PHARMACY PRACTICES COMMITTEE MEETING Tuesday, 30 October, 2012 at 1.30 pm Seminar Room, Migdale Hospital, Cherry Grove, , IV24 3ER

Application by Gareth Dixon of MITCHELLS CHEMIST LTD for the provision of general pharmaceutical services at The Former Bonar Bridge News, Dornoch Road, Bonar Bridge, IV24 3EB

PRESENT Okain Maclennan (Chair) Margaret Thomson (Lay Member) Michael Roberts (Lay member) Susan Taylor (GP Sub Committee Nominate) Fiona Thomson (APC Non Contractor Nominate) John McNulty (APC Contractor Nominate)

In Attendance Andrew J Green (Area Regulations, Contracts & Controlled Drugs Governance Pharmacist) Helen M MacDonald (Community Pharmacy Business Manager) Gareth Dixon, Mitchells Chemist Ltd, Applicant Donna Gillespie, Mitchells Chemist Ltd, Applicant Support Christopher Mair, GP Sub Committee Andrew Paterson, Area Pharmaceutical Committee

Observers Nicola Macdonald (APC Contractor Nominate NHS PPC Member in training)

1. The Chair welcomed everyone to Bonar Bridge. He asked all members to confirm that they had all received the papers for the hearing and had read and considered them. All members affirmed these points.

2. APPLICATION FOR INCLUSION IN THE BOARD’S PHARMACEUTICAL LIST

Case No: PPC – Bonar Bridge, . Mitchells Chemist Ltd, The former Bonar Bridge News, Dornoch Road, Bonar Bridge, IV24 3EB.

The Chair asked each Committee member if there were any interests to declare in relation to the application being heard from Mitchells Chemist Ltd. No interests were declared.

3. The Committee was asked to consider the application submitted by Mitchells Chemist Ltd to provide general pharmaceutical services from premises sited at The former Bonar Bridge News, Dornoch Road, Bonar Bridge, IV24 3EB under Regulation 5(10) of the National Health Service (Pharmaceutical Services) () Regulations 2009, as amended.

The Committee had to determine whether the granting of the application was necessary or desirable to secure the adequate provision of pharmaceutical services in the neighbourhood in which the Applicant’s proposed premises were located.

The Committee, having previously been circulated with all the papers regarding the application from Mitchells Chemist Ltd, agreed that the application should be considered by oral hearing.

P1 Signed Copy of Mitchells Chemist Ltd Dornoch _ PPC 30 October 2012 NOTES.doc Prior to the hearing, the Committee had, as a group, visited the neighbourhood as defined by the applicant surrounding the applicant’s proposed premises, which comprised three primary schools, post offices, churches, community halls, a day care centre, community hospital, hotels and holiday accommodation (including lodges and B&Bs), golf and football clubs, youth hostel, country estates, a visitor centre and shops where other daily needs and services were accessed, including fuel and the Highland Council service point.

There was no secondary school, or dental practice in the proposed neighbourhood.

After a visit of the proposed pharmacy premises, facilitated by the applicant, the Committee walked past the car park immediately behind the proposed pharmacy premises to view the site of the GP practice where parking available for patients and surgery access was noted.

The hearing was convened under paragraph 3(2) of Schedule 3 to the National Health Service (Pharmaceutical Services) (Scotland) Regulations 2009 as amended (“the Regulations”). In terms of this paragraph, the Pharmacy Practices Committee “shall determine an application in such a manner as it thinks fit”. In terms of Regulation 5(10) of the Regulations, the question for the Pharmacy Practices Committee is whether “the provision of pharmaceutical services at the premises named in the application is necessary or desirable to secure adequate provision of pharmaceutical service in the neighbourhood in which the premises are located by persons whose names are included in the Pharmaceutical List.”

The Applicant, Support and Interested parties were invited into the meeting at around 1.30 pm

4. The Chair welcomed:-

The applicant, Gareth Dixon of Mitchells Chemist Ltd who was supported by Donna Gillespie, the Interested Parties who had submitted written representations during the consultation period and who had chosen to attend the hearing, were Christopher Mair, GP Sub Committee and Andrew Paterson, Area Pharmaceutical Committee (“the Interested Parties”). The Chair then invited the Committee members to introduce themselves. Committee members introduced themselves to the applicant and all other parties, and all other parties introduced themselves to the Committee.

The Chair asked the applicant and the Interested Parties to confirm that they were not attending the Committee in the capacity of solicitor, counsel or paid advocate. They each confirmed that they were not.

5. The Chair reminded everyone that the meeting had been convened to hear the application from Mitchells Chemist Ltd for the provision of general pharmaceutical services at the former Bonar Bridge News, Dornoch Road, Bonar Bridge, IV24 3EB. The application would be considered against the legal test contained in Regulation 5(10) of the National Health Service (Pharmaceutical Services) (Scotland) Regulations 2009, as amended.

6. Regulation 5(10) was read out:

An application shall be granted if the Board is satisfied that the provision of the pharmaceutical services at the premises is necessary or desirable in order to secure adequate provision of pharmaceutical services in the neighbourhood in which the premises are located.

7. The Chair then described the format of the hearing, reminding those attending that no new evidence could be introduced at the summing up.

P2 Signed Copy of Mitchells Chemist Ltd Dornoch _ PPC 30 October 2012 NOTES.doc The procedure adopted by the Committee at the hearing was that the Chair asked the applicant to make his submission. There followed the opportunity for the Interested Parties and the Committee to ask questions. The Interested Parties would then make their submissions. There followed the opportunity for the applicant and the Committee to ask questions of the Interested Parties in turn. The Interested Parties and the applicant would then be given the opportunity to sum up.

The Chair then asked the applicant to give his statement.

7.1. The Applicant’s Case

Gareth Dixon of Mitchells Chemist Ltd stated “Thank you very much, I shall try and be brief. Mitchells Chemist Ltd in Dornoch was taken over by wife and I in 2006 and a second pharmacy in Golspie was purchased in 2011. The company has a proven record of working in small rural Highland communities and for being active and enthusiastic regarding the provision of new and existing services. The Dornoch branch has over 50% more minor ailment service patients (MAS) registered compared to the Highland average and 58% above that for chronic medication service (CMS) patients registered above the highland average. Patients are actively encouraged to access advice and health services e.g. smoking cessation and we are very active with health promotion though our social networking sites and we support other causes such as “Wear it Pink Day” for breast cancer and “Movember”.

We also provide additional services including blood pressure, diabetes and cholesterol checks, and the provision of private flu vaccinations is also available. Since acquiring the Golspie pharmacy in November 2011, we have pushed for CMS registrations to have been increased from 3 patients to 149 patients in August 2012, bringing the number of registrations up to the Scottish average within 7 months. This demonstrates that patients in this type of rural community like to engage with these services and that the pharmacies are always trying to provide a high class pharmaceutical service. In May 2012 the Dornoch smoking cessation quit rate was 44% compared to 41% for Highland and 39% for Scotland, thereby proving a higher than average patient engagement is possible in a small rural environment. This hopefully leads to an overall health improvement in the communities in which pharmacies are situated.

Although Dornoch and Golspie have relatively small rural communities, they have both proved to be very successful at achieving positive health outcomes. I am just trying to show that we have a proven record of providing pharmaceutical services in these types of communities.

With regard to the proposed neighbourhood boundaries and as with most rural Highland communities, which I am sure you have seen this morning, this extends over a large geographical area and, although there are distinct communities within the neighbourhood, we believe that Bonar Bridge is where these communities come together to access their services

I’ve tried to describe the proposed neighbourhood by starting at Spinningdale on the A949, heading north to Bonar Bridge including the surrounding areas on this road. From Bonar Bridge it would reach as far south as Fearn along the A836 including Ardchronie and Kincardine. Then west to Croick including Ardgay and West Gruinards. To the north along the A836 to Achinduich and along the A837 as far as Oykel Bridge including Inveran and Rosehall and also east as far as Migdale including Tulloch, Ardens and Achuan.

As for the existing population, the GP practice populations in the area I have taken appear to be remaining fairly static over the last 9 years - that is the GPs in the Sutherland area which I have compared.

P3 Signed Copy of Mitchells Chemist Ltd Dornoch _ PPC 30 October 2012 NOTES.doc Currently , Golspie and Dornoch practice populations all benefit from the access to pharmacy services but despite the fact that has a greater population than Lairg it lacks the access to pharmaceutical services. The proposed neighbourhood overlaps various datazones and information which was provided by Cameron Thomas of The Highland Council.

The proposed neighbourhood has a progressively ageing population and has a greater percentage of pensionable population compared with the rest of the Highland area and Scotland. Within the population of the proposed neighbourhood 33.1% of residents are over 60 years of age. This is higher than Highland and the Scottish average. Typically it is this group that could benefit from additional services a Pharmacy could provide. Studies have shown that many hospital admissions are caused by preventable medicine related problems. Patients, especially older people and those with chronic conditions, often receive treatment with four or more medicines. These patients are more likely to develop side effects which, in turn, can result in more medication being prescribed. A regular medication review by the patient’s pharmacist, working in partnership with their GP, could reduce the incidence of these medicine related illness

With the existing services in the proposed neighbourhood, Bonar Bridge currently acts as a central hub for the surrounding area as it has a Spar shop – known as Kyle Bakery, (which, if you have been in you will see does a minor range of general sales list medicines and toiletries), police station, post office, library, bistro, café and craft shop, primary school, Highland Council Service Point, the Creich Medical Practice, The Bradbury Day Care Centre, a 22 bed GP lead Migdale Community Hospital, two hotels and other guest house accommodation; is on the main tourist route which includes the Falls of Shin Visitor Centre, Alladale Wilderness Lodge and Wildlife Reserve, Bonar Bridge Golf Club, Inveroykel Lodge, Lairg Estate, Glencalvie Estate and Carbisdale Castle as well as numerous fishing, walking and cycling activities available in the area. There is currently no pharmacy or dental practice within the Bonar Bridge neighbourhood.

With regards to public transport - MacLeod’s Coaches runs a return bus services from Tain to Lairg, via Ardgay and Bonar Bridge, up to four times a day, Monday to Saturday. A Dial-A- Bus service is available within a 6 mile radius of Ardgay Station, plus Strathcarron Road as far as Croick, also to and from Dornoch and the Lawson Memorial Hospital in Golspie up to twice daily, three times a week.

The Bradbury Day Care Centre provides a return bus service to Tain once a week and to Alness once a week.

I don’t know why I left it out of my initial submission to the Committee but, there are rail stations at Ardgay and Inveran which have a service passing through them seven times a day and I will leave information on that behind for the Committee to view should they wish to. A return rail service operates to Invershin Rail Station (approximately 3 miles north of Bonar Bridge) three times daily Monday to Saturday and twice daily on Sundays.

Due to a lack of public transport as a result of the extensive geographical area, many people rely on the use of their own vehicle or asking someone else to transport them.

P4 Signed Copy of Mitchells Chemist Ltd Dornoch _ PPC 30 October 2012 NOTES.doc As part of the public consultation process, required for any new community pharmacy contract application, as the proposed neighbourhood covers a large geographical area which is generally covered by two local newspapers an advert inviting comments was placed in both the Northern Times and the Ross-shire Journal. GPs at Creich Medical Practice were informed of the intended application advert before it appeared in the newspapers, although this was only 24-48 hours before the applicant advert was publicised. Unfortunately a meeting could not be arranged until after the advert appeared due to time constraints. During the resulting discussion the additional services a community pharmacy could provide were outlined. Also that if a pharmacy contract was to be awarded it would necessitate a good working relationship with the practice for the patients to fully benefit.

The Creich and Ardgay Community Council Meetings were attended by myself to outline the proposed pharmaceutical services. At that point, I did not ask the councils to make comment but it was explained what pharmaceutical services are, their intended benefits to the community and that if the application were to be successful it would result in the cessation of dispensing services at Creich Medical Practice. It was also explained that if the community response to the consultation was favourable then the application would be submitted to the Highland Health Board and at that point the Community Council would be contacted for a formal response. The community response was mostly favourable and it was the responses that were received that contributed towards the proposed pharmacy neighbourhood.

Sorry, but the next piece I am going to read comes directly from “The Right Medicine” (meaning the Scottish Executive publication – The Right Medicine: A Strategy for Pharmaceutical Care in Scotland. Edinburgh: Scottish Executive; 2005), as they say it better than me:-

Community pharmacists are a cornerstone of primary care and make a vital contribution to patient care and health improvement, both as individual professionals and as part of the wider National Health Service. Pharmaceutical care reflects a systematic approach that makes sure that the patient gets the right medicines, in the right dose, at the right time and for the right reasons. It is about a patient-centred partnership approach with the team accepting responsibility for ensuring that the patient’s medicines are as effective as possible and as safe as possible. This is done by identifying, resolving and preventing medicine- related problems so the patient understands and gets the desired therapeutic goal for each medical condition being treated. Pharmacists can and do make a unique contribution to improving patient care. Medicines are the most common of all the steps taken by clinicians to help treat patients; and of all the healthcare professions, pharmacists have the widest knowledge in the science and use of medicines. Pharmacy focuses on empowering and protecting patients. Pharmacists have a key role to play in ensuring health gain wherever medicines are used.

Pharmacists provide care not just to patients but to the wider general public. The ’pharmaceutical health’ of the nation depends on good access to medicines, advice and to tailoring therapy to the needs of individuals. Community pharmacists are often patients’ first point of contact, and for some their only contact, with a healthcare professional. This creates a unique opportunity to improve the gateways for signposting, accessing and providing services and information on health and health issues to a broad spectrum of the population. This includes the most vulnerable in our communities; older people, people with mental health problems, homeless people, travellers and drug mis-users. All of these are people who might have difficulty, for lifestyle reasons, in accessing healthcare. Pharmacists have always worked to promote, maintain and improve health. Pharmacists offer non-judgmental help with a range of products and advice. Pharmacists provide a valuable link between the NHS and the public.

P5 Signed Copy of Mitchells Chemist Ltd Dornoch _ PPC 30 October 2012 NOTES.doc The pharmacy presents a familiar unthreatening environment where advice and expertise on medicines and major health messages can be delivered to the public at large. Pharmacists work to minimise problems with medicines by providing advice on their safe storage, use and disposal. This helps to ensure patients and the public get maximum benefit and minimal risk from medicines. Currently, however, there are difficulties in accessing pharmaceutical services in some of Scotland’s most remote and rural areas as well as in deprived communities. Community pharmacy has already been recognised as one of the key partners within NHS24. Where appropriate, the public would be directed to community pharmacies for advice and support in managing minor ailments, for answers to questions about their medicines and, if necessary, to access medicines.

In general, the view has been taken that it is preferable for doctors to prescribe and for pharmacists to dispense. In that way, the pharmacist brings his/her separate expertise to bear upon the questions of whether the drug has been appropriately prescribed and whether the dosage is within normal limits.

Pharmacy services differ considerably from a GP dispensing service. Apart from providing a dispensing service, over the counter medicines sales and advice a community pharmacy provides the core pharmacy contract services:

The Minor Ailment Service (MAS) allows eligible individuals to register with and use a community pharmacy as the first port of call for the treatment of common illnesses on the NHS. A patient registers with the community pharmacy of their choice in order to use MAS. Once registered they can present at any point with symptoms and the pharmacist, having ascertained whether the patient is still eligible to use the service, will treat, advise or refer them to another health care practitioner where appropriate.

Also the Acute Medication Service (AMS) – which introduced the Electronic Transfer of Prescriptions (ETP) and supports the provision of pharmaceutical care services for acute episodes of care and any associated counselling and advice; and the latest one, which we are all currently very active in providing:- Chronic Medication Service (CMS) – which allows patients with long-term conditions to register with a community pharmacy of their choice for the provision of pharmaceutical care and, as part of a shared agreement between the patient, community pharmacist and the General Practitioner (GP), it introduces a more systematic way of working and formalises the role of community pharmacists in the management of individual patients with long term conditions in order to assist in improving the patient’s understanding of their medicines and optimising the clinical benefits from their therapy.

The Public Health Service (PHS) , which incorporates the display of posters, provision of smoking cessation services and emergency hormonal contraception and allows the contribution of pharmacists to health protection, health improvement and medicine safety aims to encourage the pro-active involvement of community pharmacists and their staff in supporting self care, offering suitable interventions to promote healthy lifestyles and establishing a health promoting environment across the network of community pharmacies by participating in national and local campaigns. In independently owned pharmacies we can also provide information from NHS Scotland and our own campaigns reflecting the same issues at the same time.

Unscheduled Care - enables community pharmacists to provide patients with up to one prescribing cycle of their repeat medicines and appliances when the patient’s prescriber is unavailable; the surgery is closed or the out-of-hours system is in operation. Community pharmacies also provide a valuable support service to both NHS24 and the Out of Hours (OOH) service. Sometimes when patients are reviewed by a pharmacist, it is the pharmacist’s opinion that they require Direct Referral to OOH services which happens a lot in pharmacy.

P6 Signed Copy of Mitchells Chemist Ltd Dornoch _ PPC 30 October 2012 NOTES.doc We have a direct to professional number for the Highland Hub, stopping the patient having to go through the whole process themselves again with NHS 24. In Dornoch, the service is used for holiday makers, reducing the workload for GPs by referring them to the pharmacy. With regard to pharmaceutical need within the proposed neighbourhood, the proposed neighbourhood does not contain any pharmaceutical services other than the dispensing service provided by the Creich Medical Practice. All residents have to travel a significant distance, even by rural standards, to access these services. The nearest pharmaceutical services currently available are provided by the Co-op Pharmacy in Lairg (11 miles to the north), Mitchells Chemist in Dornoch (14 miles to the east) and the two Co-op pharmacies in Tain (16 miles to the south east). There is no history of there ever being a pharmacy in Bonar Bridge although there was a shop many years ago which was known as “The Chemist Stores” which stocked toiletries and some general medicines.

As part of the business model, research was conducted to establish the viability of a community pharmacy within the proposed neighbourhood. As part of this research the dispensing figures for the nearest pharmacies and some newly granted contracts were requested and are included in my pack.

The proposed premises, as you know as you visited these this morning, is closely situated to the Creich Medical Practice on Dornoch Road and is currently in a dilapidated state. This is due to the water tank having exploded and not being occupied for the last 3-4 years, effectively leaving the premises to have been locked and left to rot.

The proposed premises were purchased by Mitchells Chemist Ltd in May, 2012 and were originally built in 1901 with various additions made over the years. On the ground floor the property comprises a spacious shop unit, a large store to the rear with toilet facilities and an office. From an inner hall, stairs lead to the upper floor which is presently laid out as a flat. If the application were to be successful, extensive renovation is intended. The flat above would be given it’s own entrance to provide a secure entrance separate from the pharmacy. Pending planning approval, the pavement outside the premises would be elevated or a ramp installed to allow for disabled access to street level and, on talking to planners would be more aesthetically pleasing if raised.

Mark Forbes from Retail Design Consultants Ltd, has over 20 years of experience exclusively designing and fitting pharmacies, was contacted and provided some preliminary drawings for the planned layout of the premises. I intend to take out the stairs and have a flat above the ground floor premises with completely separate access. I have already worked with Mark, who is very professional and switched on regarding pharmacy requirements and the accessibility needs for disabled.

The Chair thanked Mr Dixon for his statement on behalf of Mitchells Chemist Ltd and invited the Interested Parties and then members of the Committee to ask questions of him.

7.2 Questions from Mr Andrew Paterson, Area Pharmaceutical Committee to the Applicant

Mr Paterson had no questions for the Applicant.

7.3 Questions from Dr Christopher Mair, GP Sub Committee to the Applicant

Dr Mair had no questions for the Applicant.

P7 Signed Copy of Mitchells Chemist Ltd Dornoch _ PPC 30 October 2012 NOTES.doc 7.4 Questions from the Committee to the Applicant

Mr Roberts asked how the applicant had arrived at the description of the proposed neighbourhood. Mr Dixon replied that this had mainly been done by speaking to the local population, asking where the existing GP patient population travelled to and from in conjunction with the knowledge that, from his pharmacy in Dornoch, he had dispensed for patients from as far away as Spinningdale.

Mr Roberts then asked if he dispensed for patients in the nearby vicinity from the Golspie pharmacy which he owned. Mr Dixon replied that the Golspie pharmacy tended only to service the population as far as Rogart.

Dr Taylor referred to Mr Dixon’s mention of contact with GP practices and wondered how he envisaged that would work in this community. Mr Dixon replied he felt this would be positive from his initial discussions with the practice.

Dr Taylor then went on to enquire, in relation to unscheduled care and access to NHS 24 services out of hours if there was a mechanism by which he could be contacted out of hours by the NHS if required.

Mr Dixon replied in the affirmative, adding that he had in the past been contacted by NHS 24 to dispense urgent prescriptions.

Mrs Margaret Thomson advised she had not heard much in the Applicant’s presentation about people with disabilities, and not solely those in the elderly population, and wondered if he agreed that there may be people in that category within the community and how would he envisage a pharmacy benefiting that patient group. Mr Dixon replied that there certainly were a number of disabled patients in the area which he had heard about from discussion with the district nurses and imagined they would certainly benefit from engaging with the services provided through a community pharmacy.

Mrs Margaret Thomson then wondered how the applicant would service that community and enquired whether he would visit them or expect them to visit him at the pharmacy. Mr Dixon advised that, being an independent contractor, he has the ability to visit patients and does actually make the effort himself, particularly if there is a new medicine but that he could not say that that was usual practice or provide assurance that this would happen for every disabled patient.

Mr Roberts enquired, with regard to public transport, whether there was transport available for patients from the Main Road to the Hospital. Mr Dixon advised that he was not aware of any scheduled services, however, it may be that the Dial-A-Bus Service would offer some Service.

Mr McNulty advised that he had noticed that the applicant had said he would be the Responsible Pharmacist on the application form and wondered who would be the pharmacist at the new premises if the application was granted. Mr Dixon replied that he had been in talks with those pharmacists that he had already worked with who had left the area to pursue pharmacy work/attend college and that he would be encouraging them to come back. He further stated he acknowledged what Mr McNulty was saying that in a remote and rural area there may be difficulties in securing the services of relatively qualified staff.

P8 Signed Copy of Mitchells Chemist Ltd Dornoch _ PPC 30 October 2012 NOTES.doc 8. The Interested Party’s Case – Mr Andrew Paterson, Area Pharmaceutical Committee

Mr Paterson stated “I am here to represent the Area Pharmaceutical Committee (APC) and to provide the opinion of the APC. I will endeavour, therefore, to answer questions at the end but will refrain unless it is an area where there have been previous discussions by the APC and I therefore know the opinion of the Committee. The APC agreed with the applicant’s proposed boundaries and definition of the neighbourhood as these appeared to be reasonable.

It is the APC’s view that current pharmaceutical services in the proposed neighbourhood are inadequate. Although dispensing services are currently provided by a local GP surgery, patients in this neighbourhood have no access to the additional pharmaceutical services offered by a community pharmacy without the need to travel considerable distances to access them. This lack of access to pharmaceutical services in the opinion of the APC makes the current service inadequate.

The APC believe that although the letters of support have not demonstrated an inadequacy with the current dispensing service offered by the GP practice they have highlighted a desire from within the local community for other pharmaceutical services not offered by the GP surgery.

The APC agreed that the application would secure adequacy because it will provide the additional pharmaceutical services within the neighbourhood that are not currently available

After reviewing and discussing the application and supporting documentation the professional advice from the APC to the Pharmacy Practices Committee is to recommend the application is granted. Thank you”.

The Chair thanked Mr Paterson for his statement and invited the Applicant, Interested Parties and then members of the Committee to ask questions of him.

8.1 Questions from the Applicant to Mr A Paterson, Area Pharmaceutical Committee

The applicant had no questions for Mr Paterson.

8.2 Questions from Dr C Mair to Mr A Paterson, Area Pharmaceutical Committee

Dr Mair had no questions for Mr Paterson.

8.3 Questions from the Committee to Mr A Paterson, Area Pharmaceutical Committee

Members of the Committee had no questions for Mr Paterson.

9. The Interested Parties’ Case – Dr Christopher Mair for the GP Sub Committee

Dr Mair stated “I am the GP here today, representing the view of the Area Medical Committee and would refer the Committee to the letter sent to represent those views from the GP Sub Committee.

Financial viability for a pharmacy is seen to be achieved with a dispensing turnover of at least £400,000. The dispensing turnover for the Bonar Bridge/Ardgay practice is £270,000 which is only two thirds of that which would be required and as such, cannot be regarded as a sustainable model.

P9 Signed Copy of Mitchells Chemist Ltd Dornoch _ PPC 30 October 2012 NOTES.doc The pharmaceutical arrangements for the patients are fully met by the current dispensing arrangements and I would argue in a manner of luxury as access to these are extremely available and prompt, in that people do get their medicines dispensed more rapidly than in a pharmacy, which can be delayed due to the distance between prescriber and pharmacist and any delay would probably be intimated as an issue for patients in having their needs met.

The surgery is actually open for longer hours than those indicated would be offered by the applicant and the dispensing of acute scripts is done at the time of consultation. In terms of non dispensing services that the pharmacy would offer, be it the highlighted smoking cessation service, minor ailments or emergency hormonal contraception, these are all currently met by the practice in a timely matter and same day appointments are available due to staffing levels.

The area covered by the practice extends beyond that proposed to be serviced by the pharmacy application, with a patient population from as far as Ledmore Junction and Edderton.

In terms of the chronic medication prescribing aspect of the community pharmacy, we receive regular presentations and analysis of our prescribing and this comes out more favourably and less than per practice, on a demographic practice on target areas of non steroidal anti-inflammatory drugs, asthma clinics, and benzodiazepines. We perform above standard practice behaviour because of the integrated nature of the practice and patients are always seen by a doctor as we do not have a practice nurse, resulting in the provision of a high level of medical care.

Regarding disability access, the GP premises provides for parking at the site, directly in front of the premises which you will see on your way out. The proposed pharmacy premises on the corner is a bit of a black spot and would make it difficult for disabled patients to access when they currently have disabled access at the surgery.

The Chair thanked Dr Mair for his statement and invited the Applicant, Interested Parties and then members of the Committee to ask questions of him.

9.1 Questions from the Applicant to Dr C Mair, GP Sub Committee

The applicant had no questions for Dr Mair.

9.2 Questions from Mr A Paterson, Area Pharmaceutical Committee to Dr C Mair, GP Sub Committee

Mr Paterson had no questions for Dr Mair.

9.3 Questions from the Committee to Dr C Mair, GP Sub Committee

Mr McNulty enquired about the staffing level maintained currently by Dr Mair at the dispensing practice. Dr Mair replied that “the pharmacy” (meaning the dispensary in the GP practice) had been run by the Dispensing GPs since 1991, prescriptions were monitored by GPs and all repeat prescribing was done by through the GP for those patients receiving medicines for chronic medication. He advised that the identification and packaging of medicines was carried out by staff trained by the doctors and the senior dispenser of this had done some pharmaceutical training, albeit this was some time ago, in the making up of prescriptions.

Mr McNulty enquired if the staff were trained to NVQ level. Dr Mair replied they were not.

P10 Signed Copy of Mitchells Chemist Ltd Dornoch _ PPC 30 October 2012 NOTES.doc Mr McNulty asked, that aside, was each prescription looked at by the GP. Dr Mair replied in the affirmative, that the GP makes the final checks and that for the first 10-15 years of dispensing history they used to drag through the notes in order to do so but this is no longer required.

Mr McNulty asked if the same process was followed for prescriptions for CDs (meaning controlled drugs) to which Dr Mair confirmed it was.

Mr McNulty enquired if there were any methadone patients registered at the surgery. Dr Mair advised the Committee they did not and that there was not a demand for that service at the practice and never has been at any stage.

Mr Roberts referred to Dr Mair’s comment that the practice neighbourhood extended further than that proposed by Mr Dixon in his application. Dr Mair replied that yes, this extended to Ledmore Junction, farther on the west beyond Oykel Bridge and to Edderton to the south with the odd patient beyond these boundaries and across the Struie (Struie Hill) where there were wind farms and used to be a pub and now a number of dwellings.

Dr Taylor referred to Dr Mair’s mention of availability of appointments at the Practice and enquired whether these were all by consultation or via drop-in surgeries.

Dr Mair advised that all consultations were carried out by appointment, but had previously been drop in. He explained that with the change in the GP contract they had moved to an appointment only system, however, they do open until 7pm sometimes and that realistically, patients would be seen the same day but that they made extra exceptions on occasions, particularly for those working remotely from their home i.e. offshore.

Dr Taylor enquired if it would, and if so how Dr Mair felt it would impact on practice and dispensary staff, if there was a change in the dispensing service provided by the Practice.

Dr Mair replied that it would certainly have a big impact, particularly in terms of continuity and level of service provided by medical staff from within the area; with 3 GPs currently working which would possibly change and be an ongoing issue, although he recognised that that was not necessarily a question for this Committee to entertain.

Mr Roberts enquired whether there was any provision of delivery of prescriptions to patients by the Practice. Dr Mair advised that this was provided, where appropriate, and that they did post out medicines to patients and that district nurses would take these to patients and, sometimes themselves. He also advised that when carrying out home visits, the GPs had the ability to provide a full prescription cycle to patients rather than a starting pack but would lose the ability to do so if dispensing services were lost and this would result in quite a material change which could be quite an important issue for the community. Dr Mair added that the neighbourhood was in a geographical territory where a large element of the community had access to personal transport but that the public transport available, should it be required, was derisory.

Mrs Margaret Thomson enquired, in relation to the dispensing aspect, whether the three GPs referred to by Dr Mair were all employed full time. Dr Mair replied that they worked ¾ time.

Mrs Margaret Thomson then asked how many people staff the dispensary at any one time. Dr Mair advised that there were five staff and two or three were present in the dispensary at any one time.

Mrs Margaret Thomson enquired if those involved in the making up of prescriptions were all trained as dispensers. Dr Mair replied that they were not.

P11 Signed Copy of Mitchells Chemist Ltd Dornoch _ PPC 30 October 2012 NOTES.doc Mrs Margaret Thomson then asked if it was the GPs that were issuing the prescriptions and the dispensing staff that were making these up, then who was it who provided the final check. Dr Mair advised that prescriptions were dispensed by a member of the dispensary staff and were checked by another dispenser. To clarify, Mrs Margaret Thomson said, so the GPs prescribe, the dispensing staff make up the prescription, and then could Dr Mair inform her whom it was who carried out the final prescription check. Dr Mair replied that a doctor carries out the final check. Mrs Margaret Thomson enquired if the dispensers undertook training to do this. Dr Mair replied they did not.

10. Summing up

The Applicant and Interested Parties were then given the opportunity to sum up.

10.1 Dr C Mair, GP Sub Committee stated “A new pharmacy would be a major change to the area and needed to demonstrate that it would add and would not take away from the current provision of services. I am of the view that in fact the type of vision required for the area is different than that in an urban area and in order to do so may not be as comprehensive but all additional pharmaceutical services are currently met within a high staff level within the practice”.

10.2 Mr A Paterson, Area Pharmaceutical Committee stated “ I would refer the Committee to the statement presented by the Area Pharmaceutical Committee which recommends that the application is granted”.

10.3 Gareth Dixon for Mitchells Chemist Ltd, Applicant stated “within the proposed neighbourhood there are currently no pharmaceutical services. Therefore, it is both necessary and desirable to grant this contract. As discussed, the nearest pharmaceutical services are provided by the Co-op Pharmacy in Lairg at a distance of eleven miles. The proposed neighbourhood has a progressively ageing population and has a greater percentage of pensionable population compared with the rest of the Highland area and Scotland and this group tend to derive the most benefit from pharmaceutical services.

As a company I would like to thank all the residents of the proposed neighbourhood, Members of the , Members of Parliament and Community Councillors who all took time to make comment, especially NHS Highland Pharmaceutical Services for all their time and patience and finally the Pharmacy Practices Committee for giving up time for consideration of this application. We understand that with the allocation of NHS resources that difficult choices require to be made and we will respect whatever decision the Committee makes.

At the conclusion of the summing up, the Chair asked the applicant and all of the interested parties if they considered that they had had a fair hearing. Mr Dixon, Ms Gillespie, Dr Mair and Mr Paterson replied “yes”.

The Chair advised that a written decision would be sent out within 15 working days. A letter would be included with the decision advising of the appeal process. The Chair then thanked the parties for attending.

Mr Dixon, Ms Gillespie, Dr Mair, Mr Paterson and Mr Andrew Green, Area Regulations, Contracts & Controlled Drugs Governance Pharmacist left the meeting.

11. DECISION Having considered all the evidence presented to it, and the Committee's observations from the site visits, the Committee had firstly to decide, the question of the neighbourhood in which the premises to which the application related, were located.

P12 Signed Copy of Mitchells Chemist Ltd Dornoch _ PPC 30 October 2012 NOTES.doc The Committee took into account a number of factors in defining the neighbourhood including the natural and man-made boundaries, who resides in it, neighbourhood statistics, the location of existing shops, health services and schools, land use and topography, and the distance and the means by which residents are required to travel to existing pharmacies, if they chose to do so, all of which were located outwith the proposed neighbourhood and other services.

Special regard was made to the requirements of the Equality Act 2010:

• the need to eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by the Act;

• advance equality of opportunity between people who share a protected characteristic and those who do not;

• foster good relations between people who share a protected characteristic and those who do not.

The Committee considered the applicant's definition of the neighbourhood and how this compared to those put forward by the Interested Parties as well as comments received from the public consultation, and it was unanimously agreed that the neighbourhood was as defined by the applicant in his submission.

11.1 Neighbourhood: After considerable discussion, the Committee agreed that the neighbourhood had been as clearly defined by the applicant as was possible, and had been difficult to define due to the nature of the spread of the population and rural geography. Taking all this into account, the Committee supported the applicant’s definition of the neighbourhood and considered the detail of that neighbourhood and where the boundaries would lie as follows:-

North: the northern boundary was agreed, as proposed by the applicant to be Achinduich on the A836, taking in the surrounding areas. It was not considered that residents beyond this point would access pharmaceutical services from Bonar Bridge as there was adequate service provision in the village of Lairg which would be closer and seemed to be more probable that residents beyond Achinduich would more likely consider themselves to be neighbours of the village of Lairg and more likely, though not completely, be registered with the GP Practice in Lairg.

East: bounded on the north east by the community known as Spinningdale, but no further north east from that point, as by the applicant’s own information he dispenses to some patients in Spinningdale, therefore, it would appear that those beyond that point would access services in Dornoch. To the north east of Bonar Bridge, the communities known as Tulloch, Migdale, Ardens and Achuan.

South: the south eastern boundary was agreed as proposed by the applicant as Wester Fearn on the A836, although the GP had advised the Committee that a small patient population was registered at the Creich Surgery who were resident in Edderton. The reason for this was that residents beyond this point would naturally follow the A9 south to Tain to access pharmaceutical services at either of the two pharmacies sited there and who offered all the core elements of the pharmacy contract. It was agreed that the village of Ardgay, including the communities along the Croick Road, including Wester Gruinards be included in the neighbourhood as it was necessary for those resident along the Croick Road to return back along it to Ardgay and, therefore, would access services in either Ardgay or Bonar Bridge as a matter of course.

P13 Signed Copy of Mitchells Chemist Ltd Dornoch _ PPC 30 October 2012 NOTES.doc West: the western boundary was agreed, as proposed by the applicant, to be as far – but no further than Oykel Bridge on the A837. The Committee felt that, although it had been advised by the GP that there was some patients resident between Oykel Bridge and Ledmore Junction that, and in particular as this area was vast and sparsely populated, any residents therein would not consider themselves to be a neighbour of Bonar Bridge for the purpose of accessing daily needs or pharmaceutical services and, as a result would be more likely to consider accessing such services in Ullapool, where there was current adequate pharmaceutical provision in place.

11.2 Adequacy of Existing Provision of Pharmaceutical Services and Necessity and/or Desirability:

Having reached that decision, the Committee was then required to consider the adequacy of pharmaceutical services within that neighbourhood, and whether the granting of the application was necessary or desirable to secure adequate provision of pharmaceutical services in that neighbourhood.

The Committee noted there were no pharmaceutical services in the area but pharmaceutical services may be provided by pharmacies outwith the neighbourhood. That said, a prescribing data report run by the Health Board demonstrated only 0.5% of items prescribed from the Creich Surgery over the previous year had been dispensed at the closest pharmacy in Lairg and far less - in fact negligible amounts - from the other Sutherland pharmacies. After that analysis, it was the decision of the Health Board that no pharmacy could be construed to be an interested party, as there was no evidence that any were significantly affected by the application.

Having identified that there was negligible pharmaceutical input into the neighbourhood from outwith the neighbourhood, the Committee then considered what pharmaceutical services were available from within the neighbourhood. There were no pharmaceutical services currently provided from within the neighbourhood, although it was acknowledged that a highly quality dispensing service had been provided to patients in the neighbourhood by the Creich Surgery, which the Health Board had been most grateful to them for providing.

In addition, the Health Board acknowledged and appreciated that the surgery had done all that it could, within its restraints to emulate elements of the pharmacy contract such as minor ailments and chronic medication services, however, this could not be deemed as a pharmaceutical service.

Taking all the above into account, the Committee agreed and concluded there were no pharmaceutical services currently being offered within the neighbourhood and as a result the current provision of pharmaceutical services could not be deemed to be adequate, for the purpose of this application.

The Committee considered the letter from the GP Sub Committee. However, much of the points raised were around the financial implications to the GP Practice if the application were successful, which the Pharmacy Practices Committee, were unable to consider in their deliberations.

The Committee also took into consideration the letter from the Area Pharmaceutical Committee which agreed with the proposed neighbourhood and recognised that the provision of current pharmaceutical services were inadequate and therefore recommended the application was necessary and desirable in order to secure adequate pharmaceutical provision.

P14 Signed Copy of Mitchells Chemist Ltd Dornoch _ PPC 30 October 2012 NOTES.doc