中山市人民医院发展战略PPT(23张)

密级：内部(3年)中山市人民医院发展战略研究Research on the Strategy of zhongshancity people’s hospital院（系、所）：经济管理学院专业：MBA申请人：芦岩指导教师：吴贵生2003年3月独创性声明本人声明所呈交的论文是我个人在导师指导下进行的研究工作及取得的研究成果。

尽我所知，除了文中特别加以标注和致谢的地方外，论文中不包含其他人已经发表或撰写过的研究成果，也不包含为获得清华大学或其它教育机构的学位或证书而使用过的材料。

与我一同工作的同志对本研究所做的任何贡献均已在论文中作了明确的说明并表示了谢意。

签名：日期：2003年3月30日关于论文使用授权的说明本人完全了解清华大学有关保留、使用学位论文的规定，即：学校有权保留送交论文的复印件，允许论文被查阅和借阅；学校可以公布论文的全部或部分内容，可以采用影印、缩印或其他复制手段保存论文。

(保密论文在解密后应遵守此规定)签名：导师签名：日期：2003年月日中文摘要由于传统计划经济的影响和政府对医疗资源的严格控制，我国医院行业的整体管理水平面临入世后市场竞争愈加激烈的局面。

强化战略管理是医院在新的竞争格局下建立长期竞争优势的首要举措。

本文以中山市人民医院发展战略的规划案例为核心，论述医院发展战略的制订方法。

首先通过对我国30多家大型医院和医疗管理部门的调研，论述了我国医院行业的管理现状、发展趋势、竞争环境、竞争机会和面临的威胁。

然后，对作为三级甲等国有医院的中山市人民医院进行了内部评估，论述了其发展的规律，近几年快速成长的客观动因和主观动因，其运作现状和优势、存在问题及劣势。

在内外环境调研基础上，研究了中山市人民医院的发展战略，包括总体战略（愿景、使命、核心价值观、目标体系、战略实施策略等）、业务战略（目标、发展类别、发展策略、竞争策略）、职能战略（人力资源、技术发展、质量管理、信息化管理、财务管理、市场营销管理6大职能的现状剖析、分期目标、职能定位与发展策略）、以及发展战略的实施策略。

世纪兼程————中山市人民医院五十周年回顾中山, 唯一以伟人名字命名城市, 珠江三角洲腹地一颗璀灿明珠。

中山人为这块热土孕育了孙中山先生这么世纪伟人而深感自豪, 中山市人民医院全体职员更为置身于改革开放伟大时代, 实现孙中山先生“医国医人”远大志向而倍感骄傲。

中山市人民医院创建于1950年3月16日, 其间几易其址、几度分合, 历经一代代人艰辛努力, 励精图治, 现已发展为中山市唯一一所集医疗、预防保健、科研和教学为一体国家级“三级甲等医院”。

1994年9月, 被卫生部、联合国儿童基金会和世界卫生组织命名为“爱婴医院”; 1997年5月, 被省卫生厅和省高教厅评为“广东省高等医学院校教学医院”; 1998年10月, 被省卫生厅授予“广东省百家文明医院”; 同年5月, 与美国夏威夷皇后医院缔结为姐妹医院; 3月, 与中山医科大学联合共建博士后流动工作站; 同年9月, 成为中山医科大学临床硕士教学基地。

中山市人民医院现位于孙文中路2号, 占地3万多平方米, 建筑面积6万2千多平方米。

设有24个临床专科, 55个专科门诊和中山市抢救中心、中山市肿瘤研究所、中山市临床医学研究所、中山市血液净化中心、保健中心、影像中心、白内障诊疗中心、听力中心, 是广东省临床医学继续教育基地。

拥有职员1000多人, 其中高级职称100多人, 年门诊量90多万人次, 年住院病人1.6万人次。

除院本部外, 还拥有东区分院、竹苑门诊、烟墩门诊和莲峰门诊（郑亮均医院）。

图: 淡色全景图为底色衬托上述文字说明。

图: 院徽、院歌一、建院早期（1950-1959）1、建院前中山医疗卫生概况中山原名香山, 南宋绍兴22年（公元1153年）设县。

公元14编纂《永乐大典》载: “香山为邑, 海中一岛耳, 其地最狭, 其民最贫。

”即使贫穷, 香山人还是注意医疗保健。

明永乐元年（14）, 程胜禄在香山县治西（今孙文西路）创办医学训术班, 由此可见, 当初不仅有些人行医, 还有医疗教育。

医院经营管理必须适应市场经济发展葛建华（杭州市红会医院）随着我国社会主义市场经济体制的建立和发展，医疗服务市场已逐步形成。

以医院为主体的医疗机构必须根据医疗服务市场的需求和变化，适应市场经济的发展深化改革，完善自我，以在市场竞争中求生存、求发展。

一、当前医院管理中存在的主要问题医院经营管理要适应市场经济发展，必须取决于与市场经济同步发展的管理体制、运行机制及经营手段。

而这方面特别是管理体制、运行机制正是目前我国医院在深化改革中，感到最困感、最棘手的问题。

医院的发展主要依赖于投入。

由于政府对医院的投入不足，医疗补偿机制不健全，医院面对市场经济体制的建立和发展，要在医疗服务市场的竞争中得以生存，就自然而然地导致了畸形发展；造成一系列问题。

⒈医疗卫生资源配置不合理，政府宏观调控不到位体现在各级各部门竞相办医，重复建设，城市医疗资源过剩，基层医院服务量不足；医疗服务模式单一，不能满足人群多层次多样化的需求，尤其是慢性病防治、老年护理、康复、妇幼保健、临终关怀等方面的医疗保健需求得不到满足；绝大多数医疗机构片面追求“五脏俱全”的经营模式，但医疗服务社会化程度低，医疗资源共享程度低。

这些现象导致医疗资源闲置、过剩或利用不足。

⒉医院缺乏经营管理自主权由于卫生行政部门的办医院管医院的职能没有改变，对医院人员编制、奖金额度、设备更新等，政府及主管部门仍然采用计划经济模式，医院缺乏经营管理自主权，淡化服务意识，缺乏经营意识，更谈不上成本核算与经济管理，导致内部管理乏力，资源浪费多利用少。

⒊医疗补偿机制不健全由于国家和政府对现行医疗收费统得过死，调整速度与市场经济发展很不相适应，制定收费标准时又采用以“不含工资的成本收费”和“不含拨款的成本收费”为定价原则，收费标准普遍较低，因此造成医疗补偿不健全。

二、市场经济条件下改革和完善医院经营管理若干对策⒈建立适应市场经济的经营管理体制。

在深化改革中，一要对医疗服务与市场经济的关系作深入系统的调查分析。

中山市人民医院门急诊大楼建设项目可行性报告一，门急诊大楼建设的项目背景1. 门诊大楼的现状中山市人民医院是一所集医疗、科教、预防保健为一体的“三级甲等医院” ，其门诊大楼始建于1991 年，建筑面积7000 余平方米，当年门诊量60 万人次，日均门诊量2300 人次。

随着中山市近几年居住总人口数量的稳步增加，人们对健康意识的改变，今年门诊量120 余万人次，日均门诊量4700 人次，单天高峰门诊量达6000 人次。

尽管医院科学合理的对门诊各科室统筹安排，并对门诊实行信息化管理，最大限度的缩短病人的就诊时间，目前的门诊大楼依然显得拥挤不堪，呈超负荷运转状态，无法满足日益增加的门诊患者的需求，门急诊大楼的改造迫在眉睫。

2．改造急门诊大楼的意义医院急门诊是整个医院的重要组成部分，是医院与社会联系的窗口，也是反映医院综合服务水平的场所。

绝大多数病人，都是在门诊部中得到诊断和治疗，住院病人多数是通过急诊或门诊而入院。

随着医疗新技术的推广和应用，一些过去必需住院治疗的疾病现在逐渐可以通过门诊治疗而解决问题。

老龄化社会的到来，老年人所患的慢性疾病长期在门诊接受治疗。

门诊医疗方便快捷的特点迎合了人们生活的需要。

急门诊作为医院的门户与窗口，在吸引患者就医，引导患者消费，积极参与医改等方面起着举足轻重的作用。

随着中山市经济的发展，城镇人口素质的提高，人们对医疗卫生的要求也越来越高，改造急门诊大楼，不仅能建立舒适的就医环境，而且能够确立中山市人民医院良好的形象。

医院是社会的一部分，扩大了规模和用途的新急门诊大楼，对中山市人民医院的未来发展，对中山市卫生事业和人民身体素质的提高都有着深远的影响。

中山市人民医院概况1. 医院简介中山市人民医院创建于1950年3月16日，是中山市唯一的一所集医疗、科教、预防保健为一体的“三级甲等医院” ，现位于孙文中路2 号，占地3.2 公顷，建筑面积6.4万平方米。

全院设有病床700张，临床专科24 个，专科门诊55 个，拥有工作人员1300多人，其中高级专业技术职称135人，研究生35 人，博士5 人，研究生导师5 人。

National Hospital PharmaceuticalStrategyFinal VersionPharmaceutical Management Agency1 February 2002Table of ContentsPAGE Executive Summary 51.0 Introduction 92.0 Current Market Overview 112.1 Current purchasing arrangements 112.2 Range of pharmaceuticals purchased 112.3 Data collection and analysis 112.4 Management of access to pharmaceuticals 122.5 The primary/ secondary care interface132.6 Distribution systems 133.0 Features and Objectives of a Strategy for Nationwide HospitalPharmaceutical Purchasing 144.0 Strategy Scope 184.1 Range of product-types included 184.2 Range of initiatives to be applied 184.2.1 Price management 184.2.2 Assessment of new pharmaceuticals 194.2.3 Promotion of quality in the use of medicines 214.2.4 Logistics management 225.0 Proposed Pricing Strategy Initiatives235.1 Application of reference pricing 235.2 Initial Request for Proposals 235.3 Alternative Commercial Proposals245.4 Sole supply arrangements 246.0 Implementation of a Nationwide Pharmaceutical Pricing Policy 256.1 Consultation with hospital managers and clinicians 256.2 Communication of national prices 266.3 Transitional arrangements 276.4 Assessment criteria 287.0 Monitoring and Measuring the Impact of the Strategy 317.1 Monitoring and analysis 317.2 Setting of expenditure targets 327.3 The impact of national contracts on costs of pharmaceuticals 327.4 NZ prices compared with overseas prices 338.0 Roles and Responsibilities 348.1 PHARMAC and PHARMAC’s Board of Directors 348.2 Hospital Pharmaceuticals Advisory Committee (HPAC) 348.3 DHBNZ 348.4 District Health Board’s 348.5 Hospital Managers 358.6 Ministry of Health 358.7 Hospital Clinicians 358.8 PTAC/Hospital Clinical sub-committees359.0 Proposed Timelines and Milestones 3610.0 Summary of proposed strategy for specific issues 3711. Other considerations 3911.1 Long-term impact on pharmaceutical market 3911.2 Effect on pharmaceutical research 3911.3 Effect on opportunities for clinical education 3911.4 National data systems 4011.5 “Orphan “ Section 29 medicines 4011.6 Potential mutual benefits for the primary and hospitals sectors 4012.0 Risks, Benefits and Costs of the Strategy 4112.1 Risks 4112.2 Benefits and Costs41 Glossary of terms and abbreviations 43 Appendix 1 Authorisation to PHARMAC from the Minister of Health 45 Appendix 2 Summarised consultation responses47PHARMAC’s overall objective, as outlined in Section 47 of the New Zealand Public Health and Disability Act 2000, is to secure for eligible people in need of pharmaceuticals, the best health outcomes that are reasonably achievable from pharmaceutical treatment and from within the amount of funding provided.Executive SummaryIn response to authorisation to perform a new funct ion given by the Minister of Health in September 2001, PHARMAC, in conjunction with representatives of the District Health Boards (DHBs), developed a strategy for nationwide purchasing of hospital pharmaceuticals (the “Strategy”), and undertook consultation with DHBs (CEOs, relevant managers, and provider units), clinical groups, pharmaceutical suppliers, and those other interested parties with whom PHARMAC usually consults. A summary of those responses and PHARMAC’s response to them is attached as Appendix 2. This second and final version of the Strategy will be presented to the Minister of Health in February 2002 with recommendations reflecting the views of PHARMAC and DHB CEOs.Changes to the scope of the draft Strategy, in terms of the way it is proposed PHARMAC would be involved in assessment of New Pharmaceuticals, revisions to the proposed structure and function of Section H of the Pharmaceutical Schedule, and policy details pertaining to national sole and/or preferred supplier arrangements, should be noted. It is also proposed that the Strategy be reviewed in 2 years time.The key objectives of the Strategy are to:(a) obtain the best possible value for money spent by DHBs on Pharmaceuticalsused in hospitals;(b) improve national consistency of access to Pharmaceuticals used in hospitals;and(c) establish a co-operative purchasing framework by collaboration between theDHBs.Consultation has highlighted that many stakeholders believe improved health outcomes should also be an objective of the Strategy. While this fits well with PHARMAC’s current legislative objective, it is likely to be difficult to monitor and measure in the hospital sector without extensive research and monitoring. However, the welfare of patients will be a key consideration in any decision criteria PHARMAC adopts under this Strategy. The fiscally oriented objectives of the Strategy will need to be balanced against the needs of the DHBs’ patients and clinicians, with consideration of any adverse impact on clinical outcomes. Consultation has highlighted some of the areas where PHARMAC’s ability to achieve this balance has been noted as a concern. Those areas are addressed in this version of the Strategy.It is acknowledged that initiatives to reduce price, and manage the costs/utilisation of Pharmaceuticals used in hospitals, are already in place in most DHBs. This Strategy aims to build on these initiatives, through a process of co-operation and collaboration between PHARMAC and the DHBs, in order to improve patient outcomes, and ensure maximum value for money from current and future investment in pharmaceutical technology used in hospitals. A constructive relationship between pharmaceutical suppliers and PHARMAC will also be helpful to the success of the Strategy.Key features of the proposed Strategy, once fully functional, would include:• Management of hospital and community expenditure on Pharmaceuticals according to a joint national target (a notional figure set with reference to monies held byDHBs/hospitals). It is not intended that PHARMAC would actually purchase the Pharmaceuticals.• Nationally consistent pricing policies covering 90% of DHB's spending on Pharmaceuticals used in hospitals (with provision for choice within the limits defined in contractual “Discretionary Variance” clauses for any patients whose health needs fall outside any contractually derived policy boundaries PHARMAC might set).• The establishment of a new section of the existing Pharmaceutical Schedule (“Section H”), containing the list of Pharmaceuticals used in hospitals for which PHARMAC has negotiated national contracts on behalf of the DHBs. Section H may also list those pharmaceuticals affected by national arrangements (such as products within a therapeutic sub-group affected by preferred supplier arrangements and alternative brands of chemicals under sole supply arrangements which could only be used within DV provisions). It is likely that Section H would be published separately from, but would legally form part of, the existing Pharmaceutical Schedule.• Full compliance with any national pricing contracts (where such compliance would permit DHBs to purchase other Pharmaceuticals within the contractually agreed Discretionary Variance limits), once existing supply contracts held by DHBs have expired or been terminated. DHBs could still choose to purchase outside the DV limits but would be exposed to losing financial incentives or incurring financial penalties. No DHB would be able to enter into any contract which would compromisea national pricing co ntract.• A centralised assessment process run by PHARMAC to appraise the clinical benefits and cost-effectiveness of New Pharmaceuticals. This process would assist DHBs to ensure that access to New Pharmaceuticals in their hospitals was consistent, where appropriate, with access in other DHBs. It is proposed that, over the first two years, this national process would run in parallel with, and augment, assessment processes that would [continue to] be undertaken by each individual DHB.• Information systems that mesh full national hospital utilisation and clinical data, where possible, in a format that is consistent with similar data collected in the primary care setting.• A national programme aimed at improving quality in the use of medicines by promoting best practice in the use of Pharmaceuticals within hospitals, and at the hospital/primary care interface.The Strategy was originally developed to focus initially on the purchase of:(a) Pharmaceuticals;(b) X-ray contrast media; and(c) IV fluids.However, it is now proposed that inclusion of X-ray contrast media and IV fluids within the scope of the Strategy should wait until the proposed mechanisms for national contracting have been established for Pharmaceuticals.PHARMAC proposes that the Strategy should initially include the following elements as a minimum:(a) price management; and(b) assessment of New Pharmaceuticals; and(c) promotion of quality in the use of medicines (QUM).It is also proposed that logistics management be further investigated for possible inclusion within the scope of the Strategy.It is acknowledged that inclusion of assessment of New Pharmaceuticals and QUM brings a wider focus to the Strategy than indicated by its current title. For this reason, it is proposed that the Strategy should more correctly be referred to as the “National Hospital Pharmaceutical Strategy.”Some of the initiatives proposed by PHARMAC to manage DHB expenditure on Pharmaceuticals used in hospitals are likely to be similar to those used in the community setting, but there are some notable differences. The application of reference pricing is not proposed, procedures for managing proposals would more closely involve representatives of the DHBs (including hospital based clinicians), and implementation of sole supply arrangements would be more flexible (refer to section 5.0). An initial request for proposals process, commencing in mid-2002 is proposed. However, subject to specific caveats, PHARMAC and the DHBs would consider proposals submitted by suppliers outside of that process at any time.Key features of the Strategy would be process transparancy and consideration of clinical concerns. Clinical issues would be discussed by PHARMAC, the clinical advisory committee(s), and HPAC before changes are implemented. Choice in the range of pharmaceuticals available within therapeutic groups would be maintained although the number of brands of particular chemicals, where generic competition exists, could be limited via contractual arrangements. Discretionary Variance provisions would provide flexibility to meet the needs of small numbers of patients who may fall outside the provisions of national contractual arrangements.The Strategy provides for national co-ordination and collaborative extension of many of the current systems already in place within individual DHBs. These include systems for assessing, and contracting for the supply of pharmaceuticals, processes for assessing new Pharmaceuticals and initiatives aimed at promoting best clinical practice where Pharmaceuticals are utilised in the care of patients.Implementation of the Strategy would require consideration of existing and/or new supply contracts entered into by DHBs individually and prompt resolution of current data issues that have to date, prevented PHARMAC from compiling or accessing a national dataset of pharmaceutical utilisation and expenditure for the hospital sector. The approach to these issues we have recommended is likely to require the input of resources, as well as co-operation, from DHBs (refer to sections 6.3 and 7.1).Based on specific feedback invited on what assessment criteria should be applied to the assessment of New Pharmaceuticals and of commercial proposals arising from the strategy, PHARMAC proposes to adopt its current criteria with the addition on a hospital-specific criterion (refer to section 6.4).The anticipated benefits of the Strategy are:• gradually improved consistency of prices for and access to Pharmaceuticals throughout New Zealand;• increased dialogue and co-operation on pharmaceutical issues facing all DHBs’ provider arms;• a more co-ordinated approach to Pharmaceutical use across primary and secondary care;• greater impetus to establish a national dataset for Pharmaceuticals used in hospitals;• a modest reduction in the prices paid for Pharmaceuticals used in hospitals (which would not necessarily result in an overall fall in total Pharmaceutical expenditure);• greater co-ordination of efforts to promote cost-effective utilisation of Pharmaceuticals; and• better utilisation of DHBs’ pharmacy and/or pharmaceutical procurement resources.1.0 IntroductionIn July 2001, the Minister of Health, the Honourable Annette King, announced her intention to authorise PHARMAC to lead a strategy for nationwide hospital pharmaceuticals purchasing (the “Strategy”). The new function issued by the Minister, which was published in the New Zealand Gazette in September 2001 (copy attached asAppendix 1), fits within the context of PHARMAC’s overall objective - to secure for eligible people in need of pharmaceuticals, the best health outcomes that are reasonablyachievable from pharmaceutical treatment and from within the amount of funding provided.The specific, key objectives of the Strategy are to:(a) obtain the best possible value for money spent by DHBs on Pharmaceuticalsused in hospitals;(b) improve national consistency of access to pharmaceuticals used in hospitals;and(c) establish a co-operative purchasing framework by collaboration between theDHBs.Implicit in these objectives is the presumption that the overall health status of New Zealanders should not be compromised as a consequence of this Strategy and, where possible, should be improved. It is acknowledged that the fiscally oriented objectives of the Strategy and constraints on VoteHealth will need to be balanced against the needsof the DHBs’ patients and clinicians, in terms of clinical outcomes.PHARMAC has developed, in consultation with advisors from the DHBs via the HospitalPharmaceuticals Advisory Committee (HPAC), a Strategy document and has conducted extensive consultation with DHBs, hospital clinicians and the pharmaceutical industry.Revisions have been made following consultation and this final Strategy document will be presented to the Minister of Health with a recommendation from PHARMAC staff inFebruary 2002.In developing the Strategy, HPAC concluded that, in order to ensure continued gains from the Strategy in the longer term, consideration would need to be given to the manner in which Pharmaceuticals are utilised within hospitals, in addition to their price and availability. It acknowledged that, as a consequence of the inclusion of these concepts, the scope of the Strategy is wider than indicated by its current title. For this reason, it is proposed that the Strategy should more correctly be referred to as the “National Hospital Pharmaceutical Strategy.”The Strategy document sets out:• A detailed plan and objectives for the Strategy.• Proposed initiatives, milestones and a timeline for implementation of a two year programme beginning during the current financial year.• Details of any transitional arrangements necessary to enable PHARMAC to manage the purchasing of some Pharmaceuticals on behalf of DHBs.• A definition of roles for all parties to be involved in the implementation of the Strategy.• Assessment of the costs, risks and benefits of the Strategy.• Proposed key performance indicators.2.0 Current Market Overview2.1 Current purchasing arangementsAlthough some DHBs have already entered into joint arrangements, purchasing of pharmaceuticals for use in hospitals is in most cases currently managed by each individual DHB. Most DHBs purchase the bulk of their hospital-only pharmaceuticals via contracts with pharmaceutical suppliers. Many of these contracts are described as “bundled deals” where DHBs negotiate prices across a range of pharmaceuticals, obtaining lower prices on some products in exchange for acceptance of higher prices than they might otherwise achieve on others. Some hospitals (Auckland and Christchurch) have achieved savings by running competitive tender processes.Where the DHBs have no contracts with suppliers, pharmaceuticals are purchased at the suppliers’ hospital list prices. Where such products are available on the Pharmaceutical Schedule, the prices (ex manufacturer) paid by DHBs may be the same as the subsidy set by PHARMAC.2.2 Range of pharmaceuticals purchasedThe range of products purchased by DHBs within the existing “pharmaceutical” purchasing arrangements varies from hospital to hospital. In addition to what are conventionally considered to be pharmaceuticals, some hospitals include such things as X-ray contrast media, IV fluids, total parenteral nutrition or special foods within this function, whereas others manage some or all of these other purchases separately. A number of unapproved and/or “orphan” pharmaceuticals may also be included. This variation contributes to the difficulties associated with comparing pharmaceutical expenditure between DHBs.2.3 Data collection and analysisNo national price database exists to enable a comparison of prices paid across the sector. Hospitals currently use a variety of computer systems to record information about their pharmaceutical purchasing and utilisation. Issues of confidentiality, and a lack of consistency in the way each hospital records and/or codes data are both barriers to the compilation of a national dataset. However, work on this issue done by Counties-Manukau last year suggests that there are price disparities acr oss the DHBs, and that no individual DHB is consistently achieving the lowest prices across the entire range of commonly used pharmaceuticals. Some of this variation may be explained by differences in the timing of contract negotiations between hospitals and the complexities associated with prices negotiated for “bundles” of pharmaceuticals. However, the fact that some suppliers have insisted that the pricing information contained in their contracts be kept confidential, supports the notion that some hopsitals pay more for their pharmaceuticals than others.Hospitals are beginning to develop systems which enable them to track pharmaceutical utilisation at an individual patient level. Automated drug distribution systems in place in some areas are capable of tracking up to 95% of use to an individual patient level. However, most DHBs can still only track use at a patient level to a limited degree, and phamaceutical utilisation is not yet fully trackable within any hospital. From the limited data available, it seems likely that there is variability in the needs, and thereforedemand, for pharmaceuticals within each hospital. For example, those hospitals that provide specialists services are more likely to have a greater demand forpharmaceuticals related to that speciality. However, universally the key therapeutic groups contributing to pharmaceutical expenditure include:• antibiotics;• cardiovascular drugs;• psychiatric medicines;• anaesthetic agents; and• cancer treatments.2.4 Management of access to pharmaceuticalsSystems for determining which pharmaceuticals can be used in each hospital, and processes for assessing New Pharmaceuticals before they are made available inhospitals, are in place within all DHBs. Most hospitals also manage some type of formulary or preferred medicines list (PML). Although the degree to which adherence tothese lists is enforced varies, it is widely held that the input of local clinicians into such formularies is a factor in their acceptance and effectiveness. Where guidelines for use and/or restrictions on access to certain pharmaceuticals exist, it is acknowledged that clinician compliance with such rules is dependent on the breadth of range ofpharmaceuticals available within the hospital, and degree of clinician input into the selection of this range. Making changes to the range of agents listed on a PML orformulary can also be difficult when preferences for certain brands or products become established.Some DHBs impose restrictions on access to pharmaceuticals by exclusively stocking one product. In many cases, the continued availabilty of an alternative product relies onanother DHB contracting for its supply. There is currently little or no conscious co-ordination of this approach.Many hospitals undertake drug utilisation reviews to ensure “best clinical practice” in theuse of them and have demonstrated an ability to indirectly produce savings in pharmaceutical expenditure via this method. Most appear to endeavour to manageexpenditure on New Pharmaceuticals by subjecting them to a multi-disciplinary clinical assessment process involving clinicians, and pharmacists. Where clinical budget holding exists, service manager approval may be required before a product can be added to a PML or formulary. These processes appear to work quite well at a local level because they ensure clinicians have had input into the decisions made. However, the process can create tensions between speciality groups. Use of New Pharmaceuticals and/or existing pharmaceuticals for new indications sometimes preceeds formal assessment, and internal budgeting arrangements can be an incentive for the approval of new medicines.While hospital managers tend to consider access to subsidies for new agents in the community, the criteria against which they assess new treatments vary. The rigor of the analysis, and the degree to which cost-effectiveness is considered when determining whether pharmaceuticals should be used within each hospital also appears to be quite variable. Some cost analysis is undertaken by most hospitals prior to introduction of New Pharmaceuticals. However, cost-benefit analysis is currently rarely performed, duein part to the limited availability of reliable and meaningful costing data relevant to the sector.Differences in the assessment processes and criteria may partly account for the fact that New Pharmaceuticals (or existing pharmaceuticals for new indications) are sometimes funded within some hospitals but not in others or, where funded universally, are subject to different caveats. In these cases, problems can arise when patients transfer from one hospital or DHB to another. However, this may be more of an issue when patients transfer from tertiary or quarternary services to secondary care or where they transfer to the care of a clinician who does not normally practice in the same speciality.2.5 The primary/secondary care interfacePatients who require on-going pharmaceutical treatment after hospitalisation are often discharged with a prescription reflecting the pharmaceutical treatment administered during their stay or prescribed treatment in an out-patient setting. However, patients are rarely discharged from hospitals with supplies of the pharmaceuticals they require. Their discharge prescriptions, like prescriptions for out-patients, may not reflect the availability of pharmaceuticals in the primary care sector. In certain cases, hospitals explicitly fund pharmaceuticals because they are not available on the Pharmaceutical Schedule. The scope for improved patient care via better communication between the primary and secondary care sector, and consistency of access to pharmaceuticals in both areas is widely acknowledged.2.6 Distribution systemsThere is variation between DHBs in the way pharmaceuticals are distributed. Pharmaceuticals purchased directly from Health Support Services (HSL) in some areas, may account for 50% of the volume of pharmaceuticals nationally. HSL provides a range of services to DHBs including logistics, purchasing, and inventory management. Some DHBs utilise only the logistics services offered by HSL, while others rely on HSL to negotiate prices for some pharmaceuticals on their behalf, and purchase on consignment from HSL also. Other DHBs purchase their pharmaceuticals through other wholesalers or directly from pharmaceutical suppliers. Some have direct-to-ward delivery arrangements with such organisations.3.0 Features and Objectives of a Strategy for Nationwide HospitalPharmaceutical PurchasingThe broad objectives of the Strategy already outlined, are aimed at achieving the bestpossible value for money spent by DHBs on Pharmaceuticals used in hospitals, and to improve nationally consistency of access to Pharmaceuticals across all DHBs whereappropriate. It is acknowledged that the need for Pharmaceuticals in hospitals depends to some extent on the range of services provided by the hospital. However, there have been notable areas of common care where access to Pharmaceuticals has been inconsistent. The Strategy aims to focus on areas such as these.Opportunity exists within the broader scope of the Strategy, to maximise patient outcomes from DHBs’ investments in New Pharmaceuticals. The range of initiatives proposed in respect of price and access to Pharmaceuticals, may at times affect choice in order to create a commercial environment that is conducive to obtaining better value for money. Where this is likely, fiscal gains would be balanced against consideration of the effect on patient care. However, in acknowledgement of concerns about the long-term impact of such initiatives on health outcomes, continuation of the Strategy will be reviewed 2 years post-implementation.Since DHBs are responsible for all expenditure on pharmaceuticals, it is proposed that the success o f the Strategy would be measured, in conjunction with the impact of PHARMAC’s initiatives in the community setting, against a nominal expenditure target for both areas. No budget transferance is, however, proposed. There would be no change to the DHBs’ f unding payments to hospitals, which currently provide for their pharmaceutical use, and funding for pharmaceuticals used in primary care would remain with the DHBs.Given the range of Pharmaceuticals used in hospitals, including a larger number of unapproved and/or “orphan” pharmaceuticals than are used in the primary care setting, it is probably not possible to put national contracts in place for all Pharmaceuticals included within the scope of the Strategy. Therefore, PHARMAC’s aim would be to ultimately put in place national supply contracts for about 90% of the value of Pharmaceuticals used in hospitals. This would account for a much smaller proportion (about 10%) of the entire range of Pharmaceuticals used in hospitals. These contracts would ideally confer a net clinical and/or commercial advantage (including net savings) against the current arrangements, if not for every individual DHB, then at least across all DHBs. It is possible that some hospitals would pay more for some Pharmaceuticals but it is expected that the additional costs of those pharmaceuticals would be more than offset by savings made on others.A key objective of the Strategy would be to ensure the compliance of all DHBs with any national arrangements PHARMAC may put in place. I t is proposed that hospitals would be able (and ultimately obliged) to purchase those Pharmaceuticals that are the subject of a national contract, at a single, national price negotiated by PHARMAC. Where there were no national arrangements, hospitals would be able to secure their own purchase arrangements.Compliance with national arrangements is likely to be closely linked with the fiscal and clinical acceptability of national arrangements. Therefore, key features of the Strategy would be process transparency and consideration of clinical concerns. Clinical issues。