NHS GRAMPIAN
Review of continued dispensing from the Haddo Medical Group following the
opinion of Lord Doherty
1. Actions Recommended
The Board is required to accept, reject or amend the recommendations of the
Review Group set up to consider the continued provision of dispensing from the
Haddo Medical Group. This latest review is a consequence of Lord Doherty's Judicial
Review findings against NHS Grampian, published on 9th September 2014, in
respect of the decision to allow continued dispensing of medicines by the Haddo
Medical Group for patients living in all areas except that covered by the Tarves
neighbourhood.
1. It is recommended that the Grampian NHS Board, under the authority granted to
it under the National Health Service (General Medical Services Contracts)
(Scotland) Regulations 2004 Paragraph 44 of Part 3:
a) Continues its authority for Haddo Medical Group to dispense to patients
who have a serious difficultly in obtaining their medication from a
pharmacist.
b) That this authority should be limited to dispensing to patients, living outside
the neighbourhood of Tarves, who ‘will have serious difficulty in obtaining
from a pharmacist any drugs … required for that person's treatment' by
virtue of both the need to obtain medication following the issuing of an
acute prescription and that on that day they do not have access to a car to
travel to a pharmacy.
2. It is recommended that prior to implementing this decision NHS Grampian
should:
a) Undertake an impact assessment of implementing the recommended
limitation on dispensing, by the Haddo Medical Group, to the delivery of
General Medical Services to the area and any consequences this limitation
might have on the duties of NHS Grampian in the discharge of its
responsibilities to the local population.
b) Work with local stakeholders to agree a timeline for the implementation of this
limitation on dispensing as soon as reasonably practicable, following the
impact assessment, in the interests of all affected parties.
3. It is further recommended that NHS Grampian conducts a review of general
practice dispensing across the region to formulate clear objective criteria around
interpretation of the General Medical Services regulations to ensure patients
have access to the most appropriate services to meet their clinical needs.
2. Strategic Context
The norm in primary care in Scotland, along with the rest of the UK, is that General
Practitioners prescribe medicines and community pharmacies dispense those
prescribed medicines. This norm is supported by the regulatory framework
applicable to both General Medical Services and Pharmaceutical Services.
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In some parts of rural Scotland, the NHS relies on dispensing doctors to provide
dispensing services to their own patients who are unable to secure the dispensing
services of a community pharmacy. In these cases the dispensing doctor service
plays a vital role in the provision of NHS medicines. Scottish Government has
recently amended the control of entry regulations, governing the award of new
community pharmacy contracts in Scotland, to include an assessment of the impact
of a proposed new pharmacy on existing NHS service provision, specifically
including the impact on dispensing doctor practices. These amendments do not
apply retrospectively to situations such as this, where the pharmacy is already
established.
The Haddo Medical Group has a long history of dispensing medicines to its patients
living in and around its main surgery in Pitmedden and satellite surgeries at Tarves
and Methlick. This dispensing has taken place at the request of the NHS Board
which considered that patients living in these areas historically had a serious
difficulty in accessing prescribed medicines from a pharmacy.
NHS Grampian originally reviewed the continued provision of dispensing from the
Haddo Medical Group following the opening of Tarves Pharmacy in early 2012 and
again later that year. This new review is a consequence of Lord Doherty's Judicial
Review findings against NHS Grampian, published on 9th September 2014, in
respect of the decision to allow continued dispensing of medicines by the Haddo
Medical Group for patients living in all areas except that covered by the Tarves
neighbourhood.
Lord Doherty's findings focused on two areas:
a) The decision was unlawful in not providing Tarves Pharmacy with the
opportunity to represent itself at the review panel and the NHS Board Meeting. This
was in contrast to the Community Council which was permitted to attend and present
to both. This was deemed unfair and unlawful.
b) The decision was unlawful as it permitted continued dispensing for all patients
living outside of the Tarves neighbourhood despite the review panel finding that only
a proportion of individuals in that population had a serious difficulty of access to a
pharmacy.
NHS Grampian has to decide whether patients who currently get, or are eligible to
get, their dispensed medicines from the GP practices at Pitmedden or Methlick have
a serious difficulty in accessing dispensed medicines from a community pharmacy.
The National Health Service Regulations covering General Medical Services only
permit NHS Grampian to request Haddo Medical Group to dispense for its patients
where, after consultation with the Area Pharmaceutical Committee, it is "satisfied that
a person, by reason of (a) distance;
(b) inadequacy of means of communication; or
(c) other exceptional circumstances,
will have serious difficulty in obtaining from a pharmacist any drugs, medicines or
appliances, other than scheduled drugs, required for that person's treatment..."
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3. Key matters relevant to recommendation
Legal Authority: NHS Grampian can only act within the legal authority available to it
as laid out under the National Health Service (General Medical Services Contracts)
(Scotland) Regulations 2004 Paragraph 44 of Part 3. This authority is clearly limited
to the assessment of serious difficulty and does not extend to the potential impact of
any associated decision to restrict or end dispensing services from the general
practice, regardless of how long such arrangements have been in place or the nature
of the impact. To do otherwise would expose the decision to further judicial challenge
which NHS Grampian could expect to lose if it had allowed factors to influence its
decision making that were not permissible under the regulations.
Potential for impact on General Medical Services: The Haddo Medical Group, when
previously given notice to cease dispensing for patients living in and around
Pitmedden, sought to close the satellite surgery at Tarves due to the resulting
financial impact from loss of dispensing income to the Group. The impact of the
decision to restrict dispensing on the Haddo Medical Group will need to be
considered to assure the Board that NHS Grampian continues to discharge its
responsibilities for the provision of General Medical Services to the local population.
Operational difficulties in applying the decision: There may be a number of
operational difficulties in applying the decision which will require to be addressed e.g.
the ability of the Haddo Medical Group to provide the services requested by the
Board from the more limited income stream associated with dispensing in the future,
the need for guidance to support the practice and patients in ensuring that the Haddo
Medical Group only dispense to patients under the authority provided.
Timescale of implementation: Normally NHS Grampian would provide 12 months
notice to a practice to cease dispensing for patients in order to allow for a managed
takeover of patients and the run down of stock that the practice had invested in.
Given the long period of time that has taken place since the opening of the pharmacy
in Tarves, the previous 12 month period of notice applied to an earlier decision and
the delays due to the Judicial Review it should be noted that any delay in
implementing the decision should be avoided insofar as reasonably practicable.
Wider review of dispensing practices in NHS Grampian: NHS Grampian is committed
to a review of dispensing practices in NHS Grampian. The planning of this review
started in 2013 but it became clear that there was a strong risk of legal proceedings
being brought against NHS Grampian with regard to its Haddo decision. It was felt
that to undertake the wider review whilst there was a risk that the Haddo decision
was to be challenged would be inappropriate.
NHS Grampian would have liked to have reviewed the Haddo decision as part of this
wider review. However, the urgency and timescale of decision making has been
driven, to a large extent, by Lord Doherty’s By Order hearing, which went ahead on
7th October 2014. The purpose of the By Order was to satisfy Lord Doherty that the
Health Board was taking appropriate steps to revisit its earlier decision in light of the
court’s ruling. At the Judicial Review of NHS Grampian’s previous decision Lord
Doherty granted declaratory of unlawfulness but refrained from immediately granting
decree of reduction which he recognised would give rise to administrative difficulties
for NHS Grampian and the Haddo Medical Group. Legal advice indicated that an
extended timescale to allow consideration of the decision as part of a wider review
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risked being seen as too lengthy. It was considered that this carried the risk that at
the By-Order hearing the extant decision of NHS Grampian to allow continuation of
dispensing by the Haddo Medical Group would be rolled back to the previous
decision to cease dispensing for Pitmedden patients. Legal advice was that this
would lead to cessation of dispensing for Pitmedden patients with immediate effect
whilst the Board undertook its wider review. NHS Grampian took the view that the
disruption to patient care and the impact on the GP practice, particularly in the event
of ceasing dispensing and then having to restart at a later date, were not in the best
interest of any of the parties involved.
Risk of further challenge: There may well be further challenge to this decision given
the history and strong feeling among some members of the local population and their
representatives.
4. Risk Mitigation
The key risk mitigated by implementation of this decision will be to have revisited a
decision that was deemed unlawful and in doing so complied with the judicial
requirements placed on NHS Grampian in line with the extant regulations.
5. Responsible Executive Director and contact for further information
If you require any further information in advance of the Board meeting please contact:
Responsible Executive Director
Dr Nicholas Fluck
Medical Director
nfluck@nhs.net
Contact for further information
David Pfleger
Director of Pharmacy & Medicines
Management
david.pfleger@nhs.net
9 January 2015
Additional supporting information
Board members may on request be provided access to the supporting papers
provided to the Review Group including:
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Public Consultation Responses
General Population Health Status – Health and Wellbeing Profiles
Travel Information and Mapping
The National Health Service (General Medical Services Contracts) (Scotland)
Regulations 2004
Aberdeen CHP Pharmaceutical Care Service Plan
Pharmacy and GP Practice Lists
Written submissions by interested parties and presentations
Judicial Review decision by Lord Doherty
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Appendix 1
Key milestones in the review of dispensing from the Haddo Medical Group and
provision of pharmaceutical services from Tarves and Pitmedden.
1. NHS Grampian has historically required the Haddo Medical Group to provide
dispensing services as it had agreed that patients using the main practice in
Pitmedden and the satellite practices in Tarves and Methlick had serious
difficulty in accessing prescribed medicines from a pharmacist.
2. NHS Grampian originally rejected an application for a new pharmacy in
Tarves in December 2010, but that decision was overturned by the National
Appeal Panel in June 2011 (available under hearings at:
http://www.shsc.scot.nhs.uk/shsc/default.asp?p=131
3. NHS Grampian also rejected an application for a new pharmacy in Pitmedden
in December 2010
http://www.nhsgrampian.org/nhsgrampian/gra_display_simple_index.jsp?pCo
ntentID=7680&p_applic=CCC&p_service=Content.show&
4. An appeal by the applicants for the pharmacy at Pitmedden to the National
Appeal Panel was dismissed in April 2011. (available under hearings at:
http://www.shsc.scot.nhs.uk/shsc/default.asp?p=131
5. In light of the opening of the new pharmacy at Tarves in December 2011,
NHS Grampian reviewed its requirement for dispensing by the Haddo Medical
Group. In early 2012 Haddo Medical Group were given 12 month’s notice to
cease dispensing services to registered patients living within the
neighbourhood of the pharmacy, as defined by the National Appeal Panel.
This cessation was in line with the NHS Grampian protocol in place at the
time.
6. Soon after communication of this decision NHS Grampian received feedback
from the pharmacy contractor in Tarves. This challenged the legality of using
the neighbourhood of the pharmacy to define patients who no longer have
serious difficulty in accessing prescribed medicines from a pharmacist.
Following advice from the Central Legal Office it was agreed that NHS
Grampian would revisit the decision as to which, if any, patients registered
with Haddo Medical Group should continue to receive dispensing services
from the GP practice. This advice confirmed that whilst in applying for an NHS
community pharmacy contract there was a need to demonstrate inadequacy
of services in a neighbourhood; this neighbourhood did not define the area to
which the pharmacy could be deemed to provide services.
7. In revisiting the original decision NHS Grampian undertook significant
stakeholder engagement. The main stakeholders – patients, public, public
representatives, Independent General Practice & Independent Community
Pharmacy contractors were consulted with representations, letters and survey
reports made available to the Decision Making Group. The review concluded
that the new community pharmacy took away any difficulties in obtaining
medicines in Tarves and that there was no serious difficulty of access to
pharmaceutical services for patients living in and around Pitmedden. The
recommendation was presented to, and accepted by, the NHS Grampian
Board at its April 2012 meeting.
8. April 2012 Board papers Item 8 available at:
http://www.nhsgrampian.org/nhsgrampian/files/item08alldocsDispensingHadd
oCrimmondrevised.pdf
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9. April 2012 Board minutes available at:
http://www.nhsgrampian.org/nhsgrampian/gra_display_simple_index.jsp?pCo
ntentID=5210&p_applic=CCC&
10. Following the April 2012 Board meeting NHS Grampian communicated the
NHS Board’s decision to the Haddo Medical Group and further definition of
the boundaries of continued dispensing for patients living in and around
Methlick was undertaken by Community Health Partnership representatives
and the Haddo Medical Group.
11. Following the notice to discontinue dispensing for patients living in and around
Tarves and Pitmedden, the Haddo Medical Group, which is an independent
contractor, notified NHS Grampian of its intention to close the branch surgery
in Tarves. This was reluctantly supported by NHS Grampian as there was felt
to be no other viable option and that whilst the geographical points of access
to General Medical Services offered by the Haddo Medical Group were
changing the services themselves remained the same.
12. The decision by the Haddo Medical Group to close its Tarves branch surgery
was a result of the cross subsidisation of their general medical services from
dispensing income. From an NHS Board perspective the financial support for
dispensing by general practice was put in place to cover the additional costs
of providing dispensed medicines for registered patients. Dispensing by
general practice was not envisaged to provide a net financial benefit to a
practice. Aberdeenshire Community Health Partnership worked with the
practice to explore the financial impact of the loss of dispensing income and
associated risks to the services they provide. Unfortunately, without the
additional income generated by dispensing, the practice had to review the
services it could provide in order to achieve financial balance. This led to their
decision to close the Tarves branch surgery.
13. A series of meetings continued to take place with key stakeholders and the
community following the receipt of the practice’s notification that it intended to
close the branch surgery at Tarves. A meeting in September 2012, which
was hosted by the Rt Hon Alex Salmond MSP with representatives of NHS
Grampian, the community councils and the local community focused on
concerns of some of those present that the Board had failed to assess serious
difficulty of access appropriately and that circumstances had changed since
the decision to restrict dispensing was made. NHS Grampian agreed to work
with the representatives of the community, Community Councils and other
interested stakeholders to clarify issues raised at the meeting. NHS
Grampian agreed that the concerns raised at the meeting justified a further
review of the decision to restrict dispensing for patients of the Haddo Medical
Group.
14. NHS Grampian held a further meeting with the Rt Hon Alex Salmond MSP
and representatives of the community councils in October 2012 to support the
community councils in clarifying their challenge to the NHS Grampian decision
to restrict dispensing by the Haddo Medical Group.
15. A new review panel met on 22nd November 2012 and the community councils
were offered the opportunity to present their case to the panel meeting. The
Review Panel considered all of the evidence presented to it and accepted that
the Community Councils’ presented new evidence demonstrated serious
difficulty by reason of inadequacy of means of communication. (Interpreted by
the Review Panel around the provision of public transport for a proportion of
the Pitmedden Community.)
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16. The Review Panel recommended that the Board, in light of new evidence,
reconsidered its April 2012 decision and recommended that the Haddo
Medical Group continued to dispense NHS prescriptions to its practice
population with the exception of the Tarves neighbourhood, which was
defined by the National Appeal Panel as the village of Tarves surrounded on
all sides by agricultural green land.
17. At its meeting of 4th December 2012, Grampian NHS Board accepted this
recommendation. Papers available at
http://www.nhsgrampian.org/nhsgrampian/gra_display.jsp?pContentID=8368&
p_applic=CCC&p_service=Content.show&
18. There was also agreement at the 4th December Board meeting that a wider
review of difficulty of access to pharmaceutical services would be undertaken
as part of the Board's pharmaceutical care service planning process. This
review was planned to begin later in 2013 to include consideration of existing
arrangements where the NHS Board have requested dispensing by GP
practices and the designation of some community pharmacies as essential
under the Essential Small Pharmacy Scheme. These reviews would be led by
the relevant Community Health Partnerships.
19. Reinstatement of dispensing by the Haddo Medical Group for patients living in
and around Pitmedden was followed by the Practice reopening its satellite
surgery in Tarves.
20. On 27th May 2013, NHS Grampian considered an application to provide new
NHS Pharmacy Services from a proposed pharmacy in Pitmedden, to be
located within the premises of the Haddo Medical Group. This application was
made by the community led B999 Health Trust. This application was
considered in line with the Scottish Pharmaceutical Service Regulations.
21. The application for new pharmacy services in Pitmedden was turned down on
the basis that there were adequate pharmacy services already available to
those living in Pitmedden. NHS Grampian also concluded that the area could
not support another pharmacy as this would put the sustainability and viability
of existing NHS pharmacy services at risk. The full minute of the hearing on
27th May is available at
http://www.nhsgrampian.com/grampianfoi/files/PPC_B999_20132705.pdf
22. This decision was appealed by the B999 Health Trust but the National Appeal
Panel rejected the appeal on the 7th October 2013.
23. In summer of 2014 a Judicial Review of the Grampian decision to allow
continued dispensing for patients of the Haddo Medical Group was heard.
NHS Grampian lost the Judicial Review. The report of the decision of Lord
Doherty is available at:
https://www.scotcourts.gov.uk/search-judgments/judgment?id=5f1fa8a6-898069d2-b500-ff0000d74aa7
24. In October 2014, NHS Grampian began an urgent review of the continued
dispensing for those patients who continue to have their medicines dispensed
by the Haddo Medical Group. This included patients living in and around
Pitmedden and Methlick. The review included a public consultation running
from the 3rd October through until 14th November with notifications on the
NHS Grampian website, via posters in the local community and raising
awareness with local Community Councils and elected representatives. NHS
Grampian also wrote to all patients, aged over 16, who are currently eligible
for dispensing from the Haddo Medical Group asking “if dispensing of
medicines was not available at the GP practice, would you have a serious
difficulty in getting your dispensed medicines from a community pharmacy? If
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your answer is 'yes' please describe what these difficulties would be”. Link to
the involving you webpage at
http://www.nhsgrampian.co.uk/nhsgrampian/InvolvingYou.jsp?pContentID=90
48&p_applic=CCC&p_service=Content.show&
25. The Review Group met on 10th December 2014. The note of the meeting and
recommendations are appended.
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Appendix 2
NHS Grampian - Review of Continued Dispensing from the Haddo Medical
Group
Meeting held on 10 December 2014 at 2.00pm
Conference Room, Summerfield House, 2 Eday Road
Aberdeen
Review Panel Members
Dr Nick Fluck, Medical Director NHS Grampian (Panel Chair)
Cllr Stewart Cree, Non-executive Board Member NHS Grampian
Dr Helen Moffat, Non-executive Board Member NHS Grampian
Attendees
Dr Chris Allan, Aberdeenshire Community Health Partnership (CHP)
Dr Roy Burnett, Haddo Medical Group
Mr David Craig, Tarves Pharmacy
Mrs Lindsay Craig, Tarves Pharmacy
Mr George Duncan, Udny Community Council
Mr David Hekelaar, Tarves Community Council
Cllr Paul Johnston, for Methlick Community Council
Ms Lynne Lawrence, Vice Chair, Grampian Area Pharmaceutical Committee
Mr Brian McDougall, Udny Community Council
Mrs Ann Smith, Chair, Grampian Area Pharmaceutical Committee
Ms Viv Tanner, Haddo Medical Group
Advisers to the Panel
Mr David Cooper, Patient Focus and Public Involvement Officer
Dr Caroline Hind, Deputy Director of Pharmacy
Mr Andrew Jackson, Legal Adviser
Mr Peter MacLean, Sector Lead, Health Intelligence
Note-taker
Miss Lesley Hall, Assistant Board Secretary
Introduction
The chair introduced himself and welcomed everyone to the meeting. He invited
everyone in attendance to introduce themselves. All interested parties in attendance
confirmed that they were not represented by a solicitor or legal representative.
The interested parties attending the meeting were as follows:
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Aberdeenshire Community Health Partnership (CHP)
Grampian Area Pharmaceutical Committee (APC)
Haddo Medical Group
Methlick Community Council
Tarves Community Council
Tarves Pharmacy
Udny Community Council
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The chair explained the role of the panel advisers to provide factual information at
his request. Members of the review panel confirmed that they had no personal
interest that might impact on decision-making.
Background
The chair provided the background to the proceeding explaining that NHS Grampian
was required to review the continued dispensing from the Haddo Medical Group
following the opening of Tarves Pharmacy. This review was a consequence of Lord
Doherty’s findings against NHS Grampian in the recent Judicial Review of NHS
Grampian’s decision to allow continued dispensing of medicines by the Haddo
Medical Group for patients living in and around Pitmedden.
Lord Doherty’s findings focused on two areas:
a) The decision was unlawful in not providing Tarves Pharmacy with the
opportunity to represent itself at the review panel and the NHS Board
Meeting. This was in contrast to the Community Council which was
permitted to attend and present to both. This was deemed unfair and
unlawful.
b) The decision was unlawful as it permitted continued dispensing for all
patients living in Pitmedden despite the review panel finding that only a
proportion of individuals in that population had a serious difficulty of access
to a pharmacy.
Following this ruling NHS Grampian has to decide whether patients who currently get
their dispensed medicines from the GP practices at Pitmedden or Methlick still had a
serious difficulty in accessing dispensed medicines from a community pharmacy.
The relevant regulations relate to the National Health Service (General Medical
Services Contracts) (Scotland) Regulations 2004 Paragraph 44 of Part 3. In this
respect the regulations only permit NHS Grampian to request Haddo Medical Group
to dispense for its patients where, after consultation with the Area Pharmaceutical
Committee, it was “satisfied that a person, by reason of –
(a) distance;
(b) inadequacy of means of communication; or
(c) other exceptional circumstances,
- will have serious difficulty in obtaining from a pharmacist any drugs, medicines or
appliances, other than scheduled drugs, required for that person’s treatment…”
The chair explained that following this Judicial Review by Lord Doherty, NHS
Grampian needed to look afresh at the continuation of dispensing from the Haddo
Medical Group from its branches at Methlick and Pitmedden. The scope of this
review was to assess the question of dispensing authority with respect to the
General Medical Services contract alone. The chair explained that, in line with
previous decision-making, the review would consider the broad communities of
patients living in and around Methlick and Pitmedden as two communities.
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The chair explained that the recommendation from this review would be passed to
the Grampian NHS Board and made available for interested parties to comment. The
Grampian NHS Board would then need to make a final decision based on this advice
and any other considerations presented to the Board.
Each interested party was given up to fifteen minutes to present following which
there was an opportunity for questions from the other interested parties and the
panel members.
Presentations
A very brief outline of each presentation is shown below. Where a formal
presentation was submitted this is provided as an attachment to this report. Key
cross questioning points are noted.
Haddo Medical Group
Dr Burnett gave presented the view of Haddo Medical Group. He explained the
process, which had preceded this. He emphasised the needs of vulnerable patients.
He challenged the assertion that the population was healthy, wealthy and young.
Among the information provided was access to cars and the number of prescriptions
dispensed, broken down into acute and repeat. He suggested that removing the
dispensing from the practice would have a real impact on real people as currently the
people of Pitmedden and Methlick had all essential needs in the villages. He
stressed that pharmacy delivery services were voluntary .He cited Prescription for
Excellence and the need to have a shared goal of being a world leading health care
system. To do so required dispensing to continue from all three practice sites. He
was of the view that an example of serious difficulty was a bus journey of up to 1.5
hours.
Mr Craig (Tarves Pharmacy) clarified that the delivery service was provided to any
household and not just for housebound patients
Tarves Pharmacy
Mrs Craig gave a PowerPoint presentation on behalf of Tarves Pharmacy during
which she stressed the need to safeguard patients. She pointed out that the ‘one
mile rule from pharmacy’ applied only in England and there were no controlled
localities in Scotland. She made reference to the percentage of households with
access to cars and compared the areas to other similar rural locations. She
confirmed that the most of the local pharmacies offered free collection and delivery
services. She referred to the decision of Lord Doherty and explained she was of the
view that the existence of delivery service should have been considered by the
Board previously. Mr Craig explained that it is normal practice for pharmacies to
deliver in rural areas.
There was discussion about the safeguards provided by checks within a pharmacy
setting compared to a GP dispensary.
Dr Hind clarified that electronic dispensing with barcodes enabled notification of
when a prescription had been collected.
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Methlick Community Council
Cllr Johnston presented Methlick Community Council’s PowerPoint presentation. He
highlighted that if dispensing was withdrawn from Haddo Medical Group the most
vulnerable groups would be affected. Although there may be a moral obligation on
pharmacies to deliver, it was not contractual. He pointed out that the regulations
should not be interpreted to make matters worse or increase the risk to patients.
Although the bulk of prescriptions were repeat, the dispensing of acute prescriptions
was important. He pointed out the importance of having a doctor and pharmacy
within easy reach and that reliance on buses for transport was not reliable. He
referred to the model elsewhere that anything over 1.6km from a pharmacy
constituted serious difficulty. He cited examples of people walking from outwith a
reasonable distance as having serious difficulty.
Udny Community Council
Mr McDougall spoke to the Udny Community Council’s PowerPoint presentation. He
explained that there had been recent press articles about rural bus services being
cut. He pointed out that there was no legal commitment on the practice to deliver
and felt that the delivery service was unregulated which could pose a risk to patients.
He was of the view that a consistent approach was needed for dispensing practices.
He pointed out the cost of travel and the impact of carbon emissions from vehicular
journeys.
In response to a point raised about attendees being directors of a company that had
applied to open a pharmacy in Pitmedden, those involved in the company
acknowledged that the company was still registered but there were no current
applications that would give rise to any conflict of interest. Councillor Cree clarified
that the parties involved in the company were merely presenting and were not being
asked to make any decision.
Aberdeenshire CHP
Mr Ramsay spoke on behalf of Aberdeenshire CHP. He advised that the CHP felt
strongly that the residents of Tarves, Pitmedden and Methlick should be assured of
getting appropriate level of general medical services and reliable dispensing. The
CHP delivered services across the whole of Aberdeenshire with a diverse
population, remote and rural areas and areas where transport links were infrequent
or difficult. He stressed the need for a consistent approach and cautioned against
setting a precedent. It was important to plan services for the majority, that home
delivery services were an important component of healthcare. Dispensing medicines
to a patient in an urgent situation had to be prompt, responsive and reliable. Dr Allan
referred to the Health and Wellbeing Profile. The Haddo Medical Group provided a
vital service in the area and the decision about dispensing would have an impact on
the provision of general medical services. Dr Allan suggested that distance was a
factor and that access by the types of roads in the area could lead to serious
difficulty.
(Dr Allan excused himself from meeting at this point.)
Tarves Community Council
Mr Hekelaar, representing Tarves Community Council, presented with reference to
PowerPoint. He advised that the other Community Council representatives had
adequately covered the difficulties of accessing services. He explained that there
were seven dispensing practices in Aberdeenshire, one of which was Haddo Medical
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Group. He made reference to the Primary Care Integrated Management Group’s
encouragement for a more in depth assessment in section 3.1.2 of the
Pharmaceutical Services (PCS) Plan 2013; the protocol relating to existing
dispensing GPs when a new pharmacy application was granted in the practice area;
the cross subsidy of general medical services from dispensing income; the national
context and consistency; and Lord Doherty’s decision and suggested options for
NHS Grampian. He also referred to arrangements for delivery services by pharmacy
contractors, what constitutes serious difficulty; and equality and fairness.
Grampian Area Pharmaceutical Committee (APC)
Mrs Smith, representing the Area Pharmaceutical Committee, presented the
Committees views following an extraordinary meeting in October 2014. The focus
had been on section 44 of the regulations and the issue of serious difficulty. It had
considered planned and unplanned care and long-term conditions compared to
acute. She referred to the Chronic Medication Service (CMS) that was available.
She explained the need to ensure safe, effective and timely access to medications
and how this can be provided. She advised of good communication between GMED
out of hours and community pharmacies to ensure access to dispensed medicines.
There were other tools available for the supply and access to drugs and the CPUS.
The Committee did not consider that delay in access was a serious difficulty. An
audit had been carried out in Aberlour and Dufftown in Speyside, comparing similar
rural locations. She pointed out that multi-disciplinary teams collaborate to identify
anyone having difficulties to ensure a solution. The integration of Health and Social
care would impact on the way patient-centred healthcare was delivered. The
committee had concluded that the patients of the Haddo Medical Group did not have
serious difficulty accessing dispensed medicines from a pharmacy. They concluded
that the best healthcare was provided holistically by appropriate professionals
working together.
Mrs Smith was questioned about the validity of their comparisons. She explained the
comparison considered patients in a similar scenario and distance. In response to a
query she advised that access was important for CMS but once it was in place for a
patient, there was no need to see a doctor for 24 or 48 weeks.
In response to a query about delivery services, Mrs Craig advised that deliveries
were to individual patients’ houses and not to a drop-off point.
Summaries from Interested Parties
At the conclusion of all the presentations and questioning, the interested parties who
had presented were offered the opportunity for a very brief summary of their key
points:
Haddo Medical Group – Dispensing doctors play an essential role in the dispensing
and supply of medicines. Pharmacy should complement medical services. NHS
Grampian had an opportunity to do this in a coordinated way.
Tarves Pharmacy – Patients do not have serious difficulty. The pharmacy is highly
motivated to provide a service and the free delivery services by local pharmacies
should not be discounted.
Methlick Community Council – The practice serves a rural area and unnecessary
journeys cause delays that could lead to serious risk. Distance should be a
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determination, beyond which there was a serious difficulty. Delivery service was not
a solution to the serious difficulty.
Udny Community Council – Patients have serious difficulty because of distance,
reduction in bus service and cost of transport. They should not be put at risk by
unregulated delivery arrangements. A consistent approach was required.
Tarves Community Council – Consistent arrangements required for rural areas
and dispensing throughout NHS Grampian.
Aberdeenshire CHP – There are many rural areas across Aberdeenshire with
patients who are infirm, disabled, deprived. Inevitably there are sections of the
community who have difficulty accessing services.
APC – Patients of Haddo Medical Group registered at Pitmedden and Methlick do
not have serious difficulty of access. The best healthcare is provided holistically by a
multi-professional team finding solutions.
The panel sought clarification about the basis on which other dispensing practices in
Aberdeenshire were authorised to dispense and Dr Hind agreed to obtain this
outwith the meeting. This information was supplied to the panel and is included for
reference:
Banff & Gamrie
They dispense from the Gardenstown Branch surgery. Patients are flagged
on the system if they live in that area (originally a separate practice). They
do not dispense to all the flagged patients e.g. if they work in Banff they
may use a Pharmacy there.
Auchenblae
Do no dispense to patients who live in Stonehaven. When a GP prescribes
at the practice they do tend to get it dispensed there.
Glenlivet
Dispense to patients other than those in towns with a Pharmacy - Dufftown,
Aberlour, Rothes, Grantown on Spey. Will dispense to patients at an
evening clinic when the Pharmacies have closed.
Portlethen
Patients who live more than a mile from a Pharmacy
Rhynie
Patients living in their Practice area. They all live nearer the Practice than a Pharmacy
Rinnes (Dispense from Branch at Tomintoul)
Clinical system identifies the Tomintoul patients. This was information
downloaded from the previous practice when the practices merged. New
patients registering at Tomintoul will be eligible.
Scotstown (Dispense from branch at Udny)
Udny patients identified on the Practice system. No dispensing from Bridge
of Don. Also don't dispense for patients who live near Ellon. Not clear how
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they are identified but mileage was mentioned possibly 2 miles from
Pharmacy.
Skene
Patients outwith Westhill - identified by Post Code.
Strathdon
All patients registered with the Practice
The chair asked all the interested parties if they agreed they had been given a fair
opportunity to present their case, which they all confirmed.
The chair advised that the recommendation of the Review Panel will be published
before the Christmas break on the NHS Grampian involve website. The interested
parties present would have the opportunity to provide a commentary on the
recommendation in writing and these would be submitted to the NHS Grampian
Board along with the recommendation. Any commentaries from interested parties
need to be with the Board by responding to the Board Secretary, Mrs Laura Gray, by
5 January 2015.
Grampian NHS Board will consider the recommendation of the Review Panel and
accept, reject or amend the recommendation at a Board meeting on 16 January
2015.
The technical advisors and interested parties were invited to remain in the building
until the panel confirmed that no further technical advice was required. Once the panel
clarified that no further technical advice was needed the parties were free to go.
Consideration
The panel considered all the information provided, as listed in the Appendix, and the
presentations and information presented during this meeting. They had available the
responses from patients and members of the public. The panel based its decision on
the merits of the presentations, having weighed up all the information that had been
submitted in writing and during the meeting.
The first consideration was whether any residents in either the Pitmedden or
Methlick areas had at any time a serious difficultly in obtaining their medications
under the criteria described in the general medical services (GMS) regulations. The
panel considered strong representation that the additional journey time required if an
individual was purely reliant on public transport or walking could be onerous. The
panel also recognised that the situation for any individual patient was dynamic in that
a patient may find it more difficult on one day and then experience little
inconvenience on another dependent on personal circumstances, acute illness or
public transport issues. The panel recognised that the need to fill a prescription
rapidly related to the circumstances of prescribing (Acute verses Chronic or Repeat)
and clinical acuity of the illness. The panel considered the access to a delivery
service from the pharmacy that could mitigate difficulties in reaching a pharmacy. In
balancing these considerations the panel reached the conclusion that some patients
on some occasions would have a serious difficulty in obtaining medication in a timely
manner after a doctors appointment that led to an acute prescription. This should not
be an issue for those in receipt of chronic repeat prescriptions and will largely affect
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those who attend the surgery on foot or require public transport to reach the
pharmacy after the consultation. Quantification of how many individuals that this
might affect was not within the scope of this review but it was considered that it
would likely be a small subset of all patients receiving prescriptions from the
respective GP practices.
The second consideration was to ascertain a reasonable approach to identifying
those individuals who had serious difficulty in obtaining their medication. The panel
recognised that there were no Scottish or NHSG guidelines that offered a method of
deciding on access to medicines under these regulations. In NHS Grampian the GP
practices that currently prescribe do not follow a set criteria and therefore offers no
benchmark on which to base a recommendation. The panel considered that in this
case the most appropriate way forward would be to reflect the specific difficulties
faced by the local population. Firstly there was little to suggest that chronic or repeat
prescriptions should present a serious difficulty for patients as the supply of the
medication could be carried out in a planned manner or delivered directly to home.
Acute prescriptions offer more challenges as planning is more difficult, the individual
may be incapacitated by illness and the medication is more likely to be required
urgently. Individuals without access to a car for whatever reason on the day they
receive their acute prescription might therefore have considerable difficulty and delay
in obtaining their medication. Home delivery seemed an unlikely universal solution
for these patients, as same day supply would be problematic particularly in afternoon
or late clinics. Of course there may be rare exception circumstances where other
patients are unable to access the pharmacy e.g. road closure etc.
Recommendation
1. The review group recommends that the Haddo Medical Group should be
allowed to continue dispensing to patients who have a serious difficultly in
obtaining their medication.
2. This authority should be limited to dispensing to patients who have serious
difficulty by virtue of both the need to obtain medication following the issuing of
an acute prescription and that on that day they do not have access to a car to
travel to a pharmacy.
The review group also recommends that NHS Grampian conducts a review of GP
practice dispensing across the region to formulate clear objective criteria around
interpretation of the GMS regulations to ensure patients have access to the most
appropriate services to meet their clinical needs.
Submissions and information considered by the Review Group in addition to presentations
on the day:
 Public Consultation Responses
 General Population Health Status – Health and Wellbeing Profiles
 Travel Information and Mapping
 The National Health Service (General Medical Services Contracts) (Scotland)
Regulations 2004
 Aberdeen CHP Pharmaceutical Care Service Plan
 Pharmacy and GP Practice Lists
 Written submissions by interested parties and presentations
 Judicial Review decision by Lord Doherty
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Appendix 3
Comments from interested parties regarding the recommendation of the
Review Group.
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18
19
20
21
22
23
24
25
26
27
28
29