Knowsley Pharmaceutical Needs Assessment 2018-21

Knowsley Pharmaceutical Needs Assessment 2018-2021

FOREWORD

Knowsley's Health and Wellbeing Board has responsibility for the ongoing review, development and publication of the Pharmaceutical Needs Assessment (a responsibility transferred to it from the now abolished Knowsley Primary Care Trust).

This is a statutory document, by virtue of the National Health Services (Pharmaceutical and Local Pharmaceutical Services) Regulations 2013. Its content has to be taken into account by those responsible for the approval of pharmacy contract applications (at NHS England) as well as those commissioning all other health services for our local population. From a Primary Care perspective this includes Clinical Commissioning Groups and Local Authorities looking to commission and develop local services from General Practice, Dental, Optometry and Pharmacy Contractors.

As such we are very happy to present our second formal Pharmaceutical Needs Assessment 2018–2021 which outlines the Pharmaceutical Services available to our population. This document provides information around current services being commissioned and proposals for future changes and developments.

This document will be used by NHS England to make decisions on applications for new contracts and changes to existing contracts, assist Knowsley Council and Knowsley Clinical Commissioning Group when reviewing our commissioning strategies, upon which we base our decisions. It is recognised that our Community Pharmacy colleagues have a key role to play in helping us develop and deliver the best possible Pharmaceutical Services for our population.

We commend this report to you and we look forward to your continuing involvement as this document is regularly reviewed and updated.

Signed

Anthony Leo, Steve Coffey Director of Commissioning Independent Chair NHS England – North (Cheshire and Knowsley Health and Wellbeing Merseyside) Board

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READER INFORMATION

Title Knowsley Pharmaceutical Needs Assessment, 2018 - 2021

Team Public Health

Author Lisa McGurgan – Specialist Public Health Analyst

Contributors Knowsley Pharmaceutical Needs Assessment Steering Group

Knowsley Pharmaceutical Needs Assessment Steering Group Richard Holford – Public Health Specialist Reviewers Matthew Ashton – Assistant Executive Director - Public Health and Wellbeing

Circulated Knowsley Health and Wellbeing Board to

Release April 2018 Date

Annual review with supplementary statements as necessary with a Review Date formal review by April 2021

Status Final

Purpose To assess the needs for pharmaceutical services in Knowsley

The Pharmaceutical Needs Assessment (PNA) is a primary tool for NHS England and local commissioners to support the decision making process for pharmacy applications and to ensure that commissioning Description intentions for services that could be delivered via community pharmacies, in addition to other providers, are incorporated into local planning cycles.

Superseded NHS Knowsley Pharmaceutical Needs Assessment (2015) Documents

Lisa McGurgan – Specialist Public Health Analyst Contact [email protected]

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KNOWSLEY PHARMACEUTICAL NEEDS ASSESSMENT STEERING GROUP MEMBERS

Anthony Leo Director of Commissioning, NHS England – North (Cheshire and (Chair) Merseyside)

Jackie Jasper Contracts Manager, NHS England

Lisa McGurgan Specialist Public Health Analyst, Knowsley MBC

ACKNOWLEDGEMENTS

 Janette Rawlinson for her ongoing support and promotion of the patient surveys

 Cheshire and Merseyside colleagues for helping to put together the Merseyside framework and support throughout the development of the PNA

 Public Health and CCG colleagues for providing information for section 7

 Pharmacies for providing information on the services they provide

 Patients for responding to the patient pharmacy survey

 Healthwatch for engagement and distributing of patient survey

 Health and Wellbeing Board for distribution of patient survey

 Villages Housing for distribution of patient survey

 Halton Local Authority for updating the literature search

Knowsley Pharmaceutical Needs Assessment, 2018 4 | P a g e TABLE OF CONTENTS

FOREWORD ...... 2

TABLE OF CONTENTS ...... 5

EXECUTIVE SUMMARY ...... 7

1. INTRODUCTION AND PURPOSE ...... 11

2. SCOPE AND METHODOLOGY ...... 12

2.1 Scope of the Pharmaceutical Needs Assessment ...... 12 2.2 Methodology and Data Analysis ...... 12 2.3 Consultation ...... 14 2.4 Pharmaceutical Needs Assessment Review Process...... 14 2.5 How to use the Pharmaceutical Needs Assessment ...... 15

3. NATIONAL PHARMACEUTICAL CONTRACT OVERVIEW ...... 17

3.1 Essential Services and Clinical Governance ...... 17 3.2 Advanced Services ...... 18 3.3 Enhanced Services ...... 22 3.4 Healthy Living Pharmacies ...... 22 3.5 Locally Commissioned Services ...... 24 3.6 Pharmacy Survey ...... 25 3.7 Funding the Pharmacy Contract ...... 26

4. OVERVIEW OF CURRENT PROVIDERS OF PHARMACEUTICAL SERVICES ...... 28

4.1 Community Pharmacy Contractors ...... 28 4.2 Dispensing Doctors ...... 28 4.3 Appliance Contractors ...... 28 4.4 Local Pharmaceutical Services (LPS) ...... 29 4.5 Acute Hospital Pharmacy Services ...... 29 4.6 Mental Health Pharmacy Services ...... 29 4.7 Bordering Services / Neighbouring Providers ...... 29 4.8 Quality Standards for Pharmaceutical Service Providers: Community Pharmacy Contract Monitoring ...... 30

5. PHARMACY PREMISES ...... 31

5.1 Pharmacy Locations ...... 31 5.2 Pharmacy Opening Hours ...... 34 5.3 Distance Selling Pharmacies ...... 39 5.4 Residents’ Survey Summary ...... 39 5.5 Pharmacy Survey Summary ...... 43 5.6 Prescribing ...... 45 5.7 Neighbouring Local Authorities Provision ...... 45

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6. POPULATION AND HEALTH PROFILE OF KNOWSLEY ...... 48

6.1 Location ...... 48 6.2 Deprivation ...... 49 6.3 Population Structure and Projections...... 51 6.4 Life Expectancy ...... 53 6.5 All Age, All Cause, Mortality ...... 55

7. PHARMACY ACTIVITY THAT SUPPORTS LOCAL PRIORITIES ...... 59

7.1 Tobacco Control ...... 59 7.2 Alcohol ...... 63 7.3 Planned Care ...... 65 7.4 Unplanned/Urgent Care ...... 69 7.5 Supporting and Identifying People with Long Term Conditions ...... 74 7.6 Cancers ...... 78 7.7 Sexual Health ...... 79 7.8 Mental Health ...... 86 7.9 Substance Misuse ...... 89 7.10 Older People ...... 94 7.11 Palliative Care ...... 98

APPENDIX 1: POLICY CONTEXT ...... 101

APPENDIX 2: ABBREVIATIONS USED ...... 104

APPENDIX 3: COMMUNITY PHARMACY ADDRESSES AND OPENING HOURS BY AREA ...... 105

APPENDIX 4: PHARMACY SERVICES ...... 118

APPENDIX 5: CROSS BORDER SERVICES ...... 119

APPENDIX 6: PHARMACY PREMISES AND SERVICES SURVEY ...... 120

APPENDIX 7: PATIENT SURVEY ...... 125

APPENDIX 8: FORMAL CONSULTATION LETTER AND QUESTIONNAIRE .... 124

APPENDIX 9: FORMAL CONSULTATION RESPONSE ...... 130

APPENDIX 10: REFERENCES ...... 132

Knowsley Pharmaceutical Needs Assessment, 2018 6 | P a g e EXECUTIVE SUMMARY

BACKGROUND

Knowsley Pharmaceutical Needs Assessment (PNA) presents a picture of community pharmacies and other providers of pharmaceutical services, reviewing services currently provided and how these could be utilised further. Community pharmacies can support the health and wellbeing of the population of Knowsley in partnership with other community services and GP practices. Services can be directed towards addressing health inequalities and supporting self-care in areas of greatest need, thus mapping of service provision and identifying gaps in demand are essential to afford commissioners with the intelligence they need to take forward appropriate and cost effective commissioning services.

The PNA is a key tool for NHS England and local commissioners to support the decision making process for pharmacy applications and to ensure that commissioning intentions for services that could be delivered via community pharmacies, in addition to other providers, are incorporated into local planning cycles.

DEVELOPING THE PHARMACEUTICAL NEEDS ASSESSMENT

The process for the development of the Pharmaceutical Needs Assessment was agreed by the Health and Wellbeing Board, and Anthony Leo (NHS England) was identified as the Board Champion to oversee its development. As per national guidance, a virtual multi-professional steering group was established with representatives from Knowsley Council (Public Health); Community Pharmacy Professional Leads from NHS England and Knowsley Clinical Commissioning Group.

The content is closely linked to the Joint Strategic Needs Assessment (JSNA) and analysis identifies the following:

 The health and pharmaceutical needs of the population of Knowsley  Evidence of best practice via community pharmacy services  Current local provision  Gaps in local provision

CONSULTATION

An important element of any needs assessment is to capture the view of current or potential service users and understand their perspective which in turn provides valuable insight that can be used to inform plans for pharmacy services.

To capture this information, a survey was designed by the Cheshire and Merseyside Pharmaceutical Needs Assessment Steering Group which asked the public about a range of topics including the current use of pharmacy services, satisfaction with services, prescription medicines use and access to pharmacies.

Knowsley Pharmaceutical Needs Assessment, 2018 7 | P a g e Between May 2017 and July 2017, Knowsley residents were invited to give their views regarding their local community pharmacy services. In total, there were 313 responses to a survey. Results from this survey are outlined within the report.

A survey was also designed in order to gather information from all pharmacies in Merseyside. Specifically, the survey asked pharmacists about dispensing, services commissioned, accessibility and customer support. All 36 Knowsley community pharmacies completed the survey.

As part of the PNA process there is a statutory provision that requires consultation of at least 60 days to take place to establish if the pharmaceutical providers and services supporting the population in the borough are accurately reflected in the final Pharmaceutical Needs Assessment report.

LOCAL PROVISION

Every pharmacy premise has to have a qualified pharmacist available throughout all of its contractual hours to ensure services are available to patients. In general pharmacy services are provided free of charge, without an appointment, on a “walk– in” basis. Pharmacists dispense medicines and appliances as requested by “prescribers” via both NHS and private prescriptions.

There are 36 community pharmacy contracts in Knowsley with 16 “Pharmacy Contractors”. The population of the area is 147,915 which equates to approximately one pharmacy for every 4,109 residents (England average is 5,000 population/pharmacy).

In terms of the type of community pharmacies in Knowsley there are 36 delivering a minimum of 40 hours service per week. Of these pharmacies, five deliver a minimum of 100 hours service per week. There are no pharmacies in Knowsley providing services via the internet or “distance selling”.

Further details of community pharmacies operating in Knowsley can be found in Chapter 5 of the report.

TOPIC-SPECIFIC CONCLUSIONS

Tobacco Control The widespread provision of the Stop Smoking Voucher Dispensing Enhanced Service and Smoking Cessation Service ensures that residents of Knowsley, particularly in areas where smoking prevalence is high, have access to stop smoking services via their local community pharmacy. Stop smoking services are currently well served through this range of providers.

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Alcohol The majority (32) of pharmacies in Knowsley are willing and able to provide alcohol screening services in the future if commissioned with one pharmacy currently providing a private alcohol service.

Planned Care Medicines Use Reviews (MURs) are undertaken in all community pharmacies across Knowsley providing widespread coverage to all areas of the borough.

Unplanned / Urgent Care All of Knowsley's community pharmacies offer the Care At The Chemist Scheme, thus providing universal access to all areas of the borough.

Supporting and Identifying People with Long Term Conditions The NHS Health Check programme is not currently undertaken in community pharmacies across Knowsley and there are no plans to do so. The Local Authority commissioned health check service is accessible in all areas of the borough thus ensuring adequate provision in Knowsley.

However, there is provision for people with long term conditions including, Medicines Use Reviews and New Medicine Service.

Cancers Community pharmacies in Knowsley provide a signposting service and raise awareness of cancer prevention through the 'Be Clear on Cancer' campaign for example, and also provide details within pharmacies when the breast screening van is to be situated nearby. However, community pharmacies are not deemed suitable venues for cancer screening interventions.

Sexual Health Emergency Hormonal Contraception is provided by the majority of community pharmacies in Knowsley (25) and provision across the borough adequately meets the needs of the local population. Additionally, provision for Emergency Hormonal Contraception is available from other services in the borough.

Mental Health There are currently no mental health related services commissioned from pharmacies in Knowsley. However, prevalence of mental health is high in Knowsley and pharmacies are potentially well placed to detect early signs of mental health problems when consulting with patients. A detailed review of the evidence regarding the effectiveness of such community pharmacy based services would need to be undertaken before such services can be commissioned. This should not be undertaken in isolation but considered as part of the whole mental health agenda. Therefore at this time it must be considered that there is no need for provision of such services from community pharmacies.

Knowsley Pharmaceutical Needs Assessment, 2018 9 | P a g e Substance Misuse In 29 of Knowsley's 36 community pharmacies supervised consumption of prescribed medicines (methadone, suboxone) is provided and is widely accessible across the borough which suggests provision is more than adequate.

There are nine community pharmacies providing a needle exchange service in Knowsley situated mainly in Huyton and Kirkby. Further provision is provided in Kirkby and Huyton via the drugs service.

Older People The influenza vaccination programme in Knowsley is primarily managed through GP practices and coverage of this campaign is above the 75% national target as well as being higher than across the whole of England. Although there is not a requirement for community pharmacies to partake in the campaign, a programme administering vaccines is delivered by the majority (31) of pharmacies in Knowsley.

Palliative Care There are currently five community pharmacies providing a palliative care drugs supply enhanced service in Knowsley. These pharmacies are distributed equitably across the borough and provision meets the needs of the local population.

Knowsley Pharmaceutical Needs Assessment, 2018 10 | P a g e 1. INTRODUCTION AND PURPOSE

The effective commissioning of accessible primary care services is central to improving quality, and implementing the vision for health and healthcare. The community pharmacy is one of the most accessible healthcare settings. Nationally 99% of the population, including those living in the most deprived areas, can get to a pharmacy within 20 minutes by car, and 96% of people living in the most deprived areas have access to a pharmacy either through walking or via public transport.

The Pharmaceutical Needs Assessment (PNA) presents a picture of community pharmacies and other providers of pharmaceutical services, reviewing services currently provided and how these could be utilised further. Community pharmacies can support the health and wellbeing of the population of Knowsley in partnership with other community services and GP practices. Services can be directed towards addressing health inequalities and supporting self-care in areas of greatest need, so a mapping of service provision and identifying any gaps in demand is essential to afford commissioners with the market intelligence they need to take forward appropriate and cost-effective commissioning of services.

The Health Act 2009 outlined the process of market entry onto a “Pharmaceutical List” by means of PNA and provided information to Primary Care Trusts (PCTs) for their production. It amended the National Health Service Act 2006 to include provisions for regulations to set out the minimum standards for PNAs. The regulations came into force on 24 May 2010 to:

 Develop and publish Pharmaceutical Needs Assessments and;  Use Pharmaceutical Needs Assessments as the basis for the determining market entry for NHS pharmaceutical service provision.

Following the abolition of PCTs, this statutory responsibility was passed to Health and Wellbeing Boards by virtue of the National Health Service (Pharmaceutical and Local Pharmaceutical Services) Regulations 2013, which came into force on 1 April 2013. These Regulations also outline the process that NHS England must comply with in dealing with applications for new pharmacies or changes to existing pharmacies.

The Health and Social Care Act 2012 further describes the duty of “commissioners”, in accordance with Regulations, to arrange for the adequate provision and commissioning of pharmaceutical services for their population.

The Pharmaceutical Needs Assessment is thus a key tool for the NHS England and local commissioners, to support the decision making process for pharmacy applications and to ensure that commissioning intentions for services that could be delivered via community pharmacies, in addition to other providers, are incorporated into local planning cycles. Local commissioning priorities need to be driven by the Joint Strategic Needs Assessment (JSNA) of which the PNA is a key component.

Knowsley Pharmaceutical Needs Assessment, 2018 11 | P a g e 2. SCOPE AND METHODOLOGY

2.1. Scope of the Pharmaceutical Needs Assessment

The scope of the assessment of need must address the following principles:

 The safe and efficient supply of medicines, including the additional (non NHS commissioned) support services provided by pharmacies such as:

. Support for housebound patients and older people . People with learning difficulties, and . Medication administration support such as Monitored Dosage Systems (MDS)

 Pharmaceutical care that supports safe and effective use of medicines  Pharmaceutical care that provides quality healthcare and public health information and advice to all members of the population  High quality pharmacy premises that increase capacity and improve access to primary care services and medicines  Locally enhanced services which increase access, choice and support self-care  Locally commissioned pharmaceutical services that have the potential to reduce avoidable hospital admissions and reduce bed-days  High quality pharmaceutical support to prescribers for clinical and cost- effective use of resources

2.2. Methodology and Data Analysis

Key principles of the Pharmaceutical Needs Assessment are:

 Patients, the public and key stake holders are involved in the development and are essential in identifying needs  It is a developing, live document to be refreshed as required by the regulations  It continues to focus on identifying health needs which can be supported by pharmaceutical services and makes recommendations for the commissioning of those services  It is developed by a Multi-Disciplinary Pharmaceutical Needs Assessment Working Group

The process involves the following steps:

 Identification of health and pharmaceutical needs  Deciding how these needs are being met currently  Identifying any gaps  Taking into account the views of professionals, partner organisations and public.

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Figure 1: Pharmaceutical Needs Assessment Process Source: Halton Local Authority

The content is closely linked to the local Joint Strategic Needs Assessment (JSNA) and has been produced by means of structured analysis of complex data sources in order to identify the following:

 The health and pharmaceutical needs of the population  Evidence of best practice in meeting need through community pharmacy services  Current local provision of pharmaceutical services, and subsequently  Gaps in provision of pharmaceutical services

The following data sources have been used for the purposes of this Pharmaceutical Needs Assessment:

 Joint Strategic Needs Assessment (JSNA)  Public Health Annual Report  Public Health Outcomes Framework  Census Data  Data on socio-economic circumstances of the local area  Pharmacy Services Survey  Pharmacy Patient Survey  Knowsley Local Plan: Core Strategy

Knowsley Pharmaceutical Needs Assessment, 2018 13 | P a g e The residents and pharmacist survey responses informed the first draft of the PNA which then underwent a formal 60 day consultation with relevant amendments being made.

2.3 Consultation

A draft Pharmaceutical Needs Assessment was issued for formal consultation on 19 October 2017, and promoted on the Health and Wellbeing Board’s website, in the Knowsley News and disseminated widely via partners including to Knowsley Council and Knowsley CCG employees.

The draft document was distributed as follows:

 GP’s and other Primary Care Staff  Community Pharmacies  Knowsley Engagement Forum  Mental Health Trusts  Local NHS Trusts  Local Pharmaceutical Committee  Local Medical Committee  Neighbouring Health and Wellbeing Boards – Halton, Lancashire, Liverpool, Sefton and St Helens  NHS England  Clinical Commissioning Groups  Healthwatch  GP Practice Patient Participation Groups

Website and use of Survey Monkey Full documentation was published on the Knowsley Health and Wellbeing Board’s website (http://www.knowsleyhwb.org.uk) on 19 October 2017 with a Survey Monkey facility to help readers make comments on the PNA. Respondents were offered paper copies if required to make their views known.

A summary of responses received during the consultation period can be found in Appendix 9.

2.4. Pharmaceutical Needs Assessment Review Process

Once published the Pharmaceutical Needs Assessment will be considered as an integrated part of the annual commissioning cycle, as well as being under constant review for any changes which might dictate a new or diminished pharmaceutical need. Examples of such changes could include:

 New pharmacy contracts  Pharmacy closures  Changes to pharmacy locations  Changes to pharmacy opening hours  Local intelligence and significant issues relating to pharmacy enhanced service provision

Knowsley Pharmaceutical Needs Assessment, 2018 14 | P a g e  Appliance provision changes  Significant changes in Public Health intelligence or primary care service developments that may impact either complimentary or adversely on pharmacy based services

On the 5 December 2016, amendments to the 2013 Pharmaceutical Regulations came into effect (see Appendix 1: Policy Context). NHS pharmacy businesses may apply to consolidate the services provided on two or more sites onto a single site. Applications to consolidate will be dealt with as “excepted applications” under the 2013 Regulations, which means they will not be assessed against the PNA. Instead, consolidation applications will follow a simpler procedure, the key to which is whether or not a gap in pharmaceutical service provision would be created by the consolidation.

If NHS England is considers that the consolidation would create a gap in pharmaceutical services provision, it must refuse the application. If NHS England grants the application, it must then refuse any further “unforeseen benefits applications” seeking inclusion in the pharmaceutical list, if the applicant is seeking to rely on the consolidation as a reason for saying there is now a gap in provision, at least until the next revision of the PNA.

If there are any minor changes to the pharmaceutical landscape, Knowsley Health and Wellbeing Board is obliged to issue a “supplementary statement” where appropriate, unless the changes were significant enough that a new PNA was warranted and did not form a disproportionate response to the level of change identified. The Pharmaceutical Needs Assessment has to have a complete review every three years.

2.5 How to use the Pharmaceutical Needs Assessment

The Pharmaceutical Needs Assessment should be utilised as a service development tool in conjunction with the JSNA and the strategic plans from local commissioners. Mapping out current services and gaining a sense of future service needs will pinpoint the areas where the development of local pharmaceutical services may be necessary.

The Pharmaceutical Needs Assessment can be used by patients, current and future service providers and commissioners alike in the following way:

 Maps and tables detailing specific services will mean patients can see clearly where they can access a particular service  Current service providers will be better able to understand the unmet needs of patients in their area and take steps to address this need  Future service providers will be able to tailor their applications to be added to the pharmaceutical list to make sure that they provide the services most needed by the local community  Commissioners will be able to move away from the ‘one-size fits all approach’ to make sure that pharmaceutical services are delivered in a targeted way

Knowsley Pharmaceutical Needs Assessment, 2018 15 | P a g e  NHS England will be in a better position to judge new applications to join the pharmaceutical list to make sure that patients receive quality services and adequate access

Knowsley Pharmaceutical Needs Assessment, 2018 16 | P a g e 3. NATIONAL PHARMACEUTICAL CONTRACT OVERVIEW

All national NHS pharmaceutical service providers must comply with the contractual framework that was introduced in April 2013. The national framework is set out below and can be found in greater detail on the Pharmaceutical Services Negotiating Committee website.

The pharmaceutical services contract consists of three different levels;

 Essential services  Advanced services  Enhanced services

3.1. Essential Services and Clinical Governance

Essential services consist of the following and have to be offered by all pharmacy contractors:

Dispensing - Supply of medicines or appliances, advice given to the patient about the medicines being dispensed and possible interactions with other medicines. Also the recording of all medicines dispensed, significant advice provided, referrals and interventions made using a Patient Medication Record.

Repeat Dispensing - Management of repeat medication for up to one year, in partnership with the patient and prescriber. The patient will return to the pharmacy for repeat supplies, without first having to visit the GP surgery. Before each supply the pharmacy will ascertain the patient’s need for a repeat supply of a particular medicine. The pharmacist will communicate all significant issues to the prescriber with suggestions on medication changes as appropriate.

Originally this service was mainly carried out using paper prescriptions, as the Electronic Prescription Service (EPS) has developed, the majority of repeat dispensing is now carried out via EPS release 2 and is termed electronic Repeat Dispensing (eRD). eRD is much more efficient and convenient for all involved.

EPS enables prescriptions to be sent electronically from the GP practice to the pharmacy and then on to the Pricing Authority for payment. It has been deployed through two key releases. Release 1 in which the barcoded paper prescription form remains the legal prescription.

Release 2 which supports the transmission of electronic prescriptions; eRD; patient nomination of their selected pharmacy; GP cancellation of e- prescriptions; and the electronic submission of reimbursement claims to the Pricing Authority. Currently, prescriber’s can only issue an electronic NHS prescription where it is being sent electronically to a patient’s nominated pharmacy.

All pharmacies in Knowsley are currently EPS release 2 enabled.

Knowsley Pharmaceutical Needs Assessment, 2018 17 | P a g e Dispensing Appliances – Pharmacists dispense appliances in the course of their business. Whilst the Terms of Service requires a pharmacist to dispense any (non-blacklisted) medicine ‘with reasonable promptness’, for appliances the obligation to dispense arises only if the pharmacist supplies such products ‘in the normal course of his business’. All community pharmacy contractors choosing to dispense appliances in the normal course of their business are required to comply with the following Essential Services requirements.

Disposal of Unwanted Medicines - Pharmacies act as collection points for patient returned unwanted medicines from households and individuals. Special arrangements apply to Controlled Drugs (post Shipman Inquiry) and private arrangements must be adopted for waste returned from nursing homes.

Promotion of Healthy Lifestyles (Public Health) – Opportunity to make every contact count by providing one to one advice on healthy lifestyle topics, such as, smoking cessation, weight management etc. to certain patient groups who present prescriptions for dispensing. In addition promotion of national public health campaigns throughout the year as directed by NHS England.

Signposting Patients to other Health Care Providers - Pharmacists and their staff will refer patients to other healthcare professions or care providers when appropriate.

Support for Self-Care - The provision of advice and support by pharmacy staff to enable patients to derive maximum benefit from caring for themselves or their families. The service will initially focus on self-limiting illness, but support for people with long term conditions is also a feature of the service.

Clinical Governance - Pharmacists must ensure the following processes are in place:

 Use of standard operating procedures  Patient safety incident reporting  Demonstrating evidence of Pharmacist Continuing Professional Development  Operating a complaints procedure  Compliance with Health and Safety legislation  Compliance with the Disability Discrimination Act  Significant event analysis  Commitment to staff training, management and appraisals  Undertaking patient satisfaction surveys

3.2. Advanced Services

Advanced services are those pharmacy services commissioned on behalf of the NHS by NHS England. The range of enhanced services commissioned

Knowsley Pharmaceutical Needs Assessment, 2018 18 | P a g e varies across the country. Currently there are six advanced servicesi within the NHS Community Pharmacy contract:

i. Medicines Use Review (MUR) ii. Appliance Use Review (AUR) iii. Stoma Appliance Customisation (SAC) service iv. New Medicine Service (NMS) v. NHS Urgent Medicine Supply Advanced Services (NUMSAS) pilot vi. Flu Vaccination Service

Community pharmacies can opt to provide any of these services as long as they meet the requirements set out in the Secretary of State Directions.

i. Medicines Use Review (MUR) & Prescription Intervention Service - The Medicines Use Review service is an advanced service provided under the community pharmacy contractual framework and can only be provided by a pharmacist. The service includes Medicines Use Reviews to be undertaken periodically or when there is a need to intervene due to a problem that is identified while providing the dispensing service. The pharmacist conducts a structured medication review with the patient to help them manage their medicines more effectively and identify any medication related problems. The service also aims to improve patient knowledge, adherence and use of their medicines by:

 Establishing the patient’s actual use, understanding and experience of taking medications  Identifying, discussing and resolving poor or ineffective use of medicines  Identifying side effects and drug interactions that may affect adherence  Improving the clinical and cost effectiveness of prescribed medicines and reducing medicine wastage

It is for the contractor to decide which patients receive this service, although at least 70% of Medicines Use Reviews must be on patients that fall within the national target groups. These include;

 Patients taking high risk medicines  Patients recently discharged from hospital who had changes made to their medicines whilst in hospital  Patients with respiratory disease  Patients at risk of or diagnosed with cardiovascular disease and being regularly prescribed at least four medicines

All 36 Knowsley pharmacies provide the Medicines Use Review service.

ii. Appliance Use Review (AUR) - AUR is the second advanced service and was introduced into the NHS community pharmacy contract on 1 April 2010. iPharmaceutical Service Negotiating Committee (PSNC) accessed from www.psnc.org.uk/pages/advanced_services.html (June 2010)

Knowsley Pharmaceutical Needs Assessment, 2018 19 | P a g e This service can be provided by either a community pharmacy or appliance contractors, and can be carried out by a pharmacist or a specialist nurse either at the contractor’s premises or at the patient's home.

The service has a national service specification, but was originally established locally between the Primary Care Trust and their pharmacy contractors. A fee is payable to all community pharmacy and appliance contractors for each AUR they have carried out. There is a different fee depending on whether the AUR was carried out in the patient’s home or on the contractor’s premises.

AURs should improve the patient's knowledge and use of any specified appliance by:

 Establishing the way the patient uses the appliance and the patient's experience of such use  Identifying, discussing and assisting in the resolution of poor or ineffective use of the appliance by the patient  Advising the patient on the safe and appropriate storage of the appliance  Advising the patient on the safe and proper disposal of the appliances that are used or unwanted

Results from the pharmacy survey found that eight Knowsley pharmacies provide the AUR service, with a further three pharmacies saying they would provide the service soon.

iii. Stoma Appliance Customisation (SAC) Service - Stoma appliance customisation was the third advanced service in the NHS community pharmacy contract and was introduced in April 2010. This service involves the customisation of stoma appliances, based on the patient’s measurements or on a template. The aim of the service is to ensure proper use and comfortable fitting of the stoma appliance and to improve how long they are used for, thereby reducing waste and unnecessary patient discomfort. This service can be provided by either pharmacy or appliance contractors.

Results from the pharmacy survey found that seven Knowsley pharmacies provide the SAC service. Three of these where in Kirkby, two in Huyton, and one in Halewood and one in Prescot and Whiston and Cronton.

iv. New Medicines Service (NMS) - The New Medicines Service was introduced on 1 October 2011. The service can be provided by pharmacies only, and provides support with medicines adherence for patients being treated with new medicines in four conditions/therapy areas. These are asthma/ Chronic Obstructive Pulmonary Disease (COPD), type 2 diabetes, hypertension, and antiplatelet/anticoagulation therapy. The pharmacist provides face-to-face counselling about the medicine when the patient first presents with their prescription at the pharmacy. Arrangements are then made for the patient to be seen 7-14 days later to assess adherence and discuss any problems with the new medicine. The patient is followed up 14 days later to check all is well, at which point they exit this service.

Knowsley Pharmaceutical Needs Assessment, 2018 20 | P a g e All Knowsley pharmacies provide the New Medicines Service.

v. NHS Urgent Medicine Supply Advanced Services (NUMSAS) - From 1st December 2016, community pharmacies across England have been able to register on the NHS Business Services Authority (BSA) portal to provide the NHS Urgent Medicines Supply Advanced Service (NUMSAS) as part of a national pilot. The Service, which is commissioned by NHS England, allows community pharmacies to supply a repeat medicine at NHS expense, following a referral from NHS111 and where the pharmacist identifies that the patient has an immediate need for the medicine, and that it is impractical to obtain a prescription without undue delay.

The objectives of the survey included:

 Managing appropriately NHS 111 requests for urgent medicine supply  Reducing demand on the rest of the urgent care system  Resolving problems leading to patients running out of their medicines  Increasing patients’ awareness of electronic repeat dispensing

Results from the pharmacy survey found that eight Knowsley pharmacies provide the NUMSAS service, three of which are in Kirkby and the remaining five in Halewood and Huyton. A further 16 stating that they would be providing the service in the next 12 months.

vi. Influenza Vaccination Service - Community pharmacies are able to offer a seasonal influenza (flu) vaccination service for patients aged 18 years and above in at-risk groups and social care workers if they are in a patient facing role. This service is the fifth Advanced Service in the English Community Pharmacy Contractual Framework (CPCF).

Immunisation is one of the most successful and cost-effective health protection intervention and is a cornerstone of public health. High immunisation rates are key to preventing the spread of infectious disease, complications, and possible early death among individuals and protecting the population’s health. For most healthy people, influenza is an unpleasant but usually self-limiting disease. However, those with underlying disease are at particular risk of severe illness if they catch it. The aim of the seasonal influenza vaccination programme is to protect adults and children who are most at risk of serious illness or death should they develop influenza, by offering protection against the most prevalent strains of influenza virus

The service can be provided for adults by any community pharmacy in England that fully meets the requirements for provision of the service, and has notified NHS England of their intention to begin providing the service by completing a notification form on the NHS BSA website.

Results from the pharmacy survey found that 31 of Knowsley pharmacies provide the flu vaccination service, with a good distribution across the borough. A further five stating that they would be providing the service in the next 12 months.

Knowsley Pharmaceutical Needs Assessment, 2018 21 | P a g e

3.3. Enhanced Services

Enhanced services are pharmacy services commissioned on behalf of the NHS by NHS England, and can only be commissioned by NHS England. The service is developed and negotiated locally based on the needs of the local population. The PNA will inform the future commissioning need for these services. The term Local Enhanced Services (LES) can only be used to describe services commissioned by NHS England.

Enhanced services in Knowsley include;

 Out of Hours Service

3.4 Healthy Living Pharmacies

The Healthy Living Pharmacy (HLP) framework[1] is a tiered commissioning framework aimed at achieving consistent delivery of a broad range of high quality services through community pharmacies to meet local need, improving the health and wellbeing of the local population and helping to reduce health inequalities. It is a nationally agreed accreditation or ‘kite mark’ for community pharmacies which deliver proactive health and wellbeing advice as part of their day to day role.

Quality Criteria needed to demonstrate that a pharmacy is either working towards Healthy Living Pharmacy status or actually achieving this quality mark. Once progressed to the next level the pharmacy must ensure that the standards of the previous level are maintained:

 Level 1: Promotion – Promoting health, wellbeing and self-care (in July 2016, Level 1 changed from a commissioner-led process to a profession- led self-assessment process)  Level 2: Prevention – Providing services (commissioner-led)  Level 3: Protection – Providing treatment (commissioner-led)

The Healthy Living Pharmacy framework is underpinned by three enablers:

i. Workforce development – a skilled team to pro-actively support and promote behaviour change, improving health and wellbeing ii. Premises that are fit for purpose iii. Engagement with the local community, other health professionals (especially GPs), social care and public health professionals and local authorities

Key findings from the evaluation of the Healthy Living Pharmacy pathfinder sites are:[2] [3] [4]

 Increased service delivery and improved quality measures and outcomes

Knowsley Pharmaceutical Needs Assessment, 2018 22 | P a g e  60% of peopled surveyed would have otherwise gone to a GP  99% of the public surveyed were comfortable to receive the service in the pharmacy  More people successfully quit smoking in Healthy Living Pharmacies than non- Healthy Living Pharmacies  More sexual health advice given than in non- Healthy Living Pharmacies  Healthy Living Pharmacies were effective at delivering increased support for people taking medicines for long term conditions, through both Medicines Use Reviews and the New Medicine Service  70% of the contractors surveyed saying it had been worthwhile for their business  Health promotion zones within pharmacies play a vital part in supporting the public health role of the pharmacy

The Healthy Living Pharmacy Quality Mark Healthy Living Pharmacies will have a healthy living pharmacy logo that is easily identified by members of the public, healthcare professionals and commissioners. This will require marketing and publicity to ensure that people recognise what this means. A national logo exists but a local variant could be agreed if this is thought more locally acceptable.

What is a Healthy Living Pharmacy?

Figure 2: Healthy Living Pharmacy

The approach illustrated above shows that there is an ethos within a Healthy Living Pharmacy to proactively promote health and wellbeing throughout the whole pharmacy team. Additionally, a Healthy Living Pharmacy[5] have at least one Healthy Living Champion trained to level 2 qualification in ‘Understanding Health Improvement’ accredited by the Royal Society of Public Health. A Healthy Living Pharmacy will achieve defined quality criteria requirements and meets productivity targets linked to local health needs e.g. number of stop smoking quits at 4 weeks; number of targeted Medicines Use Reviews completed, tailored to local need. It builds on all existing core pharmacy

Knowsley Pharmaceutical Needs Assessment, 2018 23 | P a g e services (Essential and Advanced) with a series of locally commissioned services.

All Knowsley pharmacies are either currently Healthy Living Pharmacies (n=24) or currently working towards Healthy Living Pharmacy status (n=12).

3.5 Locally Commissioned Services

Under current regulations locally commissioned services are those developed and negotiated based on the needs of the local population. The Pharmaceutical Needs Assessment will inform the future commissioning needs for these services. These services can be commissioned from the pharmacy by the Local Authority (LA), Clinical Commissioning Group (CCG) or other commissioner. Examples of such services include emergency hormonal contraception, needle exchange, observed consumption and minor ailments. These services (under the older regulations) also used to be called “enhanced”.

Theoretically, it is possible for neighbouring Health and Wellbeing Boards or CCGs to commission similar services from pharmacies at different remuneration rates or using different service specifications. This is because financial or commissioning arrangements for services are based on local negotiation and are dependent on available resources. This does, however, lead to duplication of effort for commissioning staff and difficulties for locum pharmacists working across boundaries. Wherever possible, commissioners are advised to work together to eliminate such anomalies.

The continuity of locally commissioned service provision has often been difficult to achieve. There have been ongoing challenges around pharmacists gaining accreditation to deliver those services and individual pharmacists /locums who were accredited to provide these services may move around. This has had the potential to lead to gaps in services. Some work has been undertaken by the Community Pharmacy Competence Group (CPCG) to allow pharmacy professionals to be able to declare their own competence to deliver locally commissioned community pharmacy services, via self-declaration of Competence documents (DoCs). This self-declaration process provides assurance that pharmacy professionals are competent to provide a service while minimising bureaucracy. The requirement for self-declaration is included within local contracts for locally commissioned services, and pharmacists who fail to meet this requirement will be removed from the Knowsley Borough Council provider list.

Knowsley Pharmaceutical Needs Assessment, 2018 24 | P a g e Examples of some pharmacy-based locally commissioned services are as follows:

 Minor ailment management  Substance misuse medication services / Needle exchange scheme  Palliative care services  Emergency Hormonal Contraception service / Sexual Health services  Vascular screening  Smoking Cessation service

3.6 Pharmacy Survey

The pharmacy survey was distributed to all pharmacies in Knowsley using the Pharmoutcomes system. All Knowsley pharmacies completed the survey during May and June 2017. Below summarises the current provision of enhanced and locally commissioned services in Knowsley, as well as highlighting the willingness of pharmacies to provide services not currently commissioned in the future.

Commissioned Services The most commonly commissioned pharmaceutical services include:

 Minor Ailment Scheme – 100%  Nicotine Replacement Therapy Voucher Dispensing – 94%  Smoking Cessation Service – 72%

Where services were not locally commissioned or only provided by some pharmacies, there was a willingness from the majority of pharmacies to provide these in the future. The following services ranked highest, although the majority of pharmacies would be willing to provide any of the listed services:

 Schools Service – 86%  Contraceptive Services – 86%  NHS Health Checks – 86%  Chlamydia Treatment – 83%  Anticoagulant Monitoring Service – 83%  Anti–Viral Distribution Service – 81%

Disease Specific Medicines Management Although only two pharmacies per disease type privately provide disease specific medicines management there is a willingness from the majority of pharmacies to provide disease specific medicines management services for each of the listed types.

Screening Although the majority of pharmacies in Knowsley are not currently providing screening services, they would be prepared to provide screening services for each of the listed areas. However, there was less support for a HIV screening service (75% would be willing).

Knowsley Pharmaceutical Needs Assessment, 2018 25 | P a g e

Other Services The highest ranked services where Knowsley pharmacies stated that they were not able or willing to provide include:

 Out of Hours Services – 36%  Needle and Syringe Exchange Service – 28%  On Demand Availability of Specialist Drug Services – 25%  Phlebotomy Service – 22%

3.7. Funding the Pharmacy Contract

The essential and advanced services of the community pharmacy contract are funded from a national ‘Pharmacy Global Sum’ agreed between the Pharmaceutical Services Negotiating Committee and the Treasury. This is divided up and devolved to NHS England Local Area Teams as a cash-limited budget which is then used to reimburse pharmaceutical service activity as per the Drug Tariff (www.drugtariff.com). Funding for enhanced services has to be identified and negotiated locally, from the commissioners own budget.

NHS England requires all pharmaceutical service providers to meet the high standards expected by patients and the public. All Pharmacies are included within a programme of contract monitoring visits as independent providers of services provided under the national pharmacy contract. The delivery of any locally commissioned enhanced services is also scrutinised.

As stated within the Department of Health review ‘High Quality Care for All’ (2008), high quality care should be safe and effective as possible, with patients treated with compassion, dignity and respect. As well as clinical quality and safety, quality means care that is personal to each individual. This statement is as meaningful to pharmacies as to other NHS service providers and is the principle which NHS England adopts when carrying out the community pharmacy contract monitoring visits for essential, advanced services and locally commissioned enhanced services.

The community pharmacy contract assurance process follows a structured sequence of events including:

 A rolling programme of pre-arranged visits to pharmacies for observation of processes and procedures and a detailed interview with the pharmacist in charge and support staff  Self-assessment declarations  Scrutiny of payment submission processes  Scrutiny of internal processes for confidential data management  Recommendations for service development or improvement  Structured action plan with set timescales for completion

In addition to the structured process outlined above, NHS England will also take account of the voluntary submission of the findings from the annual community

Knowsley Pharmaceutical Needs Assessment, 2018 26 | P a g e pharmacy patient questionnaire that is undertaken by the pharmacy contractor as well as any patient complaints relevant to pharmacy services. In cases where the professional standards of an individual pharmacist is found to fall below the expected level, NHS England will work with the relevant professional regulatory body such as the General Pharmaceutical Council to ensure appropriate steps are taken to protect the public.

Knowsley Pharmaceutical Needs Assessment, 2018 27 | P a g e 4. OVERVIEW OF CURRENT PROVIDERS OF PHARMACEUTICAL SERVICES

4.1. Community Pharmacy Contractors

Community Pharmacy Contractors can be individuals who independently own one or two pharmacies or large multinational companies e.g. Lloyds, or Boots, etc. who may own many hundreds of pharmacies UK wide.

Every pharmacy premise has to have a qualified pharmacist available throughout all of its contractual hours, to ensure services are available to patients. In general pharmacy services are provided free of charge, without an appointment, on a “walk–in” basis. Pharmacists dispense medicines and appliances as requested by “prescribers” via both NHS and private prescriptions.

In terms of the type of Community Pharmacies in Knowsley there are:

 36 delivering a minimum of 40 hours service per week  Five deliver a minimum of 100 hours service per week  There are no pharmacies in Knowsley providing services via the internet or “distance selling”

Further details of community pharmacies operating in Knowsley can be found in Chapter 5 of this Pharmaceutical Needs Assessment.

4.2 Dispensing Doctors

Dispensing Doctors services consist mainly of dispensing for those patients on their “dispensing list” who live in more remote rural areas. There are strict regulations which stipulate when and to whom doctors can dispense. Knowsley does not have any dispensing doctor practices.

4.3 Appliance Contractors

Appliance contractors cannot supply medicines but are able to supply products such as dressings, stoma bags, catheters etc.

Currently Knowsley does not have an appliance contractor physically located within its area, but patients can access services from appliance contractors registered in other areas. Of Knowsley’s neighbouring areas, Liverpool is the only area to have appliance contractors physically located within their borders, three in total.

Knowsley Pharmaceutical Needs Assessment, 2018 28 | P a g e 4.4. Local Pharmaceutical Services (LPS)

This is an option that allows commissioners to contract locally for the provision of pharmaceutical and other services, including services not traditionally associated with pharmacy, within a single contract. Given different local priorities, LPS provides commissioners with the flexibility to commission services that address specific local needs which may include services not covered by the community pharmacy contractual framework. There are currently no LPS contracts in Knowsley.

4.5. Acute Hospital Pharmacy Services

There are no Acute Hospital Trusts that Knowsley ‘hosts’, however there are five Acute Hospital Trusts within the Knowsley catchment area due to the geographical location of the borough:

 Aintree University Hospital NHS Foundation Trust  Alder Hey Children’s NHS Foundation Trust (which is close to Knowsley’s border)  Liverpool Women’s NHS Foundation Trust  Royal Liverpool and Broadgreen University Hospitals NHS Trust  St Helens and Knowsley Teaching Hospitals NHS Trust (mainly Whiston Hospital),

Hospital Trusts have Pharmacy Departments whose main responsibility is to dispense medications for use on the hospital wards for in-patients, when patients are discharged from hospital following a stay and during the outpatient clinics.

4.6. Mental Health Pharmacy Services

The population of Knowsley is served by two Mental Health Trusts, namely Mersey Care NHS Trust and North West Boroughs Healthcare NHS Foundation Trust. They employ pharmacists to provide clinical advice within their specialist areas and they also commission a “dispensing service” from a Community Pharmacy to dispense the necessary medications for their patients at the various clinics across the patch.

4.7. Bordering Services / Neighbouring Providers

The population of Knowsley can access minor ailment services from pharmaceutical providers outside the Local Authority’s own boundary. When assessing pharmacy contract applications, or making enhanced service commissioning decisions, the accessibility of services close to the borders will need to be taken into account. For further information on such services, please refer to the relevant neighbouring Health and Wellbeing Boards own Pharmaceutical Needs Assessment.

Knowsley Pharmaceutical Needs Assessment, 2018 29 | P a g e 4.8. Quality Standards for Pharmaceutical Service Providers: Community Pharmacy Contract Monitoring

NHS England requires all pharmaceutical service providers to meet the high standards expected by patients and the public. All Pharmacies are included within a programme of assurance framework monitoring visits as independent providers of services provided under the national pharmacy contract. The delivery of any locally commissioned enhanced services are also scrutinised by the commissioner of each of the services under separate arrangements.

As stated within the NHS review 2008ii, high quality care should be as safe and effective as possible, with patients treated with compassion, dignity and respect. As well as clinical quality and safety, quality means care that is personal to each individual.

This statement is as meaningful to pharmacies as to other NHS service providers, and is the principle that NHS England adopts when carrying out the Community Pharmacy Contract Monitoring visits for essential services, advanced services and locally commissioned enhanced services.

The community pharmacy contract assurance process follows a structured sequence of events including:

In addition to the structured process outlined above, NHS England will also take account of the voluntary submission of findings from the annual community pharmacy patient questionnaire. This is undertaken by the pharmacy contractor as well as any patient complaints relevant to pharmacy services. In cases where the professional standards of an individual pharmacist is found to fall below the expected level, NHS England will work with the relevant professional regulatory body such as the General Pharmaceutical Council to ensure appropriate steps are taken to protect the public.

iiHigh Quality Care For All - NHS Next Stage Review Final Report , Department of Health June 2008

Knowsley Pharmaceutical Needs Assessment, 2018 30 | P a g e 5. PHARMACY PREMISES

5.1 Pharmacy Locations

Location of Pharmacies in Knowsley

Figure 3: Location of Pharmacies in Knowsley, 2017 Source: Pharmacy Survey, 2017

Knowsley Pharmaceutical Needs Assessment, 2018 31 | P a g e There are 36 community pharmacies in Knowsley which are distributed relatively evenly across the borough (see Figure 3)

Distribution of Pharmacies by Electoral Ward and Area The 36 pharmacies across four localities within Knowsley as shown in the table below.

Count of Electoral Ward Pharmacies Halewood South 2 Halewood North 1 Halewood 3 Page Moss 4 Roby 1 St Gabriels 5 St Michaels 1 Stockbridge 2 Swanside 1 Huyton 14 Cherryfield 3 Northwood 2 Whitefield 6 Kirkby 11 Prescot North 6 Prescot South 2 Prescot, Whiston & Cronton 8 Table 1: Distribution of community pharmacies by electoral ward

Accessibility to Pharmacy Knowsley pharmacies are generally placed in populated areas (See Figure 4), with the majority of pharmacies in the borough also being close to a bus stop or train station suggesting that pharmacy locations are accessible in Knowsley (more detail provided in 5.4 and 5.5). Travel time maps for car, public transport, and bicycle have not been produced as there are no gaps across Knowsley.

It is acknowledged that residents with a disability or suffering from a long-term illness may not be able to access a pharmacy as easily. These potential issues will be explored in the resident consultation section.

Knowsley Pharmaceutical Needs Assessment, 2018 32 | P a g e

Figure 4: Location of Pharmacies in Knowsley by population density, 2017 Source: Pharmacy Survey, 2017

Knowsley Pharmaceutical Needs Assessment, 2018 33 | P a g e 5.2. Pharmacy Opening Hours

NHS England is responsible for administering opening hours for pharmacies, which normally have 40 core contractual hours. A pharmacy may open for more than 40 hours where an application has been made and agreed with NHS England. There is also a provision which allows a pharmacy to apply to open for less than 40 hours, but if NHS England does grant such an application, it can specify which opening hours the pharmacy must open. The pharmacy cannot amend these hours without the consent of NHS England.

However, opening hours of community pharmacies adapt to the demands of the local population, e.g. the demands of commuters, and are influenced by the opening times of GP practices. Pharmacies are generally responsive to local demand, however, there are times when there are gaps between the times that primary care services are available and the times that pharmacies open.

A visual representation of pharmacy opening hours by electoral ward is provided in Appendix 3.

Current pharmacy opening hours show that there is good access throughout the week and at weekends across Knowsley, this section looks at this provision in detail to identify where opening hours could be improved.

Weekday Opening Hours Pharmacies in Knowsley are open between 6.30am and midnight during the week. The extended hours in Knowsley are a result of the opening of five 100 hour pharmacies.

In total, seven of Knowsley’s 36 pharmacies (19%) are open at 8:00am. All areas except Halewood have this provision which has a pharmacy that is open at 8.30am. There are four pharmacies open at 7:00am currently in Knowsley (11%).

Number of Earliest Open at Open at Locality Pharmacies Opening 7:00am 8:00am Halewood 3 8.30am 0 0 Huyton 14 7.00am 1 2 Kirkby 11 7.00am 1 1 Prescot, Whiston & Cronton 8 6.30am 2 4 KNOWSLEY 36 6.30am 4 7 Table 2: Pharmacies opening (Mon-Fri) in Knowsley Source: Pharmacy Survey, 2017

Knowsley Pharmaceutical Needs Assessment, 2018 34 | P a g e All areas of Knowsley have a pharmacy that is open until 17.30pm. Four pharmacies in Knowsley are open after 8pm, covering all areas except Halewood. Indeed, all six pharmacies are open until at least 22.30pm.

Number of Latest Open at Open at Locality Pharmacies Closing 7pm 8pm Halewood 3 18.30pm 0 0 Huyton 14 23.00pm 1 1 Kirkby 11 22.30pm 1 1 Prescot, Whiston & Cronton 8 midnight 2 2 KNOWSLEY 36 midnight 4 4 Table 3: Pharmacies open after 7pm (Mon-Fri) in Knowsley Source: Pharmacy Survey, 2017

Saturday Opening Hours Of the 36 pharmacies in Knowsley, 23 (64%) are open on a Saturday. There is no pharmacy provision after midday in Halewood on a Saturday.

Open Open Open Open Number of Open on a Locality after after after after Pharmacies Saturday 1:00pm 3:00pm 5:00pm 6:00pm Halewood 3 2 0 0 0 0 Huyton 14 8 5 5 5 2 Kirkby 11 7 5 5 3 1 Prescot, Whiston & Cronton 8 6 4 4 4 3 KNOWSLEY 36 23 14 14 12 6 Table 4: Pharmacies opening on a Saturday in Knowsley Source: Pharmacy Survey, 2017

Sunday Opening Hours There are five pharmacies open in Knowsley on a Sunday, with the majority opening for six hours. All areas apart from Halewood are covered.

Pharmacy Postcode Electoral Ward Open Close Hours Open Aim Rx Ltd L32 8RR Whitefield 9:45 20:30 10.75 Asda Pharmacy L36 7TX St Gabriels 10:30 16:30 6 Boots UK L34 5NQ Prescot North 10:30 16:30 6 Kingsway Pharmacy L36 2QA Page Moss 10:00 16:15 6.25 Tesco Pharmacy L34 5NQ Prescot North 10:00 16:00 6 Table 5: Pharmacies opening on a Sunday in Knowsley Source: Pharmacy Survey, 2017

100 Hour Pharmacy Opening Times In Knowsley, there are five 100 hour pharmacies that have opened since rules were relaxed in 2005. These pharmacies have had a significant impact on access to pharmacy services in the areas where they are located.

Pharmacy Postcode Weekday Saturday Sunday Asda Pharmacy L36 7TX 07/8:00 23:00 07:00 22:00 10:30 16:30 Aim Rx Ltd L32 8RR 07:00 22:30 08:45 20:30 09:45 20:30 Boots UK L34 5NQ 07:00 23:00 07:00 21:00 10:30 16:30 Kingsway Pharmacy L36 2QA 07:15 23:00 07:00 22:00 10:00 16:15 Prescriptions Pharmacy L34 1LT 06:30 00:00 07:30 20:00 - Table 6: 100 hour pharmacy opening times in Knowsley Source: Pharmacy Survey, 2017

Knowsley Pharmaceutical Needs Assessment, 2018 35 | P a g e

Figure 5: 100-hour Pharmacies in Knowsley, 2017 Source: Pharmacy Survey, 2017

Knowsley Pharmaceutical Needs Assessment, 2018 36 | P a g e Out-of-Hours Pharmacy Generally, out-of-hours pharmacies are those that provide a service after 6.30pm from Monday to Saturday or on a Sunday / Bank Holiday. Within Knowsley there are six such pharmacies.

Pharmacy Locality Weekday Saturday Sunday Aim Rx Ltd Kirkby 07:00 22:30 08:45 20:30 09:45 20:30 Asda Pharmacy Huyton 07/8:00 23:00 07:00 22:00 10:30 16:30 Boots UK PWCKV 07:00 23:00 07:00 21:00 10:30 16:30 Kingsway Pharmacy Huyton 07:15 23:00 07:00 22:00 10:00 16:15 Prescriptions PWCKV 06:30 00:00 07:30 20:00 - Pharmacy Tesco Pharmacy PWCKV 08:00 20:00 08:00 20:00 10:00 16:00 Table 7: Out-of-hour pharmacies in Knowsley Source: Pharmacy Survey, 2017

Knowsley Pharmaceutical Needs Assessment, 2018 37 | P a g e

Figure 6: Out of Hours Pharmacies in Knowsley, 2017 Source: Pharmacy Survey, 2017

Knowsley Pharmaceutical Needs Assessment, 2018 38 | P a g e

5.3. Distance Selling Pharmacies

A distance selling pharmacy must not provide essential services to a person who is present at the pharmacy. A distance selling pharmacy may provide advanced and enhanced services on the premises, as long as any essential service which forms part of the advanced or enhanced service is done away from the premises. There are currently no such pharmacies based in Knowsley.

5.4 Residents’ Survey Summary

Background to Survey An important element of any needs assessment is to capture the view of current or potential service users and understand their perspective, which in turn provides valuable insight that can be used to inform plans for pharmacy services.

The survey asked about a range of topics including the current use of pharmacy services, satisfaction with services, prescription medicines use and access to pharmacies.

The residents’ survey was published on the Health and Wellbeing Boards website, Knowsley MBC webpage, social media pages and Knowsley’s internal Bertha page. The survey was also widely circulated to partner organisations such as Knowsley Patient Engagement, Healthwatch, Villages Housing and Community Health Forums. Both online and paper copies were available. The survey was open from May until July 2017 and received responses from 313 residents. The following section summarise some of the main findings from the survey focusing on pharmacy use, access, and services.

Demographics of Respondents Of those that responded to the question, the proportion of males was 33.2%. This was much lower than the proportion of males in the registered population (49.6%, June 2017) meaning that the number of men responding to the survey was an under-representation.

Gender Respondents Respondents Registered Male 90 31.7% 49.6% Female 181 66.3% 50.4% Table 8: Respondent Gender distribution compared to RegisteredPopulation Population (June 17)

Knowsley Pharmaceutical Needs Assessment, 2018 39 | P a g e A comparison of the age distribution of respondents to the patient survey compared to the registered population in Knowsley shows that respondents were more likely to be aged over 40, i.e. respondents were skewed towards older people and less towards younger people.

Respondents by age band Registered population by age band 30% 25% 20% 15% 10% 5% 0% Proportionofpopulation 16 - 20 21 - 30 31 - 40 41 - 50 51 - 59 60 - 69 70 years years years years years years years or over

Figure 7: Age Profile of Patient Survey Respondents Source: Knowsley Public Health Intelligence Team

The proportion of respondents in each ethnic group from the patient survey was broadly representative of the Knowsley population.

Ethnic Group Respondents Respondents Census (2011) White 249 97.6% 97.2% Mixed 1 0.4% 1.3% Asian 2 0.8% 0.7% Black 1 0.4% 0.3% Chinese 1 0.4% 0.3% Did Not Say 1 18.5% n/a Table 9: Respondent Ethnicity distribution compared to Census 2011 data

Use of Pharmacies

Most Recent Visit to a Pharmacy Over a third of the respondents to the survey question said that they had used a pharmacy in the last week (35.9%, n=112), with a further 28.9% (n=90) stating that they had done so in the last month. Only 4.5% (n=14) had not used their pharmacy in the last six months.

Over two thirds (69.8%) of respondents said that they last went to their pharmacy to collect a prescription for themselves and 12.5% of respondents went to collect a prescription for someone else.

Reason for using the pharmacy Percentage Number (311) To collect a prescription for yourself 69.8% 217 To collect a prescription for someone 12.5% 39 Toelse get advice from the pharmacist 3.9% 12 To buy medications I cannot buy 4.2% 13 Otherelsewhere 9.7% 30 *Please note that multiple responses could be given Table 10: Responses to purpose of most recent visit to pharmacy

Knowsley Pharmaceutical Needs Assessment, 2018 40 | P a g e

Access to Pharmacy In terms of how respondents accessed their pharmacy on the most recent visit, 48.0% said they had travelled by car and 41.9% said that they had walked.

Mode of transport Percentage Number (310) Car 48.0% 149 Walking 41.9% 130 Public Transport 11.6% 36 Taxi 1.6% 5 Other 3.2% 10 *Please note that multiple responses could be given Table 11: Mode of transport in most recent visit to pharmacy

When respondents were asked about location factors influencing their use of pharmacies, the most common reasons were that the pharmacy was close to their doctor’s surgery (55.6%) and that it was close to their home (54.6%).

Location factor important to Percentage Number (304) Itrespondent is close to my doctor’s surgery (n=304)55.6% 169 It is close to home 54.6% 166 It is easy to park 26.0% 79 It is close to other shops 23.7% 72 It is in the local supermarket 9.9% 30 It is close to where I work 8.6% 26 It is near to a bus stop or train station 7.0% 21 It is close to child’s school / nursery 2.0% 6 Other 5.6% 17 *Please note that multiple responses could be given Table 12 Responses to location factors in choice of pharmacy

Respondents were asked whether or not they had a condition that affected their mobility and whether they were able to park near their pharmacy, with only 7.0% (n=21) stating that they were not able to park close enough to their pharmacy.

When respondents were asked how easy it was to get to their usual pharmacy, 95.4% (n=291) said it was easy.

The majority of respondents (91.2%, n=269) were satisfied with the opening hours of their pharmacy and had not had a problem in the last 12 months with;

 Their preferred pharmacy being closed when they needed to use it (57.0%, n=166) or,  Any problems finding a pharmacy to get a medicine dispensed, to get advice or buy medicines (90.7%, n=272).

However, of those who had required use of their pharmacy when closed, 27.2% (n=34) had found difficulties on an afternoon Monday-Friday (50.8%, n=63). When asked what they did when the pharmacy was closed almost half (48.3%, n=56) stated that they used another pharmacy and almost two thirds (35.3%, n=41) waited until their preferred pharmacy was open. Specifically, 26 respondents cited longer opening hours as improvements to the service of their

Knowsley Pharmaceutical Needs Assessment, 2018 41 | P a g e preferred pharmacy with 19 stating longer weekend opening hours particularly on a Saturday.

*please note some respondents cited more than one improvement to services

Experience of Getting a Prescription As stated previously, most respondents made their most recent visit to a pharmacy in order to get medicine on prescription. The majority of respondents (78.2%, n=190) said that they were told by staff at the pharmacy how long they would have to wait for their prescription to be prepared; 13.2% (n=32) said that they were not told but did not mind, a further 4.1% (n=10) were not told but would have liked to have been informed. Of those who were told how long they would have to wait for their prescription to be prepared, 85.8% said this was a reasonable period of time.

The majority of respondents (82.0%, n=181) got all the medicines they needed on their last visit to the pharmacy. Of those who did not, 48.0% (n=24) said the main reason for not getting all their medicines was a shortage of stock at the pharmacy.

Reason for not getting medicines Percentage Number The pharmacy had run out of the medicine (n=50)48.0% 24 My GP had not prescribed something I wanted 12.0% 6 My prescription had not arrived at the pharmacy 16.0% 8 Some other reason 24.0% 12 *Please note that multiple responses could be given Table 13: Reasons for not getting medicines on most recent visit to pharmacy

61.3% (n=26) of people not receiving all their medicines received the remaining medicines within a day of their original visit; and 4.0% (n=2) waited for more than a week.

Prescribing Almost half (49.2%, n=15) of those respondents to the question said that their pharmacy delivers medication to their home if they are unable to collect it themselves. A further 42.9% (n=130) of respondents said that they did not know whether their pharmacy provides such a service.

Almost a third (30.0%, n=15) of respondents said that they had used the delivery service from their pharmacy.

Services Provided Of those that responded 82.2% (n=226) stated that they were satisfied with the range of services pharmacies provide.

When asked which, if any, of the services listed did respondents think should be available locally through pharmacies, 90.1% (n=237) stated to get treatment of a minor illness such as a cold instead of my doctor (free of charge if you don't pay for prescriptions), followed by review of medicines on repeat prescription with advice on when it is best to take them, what they are for and side-effects to expect.

Knowsley Pharmaceutical Needs Assessment, 2018 42 | P a g e

Consultation with Pharmacists Over half of respondents to the survey question (52.1%, n=146) said that they had not had a consultation with a pharmacist in the last 12 months for any health related purpose. However, a substantial proportion (45.0%, n=126) said that they had consulted with their pharmacist.

Of those respondents who had a consultation with a pharmacist over the last 12 months, the most common reason was to receive advice regarding medicines (69.6%, n=78). A further 22.3% (n=25) received advice about a minor ailment, with 17.9% (n=20) receiving lifestyle advice, e.g. stop smoking, diet and nutrition).

Over half of consultations (57.0%, n=65) took place in a separate room to the main area of the pharmacy, with 31.6% (n=36) being at the pharmacy counter. In terms of the level of privacy given to the patient during the consultation with the pharmacist, 86.5% (n=96) rated their experience as good, very good or excellent; 5.4% (n=6) said their experience was poor or very poor.

5.5. Pharmacy Survey Summary

Background to Survey The pharmacy survey asked about a range of topics including current services pharmacies provide or would be willing to provide, opening hours, customer accessibility, and any potential gaps.

The survey was distributed to all pharmacies in Knowsley using the web-based Pharmoutcomes system and was open from May until June 2017. All pharmacies completed the survey.

The following section summarise some of the main findings from the survey.

Accessibility

Internet-Based / Mail Order Pharmacy Provision There are no pharmacies in Knowsley providing internet or mail order based provision.

Access to Bus or Train Two thirds (24) of pharmacies stated that there was a bus or train stop within 100 metres of their pharmacy.

Access for People with a Disability and /or Mobility Problem The survey asked whether Knowsley pharmacies were suitable for wheelchair access. 33 of the 36 respondents (92%) had premises that were suitable for unaided` wheelchair access at the entrance, and 100% respondents had premises that were suitable for unaided wheelchair access in all areas of the pharmacy floor.

Knowsley Pharmaceutical Needs Assessment, 2018 43 | P a g e Pharmacies were also asked if disabled parking was available at their pharmacy, with 22 out of 36 respondents (61%) stating that disabled parking was available.

All pharmacies in Knowsley were able to provide at least one of the listed disabled facilities; door assistance, disabled toilet, hearing loop, sign language, and large print labels and / or leaflets.

Under the Equality Act community pharmacies have a duty to make “reasonable adjustments” to ensure persons with disabilities can access pharmacy services. A person with a disability must not be put at a substantial disadvantage when compared to persons with no disabilities in accessing services that are provided by the pharmacy. Compliance aids such as easy-open containers, monitored dosage systems (blister packs), reminder charts/alarms, large print labels, dexterity aids, winged or plain bottle caps could be appropriate if the pharmacist decides with the patient, that this will assist the patient to use the service. Pharmacy computer systems can produce large print labels when required. Access for clients whose first language is not English Of the 36 pharmacies who responded to the pharmacy survey, twelve (33%) said that they were able to offer support to people whose first language is not English. Eleven (31%) had access to an interpreter and eleven (31%) have staff who could speak languages other than English.

Access for Same Sex Only 3% (1) of Knowsley pharmacies could not provide advice and support to a customer wishing to speak to a person of the same sex, with 17 (47%) stating that they could provide this service all of the time.

Consultation Facilities Of the 36 responses to the pharmacy survey, all 36 (100%) said that they had an on-site consultation area in which a patient and pharmacist can sit down together, and talk at a normal speaking volume without being over heard by anyone else. Of the 36 respondents with a suitable consultation area, 31 (86%) said that there was wheelchair access available.

Seven of the 36 (19%) pharmacies said that they had toilets on the premises that patients could access for screening, e.g. chlamydia and pregnancy testing.

Only one pharmacy had an offsite consultation room approved by NHS England, but 44% were willing to undertake consultations in patient’s homes or at another suitable site including by telephone.

Additional Services All community pharmacies in Knowsley said that they provide a service that collects prescriptions from GP surgeries. 92% (33) of these pharmacies also provide a service that delivers dispensed medicines (free of charge) to patients, and 89% (32) provide monitored dosage systems free of charge.

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5.6. Prescribing

In 2016/17, over 4 million (4,277,634) items were prescribed within Knowsley Clinical Commissioning Group geography. This equated to 26 items per patients, compared with 20 per patient nationally. The highest number of prescribed items in Knowsley included:

 Analgesics (302, 700)  Lipid regulating drugs (281,200)  Antidepressant drugs (273,800)  Hypertension and Heart failure (261,400)  Antisecretory Drugs and Mucosal Protectants (259,400)

The total prescribing costs of Knowsley CCG patients in 2016/17 was just under £32 million (£31, 765,403).

5.7. Neighbouring Local Authorities Provision

In addition to pharmacy services provided in Knowsley, some patients choose to use pharmacies outside of the borough for their dispensing needs. Through analysis of dispensing data, the most commonly used pharmacies outside of the borough that are used by Knowsley patients have been identified.

As quoted the 12 months between April 2016 and March 2017, almost 4.3 million prescription items were prescribed for Knowsley patients. Over 3.5 million items were dispensed by Knowsley pharmacies and, approximately 737,500 items were dispensed by 1,200 pharmacies located outside of Knowsley for patients registered with a Knowsley GP. This accounts for 17.3% of the total volume dispensed for Knowsley patients.

5% 9% 14% Sefton 7% St. Helens 2% Halton Liverpool West Lancashire Other 64%

Figure 8: Prescriptions dispensed outside of Knowsley, April 2016 to March 2017 Source: Cheshire & Merseyside Commissioning Support Unit

Almost two thirds (64%) of the items dispensed outside of Knowsley were in Liverpool (471,896 in total) with Sefton and St Helens between them accounting

Knowsley Pharmaceutical Needs Assessment, 2018 45 | P a g e for almost a quarter of items dispensed (102,220 and 50,461 items respectively).

Local Pharmacy Name Address Postcode Authority Rowlands Pharmacy 265 Pilch Lane, Huyton L14 0JF Liverpool Chemist4U 37 Greenhey Place, Skelmersdale WN8 9SA Liverpool Rowlands Pharmacy 86 Waddicar Lane, Melling L31 1DY Liverpool Unit 1, Gateacre Shopping Centre, Care Pharmacy L25 1PD Liverpool Gateacre Park Drive, Liverpool Baycliffe Road 86 Baycliff Road, Liverpool L12 6QX Liverpool Pharmacy Yew Tree Chemist 235 Finch Lane, Liverpool L14 4AE Liverpool Lloyds Pharmacy 114 Allerton Road, Liverpool L18 2DG Liverpool 4 Woodend Avenue, Hunts Cross, Lloyds Pharmacy L25 0PA Sefton Liverpool West M Saleem 16 Finch Road, Liverpool L14 4AT Lancashire Clitherow R Ltd 22 Dovecot Place, Liverpool L14 9PH Liverpool Table 14: Ten most used non-Knowsley pharmacies, 2016/17 Source: Cheshire & Merseyside Commissioning Support Unit

These non-Knowsley pharmacies are significant providers of dispensing services and potentially other pharmaceutical services to Knowsley residents, and residents in their own local authority area. However, there is scope for services to be provided to Knowsley residents by more pharmacies outside of the borough. Figure 9 shows that there are 49 pharmacies within a mile of Knowsley’s border (please see Appendix 5 for a list of these pharmacies and the services provided).

Conclusion Knowsley has good coverage of pharmaceutical services across the borough, in terms of choice, access and opening hours, with no gaps in the current provision of necessary services. The area as a whole has slightly better coverage of community pharmacies than the England average.

In addition, Knowsley has reasonable access provision with the majority of residents living within a one mile walk or a 15 minute public transport journey of a community pharmacy. Public survey results suggest that the majority of residents are satisfied with pharmacy provision, and comments provided by this survey will be fed back to community pharmacy contractors and used to plan future service provision with commissioners.

The PNA has not identified any future needs which are not already met by providers currently on the pharmaceutical list.

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Figure 9: Community Pharmacies Bordering Knowsley by 1 mile, 2017 Source: Pharmacy Survey, 2017

Knowsley Pharmaceutical Needs Assessment, 2018 47 | P a g e 6. POPULATION AND HEALTH PROFILE OF KNOWSLEY

6.1. Location

Knowsley is one of five Local Authority districts in Merseyside (and one of six districts that form Greater Merseyside with the addition of Halton Unitary Authority), located in the North West of England. Knowsley Metropolitan Borough was created in 1974 when the urban districts of Huyton, Kirkby and Prescot were grouped with the rural districts of Whiston and parts of West Lancashire to form a new local authority area.

Knowsley lies to the east of Liverpool covering an area of 8,619 hectares and is also situated 25 miles west of Manchester. The M62 motorway runs from east to west across the south of the borough with the M57 motorway running from north to south. These excellent transport links provide access to the motorway network across the country and serve several industrial and business parks within the borough.

However, although there are many opportunities due to where the borough is situated, Knowsley residents experience relatively high levels of unemployment and social deprivation which impact on their health. For many forms of disease, local people experience significantly worse health than the rest of the country.

Figure 10: Knowsley’s Location Source: Knowsley Public Health Intelligence Team

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Knowsley shares a border with following five Local Authority areas:

vii. Halton viii. Lancashire ix. Liverpool x. Sefton xi. St Helens

This is particularly relevant to the Pharmaceutical Needs Assessment as there are areas where Knowsley's population will be accessing pharmacies outside of the borough boundary, usually close to Knowsley's boundary.

6.2. Deprivation

The English Indices of Deprivation combine a range of economic, social, health and housing indicators to provide the most comprehensive picture of deprivation across England.

Knowsley is considered to be one of the most deprived Local Authority areas in England, ranking second as the most deprived area, based on the average deprivation score of each local super output area in Knowsley as defined by the English Indices of Deprivation 2015. In total, 45% of Knowsley’s population live in areas classified as being in the most deprived 10% in England, equating to 65,688 of the population. Although deprivation is widespread in Knowsley, it is most prominent in areas of Kirkby and North Huyton.

6.3. Housing

In 2016/17 Knowsley created an additional 600 homes in the borough that were completed within the year. For 2017/18, the target is 450 new homes per year in Knowsley which the Council are confident will be exceeded due to the following major developments happening in the borough in the next few years;

 Halsnead (largest development)  Earlesfield Park  Halewood development

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Figure 11: English Indices of Deprivation in Knowsley, 2015 Source: Department for Communities & Local Government

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6.3. Population Structure and Projections

Resident Populationiii

Figure 12: Knowsley Population Pyramid, 2016 Source: Office for National Statistics

In 2016, the estimated resident population of Knowsley was 147,915. Between 2006 and 2016, the estimated resident population in Knowsley fell by 873 people (approximately 87 people per year), a drop of 0.6%. This fall is attributed to net outward migration.

The average age of the Knowsley population in 2016 was 39.6 years, broadly similar to England (39.8 years). Just under a third of the population in Knowsley were aged under 25 (31.0%) with almost a quarter (22.8%) being aged 60 years or over. In comparison to England, there are proportionally less people in Knowsley aged between 30 and 49, but more people aged between 50 and 64. For every 100 people of working age in Knowsley, there are 58 children or people of pensionable age.

The proportion of the Knowsley population from a BME group is relatively low in Knowsley and was 2.8% in 2011, this compares to 14.6% across the whole of England.

GP Registered Populationiv The registered population is the number of people who are registered with a general practice in Knowsley, therefore people who live outside Knowsley may access primary care services within Knowsley and vice versa. The latest estimate of the registered population in Knowsley is 163,900 (June 2017), some 16,700 higher than the resident population.

iii iii iii Mid Year Resident Population Estimates, 2011, ONS. iv Numbers of Patients Registered at a GP Practice, June 2017, NHS Digital.

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Resident Population Projectionsv

Figure 13: Projected Change in Knowsley Population, 2016 to 2024 Source: Office for National Statistics

Although the resident population of Knowsley has generally been declining over the last 20 years, it is expected to increase by just fewer than 1,000 people (1%) from 2016 to 2024. Largest increases are anticipated in the 60-79 age group (20% increase) and the 85+ age group (36% increase), this is the equivalent of an additional 6,500 people by 2024.

The anticipated increase in the population, particularly in the older age groups, will have an impact on services locally. This is borne out with the increase in the dependency ratio (the number of children and people of pensionable age for every 100 people in the working population) which is expected to rise to 63 by 2024, an increase of eight children or people of pensionable age per 100 people of working age from 2016.

v 2014-based Subnational Population Projections for Local Authorities, ONS.

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6.4. Life Expectancy

Life expectancy at birth is used as an overarching measure of the health of the population.

Male Life Expectancy

Figure 14: Male Life Expectancy, 2001/03 to 2013/15 Source: Office for National Statistics

Between 2013 and 2015, male life expectancy at birth in Knowsley was 76.8 years. In the ten years to 2013/15, male life expectancy at birth has increased by 3.9% (3 years) in Knowsley, and the absolute gap between Knowsley and England has narrowed by 10.0% (4 months). However male life expectancy at birth in Knowsley remains significantly lower than the North West and England (78.1 and 79.5 years respectively).

Between 2011 and 2015, within Knowsley, the inequalities in male life expectancy are more pronounced with a gap of ten years between the electoral wards with the lowest and highest life expectancy: Northwood in Kirkby (71.5 years) and Halewood North (81.5 years).

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Female Life Expectancy

Figure 15: Female Life Expectancy, 2001/03 to 2013/15 Source: Office for National Statistics

Female life expectancy at birth in Knowsley was 80.4 years between 2013 and 2015. This is an increase of two years (2.6%) since 2003/05. Over the same ten year period, the absolute gap between Knowsley and England narrowed by 2% (0.8 month). However, female life expectancy at birth in Knowsley remains significantly lower than the North West and England (83.8 and 83.1 years respectively) as a whole.

Between 2011 and 2015, within Knowsley, the gap in female life expectancy at birth between the electoral ward with the lowest life expectancy and highest life expectancy was nine years. This occurred between the electoral wards of Northwood (76.4 years) and Halewood North (85.5 years).

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6.5. All Age, All Cause, Mortality

All Age, All Cause, Mortality Trends

` Figure 16: All Age All Cause Mortality, 2001/03 to 2013/15 Source: Knowsley Public Health Intelligence Team

There were 4,513 deaths in Knowsley between 2013 and 2015, approximately 1,505 deaths per year. The mortality rate from all causes in Knowsley was 1202.8 deaths per 100,000 population during this time. Since 2003/05, the all cause mortality rate has fallen by 17.8% in Knowsley compared to 16.8% in the North West and 17.2% in England. Over the ten year period since 2003/05, the absolute gap in the mortality rate between Knowsley and England has narrowed by 20.0%.

In 2015, the major causes of death in Knowsley were cancer (31% of all deaths), cardiovascular disease (24%) and respiratory diseases (15%).

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Major Causes of Ill Health and Mortality in Knowsley

Cancer

Figure 17: Under-75 Cancer Mortality, 2001/03 to 2013/15 Source: Knowsley Public Health Intelligence Team

The main cause of death in Knowsley in 2015 was cancer which accounted for 31% of all deaths. Between 2013 and 2015, there were 1,351 deaths attributable to cancer, approximately 450 per year. Of these deaths, half (678) were people under the age of 75 (premature). The premature cancer mortality rate in Knowsley during 2013/15 was 191.1 deaths per 100,000 population.

Since 2003/05, the premature cancer mortality rate has fallen by 12.9% in Knowsley and over the same period the absolute gap in the mortality rate between Knowsley and England has narrowed by 7.9%. However, the premature cancer mortality rate in Knowsley remains significantly higher than England and the North West (153.9 and 138.8 deaths per 100,000 population respectively). Indeed, Knowsley had the second highest mortality rate for cancer in England out of 152 upper tier Local Authority areas.

Between 2013 and 2015, there were 423 deaths due to lung cancer (approximately 141 per year), this accounted for 31% of all cancer deaths.

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Cardiovascular Disease

Figure 18: Under-75 Cardiovascular Disease Mortality, 2001/03 to 2013/15 Source: Knowsley Public Health Intelligence Team

Cardiovascular disease was the second largest cause of death in Knowsley in 2015, accounting for just under a quarter (24.4%) of all deaths. In total in 2013/15, there were 1,084 deaths attributable to cardiovascular disease, approximately 361 per year. Of these cardiovascular disease deaths, 373 (34.4%) were people under the age of 75. The premature cardiovascular disease mortality rate was 105.9 deaths per 100,000 population in 2013-2015.

In the ten year period since 2003/05, the premature cardiovascular disease mortality rate fell by 39.9% in Knowsley, and over the same period the gap between the mortality rate for Knowsley and England narrowed by 43.5%. However, the premature cardiovascular disease mortality rate in Knowsley remains significantly higher than England and the North West (88.5 and 74.6 deaths per 100,000 population respectively).

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Respiratory Disease

Figure 19: Under-75 Respiratory Disease Mortality, 2001/03 to 2013/15 Source: Knowsley Public Health Intelligence Team

Respiratory disease is the third major cause of death in Knowsley in 2015, accounting for 15.0% of all deaths (230 in total). In total in 2013/15, there were 769 deaths attributable to respiratory disease, approximately 256 per year. Of these deaths, 224 were people under the age of 75. The premature respiratory disease mortality rate was 65.0 deaths per 100,000 population in 2013/15.

Between 2003/05 and 2013/15, the premature mortality rate from respiratory diseases fell by 10.9% in Knowsley, and over the same period of time the absolute gap in the premature mortality rate between Knowsley and England narrowed by 4.9%. Premature respiratory disease mortality in Knowsley remains significantly higher than the North West and England (33.1 and 44.3 deaths per 100,000 population respectively).

Between 2013 and 2015, there were 361 deaths attributable to chronic obstructive pulmonary disease in Knowsley, approximately 120 per year. This accounted for almost half (46.6%) of all deaths where respiratory diseases was the cause.

Knowsley Pharmaceutical Needs Assessment, 2018 58 | P a g e 7. PHARMACY ACTIVITY THAT SUPPORTS LOCAL PRIORITIES

7.1. Tobacco Control

Level of Need Smoking is a major cause of preventable ill health and premature mortality in the UK, as well as a key risk factor for many diseases including lung cancer, chronic obstructive pulmonary disease and heart disease.

Although the prevalence of smoking has been falling, the Annual Population Survey 2016 reported that almost one in five adults in Knowsley still currently smoke (20.5%), which is significantly higher than the North West (16.8%) and also England (15.5%). In contrast to other areas, females in Knowsley are significantly more likely to smoke than males, 22.4% compared to 18.3%. Furthermore, smoking prevalence in Knowsley decreases with age and is at its highest in the 25-34 age group (41.1%).vi

Almost half (47.8%) of the adult population have smoked in the past (including those who currently smoke) which is higher than the North West and England (42.7% and 41.7% respectively). On average, those who smoke in Knowsley have 15 cigarettes (cigars or roll-ups) per day.vii

In 2015/16 approximately 12.6% of those aged 16+ who smoke in Knowsley had set a quit date, an increase of 2.6% since 2013/14. Knowsley had 3,973 successful quitters (carbon monoxide (CO) validated) per 100,000 population aged 16 years or over. This was higher than across the whole of England (1854) and the North West region (1573). Indeed, Knowsley had the third highest quit rate nationally during 2014/15 and the highest in the North West region.

To help smokers to quit locally there are a range of stop smoking services, this includes over three quarters of Knowsley pharmacies who offer stop smoking support.

Evidence of Effective Interventions in the Community Pharmacy Setting Evidence suggests that community pharmacies have a key role to play in providing advice, support and brief interventions for smoking cessation.[6][7][8][9][10][11] Details of how they can provide this support can be found in guidance published by Pharmacy Health Link.[12] However, this requires adequate training to enhance confidence and skills,[13][14] something pharmacy staff may feel they lack.[15] Training on how to match patient history and smoking status can enable pharmacy staff to tailor advice more accurately.[16] This is based on evidence that community pharmacist smoking cessation support can have similar success rates as that of nurses, but lower than that of specialist advisors. There is also some evidence that involving community pharmacy support staff in brief interventions around smoking can increase the provision and the recording of smoking status in patient’s medication records.[17] Whilst other studies show community pharmacy vi Annual Population Survey, 2016 vii Merseyside Health and Lifestyle Survey, 2012/13

Knowsley Pharmaceutical Needs Assessment, 2018 59 | P a g e smoking cessation services may produce lower quit rates than group-based support, the latter are more intensive and cost more. Nevertheless, pharmacy- led smoking cessation support can have significant impact on quit rates.[18] It is important to note that assessment of pharmacy success rates need to take client demographics in to account, as these may be different to those accessing the same services via other settings.[19] Both types of support are cost effective.[20][21] Quit rates will vary also depending on the number of sessions offered by the pharmacy.[22] Despite these differences the key message remains that the evidence strongly points to community pharmacies having a key role to play in local efforts to support people to stop smoking.[23][24] Both patients and pharmacy staff view smoking cessation counselling by community pharmacy staff positively.[25]

Local Provision The Pharmacy Stop Smoking Intermediate Service has been established to deliver one-to-one support and advice to the user, from a trained pharmacist or a member of the Pharmacy team. Where appropriate Nicotine Replacement Therapy (NRT) or Varenicline is supplied, or a referral is made to the person’s GP for a prescription of alternative stop smoking drugs. The service is provided during normal pharmacy opening hours but may not necessarily be available on every day that the pharmacy is open.

In 2016/17, 2,585 smokers were supported to quit smoking in Knowsley, out of which Knowsley Community Pharmacies supported 876 (33.9%). Amongst the smokers supported by the pharmacies 374 of them quit at 4 weeks - a quit rate of 42.7% compared with 47.7% for those supported by the specialist service.

Overall, 1,981 (76.6%) of smokers supported to quit smoking in Knowsley accessed the Nicotine Replacement Therapy (NRT) voucher scheme, which is dispensed in pharmacies. Around 60.0% of these clients were referred from the specialist service. Additionally 362 clients were prescribed Varenicline (Champix) using PGD - equivalent to 14.0% of all smokers supported by both the specialist and pharmacy services. Varenicline (Champix) using PGD is available in 33.3% (n=12) of Knowsley pharmacies.

The pharmacy survey showed that 97% of pharmacies in Knowsley are commissioned to provide Nicotine Replacement Therapy (NRT) and almost three quarters (72%) of pharmacies provide smoking cessation services. The maps below illustrate the geographical distribution of these pharmacies across Knowsley.

Some 83% of residents who participated in the residents’ survey thought that advice on stopping smoking should be available through pharmacies.

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Figure 20: Pharmacy provision for nicotine replacement therapy, 2017 Source: Pharmacy Survey, 2017

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Figure 21: Pharmacies providing smoking cessation provision in Knowsley, 2017 Source: Pharmacy Survey, 2017

Knowsley Pharmaceutical Needs Assessment, 2018 62 | P a g e Conclusions – Tobacco Control The widespread provision of the Stop Smoking Voucher Dispensing Service and Stop Smoking Intermediate Service ensure that residents of Knowsley, particularly in areas where smoking prevalence is high, have access to stop smoking services via their local community pharmacy. Additionally, the stop smoking service commissioned by the local authority is widely available to the public.

7.2. Alcohol

Level of Need Alcohol is the second biggest cause of preventable premature death in this country after tobacco and its misuse is directly linked to deaths from certain types of diseases, such as liver cirrhosis. Not only does alcohol impact on an individual’s health and wellbeing but also on other areas affecting the community such as crime, which places a strain on local public sector resources as well as health services.

According to the Health Survey for England levels of alcohol use have been rising in recent years, with 28.3% of Knowsley residents exceeding over the recommended 14 units per week.viii Although the liver disease mortality rate in Knowsley is variable, since 2003/05 the death rate has been higher than England in each year. The absolute gap in the premature mortality rate between Knowsley and England widened by 31.4% in the previous ten years. Nationally rates in mortality from chronic liver disease including cirrhosis have been rising steadily; between 2003/05 and 2013/15 liver disease mortality rose in England by 25.0%.

Figure 22: U75 Liver disease mortality, 2001/03 to 2013/15 Source: Office for National Statistics

In 2015/16 there were an estimated 3,056 hospital admission episodes for admission episodes for alcohol-related conditions per 100,000 population in Knowsley. Since 2008/09, the rate of alcohol related hospital admissions has increased by 20.6% in Knowsley. Although stark, the rate of increase has not viii Health Survey for England, 2011/14.

Knowsley Pharmaceutical Needs Assessment, 2018 63 | P a g e been as large as it has in the North West region (26.5%) or England as a whole (32.9%). However, the rate of alcohol related admissions in Knowsley remains significantly higher than it does for the North West and England whereas the absolute gap between Knowsley and England has narrowed by 2.0% since 2008/09.

Figure 23: Alcohol related hospital admissions, 2008/09 to 2013/15 Source: Local Alcohol Profiles for England, Public Health England

Evidence of Effective Interventions in the Community Pharmacy Setting There is little in the published research on this area. However, community pharmacies have been effective in supporting people to stop smoking using Brief Interventions (BI). There has been some evidence in the early literature that such an approach is also effective for alcohol within other primary care settings.[26][27] Research undertaken in the North West indicates that alcohol BI and referral to services is acceptable to both pharmacies and the public. However, this research did not consider the effectiveness of such services.[28] This level of public and pharmacist support has been shown elsewhere as well.[29] Given the UK Department of Health’s stated aim to include community pharmacies in BI to reduce alcohol harms, an important Randomised Control Trial (RCT) study was conducted in all community pharmacists in the London borough of Hammersmith and Fulham.[30] However, this study and one other showed that BI for alcohol via community pharmacies is not effective. Brown et al therefore recommend that, at this point in time, such services should not be delivered.[31] Despite this the 2011 National Institute for Health and Care Excellence (NICE) Commissioning Guide[32] recommends targeting alcohol BI to specific populations. However, success when doing this is not clear cut. A study targeting men showed good uptake[33] but another targeting women accessing emergency hormonal contraception did not.[34]

Local Provision The Cheshire and Merseyside Sustainability and Transformation Plan (STP) is the local approach to delivering the National Plan (Five Year Forward View), published in 2014. The plan sets out a vision for a better NHS, the steps that should be taken to get there, and how everyone involved needs to work together to improve health and care.

Knowsley Pharmaceutical Needs Assessment, 2018 64 | P a g e One of the goals of the Cheshire and Merseyside Alcohol STP is to reduce population level alcohol consumption and associated alcohol related harm through the implementation of system wide targeted advice and care. Key staff groups identified for the large scale delivery of targeted brief advice includes community pharmacy staff, including healthy living pharmacy leads and champions.

Of those pharmacies that responded to the pharmacy survey, 88.9% stated that they would be willing to provide an alcohol screening service in the future if commissioned, with one pharmacy privately providing this service.

Conclusions – Alcohol One pharmacy in Knowsley currently privately provides an alcohol screening service with the majority of pharmacies stating that they would be willing to provide an alcohol screening service in the future if commissioned.

7.3. Planned Care

Level of Need Based on changing population numbers and age structures it is estimated that the number of people being admitted to hospital for a planned procedure will increase. In 2015/16, there were 26,428 elective admissions to hospital for Knowsley residents. Of these admissions, 22.8% were due to diseases of the digestive system admissions, followed by neoplasms (14.1%). The table below displays the ten most common elective admissions by ICD-10 chapter of primary diagnosis.

Elective % of Total Specialty Admissions Elective Diseases of the digestive system 6032 22.8% Neoplasms 3712 14.1% Diseases of the musculoskeletal system and connective tissue 3401 12.9% Diseases of the eye and adnexa 2304 8.7% Diseases of the genitourinary system 1793 6.8% Diseases of the circulatory system 1486 5.6% Factors influencing health status and contact with health 1476 5.6% services Symptoms, signs and abnormal clinical and laboratory findings 1362 5.2% Injury, poisoning and certain other consequences of external 807 3.1% causes Diseases of the blood and blood-forming organs 669 2.5% Table 15: Elective admissions, by ICD-10 chapter of primary diagnosis, 2015/16 Source: Public Health England

The number of elective admission episodes by ward in 2015/16 in Knowsley, ranged from 24,516.49 admissions per 100,000 population in Cherryfield electoral ward to 15,548.98 admissions per 100,000 population in Whiston and Cronton electoral ward, i.e. people in Cherryfield electoral ward are over 1.3 times more likely to have a planned admission to hospital than people in Whiston and Cronton electoral ward. Indeed, the highest rates of planned hospital admissions in Knowsley generally occurred in the Kirkby areaix. ix PHE – David Nolan

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Figure 24: Elective Hospital Admissions in Knowsley, 2015 to 2016 Source: Public Health England

Knowsley Pharmaceutical Needs Assessment, 2018 66 | P a g e Evidence of Effective Interventions in the Community Pharmacy Setting Medicines adherence support services are an important part of the community pharmacist’s role.[35] A study of 10,000 adults aged 35+ found that 76% of women and 63% of men had obtained medicines or asked for advice, with 12% asking for advice but not obtaining medicines.[36] The difference in gender is not surprising and offers some particular challenges to targeting men for advice, especially around lifestyle issues. As a Men’s Health project in Knowsley found, most men being targeted for a health check (in the pilot year, 400 men aged 50-65 were given a health check) had never had such lifestyle advice from a pharmacist. However, once on-board the majority made a positive lifestyle change.[37] Despite these differences this and other studies demonstrate that pharmacies are an important first port of call for advice on minor ailments.[38]

Many people do not use their medicines correctly[39] with limited health literacy[x] impeding patients understanding of medicines instructions.[40][41] This could lead to medicines wastage, with cost implications for the healthcare system[42] as well as long-term conditions not being optimally managed. Whilst pharmacists recognise that limited health literacy can impact on medication adherence, difficulties in identifying those with low levels of health literacy impedes potential action. More training and advice on the use of aids to identify levels of health literacy need to be employed to increase awareness and confidence amongst pharmacy professionals.[43]

Local Provision The New Medicine Service (NMS) is an advanced service providing support for people with long-term conditions who have been newly prescribed a medicine to help improve medicines adherence. As part of the service, community pharmacists provide extra support for patients taking new medicines for high blood pressure, diabetes, asthma, chronic lung problems and for medicines that thin the blood.

Medicines Use Reviews are structured reviews undertaken by an accredited pharmacist to help patients manage their medicines – to improve their understanding, knowledge and use of medicines they have been prescribed. Within any given year, at least 70% of all Medicines Use Reviews undertaken must be on patients who fall within one of the four national target groups. It will normally be carried out face-to-face with the patient in the community pharmacy. Provision must be made for a private consultation area so that the patient and pharmacist can sit down together and speak without being overheard by any other person (including pharmacy staff).

85.9% of respondents said they thought that review of medicines on repeat prescription with advice on when to take them, what they are for and possible side-effects should be available through their community pharmacy.

x Evidence shows that health literacy - “the capacity to obtain, interpret and understand basic health information and services and the competence to use such information and services to enhance health” - is a more useful predictor of the use of preventative services than level of education.

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Figure 25: Pharmacies providing Medicines Use Reviews in Knowsley, 2017 Source: Pharmacy Survey, 2017

Conclusions – Planned Care Medicines Use Reviews (MURs) are undertaken in all community pharmacies across Knowsley providing widespread coverage to all areas of the borough.

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7.4. Unplanned/Urgent Care

Level of Need As with planned admissions, unless current trends can be stemmed, the number of unplanned (non-elective) admission is set to rise in Knowsley. In 2015/16, there were 22,385 non elective admissions to hospital for Knowsley residents. Of these admissions, 21.5% were due to symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified admissions, followed by diseases of the digestive system (14.2%). The table below displays the 10 most common non elective admissions by ICD-10 chapter of primary diagnosis.

Elective % of Total Specialty Admissions Elective Symptoms, signs and abnormal clinical and laboratory findings 4808 21.5% Diseases of the respiratory system 3184 14.2% Injury, poisoning and certain other consequences of external 3060 13.7% causes Diseases of the digestive system 1861 8.3% Diseases of the circulatory system 1830 8.2% Diseases of the genitourinary system 1378 6.2% Diseases of the musculoskeletal system and connective tissue 1252 5.6% Certain infectious and parasitic diseases 1122 5.0% Mental and behavioural disorders 822 3.7% Diseases of the skin and subcutaneous tissue 669 3.0% Table 16: Non -elective admissions, by ICD-10 chapter of primary diagnosis, 2015 to 2016 Source: Public Health England

The number of non-elective admission episodes by ward in 2015/16 in Knowsley, ranged from 19,508.30 admissions per 100,000 population in Northwood electoral ward, to 12,409.21 admissions per 100,000 population in Roby electoral ward, i.e. people in Northwood electoral ward are over 1.5 times more likely to have a planned admission to hospital than people in Roby electoral ward. Indeed, the highest rates of planned hospital admissions in Knowsley generally occurred in the Huyton area.xi

xi Phe – David Noplan

Knowsley Pharmaceutical Needs Assessment, 2018 69 | P a g e

Figure 26: Emergency Hospital Admissions in Knowsley, 2015 to 2016 Source: Public Heath England

Knowsley Pharmaceutical Needs Assessment, 2018 70 | P a g e Evidence of Effective Interventions in the Community Pharmacy Setting Several of the research papers identified by the literature search included in their health outcomes a reduction in unplanned/emergency admissions. An enhanced medicines management scheme of patients with heart failure post discharge from hospital included community pharmacists as part of multi- disciplinary teams, this improved patient outcomes and decreased unplanned readmissions.[44] Unfortunately, a scheme focused on medicine reviews of high risk elderly found no difference in hospital admissions, but did result in modest prescribing savings. However, it was not possible to determine the cost- effectiveness of this intervention.[45] Similarly a study by Walker et al also failed to reduce hospital readmissions. Using a quasi-experimental study evaluating post discharge health care resource use of patients discharged from hospital, the study intervention added a pharmacist to the discharge team to identify and reconcile medication discrepancies at discharge.[46]

Results revealed that whilst the pharmacist identified medication discrepancies at discharge and reconciled all of them, no significant differences in hospital readmission rates and emergency department visits were found. The authors do note that the strength of the intervention might have been compromised by (1) broad inclusion criteria that might not have identified patients at high risk for hospital readmission and (2) the pharmacist not completing follow-up calls for all intervention patients. Other studies have helped to identify and reconcile medication changes, as well as reducing hospital admissions[47] and readmissions.[48]

The Discharge Medicines Review (DMR) service provided by community pharmacists in Wales is designed to ensure that patients returning home from hospital are prescribed the right medicines, and gives them an opportunity to ask their pharmacist about their medicines. Evaluation has shown it benefits patients, results in reductions in readmissions to hospital and provides a possible three to one return on investment.[49] The service will now be incorporated into the contractual framework for community pharmacies in Wales.[50]

The community pharmacist is an important first port of call for advice on minor ailments.[51] A survey conducted in support of the development of the White Paper of pharmacies found that 14% of people had used pharmacies to treat one-off common conditions, such as colds, coughs, aches and pains, and stomach problems.[52] Thus, increasing the use of minor ailments schemes would be beneficial for both GP workload and A&E attendance. Other studies have shown that helping patients to take medication correctly, such as, asthma and chronic obstructive pulmonary disease can reduce emergency hospital admissions associated with these conditions.[53] A study in London demonstrated that pharmacy-based minor ailment schemes are feasible and acceptable in the refugee community.[54] Programmes can be cost saving, especially when societal costs are included, and can increase access to healthcare.[55] They can provide the same health-related outcomes and quality of life measures at lower cost, compared to treating minor ailments in primary or emergency secondary care.[56] From a patient perspective, inaccessibility of the GP and perceived non-serious nature of the condition enhance the

Knowsley Pharmaceutical Needs Assessment, 2018 71 | P a g e likelihood of using the community pharmacist, whilst lack of privacy and perceived potential of misdiagnosis are the main concerns.[57]

Attributes of a community pharmacy and its staff may influence people's decisions about which pharmacy they would visit to access treatment and advice for minor ailments. In line with the public's preferences, offering community pharmacy services that help people to better understand and manage symptoms, are provided promptly by trained staff who are friendly and approachable, and in a local setting with easy access to parking, has the potential to increase uptake amongst those seeking help to manage minor ailments. In this way it may be possible to shift demand away from high-cost health services and make more efficient use of scarce public resources.[58]

Local Provision Unplanned admissions to hospital are distressing and disruptive for patients, carers and families. Many unplanned admissions are for patients who are elderly, infirm or have complex physical or mental health and care needs which put them at high risk of unplanned admission or readmission to hospital.

Nationally, guidance (which is adhered to in Knowsley) recommends that GP practices become part of an enhanced service designed to help reduce avoidable unplanned admissions by improving services for vulnerable patients and those with complex physical or mental needs, who are at high risk of hospital admission of readmission. The enhanced service requires practices to identify patients who are at high risk of unplanned admission, and manage them appropriately with the aid of risk identification tools, a case management register, personalised care plans and improved same day telephone access.

Minor Ailments Scheme: Care at the Chemist Unlike GPs, community pharmacies are a ‘walk up and get seen’ service. As such they are a key resource for advice on treating minor, self-limiting ailments and the purchase of appropriate over-the-counter medicines, under the supervision of a pharmacist. The service is open to those registered with a GP and / or resident in Knowsley and to all eligible pharmacies who wish to participate. The service cannot be commissioned from internet only pharmacies. The aim of the service is to improve access and choice for people with minor ailments by promoting self-care through the pharmacy, including provision of advice and where appropriate, medicines without the need to visit their GP practice. The service provides additional benefit by creating capacity within general practice to provide services to patients requiring more complex management such as long term conditions.

Knowsley’s pharmacies provide the Care at the Chemist (CATC) service across the borough. The service is well used, with data showing higher uptake in pharmacies in the more deprived wards of Knowsley. Available data illustrates a large variation in client uptake between pharmacies. Patients access the service for the most common ailments such as minor pain, coughs and colds, stomach upset and head lice.

Knowsley Pharmaceutical Needs Assessment, 2018 72 | P a g e

Figure 27: Care at the Chemist Pharmacies in Knowsley, 2017 Source: Pharmacy Survey, 2017

Knowsley Pharmaceutical Needs Assessment, 2018 73 | P a g e In the past, there have been occasional difficulties in the provision of Care At The Chemist (CATC) at border locations around the CCG. However, there is now a mutual agreement for pharmacies from the neighbouring CCGs of Halton, Liverpool and St Helens to provide Minor Ailment Services to residents of Knowsley.

90.1% of respondents to the patient survey stated that they would like to see treatment of minor illness within community pharmacies

Conclusions – Unplanned / Urgent Care All of Knowsley's 36 community pharmacies offer the Care At The Chemist (CATC) scheme, as well as bordering pharmacies, thus providing universal access to all areas of the borough.

7.5. Supporting and Identifying People with Long Term Conditions

Level of Need Cardiovascular Disease (CVD) is a term which relates to a disease of the heart or blood vessels. It covers a range of conditions including heart disease, stroke, peripheral arterial disease and aortic disease. CVD can lead to poor quality of life and disability, with subsequent cost and resource implications for health and social care. Most premature deaths from CVD amongst people aged less than 75, are preventable.

Following cancer, cardiovascular disease is the second largest cause of premature death in Knowsley, accounting for approximately 360 early deaths every year.

In Knowsley, 24.4% of all deaths between 2013 and 2015 were due to this cause with the mortality rate being significantly higher than the North West and England as a whole. Figures indicate that the mortality rate amongst men in Knowsley is almost twice the female rate (140.2 compared to 75.1 per 100,000). Evidence shows that there is a strong positive correlation between premature mortality and deprivation (see section 6.5).

Knowsley has a higher prevalence of circulatory disease than nationally, with relatively high mortality rates and identification of patients with such conditions by primary care.

In 2015/16, the proportion of people on hypertension registers in primary care was 15.0% in Knowsley, compared to 13.8% across the whole of England. Whilst the figure is high, evidence suggests that a large number of people with hypertension remain unknown to primary care. Similarly, there were 4.3% of people on coronary heart disease registers in Knowsley during 2015/16, compared to 3.2% nationally.

Knowsley Pharmaceutical Needs Assessment, 2018 74 | P a g e Evidence of Effective Interventions in the Community Pharmacy Setting Research studies on the community pharmacy role in reducing the risk and improving outcomes for patients with cardiovascular disease (CVD) are one of the areas where evidence of effectiveness is strongest. Hypertension (High blood pressure) Community pharmacy-based initiatives are particularly effective in reducing systolic blood pressure.[59][60][61] High blood pressure is a major risk factor for cardiovascular disease and stroke. Yet, data has shown a high percentage of undiagnosed high blood pressure in the population. Community pharmacies can play an effective and cost-effective role in both opportunistic screening[62][63] and management of high blood pressure.[64][65][66][67][68][69][70] This is especially effective when done as part of a wider multi-disciplinary team collaborative.[71][72] Such collaborative models have been recognised as of value by both the Royal College of General Practitioners and Royal Pharmaceutical Society.[73 This is the case for both uncontrolled high blood pressure[74] and when it is already well controlled.[75] Initiatives are most cost effective when managing high risk patients.[76] There is also a high degree of patient satisfaction with community pharmacist led high blood pressure management programmes.[77][78][79] This is especially so amongst those with long term conditions where a long-term relationship underpins high levels of engagement.[80] There are opportunities to expand this role beyond medicines advise and adherence to the inclusion of dietary advise. This should focus on preventing or treating high blood pressure through reducing sodium (salt) intake, as part of a comprehensive approach to improving outcomes. Support and training is needed to do this.[81]

Managing Long-Term Conditions In addition to screening and management of high blood pressure, community pharmacy is an effective setting for risk assessment and management of cholesterol and management of people at risk of cardiovascular disease.[82] They are less effective for more complex, multi-component interventions aimed at addressing medicines management and lifestyles as part of one programme.[83][84] Even when successful such complex interventions may not be cost-effective.[85] NICE produced public health guidance on proactive case finding to reduce health inequalities in deaths from cardiovascular disease and smoking-related deaths.[86] It included a recommendation to provide services in places that are easily accessible to people who are disadvantaged (such as community pharmacies and shopping centres), and at times to suit them. However, an evaluation of the North Tees Health Checks programme, pharmacy element, was carried out in 2010-2011.[87] The evaluation was conducted by interviewing staff from community pharmacies, staff members from the commissioning Primary Care Trusts and Local Pharmaceutical Committee members, and found a number of challenges presented covering four categories:

i. Establishing and maintaining pharmacy Healthy Heart Checks ii. Overcoming IT barriers iii. Developing confident, competent staff and iv. Ensuring volume and through flow in pharmacy.

Knowsley Pharmaceutical Needs Assessment, 2018 75 | P a g e It thus concluded that delivering NHS Health Checks through community pharmacies can be a complex process, requiring meticulous planning, and may incur higher than expected costs. Given these barriers, the local implementation of the NHS Health Checks programme should continue to be run through GP practices until such barriers can be overcome and evidence suggests pharmacy-run programmes do not incur higher costs. However, it is clear from the evidence that community pharmacies can play a role in supporting people with long-term conditions.

Community pharmacy-based interventions can be effective in the management of those with Type 2 diabetes, and the pharmacist can be an important member of the multi-disciplinary team managing patients with diabetes.[88][89] Research has shown interventions can reduce HbA1c levels,[90][91][92][93][94] improve glycaemic control,[95][96][97] bring about improvements in CVD risk in patients with diabetes[98] and general adherence to clinical guidelines through patient education and medicines assessments.[99] They can be effective in targeting those at high risk, providing them with point-of-care blood glucose testing and referral being more effective and cost effective than targeting and referral alone. This can reduce emergency hospital admissions. Type 2 diabetes and other CVD screening is effective in diagnosing new cases and bringing about positive therapy changes[100][101] and simple tools can be developed to do this.[102]

Long-term condition management initiatives run in the community pharmacy setting do not have to be pharmacist-led to be effective. A peer health educator programme in which GPs referred older patients with hypertension to a community-pharmacy based volunteer health programme was well received by patients and GPs.[103]

Self-Care Pharmacists are more likely to see self-care in terms of patient responsibility and active involvement in their care than in broader concepts of patient autonomy and independence. Pharmacists have a lead role in medicines- related self-care support.[104] In particular, there are opportunities for community pharmacists to provide self-care support to those with long-term conditions, as they are regular users of pharmacy services. Whilst many patients are already actively engaged in self-care e.g. medicines adherence, many others suggest they need support of professionals as well as family and friends. However, the reason for patients not using the pharmacist to support them to self-care is a lack of awareness of the role community pharmacists can play. This would enable support from community pharmacists to be tailored and ‘marketed’ more effectively to both patients and general practitioners/ primary care staff.[105][106[107]

Reviews and evidence on the role of community pharmacists in delivery public health interventions on weight management have been mixed. A review of three weight management studies, found positive impacts on weight and waist circumference in two of the studies in which programmes offered behavior change support.[108] NICE guidance on obesity[109] includes pharmacists in the range of healthcare professionals who should take action to support behaviour change in relation to weight loss. It also maintains that, with training, pharmacy

Knowsley Pharmaceutical Needs Assessment, 2018 76 | P a g e support staff could also fulfill this role. However, it does not contain specific recommendations for pharmacies. A systematic review of alcohol reduction, smoking cessation and weight management interventions included 5 high quality studies on weight management within community pharmacy settings. Of the three studies that compared pharmacy-based with primary care-based interventions, none of the pharmacy-based interventions showed any significant differences in outcomes compared with controls. They concluded that primary care, including pharmacy settings, were not as cost effective as community settings in reducing positive weight management outcomes.[110] This is supported by other reviews and studies such as Gordon[111] and Phimarn.[112]

Added to this there are differing perceptions among the public and pharmacy staff when prescribing weight loss medications or over-the-counter weight loss products, with issues such as conflict of interest[113] and preference for dietician- led or commercial weight loss programmes.[114]. However, accessibility and availability of products work in pharmacies favour, especially where non- commercial educational materials are available. Pharmacy-led programmes may be able to bring about desired outcomes such as weight loss, reduction in waist circumference and blood pressure.[115][116][117][118] Programme components, appropriate training and resources need to be carefully considered as not all programmes show similar positive results.[119] This includes the need to take different population groups in to account.[120] Barriers include training[121] as well as capacity and reimbursement.[122][123]

Local Provision The NHS Health Check programme is a mandatory public health service for local authorities. It is a systematic vascular risk assessment and management programme to help prevent various cardiovascular diseases (CVD) including heart disease, stroke, diabetes and dementia and kidney disease. The eligible cohort includes people between 40 to 74 years of age who, have no previous diagnosis of CVD and are not currently taking statins. The check is offered once every five years.

The Department of Health expects 20% of the eligible population to be invited each year over a five year rolling programme with an uptake of 50% moving towards an uptake target of 75%. In 2016, 3,900 people aged between 40 and 74 were offered a health check in Knowsley with 80.9% receiving a health check.

Health checks are not currently undertaken in community pharmacies, however management of long-term conditions is included as part of the commissioned services discussed previously: Care At The Chemist (CATC), Medicines Use Reviews (MURs), and New Medicines Service (NMS).

84.6% of respondents to the patient pharmacy survey stated that they thought tests to check blood pressure, cholesterol, diabetes and other conditions should be available through community pharmacies. Similarly, 71.8% thought that weight management services/advice should be available and 88% thought that advice on stopping smoking should be available.

Knowsley Pharmaceutical Needs Assessment, 2018 77 | P a g e Conclusions – Supporting and Identifying People with Long Term Conditions The NHS Health Check programme is not currently undertaken in community pharmacies across Knowsley and there are no plans to do so. The local authority commissioned health check service is accessible in all areas of the borough thus ensuring adequate provision in Knowsley.

However, there is provision for people with long-term conditions included in the Care At The Chemist scheme, Medicines Use Reviews and New Medicine Service.

7.6. Cancers

Level of Need Whilst there have been significant improvements in Cancer outcomes in recent years, it is important to recognise that a substantial reduction in deaths from cancers can be achieved through lifestyle changes such as; giving up smoking, increasing physical activity and reducing alcohol consumption. However, interventions to bring about this change are long-term.

In the short-term the most likely way to improve survival times and reduce deaths from cancer is to get people who have symptoms to come forward for treatment faster.

Section 6.5 shows that rates of cancer mortality in people aged under 75 years of age in Knowsley are higher than those found in the North West region and England, however the rate in Knowsley has been reducing and has done so by 12.9% over the last decade.

Evidence of Effective Interventions in the Community Pharmacy Setting See also tobacco control

The community pharmacy is an ideal place for the public to obtain information on cancer. Pharmacy-based information, such as touch screen technology, appears to be effective in raising awareness of sun risks, and trained pharmacists are more likely to be proactive in counselling clients. However, the effect of this advice on the behaviour of clients is currently unknown.[124] This could be rolled out to include awareness campaigns about skin and bowel cancer and screening. Feedback from health improvement campaigns shows the community pharmacy is an acceptable location for cancer prevention campaigns[125] and discussions about prevention and early detection of cancer.[126] For those with established cancers, pharmacies can play an important role in identifying common drug-related problems via medication therapy management (MTM) services.[127] Oral anticancer medications offer patients advantages over traditional intravenous anticancer therapy. However, patients and their caregivers must be well educated in how to use them to reduce risk and achieve the best possible outcomes. Whilst oncology teams play the central role in this, community pharmacists can make an important contribution. This can include an understanding of patient and system barriers

Knowsley Pharmaceutical Needs Assessment, 2018 78 | P a g e with these medications, proper administration and adherence, drug and food interactions, safe handling and disposal.[128] However, this is not without its challenges and issues such as safe infrastructure with education and training are needed.[129]

Local Provision The ‘Be Clear on Cancer’ campaign is a national campaign that is used to promote awareness and early diagnosis of cancer in order to encourage people to visit their GP sooner rather than later. Pharmacies are provided with specific materials to be used within their settings promoting the campaign.

In addition, Knowsley pharmacies are provided with details about when the breast screening van will be located in the pharmacy’s area.

Conclusions – Cancers Community pharmacies in Knowsley provide a signposting service and raise awareness of cancer prevention through the 'Be Clear on Cancer' campaign and also provide details within pharmacies when the breast screening van is to be situated nearby. However, community pharmacies are not deemed suitable venues for cancer screening interventions.

7.7. Sexual Health

Level of Need From the 1 April 2013, local authorities have been mandated to commission comprehensive open access sexual health services, including free sexually transmitted infection (STI) testing and treatment and free provision of contraception.

Chlamydia was the most common sexually transmitted infection diagnosed in Knowsley during 2016 with 448 cases, a rate of 304.3 per 100,000 population. This rate has decreased by 33% since 2012, and is lower than both the North West region (417.7) and England as a whole (364.2).

Figure 28: Chlamydia diagnostic rate per 100,000 population, 2012 to 2016 Source: Public Health England

Knowsley Pharmaceutical Needs Assessment, 2018 79 | P a g e There were 84 under-18 conceptions in Knowsley during 2015, a rate of 31.8 per 1,000 females aged 15-17. The rate in Knowsley during 2015 was significantly higher than England (20.8) and higher than the North West region (24.7), Liverpool City Region (28.7) and Knowsley's Statistical Neighbour Group (29.7).

Between 1998 and 2015, the rate of under-18 conceptions has fallen by 42% in Knowsley. Over this time period, Knowsley’s rate was higher than England by 8.2 (1998) and at 2015 it was higher by 11, therefore the gap has widened by 34%.

63.1% of under-18 conceptions in Knowsley during 2015 led to a termination in pregnancy. This was markedly higher than England (51.2%) and the North West region (52.1%).

Within Knowsley, under-18 conception rates were worst in the electoral ward of Northwood and lowest in Roby and Swanside electoral wards.

Figure 29: Under-18 Teenage Conceptions, 1998 to 2015 Source: Office for National Statistics

There were 743 abortions in Knowsley during 2016, giving an age-standardised abortion rate of 24.4 per 1,000 females aged 15-44. This rate has remained relatively stable over the last five years, however is significantly higher than the North West region (18.0) and England (16.1). Between 2012 and 2016, the abortion rate in Knowsley has increased by 6.1%, or by 1.4 abortions per 1,000 females aged 15-44. This compares with a rise of 2.9% in the North West region and a fall of 3.0% across the whole of England.

The 20-24 age group had the highest age specific abortion rate in Knowsley during 2016 of 45.8 abortions per 1,000 females aged 20-24. This was substantially higher than the North West region (30.3) and England (27.2). Indeed, for each age group, Knowsley had a higher age specific abortion rate than the North West region and England in 2016. Overall, 41.9% of abortions in Knowsley were repeat abortions in 2016, higher than England (38.0%).

Knowsley Pharmaceutical Needs Assessment, 2018 80 | P a g e There were a marginally higher proportion of NHS funded abortions in Knowsley during 2016 (99.1%) compared to the North West region (99.1%) and England (98.2%).

Figure 30: Age-Standardised Abortion Rates, 2012 to 2016 Source: Department of Health

The Emergency Hormonal Contraception (EHC) service is delivered through 25 pharmacies in Knowsley which provide important access to EHC, and a greater choice of pharmacy, which may be important to preserve anonymity. Without this service, access would only be available via a GP appointment or sexual health service clinic.

In the 12-month period between April 2016 and March 2017, 748 emergency hormonal contraception prescriptions were written for people registered with a Knowsley GP, equating to a cost of £4,427. These prescriptions were then dispensed by pharmacies in and outside of Knowsley.

The number of items prescribed in Halewood was significantly lower than Knowsley as a whole, conversely the number of items prescribed in Kirkby was significantly higher than Knowsley as a whole.

Evidence of Effective Interventions in the Community Pharmacy Setting NICE guidance on contraceptive services for young people (up to the age of 25),[130] key recommendations include:

 Establish collaborative, evidence-based commissioning arrangements between different localities to ensure comprehensive, open-access services are sited in convenient locations, such as city centres, or near to colleges and schools. Ensure no young person is denied contraceptive services because of where they live  Ensure pharmacies, walk-in centres and all organisations commissioned to provide contraceptive services (including those providing oral emergency contraception) maintain a consistent service. If this is not possible, staff should inform young people, without having to be asked, about appropriate alternative, timely and convenient services providing oral emergency contraception

Knowsley Pharmaceutical Needs Assessment, 2018 81 | P a g e  Doctors, nurses and pharmacists should, where possible, provide the full range of contraceptive methods, especially long-acting reversible contraception (LARC), condoms to prevent transmission of STIs and emergency contraception (both hormonal and timely insertion of an intrauterine device). Adequate consultation time should be set aside  Provide additional support for socially disadvantaged young people to help them gain immediate access to contraceptive services and to support them, as necessary, to use the services. This could include providing access to trained interpreters or offering one-to-one sessions. It could also include introducing special facilities for those with physical and sensory disabilities and assistance for those with learning disabilities  Ensure all young women are able to obtain free emergency hormonal contraception, including advance provision  Offer support and referral to specialist services (including counselling) to those who may need it. For example, young people who misuse drugs or alcohol and those who may have been (or who may be at risk of being) sexually exploited or trafficked may need such support. The same is true of those who have been the victim of sexual violence  Ensure young men and young women know where to obtain free advance provision of emergency hormonal contraception  In addition to providing emergency hormonal contraception, professionals should ensure that all young women who obtain emergency hormonal contraception are offered clear information about, and referral to, contraception and sexual health services  Encourage all young people to use condoms and lubricant in every encounter, irrespective of their other contraceptive  Ensure staff are familiar with best practice guidance on how to give young people aged under 16 years contraceptive advice and support.[xii] Ensure they are also familiar with local and national guidance on working with vulnerable young people

A review of the contribution of community pharmacists to the public health agenda[131] found:

 Emergency hormonal contraception (EHC) can be effectively and appropriately supplied by pharmacists  Pharmacy supply of EHC enables most women to receive it within 24 hours of unprotected intercourse  Community pharmacies are highly rated by women as a source of supply and associated advice for EHC on prescription, by Patient Group Directions (PGDs), or over-the-counter (OTC) sales  10% of women, choose pharmacy supply of EHC in order to maintain anonymity  Pharmacists were positive about their experience of providing emergency hormonal contraception through PGDs and over-the-counter sales

xii. Department of Health (2004) Best practice guidance for doctors and other health professionals on the provision of advice and treatment to young people under 16 on contraception, sexual and reproductive health. London: Department of Health.

Knowsley Pharmaceutical Needs Assessment, 2018 82 | P a g e  The role of pharmacy support staff in provision of EHC services is reported by pharmacists to be important

There is support from both customers and pharmacists for the provision of a wider range of sexual health services beyond EHC, including short supply progesterone-only pill[132][133] and progestogen only injections[134] to ensure ease of access to effective contraception as well as chlamydia screening.[135] In particular pharmacy-based EHC consumers are at high risk of chlamydia and would be willing to accept a chlamydia test from the pharmacy.[136 Although pharmacies in the UK cannot provide sexual and reproductive healthcare beyond retail condoms and EHC, a Scottish pilot study suggests that for women obtaining EHC from a pharmacy simple interventions such as supplying one month of a progesterone-only pill, or offering rapid access to a sexual health clinic, hold promise as strategies to increase the uptake of effective contraception after EHC.[137]

NICE guideline NG68[138] recommends that all existing services that are likely to be used by those most at risk should provide condom schemes. This could include services provided by the voluntary sector (such as advice projects and youth projects), school health services and primary healthcare (including GP surgeries and community pharmacies). There should be links made between such condom schemes and local sexual and reproductive health services. For example, they should consider:

 Providing condoms with information about local sexual health services  Displaying posters and providing leaflets advertising local sexual health services where condoms are available

Local Provision Across Knowsley, emergency hormonal contraception is a locally commissioned service provided free of charge against a Patient Group Direction (PGD) by a team of accredited pharmacists. As individual pharmacists are accredited rather than pharmacies, this service cannot be guaranteed in any one pharmacy at any one particular time. However, all pharmacies can still sell emergency hormonal contraception over the counter (in line with the product license) although its indications are limited in comparison to the PGD route. This provides women with the opportunity to have ease of access to emergency hormonal contraception which is an important factor in effectiveness, as the sooner the emergency hormonal contraception is taken the more effective evidence states it to be.

As a result, patients receive a holistic service including advice and signposting for long term contraception, sexually transmitted infection screening and sexual health advice. Whilst pharmacies providing emergency hormonal contraception can signpost people to other services, neither chlamydia screening nor screening for other sexually transmitted infections (STIs), is available.

A list of providers in Knowsley is given below:

Knowsley Pharmaceutical Needs Assessment, 2018 83 | P a g e  Pharmacy under patient group direction (locally commissioned service)  GP’s  Walk in Centre  A&E  Community Sexual Health Services  School nursing  Genito-urinary medicine (GUM)

Figure 31 shows the distribution of pharmacy EHC services in Knowsley. Some pharmacies that have been commissioned to provide the service are currently not providing the service. From previous experience this is generally due to accredited pharmacists moving on from that location or accreditation requirements for pharmacists not being completed.

Comparing the rate of under-18 conceptions and the location of pharmacies providing EHC one can conclude that areas with high conception rates are provided for in terms of pharmacies providing an EHC service. This is confirmed by the number of EHC items supplied in Knowsley between April 2016 and March 2017, where significantly high levels of EHC dispensing are correlated with high levels of teenage conceptions in Kirkby; conversely significantly low levels of EHC dispensing are correlated with relatively lower levels of teenage conceptions in Halewood.

Knowsley Pharmaceutical Needs Assessment, 2018 84 | P a g e

Figure 31: Pharmacy provision for emergency hormonal contraception, 2017 Source: Pharmacy survey, 2017

Knowsley Pharmaceutical Needs Assessment, 2018 85 | P a g e Conclusions – Sexual Health Emergency Hormonal Contraception (EHC) is provided by the majority of community pharmacies in Knowsley (25) and provision across the borough adequately meets the needs of the local population. Additionally, provision for Emergency Hormonal Contraception is available from other services in the borough as well as community pharmacies close to the Knowsley border.

7.8. Mental Health

Level of Need Mental ill health represents up to 23% of the total burden of ill health, and is the single largest cause of disability in the UK. Mental health is complex and covers a wide range of conditions such as depression, anxiety disorders and obsessive compulsive disorders, through to more severe conditions like schizophrenia.

The negative impact of poor mental health and wellbeing can be felt across all areas of life including increased risk of physical ill health, drug and alcohol misuse, lower educational attainment and employment levels as well as wider social exclusion (No Health Without Mental Health).

Mental health disorders do not just affect individuals but also their families, friends and colleagues. The total economic cost of mental health problems in England is estimated to be around £105 billion (of which £30 billion is work related) and it has been estimates that cost of health services to treat mental illness could double over the next 20 years.

In 2015/2016 almost 15,000 adults in Knowsley are currently diagnosed with depression by their GP, equating to 11.5% of the 18+ population, which is higher than 8.3% nationally. Latest figures suggest 16.6% of people with anxiety and or depression in Knowsley entered Improving Access to Psychological Therapies (IAPT) services, which is above the national target of 15%.

Prevalence of severe mental illness in 2015/16 in Knowsley (people diagnosed with schizophrenia, bipolar disorder or other psychoses or on lithium therapy) is 0.98% and is higher than England (0.90%).

The rate per 1,000 working age population of claimants for Employment Support Allowance (ESA) for mental and behavioral conditions in Knowsley in 2016 was 57.0.

Knowsley Pharmaceutical Needs Assessment, 2018 86 | P a g e

Figure 32: Prevalence of Mental Health Conditions, 2015/2016 Source: Health and Social Care Information Centre

Rates of mental health prescribing in Knowsley are similar to the North West region but higher than England as a whole. Knowsley’s primary care prescribing spend on mental health per person was higher than England; £17.81 per person compared to £12.31.

In 2015/16, there were 496 emergency hospital admissions for intentional self- harm in Knowsley. The admission rate for females was higher than males, 383.7 per 100,000 females compared to 281.3 per 100,000 males. There has been an increase in such admissions, emergency admissions for self-harm in Knowsley are significantly higher than the North West region and England.

Figure 33: Emergency hospital admissions for intentional self-harm, 2010/2011 to 2015/2016 Source: Health and Social Care Information Centre

Evidence of Effective Interventions in the Community Pharmacy Setting No relevant studies on the early detection of depression were found in the literature review undertaken. A report by the Department of Health on the public health role of pharmacists acknowledges this lack of an evidence base, suggesting that it is not beyond the scope of community pharmacists to have a role in mild to moderate mental ill health. For example, customers purchasing products to reduce stress and anxiety, such as sleeping products, could be offered support and advice from appropriately training pharmacists such as

Knowsley Pharmaceutical Needs Assessment, 2018 87 | P a g e signposting or referral to local services.[139] This role in detecting the early signs and symptoms of mental health problems, and providing information on how to deal with them is supported by a joint pharmacy report, in which they conclude that there is a potential role for pharmacy staff to offer support and advice in relation to mental health issues.[140] Studies have also shown that the community pharmacist can make a valuable contribution to community mental health teams (CMHTs).[141][142][143]

The stigma of mental illness can be a barrier to effective medication management in the community pharmacy setting. Self-stigma impeded consumers’ community pharmacy engagement. Positive relationships with knowledgeable staff are fundamental to reducing stigma. Stigmatising views can also be held by health professionals resulting in the giving of biased/inaccurate advice and behaviours. Awareness raising training for pharmacy staff can improve communications and reduce negative experiences.[144] This is not surprising given that mental health literacy - ‘knowledge and beliefs about mental disorders which aid in their recognition, management or prevention’ - is poor, especially compared to physical health issues such as long-term conditions. Healthcare professionals, including community pharmacists view education campaigns as important in addressing this.[145] The focus on products and business required of community pharmacies can inhibit a more patient-centred pharmacy culture, despite undergraduate training programmes promoting this.[146] Research is scarce on medication support interventions for people with mental health problems, but broader medicines management for long-term conditions can inform the development of mental health focussed medication support services.[147]

Local Provision Mental health is one of two priorities for Knowsley’s Health and Wellbeing Board. The focus for improved mental health and wellbeing is in the following areas:

 Establishment of Single Point of Referral for Mental Health services  Design, specification and procurement of Knowsley Community Consultant Led Mental Health service (operating within Neighbourhub model)  Low level on-going support to individuals and families to help them achieve and maintain good mental health (Key Workers; Care Navigators; School Buddy Systems)  Dementia Friendly Community and post diagnosis support, working with patients, their families and other stakeholders  Anger Management  Mental Health Shared Care and Primary Care development  Neuro Development Pathway ASD/ADHD  CAMHS service specification (linking into wider children/young people MH transformation)  Responsive and Accessible Early Intervention Psychosis  IAPT National Standards  Low level counselling/talking therapies  Community Eating Disorder Services

Knowsley Pharmaceutical Needs Assessment, 2018 88 | P a g e  Children and young people’s IAPT (linking into CAMHS service specification)  Improving Perinatal Mental Health Care  Bringing education and local children and young people’s mental health services together around the needs of the individual child through a joint mental health training programme  Commissioning to allow earlier intervention and responsive crisis services  Access to support prior to and during crisis point: Street Triage development  Urgent and Emergency Access to Crisis Care: Step Up/Step Down Intermediate Care for Mental Health including 'crisis bed' provision  Quality of treatment and care when in crisis  Recovery and staying well / preventing future crisis

There are currently no mental health related services commissioned from pharmacies in Knowsley.

Conclusions – Mental Health There are currently no mental health related services commissioned from pharmacies in Knowsley, however, there are a high number of dementia champions in pharmacies. Prevalence of mental health is high and pharmacies are potentially well placed to detect early signs of mental health problems when consulting with patients. A detailed review of the evidence regarding the effectiveness of such community pharmacy based services would need to be undertaken before such services can be commissioned. This should not be undertaken in isolation but considered as part of the whole mental health agenda. Therefore at this time it must be considered that there is no need for provision of such services from community pharmacies.

7.9. Substance Misuse

Level of Need Drug addiction leads to significant crime, health and social costs. Evidence- based drug treatment reduces these and delivers real savings, particularly in crime costs, but also in savings to the NHS through health improvements, reduced drug-related deaths and lower levels of blood-borne disease.

Opiate and crack combined is the main problem drug in Knowsley accounting for 50% of substances used within the effective treatment population in 2015/16. Indeed, Knowsley has a higher proportion of opiate and / or crack users than nationally, although the number of drug users who inject is lower than England as a whole.

Knowsley Pharmaceutical Needs Assessment, 2018 89 | P a g e No. Rate per National

Users 1,000 Rate Opiate / Crack user 1,090 11.41 8.57 Opiate 949 9.94 7.33 Crack 664 6.95 5.21 Table 17: Prevalence of drug users, 2014/2015 Source: Public Health England

Whilst the number of opiate users in treatment has fallen slightly since 2014/2015 there has been a growth in non-opiate users in treatmentxiii

Evidence of Effective Interventions in the Community Pharmacy Setting NICE Guidance PH52 on the optimum provision of Needle & Syringe Programmes[148] places community pharmacies at the heart of the provision of these programmes.

Recommendation 8 Provide Community Pharmacy-Based Needle and Syringe Programmes - Community pharmacies, coordinators and local pharmaceutical should:

 Ensure staff who distribute needles and syringes are competent to deliver the level of service they offer. As a minimum, this should include awareness of the need for discretion and the need to respect the privacy and confidentiality of people who inject drugs. It should also include an understanding of how to treat people in a non-judgmental way.  Ensure staff providing level 2 or 3 services (see recommendation 6) are competent to provide advice about the full range of drugs that people may be using. In particular, they should be able to advise on how to reduce the harm caused by injecting and how to prevent and manage an overdose.  Ensure staff has received health and safety training, for example, in relation to blood-borne viruses, needlestick injuries and the safe disposal of needles, syringes and other injecting equipment.  Ensure hepatitis B vaccination is available for staff directly involved in the needle and syringe programme.  Ensure staff is aware of, encourage and can refer people to, other healthcare services including drug treatment services.  Ensure pharmacy staff offer wider health promotion advice, as relevant, to individuals.

Recommendation 7 Provide People with the Right Type of Equipment and Advice - Needle and syringe programme providers should:

 Provide people who inject drugs with needles, syringes and other injecting equipment. The quantity provided should not be subject to a limit but, rather, should meet their needs. Where possible, make needles available in a range of lengths and gauges, provide syringes in a range of sizes and offer low dead-space equipment.

xiii NDTMS, 2015/16.

Knowsley Pharmaceutical Needs Assessment, 2018 90 | P a g e  Not discourage people from taking equipment for others (secondary distribution), but rather, ask them to encourage those people to use the service themselves.  Ensure people who use the programmes are provided with sharps bins and advice on how to dispose of needles and syringes safely. In addition, provide a means for safe disposal of used bins and equipment.  Provide advice relevant to the type of drug and injecting practices, especially higher risk practices such as injecting in the groin or neck.  Encourage people who inject drugs to mark their syringes and other injecting equipment, or to use easily identifiable equipment, to reduce the risk of accidental sharing.  Encourage people who inject drugs to use other services as well. This includes services that aim to: reduce the harm associated with this practice; encourage them to switch to safer methods, if these are available (for example, opioid substitution therapy), or to stop using drugs; and address their other health needs. Tell them where to find these services and refer them as needed.

Research also demonstrates that community pharmacy-based supervised methadone administration services can achieve high attendance rates and are acceptable to clients.[149] NICE guidelines recommend that each new treatment of opiate dependence be subject to supervised administration for the first three months, or a period considered appropriate by the prescriber. The rationale for this recommendation is to provide routine and structure for the client, helping to promote a move away from chaotic and risky behaviour. This service requires the pharmacist to supervise the consumption of prescribed medicines at the point of dispensing in the pharmacy – ideally within a private consultation room, and ensuring that the dose has been administered to the patient.[150]

Local Provision There are two aspects to currently commissioned pharmaceutical services to substance misuse clients, these are; needle and syringe provision (NSP) services and supervised administration of methadone. Both needle and syringe provision and supervised administration are fundamental harm reduction services. Supervised administration is a service that can only be provided by a pharmacy following dispensing of the diamorphine substitute methadone. It is not part of the essential tier of the pharmacy contract, but greatly reduces harm by reduction of prescribed methadone or suboxone onto an illicit market, and protection of vulnerable individuals from overdose. Needle and syringe provision services are also provided by specialist services but pharmacies are a good choice of provider due to excellent access and existing client relationships. This service aims to assist clients to remain healthy until they are ready to cease injecting and achieve a drug free life with appropriate support. It also aims to reduce the rate of blood born infections and drug related deaths among service users by:

 Reducing the amount of sharing and other high risk injecting behaviours  Providing sterile injecting equipment and other support  Promoting safer injecting practices

Knowsley Pharmaceutical Needs Assessment, 2018 91 | P a g e  Providing and reinforcing harm reduction messages including safe sex advice and advice on overdose preventions  Improving the health of local communities by preventing the spread of blood borne infection and ensuing the safe disposal of used injecting equipment

The needle exchange service is focused on ensuring that injecting drug users have access to clean injecting equipment, are able to safely dispose of used equipment and have access to advice from pharmacists. Across Knowsley, there are nine pharmacies that provide a needle exchange service currently.

Pharmacy Address Postcode Electoral Ward Halewood Boots Roseheath Drive, Liverpool L26 9UH South Boots Cables Retail Park, Prescot L34 5NQ Prescot North Daveys chemist 112 Dinas Lane, Liverpool L36 2NS Page Moss Unit A2 1 Newtown Gardens, Aim Rx Ltd L32 8RR Whitefield Liverpool Rowlands 11 Richard Hesketh Drive, Liverpool L32 0TU Whitefield 27 Woolfall Heath Avenue, Sedem Pharmacy L36 3TH Page Moss Liverpool Sedem Pharmacy Longview Drive, Liverpool L36 6EB St Gabriels Unit 8, The Croft, Leachcroft, Care Pharmacy Ltd L28 1NR Stockbridge Liverpool TOPS Pharmacy Unit 6, Glovers Brow, Liverpool L32 2AE Whitefield Table 18: Pharmacies providing Needle Exchange Service, 2017 Source: Knowsley Public Health Team

There is also provision for needle exchange via the substance misuse service in Huyton and Kirkby.

Knowsley Pharmaceutical Needs Assessment, 2018 92 | P a g e Figure 34: Supervised Consumption in Knowsley Pharmacies Source: Pharmacy Survey, 2017

Knowsley Pharmaceutical Needs Assessment, 2018 93 | P a g e There are 29 pharmacies that currently provide supervised consumption. The service requires the pharmacist to supervise the consumption of prescribed medicines (methadone, subutex or buprenorphine), at the point of dispensing in the pharmacy within a private consultation room, and ensuring that the dose has been administered to the patient.

Conclusions – Substance Misuse There are currently 29 of Knowsley's 36 community pharmacies that provide supervised consumption of prescribed medicines (methadone, subutex or buprenorphine) and are widely accessible across the borough which suggests provision is more than adequate.

There are nine community pharmacies providing a needle exchange service in Knowsley the majority of which are situated in Huyton. Further provision is provided in Huyton and Kirkby via the substance misuse service.

7.10. Older People

Level of Need

Life Expectancy at 65 Life expectancy (as described in chapter 6.4) is an estimate of how many years a person might be expected to live.

Latest estimates for the three-year period of 2013/15 estimate that life expectancy at 65 years of age for males in Knowsley stands at 16.9 years. This is significantly lower than England as a whole where male life expectancy at 65 years of age is estimated to be 18.7 years.

Similarly, life expectancy at 65 years of age for Knowsley females in 2013/15 was significantly lower than England as a whole. In Knowsley, life expectancy at 65 years of age is estimated to be 19.0 years compared to 21.1 years across the whole of England.

Long-Term Health Problems or Disability at 65 As people get older they are more susceptible to long-term health problems or disability. This information was captured in the 2011 Census, and shows that Knowsley residents are significantly more likely to experience long-term health problems or disability that limit their day-to-day activities than the North West region or England as a whole. Indeed, 42% of Knowsley residents aged 65 or over said that they have a ‘long-term health problem that limits their daily activities a lot’ compared to 31% of people aged 65 or over in the North West region and 27% across the whole of England.

Excess Winter Deaths Excess Winter Mortality (EWM) is defined as ‘the extra numbers of deaths during the winter months in relation to the other seasons of the year,’ and is thought to be a direct consequence of the cold weather. Understanding seasonal changes in temperature are important, especially in winter months so that additional help can be made available for those that are most at risk to

Knowsley Pharmaceutical Needs Assessment, 2018 94 | P a g e these cold conditions. At risk groups such as the elderly are particularly vulnerable during this period, especially those on lower incomes and those not living in energy efficient housing. There is also a strong relationship between cold temperatures and cardiovascular and respiratory diseases.

During the 2015/16 winter period, there were 88 excess winter deaths in Knowsley compared to the rest of the year, an 8% decrease from the previous year. This represents an excess winter mortality index of 18.4%; that is 18.4% more deaths occurred in winter compared to the non-winter months. This was higher than the North West and England (15.4 and 14.6 respectively).

The largest increase in excess winter deaths in Knowsley occurred amongst those aged under 65. This was the result of the number of winter deaths not reducing as much as the non-winter deaths, therefore the gap widening. The number of winter deaths for 85+ year olds was approximately 32% higher than the non-winter periods. Approximately just under half of all excess winter deaths were caused by respiratory diseases.

Influenza Vaccinations For most people, influenza (flu) is an unpleasant illness making people feel unwell for several weeks, but it’s not serious in healthy people. However, certain people are more likely to develop potentially serious complications of flu, such as bronchitis and pneumonia. This can result in emergency hospital admissions or even death. The following groups of people are now offered free NHS influenza vaccination each year:

 All people aged 65 years and over (including those becoming 65 by 31 March 2017)  People aged from 18 to less than 65 years of age with one or more of the following medical conditions: o Chronic (long-term) respiratory disease, such as severe asthma, chronic obstructive pulmonary disease (COPD) or bronchitis o Chronic heart disease, such as heart failure o Chronic kidney disease at stage three, four or five o Chronic liver disease o Chronic neurological disease, such as Parkinson’s disease or motor neurone disease, or learning disability o Diabetes o Immunosuppression, a weakened immune system due to disease (such as HIV/AIDS) or treatment (such as cancer treatment) o Asplenia or splenic dysfunction o Morbid obesity  Pregnant women aged 18 or over (including those women who become pregnant during the flu season)  People aged 18 or over living in long-stay residential care homes or other long-stay care facilities*  Carers aged 18 or over  Household contacts of immunocompromised individuals who are aged 18 or over.

Knowsley Pharmaceutical Needs Assessment, 2018 95 | P a g e The national targets are based on World Health Organisation (WHO) targets. For this year the WHO target for Influenza for those aged 65 years and over is 75%. Everyone aged 65 and over is actively contacted and offered the flu vaccine151.

Research has shown that immunisation services can be safely provided in community pharmacy settings,[152] that the review of medication records is a useful tool in flagging up those ‘at risk’ and inviting them to take part in the programme.[153] Such programmes are also well received by both patients and doctors.[154]

Uptake for the influenza vaccination in Knowsley during the 2015/16 winter period was below the 75% target recommended by WHO at 73.6%, but higher than the North West region (72.9%) and England as a whole (70.5%).

Figure 35: Percentage of those aged 65 plus immunised against influenza Source: Public Health England

Evidence of Effective Interventions in the Community Pharmacy Setting Research shows that older people value continuity of personalised pharmaceutical care, which enables them to build a trusting relationship over time. There can be a lack of awareness of services already available from community pharmacies. Ongoing disruption in the supply of medicines caused problems for this client group, and the complexity of prescription ordering, collection and delivery systems presented challenges for participants. Good communication from the community pharmacy helped to improve the experience.[155 Dexterity problems can affect a sizable proportion of older people. Whilst this is a manufacturing issue, community pharmacy staff are on hand and should check if this is an issue when dispensing.[156] Assisting patients with dementia (and their carers) in respect of medications is a particular problem. As prevalence of this condition rises, ways of addressing this will become more pressing.[157]

Community pharmacy-based services assessing older women’s risk of osteoporosis were well received and were able to identify women at different levels of risk.[158] A follow up evaluation with women who received an intervention found that they had made lifestyle changes, such as, increased

Knowsley Pharmaceutical Needs Assessment, 2018 96 | P a g e calcium in the diet, increased physical activity and took relevant medication.[159][160][161].

Medicines reviews for the elderly are both perceived favourably by participants[162] and can help reduce prescribing costs.[163] However, it is unclear if such interventions are cost effective as the cost of the interventions was not detailed.

NICE guidance on medicines management in care homes was published March 2014.[164] It states that helping residents to look after and take their medicines themselves is important in enabling residents to retain their independence. Care home staff should assume residents are able to look after and manage their own medicines when they move into a care home, unless indicated otherwise. An individual risk assessment should be undertaken to determine the level of support a resident needs to manage their own medicines.

The guideline considers all aspects of managing medicines in care homes and recommends that all care home providers have a Care Home Medicines Policy. The policy should ensure that processes are in place for safe and effective use of medicines in the care home. Sections of the guideline provide recommendations for different aspects of managing medicines covered by the care home medicines policy.

Local Provision Locally the annual seasonal influenza vaccination programme is primarily managed through GP practices, as well as more recently community pharmacies.

Of the 36 respondents to the pharmacy questionnaire, five said that they provide advice for care homes in Knowsley, with 26 stating that they would be willing to provide this service. Over half of pharmacies provided a Medicines Administration Record (MAR) service in care homes, with three pharmacies providing a domiciliary medicines use review, and with 29 pharmacies willing to provide the service.

There are no additional services commissioned in Knowsley from community pharmacies for care home patients, or to support care home managers/staff.

Many pharmacies provide additional services to care homes, such as delivery, dispensing into MDS (blister packs), and MAR charts as described, often free of charge.

Conclusions – Older People The influenza vaccination programme in Knowsley is primarily managed through GP practices and coverage of this campaign is slightly below the 75% national target. Although there is not a requirement for community pharmacies to partake in the campaign, a programme administering vaccines is delivered by 30 pharmacies in Knowsley.

Knowsley Pharmaceutical Needs Assessment, 2018 97 | P a g e 7.11. Palliative Care

Level of Need The Department of Health End of Life Care Strategy165 states that patients should have access to:

 Rapid specialist advice and clinical assessment-through 24/7 telephone helplines and rapid access to home care  9 to 5 access to specialist nurses – 7 days a week including bank holidays  High quality care in the last days of life- Liverpool Care Pathway  Coordinated care and support, ensuring that patients needs are met- in hospices and care home with palliative care beds

Coordinated care will be delivered through multi-agency training and the ‘Gold Standards Framework’. Pharmacists play a vital role for patients who have stipulated their preferred priorities of care and wish to die at home

During 2015, there were 1,526 deaths in Knowsley, with three causes accounting for 70.4% of them. Cancer was the biggest cause of death with 471 (30.9% of the total) followed by cardiovascular disease with 373 deaths (24.4% of the total). A further 230 of deaths (15.0% of the total) were due to respiratory disease.

Deprivation, availability of appropriate home care, and whether the individual is living with relatives or alone are all factors in determining the likelihood of a home death[166] [167].

In 2013/15, the majority of Knowsley residents who died did so in hospital (52.3%). A further 21.2% died in a hospice or residential/nursing/care home.

Place of Death Deaths Proportion Hospice 229 5.0% Hospital 2,362 52.3% Residential/Nursing/Care Home 730 16.2% Elsewhere 1192 26.4% Table 19: Place of Death in Knowsley, 2013/2015 Source: Primary Care Mortality Database

Evidence of Effective Interventions in the Community Pharmacy Setting Palliative care is designed to provide pain relief and improve the quality of life of patients with life-threatening illness. The number of patients with chronic, slowly debilitating conditions has risen. This means that even where patients die in a hospital or other care institution, many will live in their own homes with the need to manage the condition for some time before this happens. NICE guidance on palliative care shows that, amongst other things, there was inadequate access to pharmacy services outside normal working hours[168] so local schemes should seek to address this issue. Pharmacists are a vital part of the multi-disciplinary team supporting an individual and their family during this time, ensuring that medications are assessed and the effectiveness of medications is reviewed as needs change.[169] As timely access to medicines

Knowsley Pharmaceutical Needs Assessment, 2018 98 | P a g e is vital, especially as the preferred place of care is the home environment, stock control can hinder effective provision. Knowing the level of need locally is an important part of this.[170] Details about key patient groups such as those with end-stage cancer can be poor, with opportunities to embed community pharmacists in to palliative care teams missed.[171] Community pharmacists are generally positive about providing services and support for palliative care patients. They may not have a full understanding of it however, as there is a need for training and support to facilitate their involvement.[172]

Local Provision There are currently five pharmacies providing a palliative care drugs supply locally commissioned service, with an aim to work on revising the palliative care formulary with the local consultants in 2018/19. The intention of the service is to improve access to palliative care medicines when they are required. The pharmacies were historically selected based on opening hours and geographical spread. 100 hour pharmacies would be expected to provide this service and to provide considerable enhanced access, as requests for palliative care medicines may be both urgent and unpredictable.

Pharmacies that provide the service maintain a stock of a locally agreed range of palliative care medicines and commit to ensuring continuity of supply, so that users of this service have prompt access to these medicines during the opening hours of the pharmacy. Pharmacists are able to support users, carers and clinicians by providing information and advice.

To help ensure patients care is joined-up and to improve accessibility, a list of participating pharmacies and the Pharmacy Palliative Care Drug Formulary is shared with providers of Out of Hours Care, Walk-in-Centres, specialist palliative care nurses and district nursing teams.

Conclusions – Palliative Care There are currently five community pharmacies providing a palliative care drugs supply locally commissioned service in Knowsley, with an aim to work on revising the palliative care formulary with the local consultants in 2018/19.

These pharmacies are distributed equitably across the borough and provision meets the needs of the local population.

Knowsley Pharmaceutical Needs Assessment, 2018 99 | P a g e

Figure 36: Pharmacies providing palliative care drugs in Knowsley, 2017/18 Source: Knowsley CCG

Knowsley Pharmaceutical Needs Assessment, 2018 100 | P a g e APPENDIX 1: POLICY CONTEXT

‘A Vision for Pharmacy in the New NHS’

In July 2003, the Department of Health launched ‘A Vision for Pharmacy in the New NHS’ which identified and aligned the ambitions for pharmacy alongside the wider ambitions for the NHS as a whole.

As part of the ‘Vision for Pharmacy’ a new community pharmacy contractual framework was put in place in April 2005. It comprised three tiers of services – essential, advanced and local enhanced services:

i. Essential services are those which every pharmacy must provide, including dispensing. ii. Advanced services are those which, subject to accreditation requirements, a pharmacy contractor can choose to provide. At present, there are three advanced services, Medicines Use Review, AURs and SAC. iii. Local enhanced services, such as health and lifestyle advice or help for substance misusers, are commissioned locally by PCTs direct with contractors.

Around 85% of community pharmacy income nationally comes from NHS services. A growing source of income to community pharmacies comes from providing enhanced services commissioned by the former Primary Care Trusts.

‘Our Health, Our Care, Our Say’

This White Paper in January 2006 set out a new strategic direction for improving the health and well-being of the population. It focused on a strategic shift to locate more services in local communities closer to people’s homes. This recognised the vital role that community pharmacies provide in providing services which support patients with long term conditions and make treatment for minor illnesses accessible and convenient.

‘Pharmacy in England - Building on Strengths Delivering the Future’

In April 2008 the government revealed its plans in a Pharmacy White Paper and subsequently a consultation was undertaken on the proposed changes to the regulations for pharmacy.

The White Paper set out a vision for improved quality and effectiveness of pharmaceutical services, and a wider contribution to public health. Whilst acknowledging good overall provision and much good practice amongst providers, it revealed several areas of real concern about medicines usage across the country which it seeks to address through a work programme to challenge and engage Primary Care Trusts, pharmacists and the NHS.

It identified practical, achievable ways in which pharmacists and their teams can improve patient care and a reinvigorated vision of pharmacy’s potential to contribute to a fair, personalised, safe and effective NHS. This vision demonstrated how pharmacy can expand its role in an NHS which focuses as much on prevention as it

Knowsley Pharmaceutical Needs Assessment, 2018 101 | P a g e does on treating sick people, helping to reduce health inequalities, supporting healthy choices, improving quality and promoting well-being for patients and public alike.

An overview of the White Paper is set out in the table.

Figure A: Pharmacy White Paper – Summary

Building on strengths – delivering the future The Aims of the White Paper, Pharmacy in England

Supporting healthy living and better care Better, safe use of medicines Community pharmacies will become ‘healthy Safe medication practices should be living’ centres providing a primary source of embedded in patient care by identifying, information for healthy living and health introducing and evaluating systems designed improvement. to reduce unintended hospital admissions related to medicines use. Pharmacy will be integrated into public health initiatives such as stop smoking, sexual health Identifying specific patient groups for MURs, services and weight management, or offer using MURs and repeat dispensing to identify screening for those at risk of vascular disease and reduce the amount of unused medicines – an area where there are significant variations and including pharmacists in care pathways for in access to services and life expectancy long-term conditions are all examples of this. around the country.

Access and choice Integration and interfaces Community pharmacies improve access and Community based pharmaceutical care will be choice through more help with medicines. This developed which will involve creating new will be realised by developing MURs, repeat alliances between hospital and community dispensing, access to urgent medicines, pharmacists as well as primary care emergency supply and working with hospitals pharmacists and pharmacy technicians. on medicine reconciliation.

Quality Underpinning all of this in the White Paper and the other policy drivers mentioned earlier is continual improvement in quality. This is a recurring theme throughout all the policy drivers currently influencing the development of community pharmacy. This refers to staff, premises and services alike. PCTs have a responsibility to ensure continuous quality by monitoring the community pharmacy services against the strategic tests.

‘Healthy Lives, Healthy People’

The public health strategy for England (2010) stated:

“Community pharmacies are a valuable and trusted public health resource. With millions of contacts with the public each day, there is real potential to use community pharmacy teams more effectively to improve health and wellbeing and to reduce health inequalities.”

This is relevant to local authorities as they take on responsibility for public health in their communities. In addition, community pharmacy is an important investor in local communities through employment, supporting neighbourhood and high street economies, as a health asset and long term partner.

Market Entry by Means of PNAs and Quality and Performance (Market Exit)

Knowsley Pharmaceutical Needs Assessment, 2018 102 | P a g e

The NHS Act 2006 required the Secretary of State for Health to make Regulations concerning the provision of NHS pharmaceutical services in England. The Health Act 2009 amended these provisions by providing that

PCTs must develop and publish local pharmaceutical needs assessments

 PCTs would then use their PNAs as the basis for determining entry to the NHS pharmaceutical services market.

The Health Act 2009 also introduced new provisions which allow the Secretary of State to make regulations about what remedial actions PCTs can take against pharmacy and dispensing appliance contractors who breach their terms of service or whose performance is poor or below standard.

The first set of regulations dealing with the development and publication of PNAs, the NHS (Pharmaceutical Services and Local Pharmaceutical Services) (Amendment) Regulations 2010 were laid on 26 March 2010 and came into force on 24 May 2010.

Later the National Health Service (Pharmaceutical Services) Regulations 2013 and draft guidance came into force concerning the remaining provision under the Health Act 2009. According to these, from 1 April 2013, every Health and Wellbeing Board (HWB) in England has a statutory responsibility to publish and keep up to date a statement of the needs for pharmaceutical services of the population in its area, referred to as a pharmaceutical needs assessment (PNA). This is of particular relevance for local authorities and commissioning bodies.

Knowsley Pharmaceutical Needs Assessment, 2018 103 | P a g e APPENDIX 2: ABBREVIATIONS USED

AUR Appliance Use Review A&E Accident and Emergency BME Black and Minority Ethnicities CAMHS Child and Adolescent Mental Health Service CATC Care At The Chemist CCG Clinical Commissioning Group COM Central Operations Mersey COPD Chronic Obstructive Pulmonary Disease CVD Cardio Vascular Disease DRP Drug Related Problems EHC Emergency Hormonal Contraception EWM Excess Winter Mortality GP General Practice / General Practitioner GUM Genito-urinary Medicine HWBB Health and Wellbeing Board IT Information Technology JSNA Joint Strategic Needs assessment LAPHT Local Authority Public Health Team LARC Long-Acting Reversible Contraception LES Local Enhanced Service LPC Local Pharmaceutical Committee LPS Local Pharmaceutical Services MBC Metropolitan Borough Council MDS Monitored Dose System MTM Medication Therapy Management MUR Medicines Use Review NHS National Health Service NHSE NHS England NICE National Institute for Health and Care Excellence NMS New Medicines Service ONS Office of National Statistics PCG Pharmacy Contracts Group PCT Primary Care Trust PGD Patient Group Direction PNA Pharmaceutical Needs Assessment PSNC Pharmaceutical Services Negotiating Committee RCT Randomised Control Trial SAC Stoma Appliance Customisation STI Sexually Transmitted Infection WHO World Health Organisation

Knowsley Pharmaceutical Needs Assessment, 2018 104 | P a g e APPENDIX 3: COMMUNITY PHARMACY ADDRESSES AND OPENING HOURS BY AREA

Halewood

Pharmacy Address Postcode Electoral Ward Boots Pharmacy Roseheath Drive, Liverpool L26 9UH Halewood South Cohens Chemist Hollies Road, Halewood Village, Liverpool L26 0TH Halewood South M.R. Jacobs Pharmacy Ltd. 18 Camberley Drive, Liverpool L25 9PU Halewood North

Huyton

Pharmacy Address Postcode Electoral Ward Asda Pharmacy Asda Huyton, Supercentre, Huyton Lane, Liverpool L36 7TX St Gabriels Boots Pharmacy 47 – 49 Derby Road, Liverpool L36 9UQ St Gabriels Daveys Chemist The Bluebell Centre, 2 Blue Bell Lane, Liverpool L36 7XY St. Michaels Daveys Chemist 43 – 45 Manor Farm Road, Liverpool L36 0UB St Gabriels Daveys Chemist 112 Dinas Lane, Liverpool L36 2NS Page Moss Kingsway Pharmacy 5 Kingsway Parade, Liverpool L36 2QA Page Moss Lloyds Pharmacy Gresford Medical Centre, Pilch Lane, Liverpool L14 0JE Swanside Lloyds Pharmacy 5 Tarbock Road, Huyton, Liverpool L36 5XN St Gabriels Rowlands Pharmacy 40 Hillside Road, Liverpool L36 8BJ Stockbridge Sedem Pharmacy 27 Woolfall Heath, Liverpool L36 3TH Page Moss Sedem Pharmacy Longview Drive, Liverpool L36 6EB St Gabriels Care Pharmacy Ltd T/A Unit 8, The Croft, Liverpool L28 1NR Stockbridge Superdrug Pharmacy Derby Road, Superdrug 48, Huyton L36 9UJ Roby Well Pharmacy Woolfall Health Avenue, Huyton L36 3TN Page Moss

Knowsley Pharmaceutical Needs Assessment, 2018 105 | P a g e Kirkby

Electoral Pharmacy Address Postcode Ward Aim Rx Ltd Unit A2 1 Newtown Gardens, Liverpool L32 8RR Whitefield L Rowland & Co (retail) Ltd St Laurence’s Medical Centre, 32 Leeside Avenue, Liverpool L32 9QU Cherryfield Rowlands Pharmacy Ebony Way, Towerhill L33 1ZQ Northwood Rowlands Pharmacy 17 - 19 Broad Lane, Liverpool L32 6QA Cherryfield Rowlands Pharmacy 58 Copplehouse Lane, Liverpool L10 0AF Cherryfield Rowlands Pharmacy 11 Richard Hesketh Drive, West Vale, Liverpool L32 0TU Whitefield Rowlands Pharmacy 54 – 58 St Chads Parade, Kirkby, Liverpool L32 8UG Whitefield Rowlands Pharmacy St Chads Walk-in-Centre, St Chads Drive, Kirkby L32 8RE Whitefield Rowlands Pharmacy 81 Kennelwood Avenue, Liverpool L33 6UE Northwood Rowlands Northwood 5 Old Rough Lane, Northwood, Liverpool L33 6XE Whitefield TOPS Pharmacy Unit 6, Glovers Brow, Liverpool L32 2AE Whitefield

Prescot, Whiston, Cronton & Knowsley Village

Pharmacy Address Postcode Electoral Ward Boots Pharmacy 42 Eccleston Street, Prescot L34 5QJ Prescot North Boots Pharmacy Old Colliery Road, Prescot L35 3SX Whiston & Cronton Boots Pharmacy Cables Retail Park, Prescot L34 5NQ Prescot North WGA UK LTD 32 Molyneux Drive, Prescot L35 5DY Prescot South Rowlands Pharmacy 67 Eccleston Street, Prescot L34 5QH Prescot North Care Pharmacy Ltd 70A Sugar Lane, Prescot L34 0ER Prescot North Tesco Pharmacy Cables Retail Park, Steley Way, Prescot L34 5NQ Prescot North

Knowsley Pharmaceutical Needs Assessment, 2018 106 | P a g e Weekday Opening Hours

Pharmacy open hours differ on a Monday: Mon 08:00 – 23:00; Tue-Fri 07:00 – 23:00. Core hours in grey.

Knowsley Pharmaceutical Needs Assessment, 2018 107 | P a g e Saturday Opening Hours

Knowsley Pharmaceutical Needs Assessment, 2018 108 | P a g e Sunday Opening Hours

Knowsley Pharmaceutical Needs Assessment, 2018 109 | P a g e APPENDIX 4: PHARMACY SERVICES

Key 100-hour 100 hour pharmacy SUPCON Supervised Consumption EHC Emergency Hormonal Contraception MUR Medicine User Review PALL Palliative Care Scheme CATC Care At The Chemist CONSR Consulting room DOM Domiciliary Care NRT Nicotine Replacement Therapy NSP Needle Syringe Exchange SMCs Smoking Cessation

Knowsley Pharmaceutical Needs Assessment, 2018 110 | P a g e

APPENDIX 5: CROSS BORDER SERVICES

The following list of 49 pharmacies includes those that are located within 1 mile of Knowsley’s boundary and some of the main services they provide. This has been done in order to demonstrate potential access to pharmacies outside of Knowsley.

Knowsley Pharmaceutical Needs Assessment, 2018 111 | P a g e APPENDIX 6: PHARMACY PREMISES AND SERVICES SURVEY

A questionnaire to gather information from all pharmacies was devised as a collaborative exercise with Merseyside Local Authority Pharmaceutical Needs Assessment Leads and NHS England, Merseyside Area Team. It was conducted using the web based Pharmoutcomes system. Below are the communication and the questions asked.

PNA PHARMACY QUESTIONNAIRE HEALTH AND WELLBEING BOARD Premises Details

Contractor Code (ODS Code) Name of contractor (i.e. name of individual, partnership or company owning the pharmacy business) Trading Name Address of Contractor pharmacy Is this pharmacy one which is entitled to Pharmacy Access Scheme Yes No Possibly payments? Is this pharmacy a 100-hour pharmacy? Yes Does this pharmacy hold a Local Pharmaceutical Services (LPS) Yes contract? (i.e. it is not the ‘standard’ Pharmaceutical Services contract) Is this pharmacy a Distance Selling Pharmacy? (i.e. it cannot Yes provide Essential Services to persons present at or in the vicinity of the pharmacy) Pharmacy email address Pharmacy telephone Pharmacy fax (if applicable) Pharmacy website address (if applicable) Can the LPC store the above information and use it to contact you? Yes

Core Hours of Opening

Day Open from To Lunchtime (From – To) Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Total Hours of Opening

Day Open from To Lunchtime (From – To) Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Knowsley Pharmaceutical Needs Assessment, 2018 112 | P a g e

Consultation Facilities

There is a consultation area (meeting the criteria for the Medicines Use Review service) (tick as appropriate) On premises None, or Available (including wheelchair access), or Available (without wheelchair access), or Planned within the next 12 months, or Other (specify) Where there is a consultation area, is it a closed room? Yes

During consultations are there hand-washing In the consultation area, or facilities Close to the consultation area, or None

Patients attending for consultations have access to toilet facilities Yes

Off-site The pharmacy has access to an off-site consultation area (i.e. one Yes which the former PCT or NHS England local team has given consent for use) The pharmacy is willing to undertake consultations in patient’s home / Yes other suitable site

Languages spoken (in addition to English)

IT Facilities

Select any that apply. Electronic Prescription Service Release 2 enabled NHSmail being used NHS Summary Care Record enabled Up to date NHS Choice entry

Healthy Living Pharmacies (HLP)

Select the one that applies. The pharmacy has achieved HLP status The pharmacy is working toward HLP status The pharmacy is not currently working toward HLP status

Services

Does the pharmacy dispense appliances? Yes – All types, or Yes, excluding stoma appliances, or Yes, excluding incontinence appliances, or Yes, excluding stoma and incontinence appliances, or Yes, just dressings, or Other [identify] None

Advanced Services

Does the pharmacy provide the following services? Yes Intending to begin No - not intending within next 12 months to provide Medicines Use Review service

Knowsley Pharmaceutical Needs Assessment, 2018 113 | P a g e New Medicine Service Appliance Use Review service Stoma Appliance Customisation service Flu Vaccination Service NHS Urgent Medicine Supply Advanced Service

Enhancedxiv and Other Locally Commissioned Services

Which of the following services does the pharmacy provide, or would be willing to provide? Currently Currently Currently Willing to Not able or providing providing providing provide if willing to under contract under under commissioned provide with the local contract contract with NHS England with CCG Local Team Authority Anticoagulant Monitoring Service Anti-viral Distribution (2) Service(xv) Care Home Service Chlamydia Testing (2) Service(2) Chlamydia (2) Treatment Service(2) Contraceptive (2) service (not EC) (2) Disease Specific Medicines Management Service: Allergies Alzheimer’s/demen tia Asthma CHD COPD Depression Diabetes type I Diabetes type II Epilepsy Heart Failure Hypertension Parkinson’s disease Other (please state) Emergency (2) Contraception Service(2) Emergency Supply Service

xiv ‘Enhanced Services’ are those commissioned by the local NHS England Team. CCGs and Local Authorities can commission Other Locally Commissioned Services that are equivalent to the Enhanced Services, but for the purpose of developing the PNA are called ‘Other Locally Commissioned Services’ not ‘Enhanced Services’ xv These services are not listed in the Advanced and Enhanced Services Directions, and so are not ‘Enhanced Services’ if commissioned by the local NHS England Team. The local NHS England Team may commission them on behalf of the CCG or Local Authority, but when identified in the PNA they will be described as ‘Other Locally Commissioned Services’ or ‘Other NHS Services’

Knowsley Pharmaceutical Needs Assessment, 2018 114 | P a g e Currently Currently Currently Willing to Not able or providing providing providing provide if willing to under contract under under commissioned provide with the local contract contract with NHS England with CCG Local Team Authority Gluten Free Food Supply Service (i.e. not via FP10) Home Delivery (2) Service (not appliances)(2) Independent Prescribing Service If currently providing an Independent Prescribing Service, what therapeutic areas are covered? Language Access Service Medication Review Service Medicines Assessment and Compliance Support Service Minor Ailment Scheme MUR Plus/Medicines (2) Optimisation Service(2) If currently providing an MUR Plus/ Medicines Optimisation Service, what therapeutic areas are covered? Needle and Syringe Exchange Service Obesity management (2) (adults and children)(2) Not Dispensed Scheme On Demand Availability of Specialist Drugs Service Out of Hours Services Patient Group Direction Service (name the medicines covered by the Patient Group Direction) Phlebotomy (2) Service(2) Prescriber Support Service Schools Service Screening Service Alcohol Cholesterol

Knowsley Pharmaceutical Needs Assessment, 2018 115 | P a g e Currently Currently Currently Willing to Not able or providing providing providing provide if willing to under contract under under commissioned provide with the local contract contract with NHS England with CCG Local Team Authority Diabetes Gonorrhoea H. pylori HbA1C Hepatitis HIV Other (please state) Seasonal Influenza (2) Vaccination Service(2) Other vaccinations(2) Childhood (2) vaccinations Hepatitis (at risk (2) workers or patients) HPV (2) Travel vaccines (2) Other – (please state) Sharps Disposal (2) Service(2) Stop Smoking Service Supervised Administration Service Supplementary Prescribing Service (what therapeutic areas are covered?) Vascular Risk (2) Assessment Service (NHS Health Check)(2)

Non-Commissioned Services

Does the pharmacy provide any of the following? Collection of prescriptions from GP practices Delivery of dispensed medicines – Free of charge on request Delivery of dispensed medicines – Selected patient groups (list criteria) Delivery of dispensed medicines – Selected areas (list areas) Delivery of dispensed medicines - Chargeable Monitored Dosage Systems – Free of charge on request Monitored Dosage Systems – chargeable

Is there a particular need for a locally commissioned service in your area? If so, what is the service requirement and why.

Details of the Person Completing this form:

Knowsley Pharmaceutical Needs Assessment, 2018 116 | P a g e Contact name of person completing questionnaire, if questions arise Contact telephone number

APPENDIX 7: PATIENT SURVEY

Between May 2017 and August 2017, Knowsley residents were invited to give their views regarding their local community pharmacy services. In total, there were 313 responses to the survey which explored the frequency and nature of visits to local pharmacies, and their experiences and opinions of pharmacy services. The survey was mainly conducted online via Survey Monkey but was widely distributed by Healthwatch. Pharmacies and GP practices were also invited to encourage their patients to complete the questionnaires at their premises and several establishments across the borough did so.

Knowsley Patient Survey of Community Pharmacy Services

Dear Knowsley Resident,

Knowsley Health and Wellbeing Board would like to engage with local residents about their use of local pharmacies. This is so we can ensure the services provided meet your needs.

We would be grateful if you could take a few minutes to complete this survey. Your answers will be treated in the strictest confidence and will be kept anonymous. They will NOT be passed on to anyone and your pharmacist or GP will NOT see your answers.

Thank you for your time in advance. Your answers are important to us.

What is a Pharmacy?

Some people call them a chemist, but in this survey we use the word pharmacy. By pharmacy, we mean a place you would use to get a prescription or buy medicines which you can't buy anywhere else.

Q1 Why did you visit the pharmacy? Please select one box only To collect a prescription for To get advice from the pharmacist yourself To collect a prescription for To buy other medications I can’t someone else buy elsewhere Other (Please specify below)

Knowsley Pharmaceutical Needs Assessment, 2018 117 | P a g e

When did you last use a pharmacy to get a prescription, buy medicines or get advice? Q2 Please select one box only

In the last week

In the last two weeks

In the last month

In the last three months

In the last six months

Not in the last six months

Q3 How did you get to the pharmacy? Please select all that apply

Walking Taxi

Public Transport Bicycle

Car Other (Please specify below)

Motorbike

Thinking about the location of the pharmacy, which of the following are the most Q4 important to you? Please select all that apply

It is close to my doctor's surgery It is near to the bus stop / train station

It is close to my home It is close to where I work

It is close to other shops I use It is close to/in my local supermarket It is close to my children's school or None of these nursery It is easy to park nearby Other (Please specify below)

Q5 How easy is it to get to your usual pharmacy? Please select one box only

It is very easy It is not easy at all

It is quite easy It is very difficult It is very inconvenient for me to get to a It is not easy pharmacy and can cause a problem for me

If you have a condition that affects your mobility, are you able to park close enough to Q6 your pharmacy?

Knowsley Pharmaceutical Needs Assessment, 2018 118 | P a g e

Yes Don’t Know

No Not Applicable

Does your pharmacy deliver medication to your home if you are unable to collect it Q7 yourself? Don’t know / I have never used Yes No this service

In the last 12 months have you had any problems finding a pharmacy to get a medicine Q8 dispensed, to get advice or buy medicines?

Yes No (GO TO Q11)

If Yes, what was your main reason for going to the pharmacy? Please select one box Q9 only

To get medicine(s) on a prescription To get advice at the pharmacy To buy medicine(s) from the Other (Please specify below) pharmacy

Q10 Please tell us what was the problem in finding a pharmacy?

Q11 Are you satisfied with the opening hours of you pharmacy?

Yes No (please specify below)

In the last 12 months how many times have you needed to use your usual pharmacy Q12 (or pharmacy closest to you) when it was closed?

Once or twice Five or more times I haven’t needed to use a pharmacy Three or four times when it was closed (GO TO Q16)

Q13 What day of the week was it?

Monday to Friday Sunday

Saturday Bank Holiday

Can’t remember

Q14 What time of the day was it?

Knowsley Pharmaceutical Needs Assessment, 2018 119 | P a g e Morning Evening (after 7pm)

Lunchtime (between 12pm – 2pm) Can’t remember

Afternoon

Q15 What did you do when the pharmacy was closed?

Went to another pharmacy Went to a hospital Waited until the pharmacy was Went to a Walk-in-Centre open

Other (Please specify below)

Q16 Did you get a prescription the last time you used a pharmacy? Can’t remember (GO TO Yes No (GO TO Q19) Q19)

Did the staff at the pharmacy tell you how long you would have to wait for your Q17 prescription to be prepared?

Yes No, but I did not mind No, but I would have liked to have Can’t remember been told

Q18 If Yes, was this a reasonable period of time?

Yes No

Q19 Did you get all the medicines that you needed on this occasion?

Yes (GO TO Q23) No

Can’t remember (GO TO Q23)

What was the main reason for not getting all of your medicines on this occasion? Q20 Please select one box only The pharmacy had run out of my My prescription had not arrived at the medicine pharmacy My GP had not prescribed Some other reason something I wanted

Q21 How long did you have to wait to get the rest of your medicines?

Later that same day The next day

Two or more days More than a week

Q22 Did the pharmacist offer to deliver the remainder of your prescription to your home?

Yes No

Knowsley Pharmaceutical Needs Assessment, 2018 120 | P a g e If you have needed to use a hospital pharmacy (e.g. as an outpatient or on discharge Q23 following a stay in hospital), would you like to have the option to have the prescription dispensed at your local pharmacy?

Yes I have never used a hospital pharmacy

Have you had a consultation with the pharmacist in the last 12 months for any health Q24 related purpose? No (GO TO Yes Can’t remember (GO TO Q28) Q28)

Q25 What advice were you given during your consultation? Lifestyle advice (e.g. stop smoking, diet Advice about a minor ailment and nutrition, physical activity etc.) Medicine advice Emergency contraception advice

Other (Please specify below)

Where did you have your consultation with the pharmacist? Please select one box Q26 only In the dispensary or a quiet part of At the pharmacy counter the shop In a separate room Over the telephone (GO TO Q28)

Other (Please specify below)

How do you rate the level of privacy you have in the consultation with the Q27 pharmacist?

Excellent Very Good

Good Fair

Poor Very Poor

Q28 Please tell us how you would describe your feelings about pharmacies.

I wish pharmacies could provide more services for me

I am satisfied with the range of services pharmacies provide

Don’t know

Knowsley Pharmaceutical Needs Assessment, 2018 121 | P a g e

Which, if any, of the services below do you think should be Not Q29 available locally through pharmacies? Yes No sure Please select one box in each row. To get treatment of a minor illness such as a cold instead of my doctor (free of charge if you don’t pay for prescriptions) Advice on stopping smoking and/or vouchers for nicotine patches/gum etc. Advice on contraception and the supply of the 'morning after' pill free of charge Weight management services and advice on diet/exercise for weight management Tests to check blood pressure, cholesterol, whether I might get diabetes or other conditions Advice and treatment for alcohol misuse

Advice and treatment for drug misuse Review of medicines on repeat prescription with advice on when it is best to take them, what they are for and side effects to expect Provision of Flu vaccinations

Q30 Is there anything you particularly value as a service from pharmacies?

Is there anything else, or any service that you feel could be provided by local Q31 pharmacies?

The following questions are OPTIONAL and you DO NOT have to answer them, however they will help us to understand a bit more about the people that use local pharmacies.

All answers will be kept STRICTLY confidential and anonymous. No individual will be identified.

Q32 Are you?

Male Female

Q33 How old are you?

16 – 20 years 51 – 59 years

Knowsley Pharmaceutical Needs Assessment, 2018 122 | P a g e 21 - 30 years 60 – 69 years

31 - 40 years 70 years or over

41 – 50 years

Q34 Please tell us your postcode

Q35 Disability: Do you have any of the following? Please select all that apply

Physical Impairment Mental Health / Mental Distress

Visual Impairment Learning Difficulty Long Term Illness that affects your Hearing Impairment / Deaf daily activity

Other (Please specify below)

Q36 Ethnicity: Do you identify yourself as:

Asian - Bangladeshi Asian - Indian Asian - Pakistani Asian – Other Black - African Black - British Background Black – Other Black - Caribbean Chinese Background Mixed Ethnic Mixed Ethnic Other Chinese Background – Background - Black Asian & White African & White Mixed Ethnic Mixed Ethnic Background - White - British Background - Other Caribbean & White

White - English White - Irish White - Scottish White – Gypsy / White - Welsh White Other Traveller Prefer not to say

Thank you for participating in this survey, your time and comments are appreciated.

Please be reassured that the information you provide is kept strictly confidential and anonymous.

No individuals will be identifiable.

Knowsley Pharmaceutical Needs Assessment, 2018 123 | P a g e APPENDIX 8: FORMAL CONSULTATION LETTER AND QUESTIONNAIRE

Dear Sir / Madam

Pharmaceutical Needs Assessment (PNA) 2018-2021 Consultation Invitation to Participate

During the reorganisation of the NHS the responsibility for production of the Pharmaceutical Needs Assessments (PNAs) transferred to the Health and Wellbeing Boards (HWB) which are hosted by Local Authorities.

As a statutory responsibility of the Health and Wellbeing Board, as set out under the NHS (Pharmaceutical Services and Local Pharmaceutical Services) Regulations 2013 (SI 2013 No. 349) a new Pharmaceutical Needs Assessments is being developed.

A PNA is a document which records the assessment of the need for pharmaceutical services within a specific area. As such, it sets out a statement of the pharmaceutical services which are currently provided, together with when and where these are available to a given population. The same Regulations require NHS England to use the PNA to consider applications to open a new pharmacy, move an existing pharmacy or to commission additional services from pharmacy.

The Health and Wellbeing Board has established a Pharmaceutical Needs Assessments Steering Group to oversee the development of the new PNA. This Group includes membership from our partner organisations and the Local Pharmaceutical Committee.

As part of the development process, the Regulations require that the HWB undertakes a formal consultation on a draft of its PNA. The key outcomes for this consultation are:

 To encourage constructive feedback from a variety of stakeholders

 To ensure a wide range of primary care health professionals provide opinions and views on what is contained within the PNA

Taking this into account, we would like to invite you to participate in this consultation, which will run from 19th October until 31st December 2017.

 The draft PNA can be found on our website by via the following link http://www.knowsleyhwb.org.uk/documents/

 A consultation response form has been developed to facilitate comment and feedback. This may be accessed on the same website or via the following link:

Knowsley Pharmaceutical Needs Assessment, 2018 124 | P a g e https://www.surveymonkey.co.uk/r/PNA-Consultation2017

 Submitting responses: You may choose one of the following options to submit your response:

o Complete your response online

o Complete the form electronically and send to the email address on the form

o Complete the form and return it by post to the address on the form

In order to limit the environmental impact of this consultation, Knowsley Metropolitan Borough Council has decided not to send a copy of the draft PNA with this letter. However, if you require a paper version of the PNA, please contact Janette Rawlinson on 0151 443 4906 who will arrange to provide this within 14 days of your request.

All feedback received by 31st December 2017 will be collated and presented to the Pharmaceutical Needs Assessments Steering Group, for consideration on behalf of the Health and Wellbeing Board. A consultation report will be included within the final PNA document. This will provide an overview of the feedback received and set out how the comments have been acted upon. An updated PNA including consultation process and responses will be presented to the Health and Wellbeing Board in March 2018 and published shortly afterwards.

We look forward to receiving your feedback on the draft PNA.

Yours faithfully

Anthony Leo Director of Commissioning, NHS England – North (Cheshire and Merseyside) PNA Sponsor, Knowsley Health & Wellbeing Board

Knowsley Pharmaceutical Needs Assessment, 2018 125 | P a g e

Knowsley Pharmaceutical Needs Assessment Consultation

Please place an ‘X’ in the box that best matches your answer

Q1 Has the purpose of the Pharmaceutical Needs Assessment (PNA) been explained sufficiently in Section 1 of the report?