Appendix 1
Dispensing of NHS prescriptions by the Haddo Medical Group
for the population who live in and around Pitmedden
Findings of the
Review Panel convened on
Thursday 22 November 2012
Chaired by
Adam Coldwells
Executive Summary and recommendation to the Board of NHS Grampian
The Review Panel was convened to review the outcome and recommendations of
the Dispensing Doctor Decision Making Group (January 2012) which reviewed the
ongoing requirement for the Haddo Medical Group to continue dispensing for its
patients in light of the opening of a new pharmacy in Tarves. The Review Panel has
met and makes, in this report, a recommendation to Grampian NHS Board. The
Board previously considered this matter in April 2012.
The Review Panel considered the written submissions from the Community
Councils, Rt Hon Alex Salmond MSP and Mark McDonald MSP and received a
verbal presentation on behalf of the Community Councils. The Review Panel has
also had the opportunity to access information made available to the Dispensing
Doctor Decision Making Group. The Review Panel has considered these
submissions, and the challenges to the original decision posed in the context of the
current regulations:
The National Health Service (General Medical Services Contracts)
(Scotland) Regulations 2004, Part 3 Prescribing and Dispensing –
paragraph 44 Provision of Dispensing Services relating to NHS
Boards requiring GP practices to undertake dispensing for their
patients
44.—(1) A contractor may secure the provision of dispensing
services to its registered patients only if it is authorised or required to
do so by the Health Board in accordance with this paragraph.
(2) Where the Health Board, is satisfied, after consultation with the
area pharmaceutical committee, 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 Health Board shall require or authorise
the contractor with whom the person is a registered patient to supply
such drugs, medicines and appliances to that person until further
notice.
The Review Panel considered all of the evidence presented to it and believes that
the Community Councils presented new evidence which 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.)
The Review Panel recommends that the Board, in light of this new evidence,
reconsiders its April 2012 decision and recommends that the Haddo Medical Group
continues 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.
2
Background
This section provides a timeline of events prior to the Review Panel meeting.

For the vast majority of patients in NHS Grampian, medicines are prescribed
by GPs (General Practitioners) and dispensed by community pharmacists
(local chemists). This separation of pharmaceutical and general medical
services supports safety in medicines supply and recognises that
pharmaceutical services are broader than the supply of dispensed medicines.
In areas where access to community pharmacy is poor the Health Board,
under the General Medical Service Regulations, can require a GP practice to
dispense for its patients. This is only allowed where the Health Board has
agreed that patients registered with the practice have a serious difficulty in
accessing prescribed medicines from a pharmacist.

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.

NHS Grampian originally rejected the application for a new pharmacy in
Tarves in December 2009, but that decision was overturned by the National
Appeal Panel in June 2010 - available under hearings at:
http://www.shsc.scot.nhs.uk/shsc/default.asp?p=131

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&


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

In light of the opening of the new pharmacy at Tarves, NHS Grampian
reviewed its requirement for dispensing by the Haddo Medical Group. In early
2012 Haddo Medical Group were given 12 months’ notice to cease dispensing
services to registered patients living within the neighbourhood of the
pharmacy, as defined by the National Appeal Panel as the village of Tarves.
This cessation was in line with the NHS Grampian protocol in place at the
time.

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
3
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.

In revisiting the original decision NHS Grampian undertook significant
stakeholder engagement. The main stakeholders – patients, public, public
representatives, Independent General Practice & Independent Community
Pharmacy 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.
4 April 2012 Board papers Item 8 available at:
http://www.nhsgrampian.org/nhsgrampian/files/item08alldocsDispensingHadd
oCrimmondrevised.pdf
4 April 2012 Board minutes available at:
http://www.nhsgrampian.org/nhsgrampian/gra_display_simple_index.jsp?pCo
ntentID=5210&p_applic=CCC&

Following the 4 April 2012 Board meeting NHS Grampian communicated its
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.

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.

The decision by the Haddo Medical Group to close its Tarves branch surgery
is a result of the cross subsidisation of their general medical services from
dispensing income. Financial support for dispensing by general practice at the
request of an NHS Board 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 has 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 has had to review the services it can
provide in order to achieve financial balance. This has led to their decision to
close the Tarves branch surgery.
4

A series of meetings took 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 and First Minister for Scotland 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 review of the decision to restrict dispensing for
patients of the Haddo Medical Group and has put in place arrangements for a
review using an independent Review Panel, the outcome of which will be
presented to the Board before the end of 2012.

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.

The Review Panel met on 22 November 2012 and the community councils
were offered the opportunity to present their case to the panel meeting. The
recommendations from the Review Panel are now presented to the NHS
Board for final decision making. Community council representatives have also
been invited to present at the Board meeting.

The practice has always assured the local community that residents in Tarves
will have access to the full range of services delivered by Haddo Medical
Group and informal feedback indicates that there have been no service
problems since the Tarves branch surgery closed on 7 Sept 2012.
5
Review panel membership and format
This report is prepared for the December 2012 meeting of Grampian NHS Board
following a Review Panel hearing convened on Thursday 22 November 2012. The
Review Panel was convened at the request of the Chief Operating Officer
(Dr Pauline Strachan) following a series of meetings between the Chief Executive
(Mr Richard Carey) and a number of politicians and the local Community Councils.
The Review Panel comprised the following membership:
Mr Adam Coldwells (Chair)
General Manager, Aberdeenshire CHP and Moray CH&SCP
Dr John Reid
Area Medical Committee
Mr Ken Manson
Area Pharmaceutical Committee
Mr David Stewart
External Representative from NHS Fife
Ms Norma Urquhart
Public Representative
The Review Panel considered its remit and agreed that it was concerned only with
the relevant regulations as quoted on page 2 of this report. The Review Panel was
very clear that it was NOT considering the closure of the Tarves branch surgery as
this was beyond its remit.
The Review Panel received four written submissions from:
1. Mark McDonald, Regional MSP for the North East
2. Alex Salmond, Constituency MSP for Aberdeenshire East and First Minister
3. Co-signed submission from Brian McDougall, Secretary, Udny Community
Council and Bob Davidson, Chairman, Tarves Community Council.
4. Tamsin Morris on behalf of the Udny and Tarves Community Councils
The Review Panel also received, at its hearing on 22 November 2012, a verbal
submission from the Community Council group (presented by Chris York and David
Hekelaar) to support their written submission. In addition, this allowed the panel to ask
questions of the Community Council representatives.
The Review Panel agreed that a copy of this paper, prepared for the Grampian NHS
Board, would be sent to all those who made a submission to the review panel at the
same point that the papers are circulated to the Board members.
The Review Panel considered the written and verbal submissions, the information
provided about previous decision making and the information used by the
Dispensing Doctor Decision Making Group that met in January 2012.
6
Although the Review Panel was presented with considerable information there was
one over-riding new analysis of information presented on behalf of the Community
Councils which, the panel believe, demonstrated serious difficulty by reason of
inadequacy of means of communication. (Interpretation of this by the panel
concerned the use of public transport by a proportion of the population of
Pitmedden.) The full analysis was presented to the panel.
In summary, the analysis showed likely “whole episode” times for patients to be seen
by a doctor and then get their drugs dispensed (including bus times) The analysis
surveyed some 450 residents and demonstrated availability of access to a car during
normal working hours. All of the analysis provided likely numbers of the population
(using 95% confidence intervals from the survey) who might be involved. The
majority of the Review Panel believed that serious difficulty was demonstrated.
The Review Panel considered the impact of these scenarios on the population and
concluded that a proportion of the population would have serious difficulty. This
suggested that Haddo Medical Group should continue to dispense to its practice
population in all areas except that covered by the Tarves neighbourhood.
The Review Panel considered this serious difficulty very carefully against the
provision of a ”twice daily delivery service” by the Tarves Pharmacy but felt that, on
balance, serious difficulty was still demonstrated.
Recommendation for the Grampian NHS Board
The Review Panel therefore recommends to Grampian NHS Board that the Haddo
Medical Group continues to dispense NHS prescriptions for its practice population in
all areas except that covered by the Tarves neighbourhood which was defined by the
National Appeal panel as the village of Tarves surrounded on all sides by agricultural
green land.
7