Pharmacist provision of subsidised Nicotine Replacement Therapy and the Emergency Contraceptive Pill

Medicines

Decision

Eligible people will be able to access two types of funded pharmaceutical from community pharmacists without a prescription.

The change relates to two products that pharmacists can already sell without a prescription:

  • nicotine replacement therapy (NRT)
  • the emergency contraceptive pill (levonorgestrel tablets) (ECP)

These changes will take effect from:

  • 1 October 2017 for NRT
  • 1 December 2017 for ECP

Changes to the original proposal

This was the subject of a consultation letter dated 20 July 2017, and having carefully considered consultation feedback, we have made the following changes:

For ECP, the decision will take effect from 1 December 2017, not 1 October 2017 as originally proposed. This delay is to give DHBs and pharmacies time to work through service provision arrangements for the supply of ECP.

Who we think will be most interested

This decision will be of interest to:

Community pharmacists, general practitioners, other prescribers, sexual and reproductive health services, NRT providers, DHBs, PHOs, suppliers and wholesalers, and people who may need to access nicotine replacement therapy or the emergency contraceptive pill.

What is the effect of this decision?

For patients

Patients will have an additional means of accessing these funded products and no prescription will be required.

Currently, people who want to quit smoking can access funded NRT on prescription or through a Quitcard provider. From 1 October 2017, people will have further opportunities for quit attempts with funded NRT provided by pharmacies.

Women seeking emergency contraception can currently access funded ECP through their GP and other services such as Family Planning Clinics.  From 1 December 2017, the proposal will allow women to access funded ECP without a prescription from pharmacies offering the service.

This decision relates only to the funding of the pharmaceutical component of smoking cessation or emergency contraception services offered by pharmacists. This means that, in addition to the $5 co-payment, a consultation fee may be charged to patients who receive NRT or ECP at the pharmacy. Patients should check with their local pharmacy if they offer these services and what the cost will be.

For community pharmacists

Community pharmacists will be able to claim for funded NRT (from 1 October 2017) and for ECP (from 1 December 2017), provided to patients without a prescription. Note that ECP can only be supplied without a prescription by a pharmacist who has completed an education programme accredited by the Pharmacy Council.

It is up to individual DHBs to decide whether to fund pharmacist consultation services for these products.

Pharmacists will be able to provide three months’ supply of NRT in monthly lots (and meeting all the Schedule rules that apply) from 1 October 2017 and claim for subsidy and dispensing fee in the same way as supply on prescription or Quitcard.

Pharmacists who are accredited by the Pharmacy Council will be able to provide the ECP, meeting all the Schedule rules that apply, from 1 December 2017 and claim for subsidy and dispensing fee in the same way as supply on prescription.

For prescribers (and existing providers of products in this proposal)

Existing mechanisms for access to these funded products will remain. NRT will continue to be available on prescription, Quitcard and Practitioner’s Supply Order (PSO). ECP will continue to be available on prescription and PSO.

For DHBs

The changes will enable DHBs to implement pharmacy-based smoking cessation programmes from 1 October 2017 and emergency contraception services from 1 December 2017.

Detail of this decision

From 1 October 2017, there will be a number of changes to Section A General Rules of the Pharmaceutical Schedule to allow pharmacists to provide subsidised access to specified products, without a prescription, that are already subsidised in the Pharmaceutical Schedule.

Broadly, these changes are:

  • A new definition of Prescribers, being those with legal prescribing rights, which includes medical practitioners, dentists, optometrists, nurse practitioners, midwives and designated prescribers, such as pharmacist prescribers, registered nurse prescribers and dietitians.
  • The existing term Practitioners will relate to all prescribers, as well as those who do not have prescribing rights but may authorise a subsidy: Quit Card providers, vaccinators and pharmacists.
  • Existing references to Practitioners will be amended to Prescribers for rules that relate to prescribing.
  • This change also clarifies that only prescribers are able to write Practitioner’s Supply Orders.

The full detail of these changes will be in the consolidated PDF Schedule on the PHARMAC website from 25 September 2017.

In addition, from 1 October 2017, existing rules 3.6 and 3.7 in Section A General Rules will be deleted and replaced with the following new rule:

3.6    Non-prescribing Practitioners

3.6.1 Dispensing on the authority of a Quitcard will only be subsidised where it is:

a. for any of the following Community Pharmaceuticals: nicotine patches, nicotine lozenges or nicotine gum; and
b. written on a Quitcard.

3.6.2 Provision of vaccines by Vaccinators

Vaccines will only be valid for subsidy in accordance with an agreement between the Contractor and the DHB, and only for direct administration of a vaccine to a patient.

3.6.3 Provision of a Community Pharmaceutical by a Pharmacist

Except where pursuant to a prescription, Quitcard or supply order, provision of a community pharmaceutical by a pharmacist will only be subsidised where specifically indicated in Section B of the Pharmaceutical Schedule.

A note will be added to the listing for nicotine in Section B of the Pharmaceutical Schedule from 1 October 2017 as follows (changes in bold):

NICOTINE

Nicotine will not be funded under the Dispensing Frequency Rule in amounts less than 4 weeks of treatment.

Note: may be provided by a pharmacist under the non-prescribing Practitioners provisions in Part III of Section A

A note will be added to the listing for levonorgestrel tab 1.5 mg in Section B of the Pharmaceutical Schedule from 1 December 2017 (changes in bold):

LEVONORGESTREL

❋ Tab 1.5mg                                                                    4.95    1     ✔ Postinor-1

    1. Maximum of 2 tab per prescription
    2. Up to 5 tab available on a PSO

Note: may be provided by a pharmacist under the non-prescribing Practitioners provisions in Part III of Section A

Our response to what you told us

We’re really grateful for the time people took to respond to this consultation. All consultation responses received by 21 August 2017 were considered in their entirety when making a decision. The below summarises the main themes raised in feedback, any changes we have made after listening to you, and other comments on the feedback.

If you have any questions, you can email us at enquiry@pharmac.govt.nz or call our toll free number (9 am to 5 pm, Monday to Friday) on 0800 66 00 50.

What you told us

This is a positive step - The proposed changes will meet Ministry of Health and local health objectives for New Zealanders, enable the development of DHB programmes and reduce barriers to access.

What you told us

There may be other costs and inequity could increase - The proposed changes relate only to the funding of pharmaceutical components (NRT and ECP). Any additional costs such as co-payments and service fees will be barriers to access for patients. It will be important that this is considered in any service provision agreed between DHBs and pharmacies.

Inequity could increase if not all DHBs enter into service arrangements with pharmacies

Our response

We agree that the funding barriers to wider and more timely uptake of NRT and ECP extend beyond the issue of subsidies.

While the change itself does not resolve the non-subsidy barriers, it enables DHBs to put in place service arrangements to do so.

What you told us

This creates a conflict of interest for pharmacists - This tacitly allows for both prescribing and dispensing to be performed by community pharmacists with potentially unintended consequences.

Our response

NRT and ECP are not prescription medicines and the generation of subsidy for these medicines is not the same as prescribing from a legal perspective. The proposal involved amending the Schedule rules to clearly reflect this distinction.

We note that this model already exists through established agreements with pharmacies in some regions.

We also consider that the Pharmacy Council Code of Ethics sufficiently addresses any potential conflicts.

What you told us

Services should be connected, not fragmented - The proposal could harm access to effective integrated care and might not achieve the desired outcomes at population level.

NRT provision needs to be connected to behavioural support services and ECP provision needs to involve referral to services for ongoing contraception planning and associated health services.

Direct and reliable reporting back to the patient’s GP must occur and be monitored.

Our response

We consider that the issue of information flows between GPs and other providers is important, and note that the issue already exists in the case of Quit Card providers and with private sale of these products. While we consider that the issue is an important one, we did not consider that it should prevent the progression of the proposal.

Management of clinical services relating to the provision of these products is the responsibility of DHBs, and resolution of these issues can be achieved through good service contracting with pharmacies.

We will work closely with TAS, who manage pharmacy contracting matters on behalf of DHBs, on this issue, and will ensure that they are aware of these concerns so that they can address them in the service contracting process.

To support this, we are delaying implementation of the ECP component until December 2017.

What you told us

There are concerns about clinical quality - A number of issues have been identified with the clinical guidelines supporting Pharmacist ECP supply and there are clinical practice concerns as a result.

Our response

We agree that it is important that pharmacists are provided the most accurate and up-to-date information as part of their training and accreditation. We understand that this feedback has separately been provided to the Pharmaceutical Society, and will ensure that TAS (on behalf of DHBs) is aware of the issues raised so that they can take these into account as part of their service contracting, and will recommend to them that they engage with respondents and the Society before finalising service specifications. To support this, we are delaying implementation of the ECP component until December 2017.

What you told us

Funded access to other products may improve outcomes – Improved clinical outcomes would better be achieved through funding additional treatment options for contraception and smoking cessation.

Our response

This change does not prevent other treatment options being funded in the future. We note that this change adds to a range of options designed to address access issues, including the funding of Jadelle on PSO earlier this year.

What you told us

Questions about additional products – People asked if we were intending to expand access to other products in this way, or just to ECP and NRT.

Our response

It is not our intention to add other products at this time, however we remain open to considering proposals for other products in the future once we have had an opportunity to review the impact of this change.