Tuesday, 8 December 2015

APSM corrects Daily Mail article market stats

An article published today (8 December 2015)  in the Daily Mail ‘High Street Chemists who charge the NHS £300 for skin creams that should cost £12’, contains a number of significant inaccuracies about the Specials market and APSM activities.
Here follows the APSM response to the facts presented within the article.

DAILY MAIL QUOTE:  The practice has been exposed by the BAD which says up to £400m a year of taxpayers’ money is being wasted on paying too much for these treatments.  Even 2% salicylic acid cream which can be effective for these conditions costs the NHS £75m per year.

APSM Response:  Dermatology Specials are a small proportion of Specials spend in primary care – approximately £1m per year.

The total spend on Specials in England in 2014 was £89.5million in primary care.  A very small percentage of this is for dermatology specials through community pharmacy.   

Only a small number of Dermatology products are in the top 500 specials*.    In the last 3 months to September 2015, 1404 items were prescribed for topical use (which would include dermatology products) at a cost of £259,360.  Over a year this is approximately £1m. (Just over 1% of all spend).

Of the 3 products mentioned specifically, Coal Tar 5% was 220 prescriptions in last 3 months less than£200,000 per year (average cost £180 - £190).  Coal Tar 10% ointment 100g was 23 in the last 3 months – less than £30,000 a year. 2% salicylic acid in aqueous cream 100g was 63 prescriptions in 3 months - approximately £50,000 over a year.

These figures are based on data for England. The estimated value for Dermatology Specials in the community including Scotland and Wales is £1.2m (an additional 20%).

*The NHS BSA lists the top 500 most reimbursed specials (in Primary Care) by cost (NIC) and number of items.  This includes items on the Drug Tariff as well as those not included in the Tariff and covers approximately 80% of the total spend on Specials each year.

DAILY MAIL QUOTE:  In Scotland they are still supplied by NHS prices but in England the pricing is governed by market forces

APSM Response:  The Scottish Tariff covers a smaller number of products (50) and uses a different mechanism for setting prices, although commercial and NHS prices are also taken into account.  Overall, the price of the majority products on the Specials Tariff in Scotland is similar to the England Tariff with some fluctuations (some are cheaper in England than Scotland and visa versa). 

Certain dermatology products may have been negotiated separately and we cannot comment on the process used.

The Specials Tariff is designed by the Department of Health to provide sustainability of supply and a mechanism to ensure that safe and effective specials are available to the NHS via a resilient supply chain that provides a fair return, ensuring the long term sustainability of the specials market.  The DH has a mechanism for deciding which products will go on Tariff and it is regularly reviewed. 

DAILY MAIL QUOTE: “The creams are made by 14 member companies”

APSM RESPONSE: Of our 13 members only a minority produce any of these creams and in very small volumes.  APSM members report that they produce a relatively small number of specials for dermatology supply to community pharmacy.  If they are asked to produce them they are generally bespoke ‘one off’ preparations, i.e. the ingredients are sourced and they are manufactured, quality checked and sent out the same day.

DAILY MAIL QUOTE:  “in prescriptions outside hospitals, £246 - £346 for every pot used”

APSM RESPONSE: The Tariff prices listed for these products as listed in the latest Tariff dated November 2015 they are:

-      100g Coal tar 5% in oint base  - £280.96
-      2% sulphur/2% salicylic acid in aqu cream  - £198.64
-       10% coal tar oint 100g - £216.36.

Prices in English November Part VIIIB

DAILY MAIL QUOTE: These traditional ointments contain coal tar, sulphur or sometimes dissolved aspirin, in aqueous cream, a base of paraffin oils used for generations for dry skin.

APSM Response:  The product examples used are not simple, effective or high street products.
Coal Tar is a particularly difficult product to manufacture.  Although it has been used for hundreds of years in skin preparations, there are concerns about its toxicity and known carcinogenic properties both for patients and those involved in manufacturer, so it can only be manufactured under special conditions.  Pharmaceutical standard coal tar as an ingredient is now very difficult to source – due to recent changes in safety and quality regulations there are now only a very limited number of raw ingredient suppliers worldwide and the cost has become prohibitive – in fact many licenced manufacturers have had to cease manufacture.   For these reasons, it is rarely used in manufacture for licenced pharmaceuticals or Specials.

In March 2013, the MHRA (Medicines and Health Regulatory Authority) issued a warning about the use of Aqueous Cream, particularly for children with eczema as it may be an irritant.  This is thought to be because of the, sodium lauryl sulfate (SLS), contained in emulsifying wax which is one of the ingredients of aqueous cream.  The National Eczema Society and NICE advise caution in its use.

DAILY MAIL QUOTE: Private manufacturers have come in as part of the drive to open up the NHS to market forces, but as a result patients and taxpayers are being penalised.

APSM Response:  Commercial manufacturers were set up in response to MHRA increased controls on specials quality and patient safety following the ‘peppermint water case’ in 2000, in which an infant died after an incorrectly formulated pharmacy preparation.  Specials are now rarely made up in a community pharmacy.  There are a small number of hospital manufacturing units which also have MHRA licences, but the commercial sector exists to meet the majority of demand.

DAILY MAIL QUOTE:  “The NHS is charged more than £300 a pot for products that could cost just £12

APSM Response: If an NHS manufacturing unit charges £12 then this reflects the price they charge, not necessarily the cost of the product – this would not be sustainable in a normal commercial environment.   The full costs of manufacture may have been allocated elsewhere within the NHS budget (staffing, capital investment, etc).   Also, for some medicines they may have been able to manufacture a batch in advance or at a later date and can achieve cost efficiencies this way, i.e. they are not always operating a same-day service. 

In England and Scotland a number of Hospital Pharmacy units are supplying Specials alongside commercial manufacturers and together we are providing essential services to patients.  However, most in-house hospital units are not geared up to large volume production across such a wide range of possible products so could not meet the demand for Specials – particularly in England. Therefore the majority of capacity and volume in the market comes from the commercial pharmaceutical manufacturing sector and so the cost structure of the market has to be based on a commercial rather than NHS funded model.

The Price Difference reflects the commercial model

The main purpose of Specials manufacture is to patient safety and to meet patient clinical need.  Commercial manufacturers are required (by the MHRA) to carry sufficient capacity to meet demands on a daily basis with more than 20,000 potential preparations on systems, it is not possible to predict demand so most orders are manufactured same day.  For the average manufacturer this can be 2-500 different orders per day.  There are inherent costs involved with maintaining a high level of production capacity to fulfil orders, as well as express delivery costs.    This same-day manufacture also includes a very stringent quality process (to pharmaceutical standards) – see attached – to ensure patient safety.  The costs associated with this intensity of commercial manufacture are reflected in the price.

DAILY MAIL QUOTE: “We have tried to discuss it with the APSM but says it doesn’t have to talk to us”.

APSM RESPONSE:  “We made a direct approach to BAD over a year ago to introduce ourselves.  We attended a meeting, shared information and agreed to attend future meetings of their Specials Working Group.”

DAILY MAIL QUOTE:  “Because of a commitment to open the NHS to market forces and competition, the Government has now prevented NHS pharmacies that manufacture these creams for hospital use from also offering them through community pharmacies”

APSM RESPONSE: “Our understanding is that any hospital pharmacy with an MHRA specials licence can – and do - supply to community pharmacy.”

Thursday, 5 November 2015


The APSM, Association of Pharmaceutical Specials Manufacturers, is reminding pharmacists of the importance of 24 hour turnaround for bespoke Specials prescriptions.  All APSM members sign up to a commitment of timely delivery to patients1 and for all members that now means next day delivery as standard.   Members report that between 95-99% of orders are despatched the same day of receipt for delivery the following.
Said, APSM Chair Sharon Griffith, “What may have started as an effort to offer competitive advantage – we’re happy to say is now the norm amongst APSM members which is good news for patients.   Patients who are prescribed Specials often have a specific and urgent clinical need - they should not have to wait for this medicine just because it isn’t a licensed or off the shelf preparation.”
Although Specials manufacturers are geared towards bespoke manufacture it can still present a challenge.  With more than 20,000 potential preparations on our systems – we can’t predict what’s coming or think ‘we’ll save it and make a batch next week’.  An order is received, it is manufactured, goes through QA and is despatched all within 24 hours.  For a typical Specials manufacturer this can mean 500 different orders a day – and of course the inherent costs associated with express delivery costs and maintaining a high level of manufacturing capacity so that orders can always be fulfilled.
As ongoing medicine supply shortages result in longer waits for prescriptions, APSM is reassuring pharmacists that Specials manufacturers are continuing to meet patient need on a daily basis – 365 days a year.  Continuity of supply is being maintained in spite of the fact that Specials are unusual and account for less than 1% of all prescriptions annually. 
Said, Sharon, “We are committed to maintaining a sustainable manufacturing base for Specials in the UK and in spite of increased commercial pressure our APSM members have continued to invest in high quality infrastructure and processes.  In the last 5 years our members have collectively invested over £100m in service improvements – which is more than the value of the Specials market.

1. Members will at all times act in the interests of customers and ultimately patients with respect to the timely preparation and supply of Special medicines.  It is recognised that members frequently supply on an urgent basis and will protocols and standards to supply in accordance with such timelines.

Tuesday, 15 September 2015

DAVID CLOUGH, Eaststone Specials is Vice Chair of the APSM

David Clough, Sales & Marketing Director for Eaststone Specials, has been appointed Vice Chair of the Association of Pharmaceutical Specials Manufacturers, APSM.
David has been in the Specials sector for five years working for commercial licensed manufacturers. Prior to that he was at Goldshield Pharmaceuticals.  He steps into the APSM role during an important phase in the development of the Specials sector.  Said David, “Since the introduction of the Tariff, the Specials sector is enjoying a period of stability and we are able to focus our attention on building a high-quality, sustainable sector that fulfils a critical role in supplying much needed medicines.  Our focus in on working with our stakeholders to ensure better knowledge and greater collaboration in decisions affecting Specials and ultimately patients.” 
“We are also keen to engage with commercial, licensed manufacturers of Specials who are not currently members.”
The Chair of the APSM is Sharon Griffiths, Managing Director of the Specials Laboratory.

More information about membership can be found at www.apsm-uk.com

Wednesday, 8 July 2015


There are positive signs that the balance between cost and quality is being restored in the Specials market – certainly according to the latest annual Specials Survey, conducted by the APSM.

For the first time since the survey began in 2012, fewer pharmacists are referring to CCGs as the first source of advice about dispensing Specials (34% compared with 52.5% in 2013), turning instead to RPS Guidelines (47.5%) or the GP (47%). However, there is still evidence of pressure to reduce Specials spend with almost two thirds of pharmacists stating that they are monitoring spend on Specials, or that they are being asked by their CCGs to reduce or monitor Specials dispensing. 

The APSM Survey also points to the fact that pharmacists have a good understanding of Specials (over 75 % feel they have enough information or experience compared with 57% in 2013) and have a positive view of the role of Specials, with 80% agreeing that they are essential to meet the special clinical needs of some patients. 

There is also encouraging evidence that the practice of splitting or crushing tablets – perhaps as an option to reduce cost – is losing support.  41.5% are comfortable to dispense tablets with instructions to split or crush, compared with 52.7% in 2013.  This is echoed in a parallel GP survey, which showed the number who were comfortable to prescribe a licensed medicine in this way has decreased slightly from 64.2% in 2013 to 53.5% today – although many would argue that is still too high for such a potentially risky practice which effectively renders the drug unlicensed. 

Although there is still concern that Specials may sometimes be prescribed unnecessarily, this is reducing –to 35% of pharmacists respondents strongly agreeing (compared with 54.6% in 2013).  We can see this reflected in the fact that 43% of respondents said that they had declined to dispense a Special in the past on the grounds of necessity or cost.   This is potentially a good sign that pharmacists are following guidelines and if necessary questioning the need or formulation with the GP first. We know from a parallel survey of GPs that they are in general much less knowledgeable about Specials (54% feel they don’t have enough knowledge or experience) and the mechanisms are in place between dispenser and Specials manufacturer to avoid unnecessary prescribing. 

However, there are anecdotal reports about patients sometimes being refused a Special on the grounds of cost rather than necessity.  This is a matter of concern and our GP research shows that GPs are certainly less confident and comfortable about Specials than pharmacists.  GPs are in the frontline and facing difficult decisions about balancing cost and quality. 

The APSM research still reflects an undercurrent of concern about cost, but this is not exclusive to Specials.  Everyone is trying to find efficiencies across the NHS and we are all mindful of this.  APSM members are operating in an increasingly competitive environment – the demands of the MHRA are greater than ever in terms of quality and this doesn’t come without a cost.  The APSM is committed to continuing to meet these standards required of us.  There are no short cuts to quality.

These are good signs that initiatives such as The Tariff, RPS Guidelines, improved information systems and quality infrastructure have resonated with pharmacists.  Our research continues to underline that the Specials Tariff has restored confidence in the supply chain (67.5% agree).  As an industry we need to continue to work with community pharmacists to ensure that they are well supported and continue to get value from the Specials supply chain.

Source.  A survey of 200 Community Pharmacists and 200 GPs.  Conducted by Opinion Health. May 2015