NHS Second Practice Third

Dispensing Inhalers Selecting the right inhaler • MDI (+Spacer)vs. Breathe Actuated • Counter • Number of doses per inhaler • Frequency of usage

Dispensing Inhalers Selecting the right inhaler

Dispensing Inhalers Other Factors to Consider: Combinations Step up/down according to NICE Check dosage instructions when changing Licensed Indication Cost Profit

Dispensing Inhalers LABA + ICS LAMA LABA + LAMA

Dispensing Inhalers LABA + ICS – MDI +/- Spacer • Fostair • Flutiform • Salmeterol + Fluticasone (Seretide, Sirdupla)

Dispensing Inhalers MDI Low dose LABA + ICS

Dispensing Inhalers MDI Medium dose LABA + ICS

Dispensing Inhalers MDI High dose LABA + ICS

Dispensing Inhalers LABA + ICS - BA • • Fostair NEXThaler Duo. Resp Spiromax or Symbicort Relvar Ellipta Seretide Accuhaler or Air. Flu. Sal

Dispensing Inhalers Low Dose LABA + ICS - BA

Dispensing Inhalers BA/DPI Medium dose LABA + ICS

Dispensing Inhalers BA/DPI High dose LABA + ICS

Dispensing Inhalers LAMA • Eklira • Spiriva – Handihaler or Respimat • Seebri • Incruse

Dispensing Inhalers LAMA

Dispensing Inhalers LABA + LAMA • • Duaklir Spiolto Anoro Ultibro

Dispensing Inhalers LABA + LAMA

Dispensing Inhalers ICS+LABA - MDI Fostair Flutiform Seretide Sirdupla generically £££ £ £ ££ ££££

Dispensing Inhalers ICS+LABA - BA Fostair Nexthaler Seretide Airflusal generically Symbicort Duo. Resp generically Relvar £££ £ ‡‡ ££ ££

Dispensing Inhalers LAMA Eklira Genuair Encruse Ellipta Seebri Breezhaler Spiriva Respimat Spiriva Handihaler ££ £ ‡‡‡ ££ ‡‡‡

Dispensing Inhalers LAMA+LABA Duaklir Spiolto Anoro Ultibro ££ ££ £ ‡‡

Dispensing NOACs N/DOACs for AF Stroke Prevention

Dispensing Gliflozins Basic Price Profit Forxiga 5 and 10 28 £ 36. 59 £ 7. 62 Jardiance 10 and 25 28 £ 36. 59 £ 4. 51 Invokana 100 and 300 30 £ 39. 20 £ 5. 81

Dispensing Gliptins Basic Price Profit Vipidia 25 mg 28 £ 26. 60 £ 7. 67 Trajenta 5 mg 28 £ 33. 26 £ 4. 10 Onglyza 5 mg 28 £ 31. 60 £ 6. 58 Januvia 100 mg 28 £ 33. 26 -£ 1. 39 Galvus 50 mg 56 £ 33. 35 -£ 1. 39

DISPENSING Back to Basics There are still some good deals out there Drug companies still want your business Discounts come and go – keep an eye on the DDA website

DISPENSING Back to Basics Minimise losses by focusing on High Cost Drugs Invest time in checking what goes out the dispensary at a loss Profit can still be made!!!!

DISPENSING Back to Basics With a little bit of extra work you can go from to to

DISPENSING Back to Basics Thank You