Decision to Refuse an Application by Medicstar

Arena Point Merrion Way REF: SHA/22127 Leeds LS2 8PA

Tel: 0203 928 2000 APPEAL AGAINST NHS COMMISSIONING BOARD Fax: 0207 821 0029 ("NHS ENGLAND") DECISION TO REFUSE AN Email: [email protected] APPLICATION BY MEDICSTAR (UK) LTD FOR A RELOCATION THAT DOES NOT RESULT IN A SIGNIFICANT CHANGE TO PHARMACEUTICAL SERVICES PROVISION UNDER REGULATION 24 FROM 344 MANCHESTER ROAD, WEST TIMPERLEY, ALTRINCHAM, WA14 5NH TO THE LIBRARY AT 405 STOCKPORT ROAD AND CAR PARK ON BAKER STREET, TIMPERLEY, ALTRINCHAM, WA15 7XR

1 Outcome

1.1 The Pharmacy Appeals Committee (“Committee”), appointed by NHS Resolution, quashes the decision of NHS England and redetermines the application.

1.2 The Committee determined that the application should be granted.

NHS Resolution is the operating name of NHS Litigation Authority – we were established in 1995 as a Special Health Authority and are a not-for-profit part of the NHS. Our purpose is to provide expertise to the NHS on resolving concerns fairly, share learning for improvement and preserve resources for patient care. To find out how we use personal information, please read our privacy statement at www.nhsla.com/Pages/How-we-use-your-information-- -FHSAU.aspx

Arena Point REF: SHA/22127 Merrion Way Leeds LS2 8PA

APPEAL AGAINST NHS COMMISSIONING BOARD Tel: 0203 928 2000 ("NHS ENGLAND") DECISION TO REFUSE AN Fax: 0207 821 0029 APPLICATION BY MEDICSTAR (UK) LTD FOR A Email: [email protected] RELOCATION THAT DOES NOT RESULT IN A SIGNIFICANT CHANGE TO PHARMACEUTICAL SERVICES PROVISION UNDER REGULATION 24 FROM 344 MANCHESTER ROAD, WEST TIMPERLEY, ALTRINCHAM, WA14 5NH TO THE LIBRARY AT 405 STOCKPORT ROAD AND CAR PARK ON BAKER STREET, TIMPERLEY, ALTRINCHAM, WA15 7XR

1 A summary of the application, decision, appeal and representations and observations are attached at Annex A.

2 Preliminary Consideration and Site Visit

2.1 The Pharmacy Appeals Committee (“Committee”) appointed by NHS Resolution, had before it the papers considered by NHS England, together with a plan of the area showing existing pharmacies and doctors’ surgeries and the location of the proposed pharmacy.

2.2 It also had before it the responses to NHS Resolution’s own statutory consultations.

2.3 An oral hearing took place to determine the application. This took place at the offices of the Greater Manchester Health and Social Care Partnership, London Road, Manchester on 3rd December, 2019.

2.4 The Committee comprised of Mr A Tomlinson (chair), Mr P Bratley and Mr S Chappell. The Applicant was represented by Mr J Devlin accompanied by Mr G Chan and Ms S F Ghai. Well Pharmacy was represented by Ms E Griffiths- Mbarek accompanied by Mr A Edwards and Greater Manchester LPC was represented by Peter Marks. Lucy Reid from NHS Resolution accompanied the Committee on the site visit and observed the hearing.

2.5 Before the hearing started the Committee undertook a site visit. The following is a brief summary of the visit but further observations appear in section 5 below.

2.6 The Committee assembled in the centre of Timperley, a busy crossroads controlled by traffic lights. There are shops, cafes and a public house close to the crossroads including two pharmacies and a Sainsbury’s local store. Parking is available on a car park only a short distance from the crossing for which there is no charge although it is limited to a three hour stay.

2.7 The Committee walked along Stockport Road to the site of the proposed surgery and pharmacy on Baker Street. There was building work in progress with the site fenced off and signs advertising the construction of apartments.

2.8 The Committee then returned to the crossroads and walked along Park Road to the site of the Applicant’s pharmacy on Manchester Road close to the westerly end of Park Road. The walk took 35 minutes at a reasonable pace. It was not considered to be a pleasant walk with some narrow and uneven pavements, two gradients where the road crossed over railway lines and many side streets to be crossed. The road was busy with mainly light vehicles although there was some commercial traffic.

2.9 On Park Road the Committee observed the Park Medical Practice in a large converted dwellinghouse and also the Station Pharmacy in a small row of shops by the Timperley tram station. There is extensive and dense housing on both sides of Park Road, most of the houses being older detached and semi detached properties with private driveways.

2.10 A number of people were observed walking along the road, mainly to and from the centre of Timperley and the tram station. The Committee also noted a bus, service number 281, driving in an easterly direction towards the centre of Timperley.

2.11 The Applicant’s pharmacy was seen to be in a parade of shops on the busy A56, Manchester Road which is a dual carriageway. There is a forecourt in front of the shops and at the time of the visit there were a number of cars and other vehicles parked there although it was clear that access on to and off the forecourt was difficult, especially when, as at the time of the visit, traffic travelling south along the road was backed up and stationary along the length of the shops.

2.12 Other shops in the parade included many food takeaways including a Subway, a hair salon, a computer shop and a kitchen shop. The Pelican public house and a hotel are just to the north of the parade, served by their own car park with signs warning that non-customers should not park there. It was noted that parking was available on the residential streets behind the parade. A car hire depot, car sales garages and a funeral undertakers were amongst the businesses on the west side of Manchester Road. Pedestrian crossings were available for crossing the road although few pedestrians were seen, the nature of the shops suggesting that they attracted few regular visitors.

2.13 The Pelican pharmacy occupied a double fronted shop towards the northerly end of the parade. There were no customers in the pharmacy at the time of the visit and the Committee did not observe any customers visiting the pharmacy in the short time that they were close by.

3 A summary of the above observations was provided to those in attendance. They were invited to comment upon them or indicate if any of the observations appeared to be inaccurate. Such comments as were made appear in the next section.

4 Oral Hearing Submissions

4.1 Mr J Devlin (for the Applicant)

4.1.1 He undertook on behalf of his client that the pharmacy would offer the same services at the new location, including the core hours currently operated and that there would be no interruption in the services provided.

4.1.2 He clarified that the pharmacy would be based on the ground floor of the apartment block being constructed at Baker Street which was due to be completed in summer 2020.

4.1.3 This was the Applicant’s second application relating to the proposed move and he stressed that the previous decision and that of NHS England had been based on assumptions.

4.1.4 He also confirmed that the move would lead to no significant change in the arrangements for the provision of pharmaceutical services. NHS England had decided that there would be no such change and no evidence had been produced to the contrary.

4.1.5 The main change in the current application was the availability of 3 months data at pages 138-332. The data referred to the provision of all services, essential, advanced and commissioned.

4.1.6 Patient Groups had been simplified. The data showed that all patients started their journey to the pharmacy from home and all the 97 patients surveyed had signed to say that the pharmacy at the new location would be as easy to get to.

4.1.7 The pharmacy was dispensing 2,500 – 2,600 items per month which was the lowest figure amongst local pharmacies. 90% of items were delivered to patients amounting to 110 items per day.

4.1.8 Very few patients accessed the pharmacy premises. The pharmacy had a stable customer base and did not open at weekends or in the evenings.

4.1.9 There were two patients groups namely (1) patients who used the delivery service and (2) patients accessing the premises for any reason. Mr Chan produced the ledgers recording deliveries. There was a part time van driver who occasionally advised patients.

4.1.10 Patients who accessed the pharmacy did so on foot or by car. There was one cyclist and none used public transport according to the survey.

4.1.11 Those objecting to the application did not have access to the information available to the Applicant.

4.1.12 Boots had stated that the Applicant had failed to produce a proper definition of patient groups but only the Applicant was in a position to do so. Further the distance between the two sites nor the walk between the sites were key considerations.

4.1.13 Well Pharmacy in their objections had focussed on a wider range of patient groups such as those starting from a surgery but the Applicant received prescriptions from over 20 surgeries and all their patients started their journey from home.

4.1.14 The Park Medical Practice with a patient list of over 5,000 would be moving to the new premises in Baker Street. The Applicant received very few prescriptions from them at present. At present the Applicant received the highest percentage of prescriptions (8%) from the West Timperley Surgery. It was not part of the regulatory test to ask where prescriptions would come from following the move.

4.1.15 The decision of NHS England was flawed in eight ways. (1) They had assumed that the patients who used the delivery service were relevant for regulation 24. (2) They wrongly criticised the Applicant for failing to consider patients in the light of the Equality Act and he referred to page 61 of the case papers. (3) They concluded mistakenly that the Applicant had not considered all the patients who actually accessed the premises. (4) They had suggested that the Applicant might cease its delivery service whereas that would be commercial lunacy. (5) They had considered the distance between the premises but no patient in the 3 month survey would be likely to walk that journey. (6) The pharmacy did not serve the population living to the west of the A56. (7) They failed to acknowledge that the pharmacy served a large area including Stockport, Ashton and Rusholme. (8) They had assumed that patients regularly used other shops on the parade but in reality that did not happen as the shops were not the type to attract regular users.

4.1.16 The data provided in the survey was quite representative of patients using the pharmacy and covered all pharmaceutical services provided there. Page 62 explained how the survey was conducted. Only 1 patient had accessed the pharmacy on foot and that patient’s home address was shown on a plan provided: It was half way between the two sites.

4.1.17 The plan at page 30 showed the starting points for those patients who drove to the pharmacy and they would have no difficulty in accessing the new location. Parking there would be easier as there were flooding issues in front of the pharmacy and parking was not permitted there. Some cars had been clamped for illegal parking. There would be 78 spaces available for public parking at the new location including 6 for disabled. The medical staff had their own car park.

4.1.18 The proposed location was also on a convenient bus route and bike racks would be provided.

4.1.19 In January 2019 30 people accessed the pharmacy in person and only one had walked. In February 2019 only 24 people accessed the pharmacy and all had driven there.

4.1.20 Following questions (some of which were answered partly by Mr Chan) he confirmed that the delivery service would certainly be continued following the move. Patients were not assessed for eligibility. If deliveries were not offered patients would go to another pharmacy.

4.1.21 There had been no change in dispensing patterns since the survey.

4.1.22 It was not known when the pharmacy opened but at that time there had been a surgery opposite on the other side of the A56.

4.1.23 The current location was not appropriate for opportunistic care.

4.1.24 The 78 spaces on the proposed car park were shared with the doctors’ patients but not staff or residents.

4.1.25 He agreed that parking was available on side streets close to the current pharmacy.

4.1.26 The survey questionnaire had been designed by Mr Chan. There had been no conversations between staff and patients and every patient who entered the pharmacy was asked to complete the survey so some had been recorded twice. No patient had refused to complete the survey.

4.1.27 Mr Chan received some e mails from patients asking for advice, usually from regular patients who received repeat prescriptions (there were very few acute prescriptions).

4.1.28 The pharmacy had no plans to charge for deliveries as there was a saving on counter assistant’s wages.

4.1.29 There were two part time van drivers.

4.1.30 Mr Chan did some home flu vaccinations.

4.1.31 A plan of the new premises had been annexed to the survey for patients to view (Tab 11). There were some seats in the pharmacy so patients could sit whilst completing the survey. There had been no intervention by staff or explanation of the survey.

4.1.32 He agreed that some patients went to the pharmacy from their place of work.

4.1.33 The delivery van went to Sale in the morning and Timperley in the afternoon. The van parked in front of the pharmacy and the driver took it home at night. The deliveries took from 10.00 am to 3.00 pm. Vans delivering stock to the pharmacy parked wherever they could, usually in front of the pharmacy.

4.2 Mr G Chan

4.2.1 He confirmed that he sometimes contacted patients by writing to them, by using the telephone or by e mail.

4.2.2 Flu vaccinations were available by appointment or he would see patients at home.

4.2.3 He served two nursing homes, one with 6 patients and one with 4.

4.2.4 No patients using a wheelchair or with mobility issues accessed the pharmacy.

4.2.5 No patients accessed the pharmacy who lived to the west of the A56 as the road was difficult to cross, there were other pharmacies available there and the pharmacy offered them a delivery service.

4.2.6 He accepted that some staff may have helped patients to complete the survey.

4.2.7 He accepted that some wording in many replies was similar, in particular the wording relating to the new location being “close to home” with better parking.

4.3 Ms E Griffiths-Mbarek (Well Pharmacy)

4.3.1 The relocation was over a significant distance and was between two different areas namely Timperley and West Timperley.

4.3.2 Few roads ran from east to west so Park Road was busy. It had taken her 45 minutes on her recent site visit to drive from one end to the other owing to congestion.

4.3.3 The walk along the road was not level, facilities at each end differed and there were differences in housing and also social differences.

4.3.4 She referred to the comments about patient groups on page 25.

4.3.5 The Well pharmacy in Timperley received prescriptions from 8 surgeries, all different from those supplying prescriptions to the Applicant. In that part of Manchester small areas had different characteristics. She described the rules relating to the provision of MURs.

4.3.6 There was no guarantee that the delivery service would not be withdrawn. Well now offered need based deliveries.

4.3.7 The Applicant had said that the driver replaced counter staff but the driver was not qualified and could not offer a pharmaceutical service.

4.3.8 The distance between the sites was a significant change. The walk had taken her 35 minutes.

4.3.9 The pharmacy at its current location was able to offer opportunistic services but this would not be the case at Stockport Road.

4.3.10 When she observed the pharmacy the previous evening she saw 6 patients accessing the pharmacy between 4.00 and 4.30 pm. 5 came out clutching bags.

4.3.11 The survey had not been impartial and had not been clearly explained to patients. She urged the Committee to give it little weight.

4.3.12 According to data available, business at the pharmacy had increased by 18% over the last 12 months and she wondered if the survey was still appropriate.

4.3.13 The lease might be about to expire in 2020 but surely there was a right to renew.

4.3.14 Following questions she confirmed that she was not aware of any patients who might walk between the two sites.

4.3.15 She did not accept the guarantee that free deliveries would continue.

4.3.16 She agreed that it had recently taken 45 minutes to drive along Park Road as a car had broken down at a junction but she pointed out that there were 5 local schools which caused a lot of extra traffic. The seven minutes that it took according to the Applicant’s traffic survey to drive from one end to the other was an average. Even for patients using a car the new location was less accessible.

4.4 Mr Peter Marks (LPC)

4.4.1 He had some concerns about the application. He lived near Park Road which was a very busy road. He had concerns in particular about the parking at the proposed site.

4.4.2 It had been calculated that each delivery cost £3.00 so 20 or 30 a day would be an expensive operation for the Applicant.

4.4.3 He was surprised at the number of MURs undertaken by the Applicant given the low numbers of patients accessing the pharmacy.

4.4.4 He was concerned that only the Applicant had access to the information submitted in support of the application.

5 Further Consideration

5.1 The Committee had regard to the National Health Service (Pharmaceutical and Local Pharmaceutical Services) Regulations 2013 (“the Regulations”).

5.2 The Committee first considered Regulation 31 of the regulations which states:

(1) A routine or excepted application must be refused where paragraph (2) applies

(2) This paragraph applies where -

(a) a person on the pharmaceutical list (which may or may not be the applicant) is providing or has undertaken to provide pharmaceutical services ("the existing services") from -

(i) the premises to which the application relates, or

(ii) adjacent premises; and

(b) the NHSCB is satisfied that it is reasonable to treat the services that the applicant proposes to provide as part of the same service as the existing services (and so the premises to which the application relates and the existing listed chemist premises should be treated as the same site).

5.3 The Committee was of the view that Regulation 31 would not be engaged by the application as it did not relate to premises or adjacent premises from which pharmaceutical services were provided.

5.4 The Committee was not required to refuse the application under the provisions of Regulation 31.

5.5 The Committee had regard to Regulation 24(1) which requires the following five conditions to be met:

(a) for the patient groups that are accustomed to accessing pharmaceutical services at the existing premises, the location of the new premises is not significantly less accessible;

(b) in the opinion of the NHSCB, granting the application would not result in a significant change to the arrangements that are in place for the provision of local pharmaceutical services or of pharmaceutical services other than those provided by a person on a dispensing doctor list—

(i) in any part of the area of HWB1, or

(ii) in a controlled locality of a neighbouring HWB, where that controlled locality is within 1.6 kilometres of the premises to which the applicant is seeking to relocate;

(c) the NHSCB is not of the opinion that granting the application would cause significant detriment to proper planning in respect of the provision of pharmaceutical services in the area of HWB1;

(d) the services the applicant undertakes to provide at the new premises are the same as the services the applicant has been providing at the existing premises (whether or not, in the case of enhanced services, the NHSCB chooses to commission them); and

(e) the provision of pharmaceutical services will not be interrupted (except for such period as the NHSCB may for good cause allow).

5.6 Pursuant to paragraph 9(1)(a) of Schedule 3 to the Regulations, the Committee may:

5.6.1 confirm NHS England's decision;

5.6.2 quash NHS England's decision and redetermine the application;

5.6.3 quash NHS England's decision and, if it considers that there should be a further notification to the parties to make representations, remit the matter to NHS England.

Regulation 24(1)(a)

5.7 In relation to condition (a), the Committee considered the map submitted by NHS England which clearly showed the locations of the existing pharmacies as well as the proposed site and medical practices within the area.

5.8 The Committee considered the information before it with regard to the patient groups who are accustomed to accessing pharmaceutical services at the existing premises. The Committee considered that it must seek to identify the patient groups who would potentially be affected by the relocation based upon the information provided by the parties. This information is most commonly going to be provided by the Applicant but others may also be able to contribute to the information on which the Committee will proceed to determination.

5.9 In this case, the Applicant has identified the patient groups as (1) patients using the Applicant’s collection and delivery service and (2) patients accessing the Applicant’s pharmacy for any reason.

5.10 The Committee also noted that 90 per cent of the Applicant’s patients used the collection and delivery service leaving only 10 per cent who were accustomed to accessing the pharmacy.

5.11 The Committee concluded that the patient group or groups who are accustomed to accessing pharmaceutical services from the existing premises are those set-out below.

5.12 NHS Resolution received no information which indicates that special consideration needs to be given to any group based on a 'protected characteristic'. However, the Committee was mindful of the need to consider any groups with protected characteristics for the purposes of the Equality Act 2010 and the Committee is therefore required to consider the elimination of discrimination and advancement of equality between a particular patient group and persons who do not share a protected characteristic.

5.13 The Committee noted that the issue of patients with protected characteristics had been raised by NHS England’s Pharmaceutical Services Regulations Committee in its consideration of the application commenting that the Applicant had only considered the protected characteristics of age and disability. The Applicant had confirmed at the hearing that no patients with any mobility difficulties accessed the pharmacy premises and that the issues of age and disability were considered in terms of accessibility to the existing and proposed premises.

5.14 The Committee noted the Applicant’s statement that 90% of patients have their prescription delivered to their home. This statistic had not been challenged. The Committee was of the view that if patients were not accustomed to accessing pharmaceutical services at the premises, then they were not subject to the test under condition (a). The Committee, however, was particularly mindful that the provision of essential services is not limited to the dispensing of prescriptions.

5.15 The Applicant had provided details to the Committee of the delivery procedure used at the pharmacy. It had been acknowledged to those objecting to the application that this was not a pharmaceutical service and that the deliveries could cease at any time without the permission of NHS England. However the Applicant had pointed out that the business was reliant on the delivery service as a source of work and that it would be commercially inappropriate to discontinue the service.

5.16 The Committee were mindful that at the proposed location the Applicant’s pharmacy would be co-located with a GP practice which would provide the pharmacy with a new source of prescriptions and therefore dispensing income

which could lead the Applicant to reconsider the provision of a free delivery service but concluded that this should not affect the outcome of the current appeal. The Committee had seen no evidence that this would be a consequence of the move which would in any event impact a patient group not currently accustomed to accessing pharmaceutical services at the existing pharmacy premises.

5.17 The Committee then considered the ten per cent of the Applicant’s patients who were accustomed to accessing the pharmacy.

5.18 The Applicant had submitted that the patients in this group did not travel to the pharmacy from a surgery but rather from other starting points, mainly from their home address although it had been accepted at the appeal hearing that some patients travelled to the pharmacy from their place of work. The reason provided by the Applicant for this which had not been challenged was that the main surgeries from which prescriptions originated such as the West Timperley Medical Centre were to the west of the busy A56 road and that patients leaving the surgery were able to visit two pharmacies closer than the Applicant’s and that patients did not like to cross the A56. It had been submitted that the pharmacy received prescriptions from over 20 surgeries and that it was not appropriate to define a patient group by reference to any single surgery.

5.19 The Committee accepted that the historical reason for this varied source of prescriptions was that the two medical practices that had been close to the Applicant’s pharmacy had both moved some distance away leaving the pharmacy with no nearby surgery.

5.20 Accordingly the Committee considered the only patient group, namely those patients who visited the pharmacy in person, and assessed how they accessed the pharmacy, whether on foot, by car or by bicycle. The Committee considered that the patient group could be broken down into categories of how persons travelled to the pharmacy. These could be considered sub-groups of a main group or patient groups in their own right. The Committee was not influenced by how these were presented provided that each was considered in turn. The Applicant had submitted that no patient travelled to the pharmacy by public transport and the evidence had not been challenged.

5.21 The Applicant’s evidence had been obtained from the results of a survey undertaken in the pharmacy over the months of December 2018 to February 2019. It had been submitted by the Applicant that the survey was representative of the patients who visited the pharmacy. A total of 97 surveys were completed although it was accepted that a patient could have completed more than one survey.

5.22 The Committee noted that in a previous appeal (SHA/19973) relating to the same proposed relocation the Applicant had submitted a survey covering a period of just one month during the summer period and the evidential value, accuracy and veracity of this survey had been challenged.

5.23 The Committee then considered the evidential value of the current survey in the light of the issues referred to below, accepting that the survey was an improvement on that produced for the previous application in terms of the sample size and the length of the period over which it was conducted.

5.24 It was firstly noted that the survey was designed and monitored by the staff in the Applicant’s pharmacy with no external professional input.

5.25 It was also clear to the Committee that patients had been assisted with their replies by members of the Applicant’s staff which could lead to some presentational bias. In particular it had been accepted that patients in completing the survey were shown plans of the new location including the parking facilities. It was noted that one of the questions in the survey stated: “patient shown plans of new location including parking”.

5.26 There was some repetitive wording within the survey suggesting that patients copied the results of other survey forms or were advised what to say. In particular “More parking”, “Better parking” and “Easier Parking” appeared several times.

5.27 The Committee were slightly surprised to be told that 100% of the patients visiting the pharmacy had agreed to complete the survey and that none had declined to do so.

5.28 There was some doubt as to the number of patients walking to the pharmacy. The Applicant at the hearing referred to a single patient who walked to the pharmacy from home but the survey referred at pages 211 and 231 of the case papers to two different patients who walked to the pharmacy.

5.29 The Applicant had also asserted that all patients started their journey from home (although it had been acknowledged that some patients travelled from their place of work) but the survey results revealed one patient travelling from Manchester Airport and many patients provided only a postcode making it difficult to establish their starting point.

5.30 The Committee noted comments made in the hearing that the survey was not impartial. The Committee reviewed the questions asked in the survey and noted that they did not look to skew or influence the answers. For example, question 2 on the survey was “Would relocation to the new premises (Baker Street) make your access to the NHS services provided by this pharmacy (when compared to the current pharmacy location):” which was followed on the next line by three choices of answer “more accessible (easier), less accessible (harder), no difference”. Persons responding to the survey circled their choice of answer. Other questions were asked in the same way with some enabling persons to give reasons or add further detail/comment.

5.31 The Committee noted that the last question on the survey asked if the person’s personal details could be shown to the NHS organisation for proof of authenticity and furthermore signatures and dates of completion were included. The Committee considered that, if NHS England wanted to authenticate the survey, it was open to NHS England to contact the patients and verify the information in the survey.

5.32 The Committee considered the points above to weigh up the evidential value of the survey. The Committee considered that, on one hand, the results of the survey should be treated with some degree of caution and hesitation as the survey was carried out by the applicant itself and not an independent third party, there was no way to verify the applicant’s statement that the survey accurately

represented the views of every patient who accessed pharmaceutical services at the premises in the relevant timescale and the numbers of patients involved were comparatively small. On the other hand, the Committee considered that there was no evidence presented to it suggesting that the survey did not accurately represent the views of every patient who accessed pharmaceutical services at the premises in the relevant timescale. There was objective dispensing data which supported the view that activity was comparatively low and third party comments agreeing that the number of persons using the premises was low. The Committee particularly noted that, should it so desire, NHS England could have initiated contact with the persons who completed the survey to authenticate answers.

5.33 The Committee therefore attributed a measured amount of weight to the survey as evidence supporting the view of the applicant.

5.34 The Committee considered the ways in which patients accessed the pharmacy and the ease with which they could access the proposed location.

5.35 There had been no convincing evidence presented to the Committee that any patient accessed the pharmacy on foot at present who lived close to the pharmacy, in particular who lived to the west of the A56. The patient who walked to the pharmacy and whose home address had been identified by the Applicant lived closer to the proposed location and accordingly would not find the new location to be significantly less accessible.

5.36 Much evidence had been presented to the Committee of the difficulties encountered in walking from the site of the pharmacy to the proposed location and this had been apparent to the Committee during the site visit but the Committee had not been presented with any compelling evidence that there would be patients who would be obliged to make this journey on foot.

5.37 The Committee were also aware that there was a bus service number 281 which operated hourly along Park Road which could be used by patients who did not have access to private transport although it noted the Applicant’s evidence that no patients used public transport to access the pharmacy at its current location.

5.38 The Committee then considered patients who drove to the pharmacy. The Applicant had submitted that parking at the current premises was difficult but the Committee did not accept that. The Committee had observed cars parking on the forecourt in front of the pharmacy and had noted that parking was possible for no charge in the residential streets behind the pharmacy.

5.39 It was accepted that accessing and exiting the forecourt could be difficult if traffic was backed up in front of the pharmacy on the A56 and that cars driving north along that road could find it difficult to turn across the line of traffic onto the forecourt. However, the Committee had also noted from the Applicant’s evidence that delivery vans regularly parked in front of the pharmacy and the wholesaler’s delivery wagon also parked there or on the adjacent pub car park.

5.40 Reference had been made in the Applicant’s evidence to occasional flooding in front of the pharmacy (illustrated on page 427) but this did not seem to the Committee to prevent patients accessing the pharmacy. The Committee were unable to assess the difficulties caused by the flooding but accepted the evidence of this contained in the Transport Accessibility Report.

5.41 The Committee were also mindful of the fact that the test in Regulation 24 involved an assessment of whether the proposed location would be significantly less accessible for those patients who are (emphasis added) accustomed to accessing the pharmacy at the current location and that they needed to establish the ease with which the proposed pharmacy location could be accessed and not any difficulties with accessing the current location.

5.42 There had been some doubt expressed as to the parking facilities available to patients at the proposed location. It was clear to the Committee that the “78 spaces” referred to in the Applicant’s evidence were not for the exclusive use of the patients visiting the pharmacy and surgery. The Committee noted the plan of the car park contained in the independent Transport Accessibility Report prepared on the Applicant’s behalf (page 364 of the case papers) and accepted from the contents of that report that parking would be better for patients at the proposed location in view of the number of free places available.

5.43 Conflicting evidence had been given of the journey time by car along Park Road to the proposed location. The Committee accepted that this was a busy road that could become congested at certain times of the day and it accepted the evidence of the representative of the LPC who had local knowledge. Taking all the evidence into account including the observations made during the site visit the Committee concluded that the journey would not make the pharmacy at its new location significantly less accessible for the patient group accustomed to accessing the pharmacy at its current location by car.

5.44 The Committee finally noted that there was a patient who accessed the pharmacy on a bicycle. This patient had indicated that the new location would not be difficult to access and the Committee had seen no evidence to dispute that.

5.45 The Committee next considered the evidence that the relocation would move the pharmacy from one area to a completely different area. It was noted that the move was from one political ward to another and that the facilities at the current location were different to those in the centre of Timperley.

5.46 The Committee accepted that the facilities close to the current pharmacy were not such that would attract members of the public on a regular basis. In contrast the facilities in the centre of Timperley including the Co-Operative store and the Sainsbury Local store were likely to attract local residents and others and the Committee had observed during the site visit that the centre was busy and vibrant. Given that patients were unlikely to shop on a regular basis close to the current location the Committee did not consider that the change of character between the areas would have any impact on the accessibility of the pharmacy at the proposed location.

5.47 It was accepted by the Committee that the Applicant’s pharmacy was not busy, dispensing well below the average number of items for the area in which it was situated. The Committee also accepted that the data supplied by the Applicant arising from the survey included patients who attended the pharmacy for services other than dispensing.

5.48 It had been submitted by Well Pharmacy at the hearing that the Applicant would attract some opportunistic callers at the current location but the Applicant had denied this. The Committee had been presented with no evidence that the Applicant received any such patients at the current location apart perhaps from

the patient who had travelled from Manchester Airport referred to in the survey. In the absence of any such evidence the Committee concluded that the Applicant did not serve any such patient group.

5.49 The Committee considered that evidence in the form of the survey had been provided to support the applicant’s position to which the Committee attributed a certain amount of weight as indicated above. The Committee considered that it was able to draw limited conclusions (set out above) regarding access for the sole identified patient group. The Committee considered that it had received no compelling evidence challenging the Applicant’s evidence of the number of patients accessing the pharmacy and the manner in which they did so.

5.50 The Committee acknowledged that only the Applicant had access to information with which an accurate assessment could be made of the patient groups served by the pharmacy. Based on the evidence submitted and about which the Committee had some reservations as mentioned above the Committee concluded that the patient group identified by the Applicant would not find the pharmacy at the new location to be significantly less accessible.

5.51 The Committee was therefore of the view that condition (a) is met.

Regulation 24(1)(b)

5.52 The Committee noted the decision of NHS England in respect of condition (b), that the granting of this application would not result in a significant change to the arrangements that are in place.

5.53 Some of those objecting to the application including the LPC had asserted that the move would lead to a significant change but no evidence of this had been given.

5.54 There had been references to the proposed clustering of pharmacies in the Timperely area but the Committee did not accept that this was a matter which should be taken into account for the purposes of this part of Regulation 24.

5.55 On the information provided the Committee was of the opinion that the granting of the application would not result in a significant change to the arrangements in place for the provision of local pharmaceutical services or of pharmaceutical services in any part of the HWB1 or in a controlled locality of a neighbouring HWB, where that controlled locality is within 1.6 kilometres of the premises to which the applicant is seeking to relocate. The Committee concluded that condition (b) is met.

Regulation 24(1)(c)

5.56 The Committee noted the decision of NHS England in respect of condition (c) that the granting of the relocation would not lead to significant detriment to proper planning in respect of the pharmaceutical services in the area.

5.57 The Committee noted that Timperley Pharmacy in written representations had suggested that the relocation would lead to a clustering of pharmaceutical services at the new site and a lack of a service on Manchester Road which would cause significant detriment to the planning of the provision of pharmaceutical services in the area.

5.58 The Committee noted that NHS England had considered this in its assessment of the application and for the reasons given, namely that they were not aware of any plans that Trafford HWB had that could be affected by the relocation and also that the move could be considered by the HWB at the next review of the PNA, did not consider that there would be any detriment to proper planning.

5.59 On the information provided the Committee was of the opinion that the granting of the application would not cause a significant detriment to the proper planning in respect of the provision of pharmaceutical services in the area of HWB1 and therefore concluded that condition (c) is met.

Regulation 24(1)(d)

5.60 The Committee noted that the Applicant had given an undertaking, in their original application form and at the outset of the hearing, that the same services will be provided at the proposed site. On the information provided, the Committee determined that condition (d) is met.

Regulation 24(1)(e)

5.61 In relation to condition (e), the Committee noted the Applicant had confirmed in their application, and subsequent representations, that there will be no interruption to service provision. On the information provided the Committee determined that condition (e) is met.

Overall

5.62 In those circumstances given that a different conclusion has been reached, the Committee determined that the decision of NHS England must be quashed.

5.63 The Committee went on to consider whether there should be a further notification to the parties detailed at paragraph 19 of Schedule 2 of the Regulations to allow them to make representations if they so wished (in which case it would be appropriate to remit the matter to NHS England) or whether it was preferable for the Committee to redetermine the application.

5.64 The Committee noted that representations on Regulation 24 had already been made by parties to NHS England, and these had been circulated and seen by all parties who made representations on the application, as part of the processing of the application by NHS England. The Committee further noted that when the appeal was circulated representations had been sought from parties on Regulation 24.

5.65 The Committee concluded that further notification under paragraph 19 of Schedule 2 would not be helpful in this case.

6 Decision

6.1 The Committee concluded that it was not required to refuse the application under the provisions of Regulation 31

6.2 The Committee quashes the decision of NHS England and redetermines the application.

6.3 The Committee has determined that conditions (a), (b), (c), (d) and (e) are satisfied.

6.4 The application is granted.

Alan Tomlinson Committee Chair

Dated this 31st day of January, 2020

A copy of this decision is being sent to:

Rushport Advisory LLP on behalf of Medicstar UK Ltd NHS England Boots UK Ltd Greater Manchester LPC Timperley Pharmacy Well

ANNEX A

Arena Point Merrion Way REF: SHA/22127 Leeds LS2 8PA APPEAL AGAINST NHS COMMISSIONING BOARD ("NHS ENGLAND") DECISION TO REFUSE AN Tel: 0203 928 2000 Fax: 0207 821 0029 APPLICATION BY MEDICSTAR (UK) LTD FOR A Email: [email protected] RELOCATION THAT DOES NOT RESULT IN A SIGNIFICANT CHANGE TO PHARMACEUTICAL SERVICES PROVISION UNDER REGULATION 24 FROM 344 MANCHESTER ROAD, WEST TIMPERLEY, ALTRINCHAM, WA14 5NH TO THE LIBRARY AT 405 STOCKPORT ROAD AND CAR PARK ON BAKER STREET, TIMPERLEY, ALTRINCHAM, WA15 7XR

1 The Application

By application dated 11 December 2018, Medicstar (UK) Ltd (“the Applicant”) applied to NHS Commissioning Board (NHS England”) for a relocation that does not result in a significant change to pharmaceutical services provision under Regulation 24 from 344 Manchester Road, West Timperley, Altrincham, WA14 5NH to the library at 405 Stockport Road and car park on Baker Street, Timperley, Altrincham, WA15 7XR. In support of the application it was stated:

In response to why the application should not be refused pursuant to Regulation 31 the applicant stated:

1.1 There are no pharmacies adjacent or in close proximity to the new premises and as such Regulation 31 is not engaged.

Information in support of the application

1.2 Patient Groups:

1.2.1 Prescriptions collected/ delivered and EPS

1.2.2 People who access pharmacy premises, walk ins via method of transport on foot or by car

1.3 All patient groups are able to access the new location as easily and some patients will see improved accessibility to pharmaceutical services in the new location.

1.4 There will be no change in the number of pharmacy contractors and this relocation will result in no significant change in distribution of pharmacies. There is reasonable choice of pharmacy services and providers within this area and this balance will be maintained. By relocating to the new premises there will be no detriment to arrangements in place and it should be viewed as being a mechanism to provide patients with improved pharmacy services locally.

1.5 The same services and same opening hours will be provided in the new location as in the current location resulting in no change to the arrangements.

1.6 Neither the PNA no any recent / current communication regarding pharmacy services point to any proposed plans to alter the provision of pharmaceutical services in the area of the HWB. There is no evidence that by allowing this application any detriment would occur.

2 The Decision

NHS England considered and decided to refuse the application. The decision letter dated 2 May 2019 states:

2.1 NHS England has considered the above application and is writing to confirm that it has been refused. Please see the enclosed report for the full reasoning.

Extract from decision report

Regulation 31

2.2 The PSRC considered and determined that the application should not be refused under Regulation 31, as it was satisfied that the applicant is not intending to relocate into premises that are the same or adjacent premises to persons included in the pharmaceutical list that could be deemed to be providing the same service. The closest pharmacies to the proposed new site are Timperley Pharmacy, 250 Stockport Road, Timperley, Altrincham WA15 7UN; and Well Timperley, 238 Stockport Road - both are 0.1 miles/0.16 km from the proposed new site (source: the NHS Site).

Regulation 24 – does the need on which the applicant based its application satisfy the elements of Regulation 24?

2.3 Consideration 1 - Is the location of the new premises significantly less accessible than the current premises, and if so why? Regulation 24(1)(a)

2.4 The applicant describes the patient groups that are accustomed to accessing services at the current premises as:

2.4.1 Prescriptions collected/delivered and EPS (Electronic Prescription Service)

2.4.2 People who access the pharmacy premises as “walk ins” (which the applicant explains as patients who “walk through the door BUT their mode of access is via car, foot or bike”)

2.5 The applicant believes that all patient groups will be able to access the new location as easily as the current location, and that some patients will see improved accessibility to pharmaceutical services in the new location.

2.6 The applicant explains that prescriptions collected/delivered and EPS account for 90% of all prescriptions, and that

2.6.1 these patients DO NOT physically access the pharmacy for their pharmaceutical services

2.6.2 these patients are serviced via on-line, driver collections and delivery etc.

2.7 It was unclear from this statement what were the full range of options available to current patients to access all essential pharmaceutical services are, due to the loose description provided in this respect: “these patients are serviced via on-line, driver collections and delivery etc”. “Etc” implies other options are available than those stated but does not specify what those further options may be.

2.8 The PSRC considered the audit results provided in the applicant’s response which was entitled “People who access pharmacy services, walk ins via method of transport on foot or by car”. The audit was conducted with patients that DO physically access the existing premises for all essential and enhanced services, and by the mode of transport specified. Covering the period December 2018 through to February 2019 the information provided showed:

2.8.1 the total number of people who are accustomed to accessing the existing premises

2.8.2 the method of accessing services – by car, on foot, etc

2.8.3 where the patient journey commenced, whether from home or a GP surgery/place of work or other location

2.8.4 Whether each person is able to access the new premises as easily (not significantly less accessible)

2.8.5 Whether there are any considerations in terms of access to the new premises in relation to The Equality Act:

2.8.5.1 Age

2.8.5.2 Disability

2.9 The PSRC noted that between December 2018 and February 2019 the audit result shows that several patients visited and accessed a range of services from the pharmacy at the current location. The result of the audit also shows the mode of transport, and based on this information the applicant’s assumptions are that:

2.9.1 for patients travelling by car, there can be no access issues to the new premises

2.9.2 the cyclist is accustomed to travelling considerable distance and is an “accomplished cyclist” therefore the distance to the proposed location would cause no undue issue

2.10 The PSRC also noted the applicant’s response to meeting the requirements of The Equality Act 2010 only refers to only two of the nine listed protected characteristics groups (age and disability). The applicant does not appear to have considered the needs in terms of access for all patients (including those who share one or more protected characteristics); in fact, the applicant has gone as far as to state that “there are no considerations under protected characteristics” to take into account.

2.11 The applicant states that collection/delivery and EPS accounts for 90% of all prescriptions and that these patients “DO NOT physically access the pharmacy”. The PSRC observed, however, that the applicant had not demonstrated that they had considered the needs of the 10% of their patients that do physically access the pharmacy for their prescription medicines; nor was it confirmed whether this particular group of patients was included in the survey carried out between December 2018 and February 2019.

2.12 The PSRC was mindful that the applicant’s collection and delivery service is a non-NHS service, which can be withdrawn by the pharmacy at any time. Equally, patients can choose to discontinue using the collection and delivery service at any time. It was also noted that EPS is purely the mechanism by which a GP practice sends an electronic prescription message to a pharmacy; patients may still choose to present at the pharmacy in person to collect their supply of medicines, and many choose to do so.

2.13 The PSRC also noted that the applicant did not elaborate on how clinical governance, participation in public health campaigns and signposting, Advanced and locally commissioned services are managed if the pharmacy is delivering these services on a mainly non-face to face basis. This is a particularly pertinent point as the applicant has stated they are accredited to provide the following advanced services: MUR, NMS, EHC, MAS, Flu vaccines, Supervised Consumption.

2.14 Based on the information provided, the PSRC was unable to satisfy itself that the applicant had provided assurances that the needs of all their existing patients had been adequately assessed.

Additional and relevant information

2.15 The PSRC took into consideration the distance between the current and proposed locations, which is approximately 1.5 miles/2.4 km when travelling along Park Road (the B5165). This is approximately a 31 minute walk or an eight minute car journey (source: Google Maps). NHS England representatives had previously undertaken a site visit (on 19 June 2018 in respect of a previous application), noting that the two locations were in distinctly different localities (West Timperley and Timperley village). At the time of the visit (which was late morning/midday) Park Road was busy with traffic, and a local resident confirmed that this road is frequently gridlocked at peak times of the day, due in part to there being a minimum of three schools located either on - or just off - Park Road itself.

2.16 The PSRC understands the applicant is seeking to relocate into a new “community hub” in Timperley village, which is to be located on the site currently occupied by the vacant building which previously housed the library. A floorplan of the new building was available to view on site, indicating that the ground floor is to be occupied by a GP practice, with space on the ground floor also being identified for a pharmacy by the building developers. According to the site plan seen at the site visit, the first floor of the new building is to be occupied by the new library and community rooms, and the second floor does not yet have a designated use. A notice displayed on the building in June 2018 indicated the new community hub was scheduled to open in early 2019, however in a later update (November 2018) it was reported that work on the development was due to start “shortly”. The development is, as of April 2019, not completed.

2.17 The PSRC was advised that the walk from the current site to the proposed location, although along a well-lit and maintained busy B-road (Park Road), is a significant distance of 1.5 miles/2.4 km. The journey along Park Road involves a long uphill gradient from its junction with Frieston Road to the bridge which crosses the canal and Metrolink line, and a further uphill gradient where the road crosses the railway line on the approach to the athletics club. The journey between the current and proposed locations also involves passing two other pharmacies (Station Road Pharmacy on Park Road, and Riddings Pharmacy on Riddings Road). The significant distance involved would likely pose a challenge for some patients who share a protected characteristic, for example; elderly patients, those with disabilities or limited mobility; parents with young children (particularly those with no access to private transport). There is an additional challenge/barrier for patients in that there are no direct public transport links between the existing and proposed sites.

2.18 The applicant – at its current location – serves the resident populations to the west of Manchester Road (Woodhouses and Broadheath) as well as to the east of Manchester Road (West Timperley and Newton Park). According to NHS Business Services Authority (NHSBSA) dispensing data for January 2019, of the 2,611 items dispensed, the highest percentage (28%/734 items) originated from West Timperley Medical Centre, which is close to the applicant’s current location. Patients who choose to visit the pharmacy premises to collect their medication and access other services would have a significant distance to travel to access pharmaceutical services from the proposed new location in Timperley village, and would pass other pharmaceutical service providers en route, specifically; Station Pharmacy and Riddings Pharmacy would become the nearest pharmacies for patients travelling from the current site to the proposed new site via Park Road. The PSRC therefore considered that the location of the new site is significantly less accessible than the current location and believed that not all patient groups would seek to continue to access services from the pharmacy at the new location.

2.19 It was also noted that in addition to being located close to where most of its patients currently access GP services, the applicant’s current location is within a parade of commercial/retail units on Manchester Road. Altrincham Lodge’s private car park adjoins the parade and the Pelican pub (with a large car park of its own) is on the far side of the Lodge’s car park. Vehicles were parked on the wide pavement directly outside the pharmacy (implying that parking is available on site). It is therefore likely that residents of West Timperley will likely access these amenities (including the pharmacy) during their daily routine, and due to the prominent main road location and available parking, it is also likely to be used by passing patients. It was therefore not adequately demonstrated to the PSRC that there would be no significant adverse impact on all patient groups, should the pharmacy relocate.

2.20 Based on the information provided by the applicant in terms of the patient groups identified in its application and supporting document, the PSRC concluded that the proposed location was significantly less accessible to those patient groups currently accessing pharmaceutical services from the current location, for the reasons stated above.

2.21 The PSRC was therefore of the view that condition (a) had not been met.

2.22 Consideration 2 - In the opinion of the NHSCB, would granting the application result in a significant change to the arrangements that are in

place for the provision of local pharmaceutical services or of pharmaceutical services other than those provided by a person on a dispensing doctor list—

2.22.1 (i) in any part of the area of HWB1, or

2.22.2 (ii) in a controlled locality of a neighbouring HWB, where that controlled locality is within 1.6 kilometres of the premises to which the applicant is seeking to relocate?

2.23 Regulation 24(1)(b)

2.24 The PSRC noted that there is no controlled locality within 1.6km of the premises to which the applicant is seeking to relocate. Whilst the PSRC felt that the loss of the pharmacy from its current location in West Timperley and introduction of the pharmacy to the proposed location in Timperley village would result in a change to the provision of pharmaceutical services that are currently in place, it considered that this may not constitute a significant change.

2.25 The PSRC was not aware of any specific plan that Trafford HWB has in respect to pharmaceutical provision which may be impacted by the relocation. However, it is aware that Trafford HWB Pharmaceutical Needs Assessment (PNA) is due to expire on 31 March 2020, consequently a review pharmaceutical services to meet the need of its residents is due to commence shortly.

2.26 On that basis the PSRC determined that the relocation would not cause significant detriment to proper planning in respect of the provision of pharmaceutical services in Trafford Health & Wellbeing Board.

2.27 The PSRC was therefore of the view that condition (b) had been met.

2.28 Consideration 3 – Is the NHSCB of the opinion that granting the application would cause significant detriment to proper planning in respect of the provision of pharmaceutical services in the area of HWB1? Regulation 24(1)(c)

2.29 The PSRC viewed The NHS Site map and list showing the location the three nearest pharmacies in relation to the current premises (A – Pelican Pharmacy). The map shows Well (B) - 0.4 miles, Terry Chemist (C) and Station Pharmacy (D) both 0.5 miles away from the existing premises.

2.30 The PSRC noted that the applicant’s pharmacy is currently situated within the Broadheath Ward close to its border with the western boundary of the Timperley ward. The proposed location is within the Village ward, which borders the Timperley ward on its eastern boundary. This demonstrates the significant distance and highlights the difference between the current and proposed locations.

2.31 It was noted that there are several pharmacies in the West Timperley area, therefore the loss of one pharmacy from this location may not necessarily lead to a gap in provision in the Trafford HWB area; however, this would be something that the Trafford HWB would consider as part of its Pharmaceutical Needs Assessment review.

2.32 The relocation of the applicant’s pharmacy to the proposed site would result in three pharmacies being located within 0.1 miles/0.16km of each other on Stockport Road (as Timperley Pharmacy and Well are both located in Timperley village, very close to the proposed site). Timperley Pharmacy operates for 100 hours over seven days, and Well pharmacy offer a total of 56 opening hours over six days. Therefore, there are no additional benefits to patients if the pharmacy relocated in terms of opening hours and services, however this does not impact of the overall provision in the HWB area.

2.33 The PSRC was not aware of any specific plan that Trafford HWB has in respect to pharmaceutical provision which may be impacted by the relocation

2.34 Considering all available information, the PSRC was not of the opinion that granting the application would cause significant detriment to proper planning in respect of the provision of pharmaceutical services in the Trafford Health & Wellbeing Board area.

2.35 The PSRC was therefore of the view that condition (c) had been met.

2.36 Consideration 4 – Are the services the applicant undertakes to provide at the new premises the same as the services the applicant has been providing at the existing premises (whether or not, in the case of enhanced services, the NHSCB chooses to commission them)? Regulation 24(1)(d)

2.37 The applicant had stated in its application that the services (including opening hours) would remain unchanged, however the core hours stated in the application differ from the core hours as approved and listed in the pharmaceutical list. The PSRC was minded to consider the signed opening hours declaration made by the applicant dated 10 December 2012 (Appendix A); in which core hours were declared as 09:00 – 17:00 Monday to Friday, a total of 40 core hours. The core hours as stated in the application are therefore inconsistent with the core hours as previously declared by the applicant in 2012.

2.38 Based on the information provided by the applicant, the PSRC could not be satisfied that the applicant was undertaking to provide the same services (which includes core opening hours) from the proposed premises, as it provides from the current premises, due to the difference in core hours.

2.39 The PSRC was therefore of the view that condition (d) had not been met.

2.40 Consideration 5 – Will the provision of pharmaceutical services be interrupted (except for such period as the NHSCB may for good cause allow)? Regulation 24(1)(e)

2.41 The applicant had specified that there would be no interruption in services.

2.42 The PSRC was therefore of the view that condition (e) had been met.

2.43 Consideration 6 - If the application was originally granted for an approved retail area exemption is the applicant planning to leave the retail area? Regulation 24(3)(a)

2.44 The PSRC was satisfied that the application had not been originally granted for an approved retail area exemption. Therefore a refusal under Regulation 24(3)(a) does not apply in this case.

2.45 Consideration 7 – Is the applicant seeking to relocate to premises that are the same, or adjacent to, premises which could be considered to be part of the same service as the existing services, and so should be treated as the same site? Regulation 31

2.46 The PSRC was satisfied, based on the information available, a refusal under Regulation 31 would not be appropriate. It was noted that the nearest pharmacies to the proposed site are Timperley Pharmacy, 250 Stockport Road and Well at 238 Stockport Road, Timperley, Altrincham, WA15 7UN, both at a distance of approx. 0.1 miles/0.16 km, and a 3 minute walk away.

2.47 The PSRC was therefore of the view that Regulation 31 did not apply in this case.

Interested Party representations

2.48 The PSRC took account of the representations received from Greater Manchester LPC, Well Head Office, Timperley Pharmacy, Baguley Pharmacy (Sharief Healthcare Ltd), Riddings Pharmacy, and Rowlands Pharmacy. The representations are summarised as follows:-

2.49 Greater Manchester LPC objects to the application as –

2.49.1 the patient groups accustomed to accessing pharmaceutical services from the existing premises would find the location of the new premises significantly less accessible

2.49.2 granting the application would result in a significant change to the arrangements that are already in place for the provision of local pharmaceutical services

2.50 Well Head Office objects to the application as:-

2.50.1 the patient groups affected as defined by the applicant should be broadened to include patient groups whose prescriptions originate from West Timperley Medical Centre, Firsway Health Centre, Washway Road Medical Centre, Grove Medical Practice, Park Medical Practice, Wilmslow Road Surgery and Timperley Health Centre (Westwood)

2.50.2 in broadening the patient groups to include the above, 93% of the prescriptions dispensed originate from a different surgery from which the applicant is proposing to move closer to

2.50.3 the applicant has failed to fully investigate the impact of the relocation on these patient groups

2.50.4 the applicant has failed to describe the route between the two sites or consider how patients access the current site, and has failed to consider where their patients start their journey and how the change of premises would impact this

2.50.5 the applicant has failed to consider the impact on patients with protected characteristics

2.50.6 The applicant has also made no reference to the sites accessibility for parking in comparison to the current site or how many patients access the current location in this manner

2.50.7 This application has recently been considered at appeal SHA/19973 and it was refused. There have been no substantial changes to the area in the few months since this application was considered

2.51 Timperley Pharmacy objects to the application as:-

2.51.1 there are two pharmacies within 100 metres of the proposed site (Timperley Pharmacy and Well), with Timperley Pharmacy being open every day of the year including Easter Sunday and Christmas Day

2.51.2 there is a significant population who would find the new premises significantly less accessible due to the long distance and physical barriers of Manchester Road and Park Road, with the journey on foot taking around 30-35 minutes along Park Road

2.51.3 patients who share a protected characteristic will have significant difficulty accessing the proposed site on foot

2.51.4 the proposed relocation will result in a reduction in the number of pharmaceutical service providers at Manchester Road

2.51.5 movement to the proposed location would result in the clustering of pharmaceutical services provision in the area

2.51.6 the existing and proposed sites are in two completely different neighbourhoods serving two completely different population groups

2.51.7 proposed site will be less accessible for patients of West Timperley Medical Centre and Barrington Medical Practice, and will be significantly less accessible for patients living in the vicinity of the current site

2.51.8 while closest surgeries to current premises are different, proposed and current pharmacies are in completely two different neighbourhoods and serve two different population. So, proposed new site will be less accessible for pharmaceutical services originating from West Timperley Medical Centre and Barrington Medical Practice. Proposed site will also be significantly less accessible for patient groups living in vicinity of current site. Dispensing of prescriptions is not the only service which pharmacies offer, there are other services like advice to patients, OTC medication and other Essential Services which are integral part of the pharmacy contract.

2.52 Baguley Pharmacy (Sharief Healthcare Ltd) objects to the application as:-

2.52.1 the significant distance between the two sites means the applicant would be serving a completely different neighbourhood in the new location

2.53 Riddings Pharmacy objects to the application as:-

2.53.1 this application has been heard before and indeed following its rejection an appeal was then heard which too was rejected.

2.53.2 A copy of their appeal response was also submitted.

2.54 Rowlands Pharmacy objects to the application as:

2.54.1 Google Maps indicate that this relocation would occur over a distance of 1.6 miles which represents a 31 minute walk or 5 minutes’ drive.

2.54.2 given the built-up nature of the area they cannot see how this relocation could be described as not proposing significant change

2.54.3 there is a Well Pharmacy and an independent 0.2 miles from the proposed location at 238 and 250 Stockport Road respectively

2.54.4 it seems unusual to grant this relocation which would exacerbate an existing cluster of pharmacies and remove a pharmacy from the centre of a residential area

2.55 Boots the Chemist (Contracts Office) objects to the application as:

2.55.1 the applicant has failed to identify all of their patient groups and in fact only consider very few

2.55.2 no evidence to show how these patient groups will or will not be affected by the relocation

2.55.3 the distance according to google maps, by foot is 2.5 kilometres and fail to see how the applicant believe that this is not a significant distance

2.56 The applicant responded to the above representations (via Rushport Advisory LLP), providing the result of an audit undertaken between December 2018 and February 2019, and also addressed Interested Parties comments.

2.57 The applicant believes it has adequately assessed the impact on all relevant patient groups, which the applicant identified as “Prescriptions collected/delivered and EPS, and People who access pharmacy premises, walk ins via method of transport on foot or by car” and states that most of the prescription activity is managed via EPS/collection and delivery service, which means there are very few patient visits to the pharmacy. This also means that the delivery of essential services by the pharmacy from its current site is done on a mainly non-face to face basis.

2.58 The applicant further argues that as there is no distance specified in the regulations for a “no significant change” application, the test is specific to the pharmacy making the application and as there is minimal physical access to the pharmacy by patients/patient groups/the public there would be no significant detriment in approving this application. Again, postcodes via car access are WA15, WA14 and M33 with outlying areas such as Stockport, Partington and Wythenshawe.

2.59 The applicant states that there is no evidence that the new premises are significantly less accessible and each person surveyed confirms the ease of the journey to the new premises is not a barrier, and for some the journey to the new premises is the same or easier as a result of where they start their journey.

2.60 The applicant concludes that it disagrees with Interested Parties comments.

2.61 The PSRC noted the representations from interested parties and the applicant’s response.

Decision

2.62 Taking into account all available information, the PSRC decided to refuse Medicstar (UK) Ltd’s application for a “no significant change” relocation.

2.63 The PSRC determined that while the requirements of Regulation 24(1)(b), (c), and (e) had been met:-

2.63.1 granting the application would not result in a significant change to the service provision arrangements in place

2.63.2 granting the application would not result in significant detriment to proper planning in respect of service provision in the Trafford HWB area

2.63.3 there would be no interruption to service provision

2.64 The application is refused due to failing to meet the requirements of Regulation 24(1)(a) and 24(1)(d):-

2.64.1 the new location is significantly less accessible for patients accustomed to accessing services from the current location for the reasons outlined by the PSRC in this report; and

2.64.2 the PSRC could not be assured that the applicant would be providing the same services and opening hours at the proposed site, as the core hours as stated in the application are not the approved, listed core hours as they appear on the pharmaceutical list

2.65 Regulation 24(3)(a) does not apply in this case.

2.66 A refusal under Regulation 31 would not be appropriate in this case.

2.67 The PSRC awarded appeal rights to Medicstar (UK) Ltd (the applicant).

3 The Appeal

In a letter dated 28 May 2019 addressed to NHS Resolution, Rushport Advisory LLP on behalf of the Applicant appealed against NHS England’s decision. The grounds of appeal are:

3.1 It is contended that the PSRC erred in its deliberation and determination.

[Regulation 24 quoted]

Regulation 24(1)(a)

3.2 It is contended that the Applicant is in the best position to identify those groups who are accustomed to using its pharmacy and therefore to be able to produce relevant evidence to show that there is no significant loss of accessibility for the members of those groups (R (On the application of Community Pharmacies (UK) Limited -v- The National Health Service Litigation Authority [20 161 EHWC 1595 (QB)).

3.3 The Applicant has very clearly identified its patient groups in its application. These are:

3.3.1 patients, who DO NOT access the Pharmacy at the existing premises (such as patients who have their prescriptions collected directly or via Electronic Prescription Service (EPS) and delivered). These comprise 90% of its patients.

3.3.2 patients, who DO access the Pharmacy at the existing premises. These comprise 10% of its patients.

3.4 The Pharmacy dispenses very few prescriptions each month (approximately 2,564 on average) and evidence has been provided to NHS England by way of data collated over a 3-month period (from December 2018 to February 2019) [see Tabs 2 & 3]. It is evident from the data collated that 90% of all prescriptions were collected directly or via EPS and delivered. These patients are not accustomed to accessing pharmaceutical services at the existing premises, thus fall outside the scope of Regulation 24(1)(a). They are serviced by means other than face to face for their access to pharmaceutical services. Where any advice, counselling or other elements of pharmaceutical services are required they receive the services via delivery, telephone and emails. Moving to the proposed location has no effect on these patient groups as they DO NOT physically access the Pharmacy. Therefore, the relocation does not make the Pharmacy less accessible to these patient groups.

3.5 The Applicant has clearly described the patient group who DO physically access the existing premises in its application. This comprises patients who access the Pharmacy via car, foot or bike.

3.6 It was stated in the Refusal Decision, "the applicant explains that prescriptions collected/ delivered and EPS account for 90% of all prescriptions and that:

3.6.1 these patients DO NOT physically access the pharmacy for their pharmaceutical services;

3.6.2 these patients are serviced via on-line, driver collections and delivery etc.

3.7 It was unclear from this statement what were the full range of options available to current patients to access all essential pharmaceutical services are, due to the loose description provided in this respect: these patients are serviced via on-line, driver collections and delivery etc. 'Etc' implies other options are available than those stated but does not specify what those further options may be".

3.8 For the avoidance of doubt, 'etc' includes emails, telephone calls, text messages and letters. It is important to note that this refers to methods used by patients who DO NOT physically access the Pharmacy.

3.9 It is incorrect to state in the Refusal Decision that "the audit was conducted with patients that DO physically access the existing premises for all essential and enhanced services". It appears that the wording of advanced services was omitted. For the avoidance of doubt, the Survey was conducted on all patients who DO access the premises for all essential, advanced and enhanced services [see Tab 42].

3.10 It was further stated in the Refusal Decision, "the PSRC also noted the applicant's response to meeting the requirements of The Equality Act 2010 only refers to only two of the nine listed protected characteristics groups (age and disability). The applicant does not appear to have considered the needs in terms of access for all patients (including those who share one or more protected characteristics); in fact, the applicant has gone as far as to state that "there are no considerations under protected characteristics" to take into account'.

3.11 It was decided in the case of R (On the application of Community Pharmacies (UK) Limited - v- The National Health Service Litigation Authority [2016] EHWC 1595 (QB) that whilst the Equality Act 2010 is a starting point for deciding issues of equal treatment, most if not all of the nine protected characteristics in the Act have very little to say about the accessibility of one location when compared with another.

3.12 The Applicant has considered age and mobility issues (disability) for all its patients not in isolation but in terms of patients' accessibility to both the existing and proposed location as the data presented to NHS England clearly shows there is no access issues in relation to these protected characteristics.

3.13 The Refusal Decision stated that "the Applicant had not demonstrated that they had considered the needs of the 10% of their patients that do physically access the Pharmacy for their prescription medicines; nor was it confirmed whether this particular group of patients was included in the survey carried out between December 2018 and February 2019".

3.14 The PSRC has failed to properly consider the survey results in that the survey was conducted on all the patients who had physically accessed the Pharmacy for the period of December 2018 and February 2019 (the "Survey") [see Tab 2- survey forms collected from patients].

3.15 The Survey has considered the following:

3.15.1 Purpose of visit: Prescription I Medical Advice I Counter Medication I Other Medical Services

3.15.2 NHS Services/ Non-NHS services

3.15.3 Mode of Transport to Pharmacy: CAR I WALK IN I BIKE I PUBLIC TRANSPORT

3.15.4 Location of Start of Journey to Pharmacy (postcode only):

3.15.5 Patient shown plans of new location including parking:

3.15.6 Will you be able to access new location by the same means?

3.15.7 Would relocation to the new premises (Baker Street) make your access to the NHS services provided by this pharmacy (when compared to the current pharmacy location): more accessible (easier) I less accessible (harder) I no difference

3.15.8 Would relocation to the new premises (Baker Street) make your journey to the pharmacy (when compared to the current pharmacy location): more accessible (easier) I less accessible (harder) I no difference

3.15.9 Do you think the level of traffic (at any time of the day) would make access to the new premises less accessible when compared to the current location of the pharmacy?

3.15.10Over 60?

3.15.11Do you require any Disability Assistance?

3.16 The Survey demonstrates that there are 43 patients who accessed the Pharmacy in December 2018, 30 in January 2019 and 24 in February 2019. Of all the patients surveyed, none of the patients found the proposed location less accessible.

3.17 As stated in the Refusal Decision, "the PSRC was mindful that the applicant's collection and delivery service is a non-NHS service, which can be withdrawn by the pharmacy at any time. Equally, patients can choose to discontinue using the collection and delivery service at any time. It was also noted that EPS is purely the mechanism by which a GP practice sends an electronic prescription message to a pharmacy; patients may still choose to present at the pharmacy in person to collect their supply of medicines, and many choose to do so".

3.18 If collection and delivery service is not provided by the Applicant, the business of the Pharmacy is likely to fail. It is nonsensical for the Applicant to consider withdraw this service.

3.19 The low number of users for the Pharmacy can be demonstrated by the prescription figures published by the NHS Business Services Authority ("NHSBSA"). When compared with other pharmacies in the area, the Pharmacy has approximately a third of the dispensing figures from the surrounding pharmacies [See Tab 4- table with dispensing figures] and the number of patients is significantly less.

3.20 Due to the low prescription figures and patient number, it can be shown that even if the 10% of prescription items was dispensed for walk in patients, this is equivalent to a few patients per day with a combined total of not more than 12 prescription items.

3.21 The Pharmacy has a record of all the deliveries per day and approximately 110 items are delivered to patients daily.

3.22 The Applicant is required to define its patient groups which it has done and to assure NHS England that patients will not experience significant issues in terms of access to pharmaceutical services at the new premises. The Applicant has therefore provided evidence in terms of how people access pharmaceutical services, by what mode of transport and where a journey starts. The Applicant can confirm that the delivery service will continue after the proposed relocation.

3.23 PSRC implied in the Refusal Decision that 'many' people chose to collect their EPS prescription from the pharmacy but failed to support this contention with any evidence. It is confirmed that most if not all of the Pharmacy's prescriptions are delivered.

3.24 In the Refusal Decision, "the PSRC also noted that the applicant did not elaborate on how clinical governance, participation in public health campaigns and signposting, Advanced and locally commissioned services are managed if the pharmacy is delivering these services on a mainly non-face to face basis. This is a particularly pertinent point as the applicant has stated they are accredited to provide the following advanced services: MUR, NMS, EHC, MAS, Flu vaccines, Supervised Consumption".

3.25 This is not the test required under Regulation 24(1)(a). In any event, the Applicant can confirm that the Pharmacy has been participating in clinical governance, public health campaigns and signposting and will continue to do so after the proposed relocation.

3.26 The low number of users of these essential, advanced and locally commissioned services in the current location is of concern to the Applicant. This is due to the poor accessibility of the Pharmacy's current location [see Tab 4- table with dispensing figures & Tab 5 -letters from independent parties regarding the lack of walk in patients].

3.27 The PSRC have a responsibility to improve the uptake of these services and should allow the relocation of the current pharmacy to proceed as the proposed location is more accessible to all patient groups.

3.28 Based on the above points, the PSRC should be satisfied that all the needs of the existing patient groups have been considered and assessed.

Additional and relevant information

3.29 In the Refusal Decision, "the PSRC took into consideration the distance between the current and proposed locations, which is approximately 1.5 miles/2.4 km when travelling along Park Road (the B5165). This is approximately a 31-minute walk or an eight-minute car journey (source: Google Maps). NHS England representatives had previously undertaken a site visit (on 19 June 2018 in respect of a previous application), noting that the two locations were in distinctly different localities (West Timperley and Timperley village)".

3.30 The two locations are both located in Timperley and the relocation criteria is not based on names of different location nor to the fact that the relocation must be on the same street. The Pharmaceutical Needs Assessment report ("PNA") should be referred by the PSRC when considering the relocation of the pharmacy.

3.31 Using the Pharmaceutical Needs Assessment report, the Health and Wellbeing Board (HWB) considers Timperley and Timperley Village to be in the South Trafford Neighbourhood and therefore this relocation is based in the same neighbourhood [See Tab 6- p4 PNA statement]. The walking distance can vary between 25-30 minutes and the car journey has been previously shown to be 4-5 minutes in the previous application. This is similar to the PSRC own observations.

3.32 The key question that ought to be considered by PSRC is the 'location of the patient group's geographic starting point of the journey to the pharmacy'.

3.33 The Applicant has provided data/ evidence in terms of how people access the existing premises, by what mode of transport, where the journey starts and how that relates to access to the new premises. From the Survey, most of the walk- in patients live closer to the proposed location. The data can be summarised below:

Dec 2018 Jan 2019 Feb 2019 People assessing 43 30 24 pharmacy Car 41 29 24 Foot 1 1 0 Bike 1 0 0

3.34 NHS England also had maps plotted in relation to those who drive, walk or use a bike as their mode of access and where their journey commences.

3.35 The evidence [see Tab 2 and Tab 7] clearly showed the small number of people accessing the existing premises (1-2 per day) were almost entirely using a car starting their journey as plotted and would experience no access issues in doing the same at the new premises. The new premises with planned dedicated patient parking will in fact facilitate easy parking compared to the issues with parking at the existing premises.

3.36 Only 1 person per month accessed the Pharmacy on foot and the start point for their journey was plotted as between the existing and new premises and as such could not be an issue which had been confirmed during collation of the data.

3.37 It is worth noting that no patient used public transport to access the Pharmacy.

3.38 It was stated in the Refusal Decision that "at the time of the visit (which was late morning/midday) Park Road was busy with traffic, and a local resident confirmed that this road is frequently gridlocked at peak times of the day, due in part to there being a minimum of three schools located either on - or just off- Park Road itself'.

3.39 Park Road can be occasionally busy with traffic but as stated earlier, the car journey times can vary between 4 minutes to 8 minutes and it is not accepted that the traffic is "gridlocked" as described in the Refusal Decision. The definition of gridlock is when "a situation where roads in a town become so blocked by cars that it is impossible for any traffic to move" and this is not the case on Park Road.

3.40 94 patients who accessed the Pharmacy by car stated that they did not find the proposed location less accessible because the car journey is less than 10 minutes. The 94 patients' starting location was included in the survey.

3.41 A Transport Accessibility Report (the "Report") has been produced and describes the traffic and accessibility issues regarding the relocation of the Pharmacy [see Tab 7 – Transport Accessibility Report].

3.42 The Report describes the traffic situation of the current location and the proposed location and therefore provides a better analysis on whether the proposed location is less accessible for the patient group that uses their cars.

3.43 Summary of traffic situation for both sites:

3.44 During the operating hours of the Pharmacy, the present location (Manchester Road A56) suffers from heavy traffic.

3.45 The Pharmacy is on a busy A Road (Manchester Road A56) and has 3 times as much traffic when compared to a B Road (Stockport Road B5165 I Baker Street) [see Tab 8].

3.46 The proposed location has less traffic and these points can be proved by the Traffic census conducted by Trafford Council [see Tab 9].

3.47 The Trafford Local Plan confirms that A roads have more traffic when compared to B roads, Trafford has a higher level of car ownership and that the A56 (Manchester Road) is noted for having a congestion issue [see Tab 9].

3.48 As highlighted in the Report, the congestion on the A56 or other busy roads have serious ramifications for economic, health and ecological wellbeing in the area.

3.49 The PSRC mentioned that it was busy on Park Road but did not consider that it is more difficult to reach the current location from Park Road as the traffic direction is moving from a B road (Park Road) to an A road (Manchester Road). In contrast, moving to a B road from an A road is easier because there is less traffic on a B road.

3.50 Referring to the accessibility issue, patients who travel by car will find the proposed location to be more accessible when compared to the current location because there is less traffic and the patients mostly live closer to the proposed location. This is confirmed in the Survey.

3.51 As stated in the Refusal Decision, "the PSRC understands the applicant is seeking to relocate into a new "community hub" in Timperley village, which is to be located on the site currently occupied by the vacant building which previously housed the library. A floorplan of the new building was available to view on site, indicating that the ground floor is to be occupied by a GP practice, with space on the ground floor also being identified for a pharmacy by the building developers. According to the site plan seen at the site visit, the first floor of the new building is to be occupied by the new library and community rooms, and the second floor does not yet have a designated use. A notice displayed on the building in June 2018 indicated the new community hub was scheduled to open in early 2019, however in a later update (November 2018) it was reported that work on the development was due to start "shortly".

3.52 The development is, as of April2019, not completed'.

3.53 The development works have begun and the old library building has been demolished. The development has been delayed for various reasons including the refusal of this application.

3.54 A public consultation was held by Trafford Council and the plans for the building to be developed into a new community hub was approved. The public were aware of the community hub project and there were no objections regarding a pharmacy and a GP practice to be in situated in that area [see Tab 10].

3.55 A public consultation was also held by the developers and there were no objections regarding a pharmacy and a GP practice to be in situated in that area [see Tab 11].

3.56 In addition to public consultations, the Trafford Clinical Commissioning Group ("CCG") has held meetings with various healthcare professionals and lay members of the Primary Care and they all came to the conclusion that relocation of the Park Road Medical Practice to the proposed site would benefit patients and fitted in to the NHS New Models of Care.

3.57 Accessibility of the new location for existing patients would have been analysed in the meetings and the conclusion was that the relocation would not make accessibility to medical services less [see Tab 12].

3.58 The PNA states that Trafford has a higher number of pharmacies than average and most of the patients live within 1 mile of a pharmacy. The majority of the patients can access a pharmacy within 15 -30 minutes and therefore the Applicant's relocation would not result in a significant change to the arrangements that are in place for pharmaceutical services in the area [see Tab 13 - p6]. The HWB has a responsibility to identify improvements or better access to services [see Tab 14 p9].

3.59 The HWB conducted a survey between September and October 2016 and out of the 53 responses, the HWB concluded that the public did not see access to pharmaceutical services as an issue [see Tab 15 p14, P50-p52].

3.60 The HWB want to keep the number of hours (as a minimum) of pharmaceutical services and do not want to see a reduction in hours of access [see Tab 16 p20].

3.61 All parties mentioned in the PNA agreed with the conclusion of the HWB [see Tab 17 p24].

3.62 From the above points, the public have been consulted and there were no accessibility issues identified in terms of accessibility of pharmaceutical services in the proposed location.

3.63 The public have been expecting this development of the community hub and the Applicant can confirm a modern design pharmacy will be built at the proposed site.

3.64 The Refusal Decision stated "the PSRC was advised that the walk from the current site to the proposed location, although along a well-lit and maintained busy B-road (Park Road), is a significant distance of 1.5 miles/2.4 km. The journey along Park Road involves a long uphill gradient from its junction with Frieston Road to the bridge which crosses the canal and Metro/ink line, and a further uphill gradient where the road crosses the railway line on the approach to the athletics club. The journey between the current and proposed locations also involves passing two other pharmacies (Station Road Pharmacy on Park Road, and Riddings Pharmacy on Riddings Road). The significant distance

involved would likely pose a challenge for some patients who share a protected characteristic, for example; elderly patients, those with disabilities or limited mobility; parents with young children (particularly those with no access to private transport). There is an additional challenge/barrier for patients in that there are no direct public transport links between the existing and proposed sites".

3.65 The above comment is a description of a person who would walk from the current location to the proposed location. The Applicant refers to the guidance note of the NHS Litigation Authority and submits that the key consideration is the 'location of the patient group's geographic starting point of the journey to the pharmacy' not the distance between the current location and the proposed location. This was affirmed in the case of R (On the application of Community Pharmacies (UK) Limited -v- The National Health Service Litigation Authority [2016] EHWC 1595 (QB).

3.66 During the Survey, this patient group "walk in by foot" was accessed. The Survey included the starting point of the patients, the service accessed by the patient and their views on whether the proposed location was less accessible.

3.67 There was only ONE patient in that period who walked into the Pharmacy by foot and stated they would prefer the Pharmacy at the proposed location as it was closer to their home.

3.68 The Pharmacy's patient group confirmed during the Survey that the new location would not be less accessible but in fact would be more accessible as it was closer to home.

3.69 The letter from Trafford Council confirmed that there had not been any complaints from the public I businesses regarding reaching local pharmacies from Manchester Road, Park Road, Stockport Road or Baker Street [see Tab 18- Letter from Council].

3.70 It is incorrect to state that there is no direct public transport link between the two sites. It is submitted that bus service 281 provides direct link between the two sites [see Tab 19 – Bus Route]. In any event the finding of the Survey confirmed that no patient accessed the Pharmacy using public transport.

3.71 The Refusal Decision states "the applicant - at its current location - serves the resident populations to the west of Manchester Road (Woodhouses and Broadheath) as well as to the east of Manchester Road (West Timperley and Newton Park). According to NHS Business Services Authority (NHSBSA) dispensing data for January 2019, of the 2,611 items dispensed, the highest percentage (28%/7 34 items) originated .from West Timperley Medical Centre, which is close to the applicant's current location. Patients who choose to visit the pharmacy premises to collect their medication and access other services would have a significant distance to travel to access pharmaceutical services from the proposed new location in Timperley village, and would pass other pharmaceutical service providers en route, specifically; Station Pharmacy and Riddings Pharmacy would become the nearest pharmacies for patients travelling from the current site to the proposed new site via Park Road. The PSRC therefore considered that the location of the new site is significantly less accessible than the current location and believed that not all patient groups would seek to continue to access services from the pharmacy at the new location".

3.72 PSRC erred in its decision to assume that the Pharmacy serves the population to the west of Manchester Road (Woodhouses and Broadheath) as well as to the east of Manchester Road (West Timperley and Newton Park). The Pharmacy serves people from all over the UK and this includes any location within the W A 14 and W A 15 postcodes.

3.73 In the Survey, the patients who accessed the Pharmacy were questioned. The Survey included the starting location of the patients, the services accessed by the patients and their views on whether the proposed location would be less accessible.

3.74 The Survey showed that there were no patients who accessed the Pharmacy at the current location after visiting the local surgery and that majority of these patients started from the Timperley Area [see Tab 7].

3.75 Local GP practices

3.76 The closest GP practices to the Pharmacy include West Timperley Medical Centre, Park Road Medical Practice and Ridding's Family Health Centre.

3.77 It is confirmed that not many patients will visit the current location after visiting these surgeries and the main reason is because each surgery has at least two closer pharmacies and patients will use these pharmacies for convenience [see Tab 20 - table with google maps data].

3.78 The walking distance to the Pharmacy after visiting the local surgeries are shown in Tab 20 and the proposed location is more accessible to the current users of the Pharmacy as most of the patient group live closer to the proposed location as stated in the Transport Accessibility Report [see Tab 7].

3.79 There are other GP practices that are further away from the current location but again, each GP practice has at least two closer pharmacies near the GP practices.

3.80 The low number of users for the Pharmacy can also be demonstrated by the prescription figures from the NHSBSA. When compared with other pharmacies in the area, the Pharmacy has approximately a third of the dispensing figures from the surrounding pharmacies [see Tab 4- Table with dispensing figures].

3.81 The figures demonstrate that the existing pharmacies that are next to the GP practice, has the most amount of prescriptions dispensed.

3.82 The Pharmacy have patients from many surgeries and nearly all the patients are on a collection and delivery basis. When patients see the doctor, any prescriptions sent electronically will be delivered to the patient as soon as possible and this service will continue in the proposed location.

3.83 Patients who may wish to access the current location after a surgery visit will usually do so by car as it is only a 5-minute drive from the three closest GP surgeries.

3.84 Therefore, from an accessibility point of view after relocation to the proposed premises, the patient groups are not significantly affected as majority of these patients live closer to the proposed premises and they travel by car (as evidenced in the Survey).

3.85 Moving to the proposed location will make access to the pharmacy better as there is better parking facilities and less traffic on Park Road and Stockport Road as compared to Manchester Road (A56).

3.86 The proposed premises will make the car journey times for patients that come directly from Park Road Medical Practice and Ridding's Family Practice shorter.

3.87 Due to other pharmacies being in a more convenient location, the Pharmacy does not have patients travelling to its premises by foot after visiting the GP.

3.88 In the Refusal Decision "it was also noted that in addition to being located close to where most of its patients currently access GP services, the applicant's current location is within a parade of commercial/retail units on Manchester Road. Altrincham Lodge's private car park adjoins the parade and the Pelican pub (with a large car park of its own) is on the far side of the Lodge's car park. Vehicles were parked on the wide pavement directly outside the pharmacy (implying that parking is available on site). It is therefore likely that residents of West Timperley will likely access these amenities (including the pharmacy) during their daily routine, and due to the prominent main road location and available parking, it is also likely to be used by passing patients. It was therefore not adequately demonstrated to the PSRC that there would be no significant adverse impact on all patient groups, should the pharmacy relocate".

3.89 PSRC erred in its decision and was irrational in its conclusion that parking was available on site on the basis that vehicles were parked outside the Pharmacy. It is confirmed that there are no parking facilities at the current premises and any vehicles that are parked on the pavement along the parade of shops are illegally parked [see Timperley Councillor's email dated 25 May 2019 at Tab 36].

3.90 The parking at the Pelican Inn is solely for their customers and a car park notice is clearly visible that prohibits non-users of the public house from using the car park [see Tab 7 - Transport Accessibility Report, page 11].

3.91 The present location suffers from a lack of parking facilities and there are parking restrictions (double yellow lines and no loading signs) outside the Pharmacy [see Tab 21 -pictures of parking at present location].

3.92 At the present location, there are 4 lanes of traffic and cars turning right to access the pharmacy need to cut though 2 lanes of oncoming traffic.

3.93 The proposed location has a public car park [see Tab 22 - pictures of parking at proposed location].

3.94 At the proposed location, there are 2 lanes of traffic and cars turning right to access the pharmacy need to cut through 1 lane of oncoming traffic.

Patients who visit the current location to access other amenities

3.95 The PSRC is incorrect to state that the residents of West Timperley will access the amenities near the Pharmacy during their daily routine. The current location is situated on a busy A road with shops that will not attract the public to come and therefore there is a lack of passing trade. The Pharmacy is surrounded by a pub, a fast food outlet that has been closed for 2 years, a gent's barber, a

door shop, a beauty salon, a computer shop and a kitchen supplier. Across the road, there is a Funeral Director and an Enterprise Car Hire [see Tab 23- map].

3.96 The reason why the current location has a lack of walk in patients is because the other local pharmacies are surrounded by better amenities that are suited for all types of patient groups. All the local pharmacies have a convenience store near them and therefore patients would prefer to use the other pharmacies.

3.97 This can be proved by the higher prescription figures of the other pharmacies who serve the same areas as the Applicant [see Tab 4].

3.98 In terms of providing pharmaceutical services, the current location has made the Pharmacy premises redundant because in recent years, West Timperley Medical Centre has moved further away and has been surrounded by Terry's Chemist and Boots. The original position of West Timperley Medical Centre was across the pharmacy (now Toyota Car Sales).

3.99 Firsway Medical Centre has also moved further away as the previous location was closer to the current location. The original position of Firsway Medical Centre was at Meadway. Firsway Medical Centre had an extra purposely built pharmacy next to the surgery and due to Firsway moving further away, Rowlands and Well Pharmacy are nearer compared to the Pharmacy.

3.100 The area has had 3 extra pharmacies since the 2 surgeries have moved further away, Cohen's Chemist in Firsway Medical Centre, 100-hour pharmacy, Timperley Pharmacy and an internet-based pharmacy near Park Road.

3.101 Analysing these pharmacy prescription figures, these pharmacies have been dispensing items nearly FIVE times more than Pelican Pharmacy.

3.102 Other reasons why the public does not use the Pharmacy are stated below:

3.102.1Lack of Parking

3.102.2Heavy Traffic along A56 Manchester Road

3.102.3Other pharmacies are better positioned and are away from the A56 Manchester Road.

3.102.4The walking pathway is constantly blocked by illegally parked cars that restrict public access [see Tab 24]

3.102.5The surface of the current location is uneven and is made up of tarmac that has been worn out [see Tab 25]

3.102.6Flooding issues outside the shop and customers can get splashed by passing cars [see Tab 26]

3.102.7Flooding issues at the Pelican Crossing [see Tab 27]

3.102.8In the winter months, the flooding issue is a hazard as the water freezes to become an ice barrier to the shop [see Tab 28]

3.102.9The A 56 Manchester Road has had many traffic accidents, and some are fatal [see Tab 29].

3.103 The relocation cannot have a significant adverse impact on the patient groups because the current location does not have any passing trade and has all the issues (stated above) that make it less desirable for the public to pass by the Pharmacy.

3.104 This is proved by the low amount of prescription items per month, letters by independent parties and the survey conducted by the pharmacy [see Tab 4- Table with dispensing figures and Tab 5 - Letters from independent parties regarding the lack of walk in patients].

3.105 The Trafford Pharmaceutical Assessment Report states the average pharmacy prescription items per month to be 6531 but the Pharmacy based at the current location (prescription item - 2564 per month) falls well below this average figure [see Tab 30 p49].

3.106 The proposed location will improve the accessibility of pharmaceutical services for the existing patient groups at the Pharmacy and other potential users of pharmaceutical services in the surrounding area for the following reasons:

3.106.1The proposed location is better than the current location as it is surrounded by local amenities that are suited to everyone and will be next to a new medical centre and a library. The proposed location does not suffer from any of the above issues [see Tab 31 - Google Map of amenities]. The proposed location has a public car park, a zebra crossing outside the proposed location and better access for patients as the walking surface is flat [see Tab 32- pictures].

3.106.2Village ward is 5th worst ward for alcohol related hospital admissions, higher than average numbers for heart attack and heart disease and highest child obesity rates in the South Trafford Ward [see Tab 33 p68]. The Relocation would improve the health outcomes of the Village Ward by providing the residents of the Village ward more options regarding their health.

3.106.3There is going to be a development further down from the proposed site. This relocation would benefit the area as the development is 0.7 miles from the proposed location [see Tab 34].

3.106.4This relocation is supported and representations have been received from various parties [see Tab 35- GP letter & Tab 36 -letters of support].

3.106.5There is no provision for loading at the current location. On the contrary there is a loading bay for pharmaceutical suppliers at the new location [see Tab 37].

3.106.6There was one patient who accessed the Pharmacy by a bike in the survey and had no issues with accessing pharmaceutical services at the proposed location. The new location has a bike park, which is more beneficial to the cyclist.

3.106.7There were no patients who accessed the Pharmacy using public transport and therefore this patient group was not affected. For

completion, an assessment of the public transport is included in this report.

3.107 Last but not least, the Pharmacy's lease is due to expire on 1 December 2020 [see Tab 41] and the Applicant will be required to relocate in any event. NHS England is asked to exercise its discretion to allow this application as this proposed relocation not only will not be significantly less accessible but will result in improved access for the Pharmacy's patient group.

Regulation 24(1)(d)

3.108 It was stated in the Refusal Decision that "the applicant had stated in its application that the services (including opening hours) would remain unchanged, however the core hours stated in the application differ from the core hours as approved and listed in the pharmaceutical list. The PSRC was minded to consider the signed opening hours declaration made by the applicant dated 10 December 2012 (Appendix A); in which core hours were declared as 09:00 - 17:00 Monday to Friday, a total of 40 core hours. The core hours as stated in the application are therefore inconsistent with the core hours as previously declared by the applicant in 2012. Based on the information provided by the applicant, the PSRC could not be satisfied that the applicant was undertaking to provide the same services (which includes core opening hours) from the proposed premises, as it provides from the current premises, due to the difference in core hours. The PSRC was therefore of the view that condition (d) had not been met".

3.109 The original application to reduce hours was requested in 2012 and the Pharmacy received confirmation from the PCT regarding the core hours (09.00 to 17.30) [see Tab 38].

3.110 The evidence provided by the PSRC states the total opening hours (core and supplementary hours) and the declared core hours which states (must equal40 hours) [see Tab 38].

3.111 The Applicant has followed the instructions from a letter from Trafford PCT regarding the core hours 09.00 to 17.30 [see Tab 39].

3.112 In the Applicant's previous application (CAS-715636-X6Q4B) [see Tab 40, p46], the NHS resolutions stated:

3.113 The Committee noted that the Applicant had given an undertaking, in their original application form,that the same services will be provided at the proposed site. However the Committee noted that NHS England and the applicant do not agree as to what the opening hours actually are. The Committee, is mindful that Schedule 4 to the Regulations provides that the opening hours listed in relation to the premises of a provider form part of the provider's terms of service and these may only be changed by virtue of an application or a notification made in accordance with the Schedule. Therefore although noting that the pharmacy is offering a half hour more each day than NHS England expects of them to, in these circumstances, the Committee determined that they had no remit to consider any change to the pharmacy opening hours in relation to Regulation 24(l)(d). Therefore on the information provided, the Committee determined that condition (d) is met.

3.114 There have been no changes since the last application regarding the opening and closing times and this has been confirmed in the application.

3.115 In the context of Regulation 24(l)(d), the Applicant undertakes that the Pharmacy will continue to provide the same services (Essential, Enhanced and Advanced services) during and after the proposed relocation.

3.116 In the above circumstances, it is submitted that the Applicant has discharged its onus to prove that the limbs of the test are met and that this relocation application ought to be granted.

3.117 [The Committee had regard to the Applicant’s supporting information at Appendix A.]

4 Summary of Representations

This is a summary of representations received on the appeal.

4.1 BOOTS UK LTD

4.1.1 Boots UK Ltd agree with the decision of NHS England and its reasoning. It respectfully asks that consideration is given to the distance involved here and the ALL patients are considered as part of the determining of this appeal.

4.1.2 The applicant/appellant has still not, in its opinion, evidenced that patients who access the pharmacy for advice or over the counter services would not find the new premises less accessible.

4.2 GREATER MANCHESTER LPC

4.2.1 Greater Manchester LPC applications sub group has reviewed this application and would like to reiterate the comments made in its original response (please see attached). Its opinion that this application does not fall within regulation 24.1 a and b has not altered.

Letter dated 16 January 2019 addressed to NHS England

4.2.2 The LPC has considered this application and has judged the application based on whether the relocation would affect the patient groups which use the pharmacy, and whether the relocation would result in a significant change to the arrangement for pharmaceutical services.

4.2.3 The LPC is of the view that in this case the application should be refused as;

4.2.3.1 The patient groups that are accustomed to accessing pharmaceutical services at the existing premises would find the location of the new premises significantly less accessible.

4.2.3.2 Granting the application would result in a significant change to the arrangements that are in place for the provision of local pharmaceutical services already in place.

4.3 TIMPERLEY PHARMACY

4.3.1 It objects the proposed relocation application and request that application be refused on following grounds.

Background

4.3.2 Pelican Pharmacy is situated in a small shopping parade on a busy Main Road.

4.3.3 Travelling distance between current site and proposed site is 2.6 to 3km (depending on route chosen)

4.3.4 Pelican Pharmacy serves the population of people living on either side of busy Manchester Road and commuters travelling through Manchester Road.

4.3.5 There is big Pub car park next to Pharmacy

4.3.6 Within in few 100 meters of proposed site there are two pharmacies

4.3.6.1 Timperley Pharmacy

4.3.6.2 Well Pharmacy

4.3.7 Timperley Pharmacy has opened every day of the year since it was first open (including Easter Sunday and Christmas Day).

4.3.8 Its opening hours are

4.3.8.1 Monday-Saturday 07:30 ---22:30

4.3.8.2 Sunday 08:00 ---18:00

4.3.9 Decision making committee would have to consider following regulation.

4.3.10 Regarding Regulation 24, the Committee would have to consider the application having due regard to the following:

(a) For the patient groups that are accustomed to accessing pharmaceutical services at the existing premises, the location of the new premises is not significantly less accessible

4.3.11 In relation to regulation 24(a)

4.3.12 The distance between existing pharmacy and proposed site is 2.7km.

4.3.13 There is significant population who would find new premises significantly less accessible due to long distance and there is a physical barrier of busy Manchester Road and Park Road.

4.3.14 Journey on foot will take around 30-35 minutes on busy Park Road.

4.3.15 There are patients who share protected characteristics such as elderly and or those who have mobility issues, will therefore have significant difficulty accessing the proposed site on foot.

4.3.16 Already disadvantaged population will suffer further due to proposed relocation.

4.3.17 Flu Jab

4.3.18 Pelican Pharmacy Provides Flu Jab service. As per data available 36 Flu Jabs were given for year 2018/2019, and 34 for year 2017/2018. Flu Jab Service is provided by Surgeries as well as by other Pharmacies. Those patients would have accessed the Pelican Pharmacy because this pharmacy is convenient to them otherwise they would have not got the service from Pelican Pharmacy.

4.3.19 MURs

4.3.20 Similarly Pelican Pharmacy has provided on an average 22 MURs per month. All those MURs would have been provided face to face. So the argument that very few patients access the pharmacy is baseless.

4.3.21 NUMSAS

4.3.22 In NUMSAS patient rings the 111 and each referral is made on the basis of closest available pharmacy or on the basis of ease of access. Pelican Pharmacy provides NUMSAS service to all those patient’s in emergency. They choose Pelican Pharmacy because this Pharmacy in its current site is convenient to them otherwise they could easily choose any other pharmacy. As mentioned in applicant’s appeal that new site will be better due to parking conditions but there are two other pharmacies already present near proposed site and those patients if want can access the same service from other providers.

4.3.23 EHC and Minor Ailment Service

4.3.24 As explained above patients access these services face to face. They access the pharmacy face to face to use these services. Again those services are provided near proposed location already. If new location would have been more accessible they would have used the services of other pharmacies.

4.3.25 Prescription Service and Car Parking and Survey Conducted

4.3.26 It could not understand the legitimacy and the authenticity of the survey conducted. This was neither an independent nor right legal test in support of relocation application. Each Pharmacy is required to conduct an annual patient satisfaction survey and publish its results. Currently there are two publications present at NHS choices for Pelican Pharmacy.

4.3.27 https://www.nhs.uk/Services/pharmacies/Overview/DefaultView.aspx?i d=346 39

4.3.28 2017/2018 Patient Survey.

4.3.29 As no latest survey was available neither on the website nor on NHS Choices link so it has to rely on information provided on these survey. As per survey most of the patient are very satisfied with the service and

they intend to come back for the service. If there would have been any concern they would have mentioned in the survey.

4.3.30 Waiting Time Audit.

4.3.31 A waiting time audit was conducted and completed on 21st January 2018. All 50 patients were satisfied from waiting times. It imagines that waiting time mean waiting in pharmacy. So those patients would have accessed the pharmacy face to face.

4.3.32 As explained above if the current pharmacy is hard to access and new location will be better due to better parking, there is already option of two service providers at the proposed location with excellent free parking facilities and more opening hours.

4.3.33 In view of the above points there is very strong argument that survey conducted is not valid and does not support the relocation application.

4.3.34 Pelican Pharmacy is situated Broadheath ward of local authority.

4.3.35 As per data from ONS

4.3.36 https://www.nomisweb.co.uk/reports/localarea?compare=E05000822

4.3.37 As per data there are 1567 people in this ward whose day to day actives are limited a lot or little limited. These are people of protected characteristics. These people are likely to use a pharmacy which is closer to their residence.

4.3.38 Similarly there are 748 households living in this ward who have access to no vehicle. These are people with protected characteristic. These would include mums with children who use buggies to commute to nearest pharmacy with their children. There will be patient who uses mobility scooters to access the pharmacy, as this would be closer to their home. Relocating the pharmacy so far will make it impossible for them to access the pharmacy service.

(b) Granting the application would not result in a significant change to the arrangements for the provision of pharmaceutical services in any part of the HWB area or in a controlled locality.

4.3.39 Proposed relocation will result in reduction in number of pharmaceutical provider at Manchester road as nearest Pharmacy (Well Pharmacy – Eastway) is about 0.7 km away

(c) The application will not cause significant detriment to the proper planning of the provision of pharmaceutical services in the area

4.3.40 Movement to the proposed new premises would result in clustering of pharmaceutical provision in this immediate relocation. This will cause significant detriment to the proper planning of provision of pharmaceutical services in the area.

4.3.41 Both existing and proposed site are in completely two different neighbourhoods serving two completely different group of population.

4.3.42 To elaborate it further if one search nearest Pharmacy (NHS Choices) to Pelican Pharmacy, the results are as following

4.3.42.1Well – Eastway (0.4Miles)

4.3.42.2Station Pharmacy (0.5 Miles)

4.3.42.3Terry’s Chemist (0.5miles)

4.3.42.4Boots (Altrincham Retail Park) (0.6Miles)

4.3.42.5Rowland Pharmacy (coppice avenue) (0.6miles)

4.3.42.6Riddings Pharmacy (0.6Miles)

4.3.42.7Broadheath Pharmacy (0.8miles)

4.3.43 Nearest GP Surgeries to existing site of Pelican Pharmacy are

4.3.43.1West Timperley Medical Centre

4.3.43.2Riddings Family Health Centre

4.3.43.3Family Surgery

4.3.43.4Dr Macdonald and Partners (Barrington)

4.3.44 Closest GP surgeries to proposed premises are

4.3.44.1Timperley Health Centre (Dr Westwood)

4.3.44.2Village Surgery

4.3.44.3Grove Medical Practice

4.3.44.4The Lake Medical Centre

4.3.44.5Brooklands Medical Practice

4.3.45 In application form the applicant has mentioned that new premises will not be less accessible to pharmaceutical services originating from Park Medical Centre.

4.3.46 While closest surgeries to current premises are different. Proposed and current pharmacies are in completely two different neighbourhoods and serves two different population. So proposed new site will be less accessible for Pharmaceutical services originating from West Timperley Medical Centre and Barrington Medical Practice. Proposed Site will also be significantly less accessible for patient group living in vicinity of current site. Dispensing of Prescription is not the only service which pharmacies offer, there are other services like advice to patients, OTC medication and other Essential Services which are integral part of Pharmacy Contract.

4.3.47 It requests the above application be refused on above-mentioned grounds.

4.3.48 [The Committee had regard to Timperley Pharmacy’s supporting information at Appendix B.]

4.4 WELL

4.4.1 For this application to be granted the Area Team [sic] must be assured that;

4.4.1.1 The same services and hours will be available post relocation.

4.4.1.2 The proposed premises must not be significantly less accessible than the current services.

4.4.1.3 Granting the relocation would not result in a significant change to the arrangements in place for pharmaceutical services or local pharmaceutical services.

4.4.1.4 Granting the relocation would not cause the significant detriment to proper planning in respect of the provision of pharmaceutical services in its area.

4.4.1.5 There must not be any interruption to service provision.

4.4.2 Defining the patient groups that use the pharmacy in the existing location is key for the NHS to make an assessment if there will be any significant impact on the reliant population post relocation. We would propose to broaden the applicant's definition of the patient groups that use the pharmacy in the existing location and propose that the following patient groups be adopted. Patients groups are where the prescriptions originate from, West Timplerley Medical Centre, Firsway Health Centre, Washway Road Medical Centre, Grove Medical Practice, Park Medical Practice, Wilmslow Road Surgery and Timperley Health Centre (Westwood).

4.4.3 The applicant is proposing to move with the surgery that accounts for only a small amount of the total dispensing. This would suggest the majority of patients the pharmacy serves in the current location, would be significantly impacted as a result of the relocation as 93% of the prescriptions dispensed originate from a different surgery from which the applicant is proposing to move closer to.

4.4.4 The applicant has failed to fully investigate the impact of the relocation on these patient groups. There has been no consideration made for the distance between the sites and how patients currently access pharmaceutical services at the current location. The applicant has also failed to consider where the patients start their journey and how the change of premises will impact this. It is hard for NHS England [sic] to fully assess the likely impact the relocation on patient groups who are currently using the existing site and how the applicant will continue to provide a full range of pharmaceutical services to those groups without such information. Adding an additional circa. 1.5 mile journey would be a barrier to accessing services and this would have a significant impact on the patients who enjoy accessing services in the current location.

4.4.5 Furthermore, the applicant has failed to consider the impact on any patient group with a protected characteristic such as age, or disability who may be impacted upon as a result of the relocation. Even a small change can be a barrier to accessing patient groups with certain protected characteristics such as disability or parents with young children. A distance of circa. 1.5 miles is a considerable distance for patients to travel post relocation. The applicant has also made no reference to the site's accessibility for parking in comparison to the current site or how many patients access the current location in this manner.

4.4.6 Whilst there may be a delivery service available from the current location as this is a non-NHS service, the NHS is right to consider that it could be removed at any time. If this service was to be removed, there would be a significant impact on the patients who would have to default back to accessing the site in person.

4.4.7 This application has recently been considered at appeal SHA/19973 and it was refused. There have been no substantial changes to the area in the few months since this application was considered.

4.4.8 Well respectfully requests that the Area Team [sic] refuse the application as it fails to fully satisfy the regulatory test for a non- significant relocation.

5 Observations on representations

5.1 RUSHPORT ADVISORY LLP ON BEHALF OF THE APPLICANT

5.1.1 Boots:

5.1.2 Boots state:

5.1.2.1 The applicant/appellant has still not, in our opinion, evidenced that patients who access the pharmacy for advice or over the counter services would not find the new premises less accessible.

5.1.3 The applicant has provided a full assessment of every patient/ patient group that is accustomed to accessing the existing premises which includes any patient that does so in respect of advice and over the counter services these being essential pharmaceutical services. Additionally, analysis has been provided in terms of the starting point and mode of transport to access the current premises and the impact in terms of accessing the new premises.

5.1.4 Boots has provided a blanket objection and has failed to particularise or provide any evidence to support its objection.

5.1.5 LPC:

5.1.6 The LPC state:

5.1.6.1 Greater Manchester LPC applications sub group has reviewed this application and would like to reiterate the comments made

in our original response (please see attached). Our opinion that this application does not fall within regulation 24.1 a and b has not altered.

5.1.7 With respect, the applicant disagrees.

5.1.8 In relation to Reg 24(1)(a)

5.1.8.1 24.-(1) Section 129(2A) of the 2006 Act (regulations as to pharmaceutical services) does not apply to an application from a person already included in a pharmaceutical list to relocate to different premises in the area of the relevant HWB (HWB1) if –

5.1.8.1.1(a) for the patient groups that are accustomed to accessing pharmaceutical services at the existing premises, the location of the new premises is not significantly less accessible;

5.1.9 The applicant has provided a full and comprehensive assessment of every patient/ patient group that is accustomed to accessing the existing premises.

5.1.10 The analysis provided includes:

5.1.10.1The purpose in relation to accessing the existing premises

5.1.10.1.1Essential pharmaceutical services (dispensing)

5.1.10.1.2Essential pharmaceutical services (ALL services other than dispensing)

5.1.10.1.3Advanced pharmaceutical services

5.1.10.1.4Enhanced commissioned services

5.1.10.2The starting point for ALL patients accessing the existing premises

5.1.10.3The mode of access to the existing premises

5.1.10.3.1Foot

5.1.10.3.2Car

5.1.10.3.3Other

5.1.10.4An assessment of ease of access to the new premises by the mode of transport that the patient is accustomed to utilising

5.1.10.5An assessment of any patient sharing a protected characteristic in relation to Equality Act and their ability to easily access new premises

5.1.11 With respect, NHS Resolution must determine this application in relation to evidence provided in terms of people accustomed to accessing the existing premises. The applicant has provided fully

reasoned evidence relevant to Regulation 24 whereby objecting parties imply that this is not the case or attempt to deflect the focus to areas and considerations that do not relate to the test to be satisfied for a no significant change relocation.

5.1.12 In relation to Reg 24(1)(b):

5.1.12.1(b) in the opinion of the NHSCB, granting the application would not result in a significant change to the arrangements that are in place for the provision of local pharmaceutical services or of pharmaceutical services other than those provided by a person on a dispensing doctor list-

5.1.12.1.1(i) in any part of the area of HWB1, or

5.1.12.1.2(ii) in a controlled locality in the area of a neighbouring HWB, where that controlled locality is within 1.6 kilometres of the premises to which the applicant is seeking to relocate;

5.1.13 The applicant has provided evidence to demonstrate that it is not a busy pharmacy compared to all the other pharmacies in the area. This is not disputed by the objectors and no party including the LPC has provided any evidence that by granting this application would result in a change of arrangements that are in place for the provision of pharmaceutical services. In any event PSRC confirmed in its previous decision SHA/19973 that the relocation would not result in a significant change to the arrangements that are in place for the provision of local pharmaceutical services.

5.1.14 Timperley Pharmacy:

5.1.15 Timperley Pharmacy refer to Reg 24(1)(a):

5.1.15.1Regarding Regulation 24, The Committee would have to consider the application having due regard to the following:

5.1.15.1.1For the patient groups that are accustomed to accessing pharmaceutical services at the existing premises, the location of the new premises is not significantly less accessible

5.1.15.1.2In relation to regulation 24(a)

5.1.15.1.3The distance between existing pharmacy and proposed site is 2.7 km.

5.1.15.2There is significant population who would find new premises significantly less accessible due to long distance and there is a physical barrier of busy Manchester Road and Park Road.

5.1.15.3Journey on foot will take around 30-35 minutes on busy Park Road.

5.1.16 In doing so they make an incorrect assumption that patients walk to access the existing premises and would do so to the new premises. The applicant has provided a full analysis showing that the number of patients accessing on foot is negligible and unlike the applicant’s assessment Timperley Pharmacy chose to ignore where a patient on foot starts the journey. With respect it refers NHS Resolution to the applicant’s thorough patient group access submissions.

5.1.17 Timperley Pharmacy state in relation to Equality Act:

5.1.17.1There are patients who share protected characteristics such as elderly and or those who has mobility issues, will therefore have significant difficulty accessing the proposed site on foot. Already disadvantaged population will suffer further due to proposed relocation.

5.1.18 The applicant has analysed any and all patients who are accustomed to accessing the existing premises for all pharmaceutical services including all shared characteristics. There is no evidence that any person with a protected characteristic would experience any detriment in accessing the new premises.

5.1.19 In respect of services other than essential pharmaceutical services, the applicant will comment as below:

5.1.19.1Flu Jab – With reference to Timperley Pharmacy’s quoted data of 34 to 36 flu jabs per year from 2017 to 2019, this is equivalent to 6 flu jabs per month during the 6-month flu season (please note that the applicant is authorised to conduct flu jabs off-site and has been doing so during the flu season) and is consistent with the applicant’s data and would have been included in the survey conducted by the applicant. This reinforced the applicant’s submission that very few patients access its pharmacy and the existing patients do not find the new location less accessible.

5.1.19.2MUR – With reference to Timperley Pharmacy’s quoted data of 22 MURs per month, this is equivalent to about one MUR per day and is consistent with the applicant’s data and would have been included in the survey conducted by the applicant. This reinforced the applicant’s submission that very few patients access its pharmacy and the existing patients do not find the new location less accessible.

5.1.19.3NUMSAS – This pilot scheme is for patients who require emergency medication and is open to patients throughout England. The number of users for this service is very low as the first point of contact is normally the GP. If a request is sent to Pelican Pharmacy, the request can be turned down if the medication is not available. In any event, this would have been included in the survey conducted by the applicant.

5.1.19.4EHC – This scheme is open to patients throughout England. The number of users at Pelican Pharmacy is very low and would have been included in the survey conducted by the applicant.

5.1.19.5Minor Ailments – this is open to patients in Trafford and the number of users is very low. These patients would have been included in the survey provided by the applicant.

5.1.20 Timperley Pharmacy provide Census 2011 data in relation to health and provision of unpaid care for Broadheath ward in the misapprehension that this data relates to the patients accustomed to accessing the existing premises. The issues being:

5.1.20.1The data (which is over 8 years old) submitted is in relation to Broadheath ward, the applicant in providing patient post-codes and mapping has shown that people accustomed to accessing the existing premises start their journey from Timperley ward area AND other areas surrounding and further afield.

5.1.20.2The data refers to by way of example ‘people describing day to day activity limited a little or a lot’ which may or may not be due to a protected characteristic. The representation made by Timperley Pharmacy is nonsensical.

5.1.20.3Timperley Pharmacy appear to be making an assumption that people with protected characteristics in Broadheath ward would be accustomed to accessing the existing pharmacy whereas the test in relation to Reg 24(1)(a) refers only to those accustomed to accessing the existing premises. The applicant has provided evidence of any person with a protected characteristic that actually is accustomed to accessing the existing premises.

5.1.21 Timperley Pharmacy are saying any of these people could access the applicant’s existing premises but again as NHS Resolution is aware this is not the test to be applied as per Reg 24(1)(a).

5.1.22 Timperley Pharmacy mention ‘clustering’, as NHS Resolution is aware The National Health Service (Pharmaceutical and Local Pharmaceutical Services) Regulations 2013 does not include ‘clustering’. It is worth pointing out that Timperley Pharmacy (at 250 Stockport Road) applied for 100 hours pharmacy contract to be situated 6 doors away from Well Pharmacy (at 238 Stockport Road). If clustering were an issue, he should not have applied to be 6 doors away from another pharmacy.

5.1.23 Well Pharmacy:

5.1.24 In terms of patient group the applicant feels that Well Pharmacy are attempting to ‘muddy the water’ by suggesting prescriptions originating from a number of surgeries should be considered. The key consideration ought to be ‘patient group accustomed to accessing pharmaceutical services at the existing premises’ (which was ignored by Well Pharmacy). Similarly, PSRC excluded ‘patient group accustomed to accessing pharmaceutical services at the existing premises’ from its decision dated 9 April 2019 and focused on ‘is the location of the new premises significantly less accessible than the current premises’. This is plainly incorrect.

5.1.25 The applicant’s patient group include any patient that is registered at the mentioned surgeries and others in the local and wider area. Where the prescription originates is not the most relevant or helpful to NHS Resolution, the applicant’s approach as below is relevant in terms of:

5.1.26 For those who are accustomed to accessing the existing premises

5.1.27 The purpose in relation to accessing the existing premises

5.1.27.1Essential pharmaceutical services (dispensing)

5.1.27.2Essential pharmaceutical services (ALL services other than dispensing)

5.1.27.3Advanced pharmaceutical services

5.1.27.4Enhanced commissioned services

5.1.28 The starting point for ALL patients accessing the existing premises (home/work/GP surgery/ other)

5.1.29 The mode of access to the existing premises

5.1.29.1Foot

5.1.29.2Car

5.1.29.3Other

5.1.30 An assessment of ease of access to the new premises by the mode of transport that the patient is accustomed to utilising

5.1.31 An assessment of any patient sharing a protected characteristic in relation to Equality Act and their ability to easily access new premises

5.1.32 Well Pharmacy state:

5.1.32.1The applicant is proposing to move with the surgery that accounts for only a small amount of the total dispensing. This would suggest the majority of patients the pharmacy serves in the current location, would be significantly impacted as a result of the relocation as 93% of the prescriptions dispensed originate from a different surgery from which the applicant is proposing to move closer to.

5.1.33 The applicant is proposing to move to a new health and social hub which includes a GP surgery and local resources such as a library and other social enterprises. The applicant has analysed all patients no matter which surgery they are registered at and there is no evidence that any patient would be significantly impacted by this relocation.

5.1.34 In making the following statement Well Pharmacy has clearly not read or failed to adequately consider the detailed analysis of those accustomed to accessing the existing premises as provided by the applicant.

5.1.34.1The applicant has failed to fully investigate the impact of the relocation on these patient groups. There has been no consideration made for the distance between the sites and how patients currently access pharmaceutical services at the current location. The applicant has also failed to consider where the patients start their journey and how the change of premises will impact this. It is hard for NHS England to fully assess the likely impact the relocation on patient groups who are currently using the existing site and how the applicant will continue to provide a full range of pharmaceutical services to those groups without such information. Adding an additional circa. 1.5 mile journey would be a barrier to accessing services and this would have a significant impact on the patients who enjoy accessing services in the current location.

Furthermore, the applicant has failed to consider the impact on any patient group with a protected characteristic such as age, or disability who may be impacted upon as a result of the relocation. Even a small change can be a barrier to accessing patient groups with certain protected characteristics such as disability or parents with young children. A distance of circa. 1.5 miles is a considerable distance for patients to travel post relocation. The applicant has also made no reference to the site's accessibility for parking in comparison to the current site or how many patients access the current location in this manner.

5.1.35 It is incorrect to consider distance in the context of Regulation 24(1)(a) and the focus ought to be the views of the patients who are accustomed to accessing the pharmaceutical services at the existing premises.

5.1.36 Well Pharmacy reference to the previous decision- SHA 19973.

5.1.37 Whilst the applicant agrees that there have been no substantial changes in the area, with respect that is of no relevance.

5.1.38 SHA 19973

5.1.39 8.24 The Committee was of the view that if patients were not accustomed to accessing pharmaceutical services at the premises, then they were not subject to the test under condition (a). The Committee, however, was particularly mindful that the provision of essential services is not limited to the dispensing of prescriptions.

5.1.40 The applicant agrees in relation to patients not accustomed to accessing the premises and this remains applicable in this application.

5.1.41 The applicant in this application provides clear evidence in relation to all pharmaceutical services including essential services not limited to the dispensing of prescriptions.

5.1.42 Walk ins

5.1.43 8.25 The Committee considered the patient groups referred to by parties, but was of the view that this could be simplified. The Committee considered from the information provided by the applicant that “walk

ins” encompassed all the other patient groups which had been described by the parties. The Committee had reservations about the survey information provided by the applicant in that it was conducted over a period of less than a month, and during the summer, which the Committee considered would not be particularly representative of footfall. However, accepting this information with caution the Committee accepted that this patient group will access the proposed premises either on foot or by car.

5.1.44 The applicant concurs in relation to ‘walk ins’ encompass all the other patient groups which had been described by the parties. This remains the case in this application.

5.1.45 The applicant has provided a much more robust analysis in light of NHS Resolution criticisms in the determination of SHA 19973.

5.1.46 8.26 The Committee considered that patients may start their journey after a visit to their GP practice or outwith a visit to the GP practice, i.e. starting their journey from home, work or in connection with a visit to other services in the locality.

5.1.47 The analysis in this application includes the detail in relation to the start of the journey.

5.1.48 8.27 The Committee noted that the applicant had provided data to support its assertion that few people did walk to the pharmacy however the Committee was mindful of its comments above regarding the voracity of the sample. The Committee also noted that over this 4 week period, 18% of patients who did come to the existing pharmacy, had travelled to the pharmacy on foot. The Committee was of the view that although the applicant maintained that those persons accessing the pharmacy on foot lived between the two sites, no information had been provided to indicate where they started their journey, Further the Committee had concerns as to how those on foot would access the proposed site and whether there were for example any barriers to access (the Committee noted that gradients and busy roads were mentioned by other parties). The Committee was also mindful of the video footage provided by the applicant which showed the car journey between the existing pharmacy and the proposed pharmacy. The Committee considered the video footage from the perspective of a patient who travelled on foot and was of the view that it demonstrated that a walk between the two locations was considerable, with narrowing pavements at some points. Therefore depending on where patients started their journey some of these features could be present for those accessing the proposed site. The Committee concluded that the applicant had not demonstrated that the proposed site was not significantly less accessible should patients wish to access the proposed premises on foot

5.1.49 It was unreasonable for the Committee to challenge the veracity of the sample without providing any evidence and on the basis of its personal feeling. The applicant has conducted a solid analysis of its patient group and provided 97 surveys in its current appeal. Each survey was signed by the patient and the authenticity of these surveys should not be in doubt. Trafford Health and Wellbeing Board Pharmaceutical Needs

Assessment was based on 53 responses received. It is therefore reasonable for the Committee to accept the applicant’s 97 responses.

5.1.50 Data is provided in relation to the post-code of every person who is accustomed to accessing the existing premises.

5.1.51 The video footage had been provided to illustrate easy access by car across the area between the existing and new premises location. This application also includes the actual starting postcode for all patients on foot and clearly shows that not a single patient is required to walk from the existing location to the new location. The evidence shows any walk to the new premises is significantly less than to the existing premises (easier access).

5.1.52 8.28 The Committee noted the applicant’s statistics which stated that 82% of patients who attended the pharmacy in person did so by using a car in order to access the existing premises. The Committee was again mindful that this was a snap shot taken over a short period of 4 weeks. The Committee noted the applicant states “outside the front of the pharmacy, parking is controlled by double yellow lines with no loading restrictions at any time. Parking on the pavement is illegal and the facts are that there are no parking facilities for the pharmacy”. The applicant also states that “the sites accessibility for parking albeit being better than the current site is not relevant. As long as the pharmacy delivery service operates this replicates the current business mode of activity that patient groups are accustomed to accessing.” This information had not been disputed by parties. The Committee however considered that accessibility by car is relevant as if patients currently access the existing premises using private transportation then they would need to be able to continue to do so at the proposed premises. The Committee was not satisfied that “the sites accessibility for parking albeit being better than the current site” without any further supporting information with regard to car parking, journeys from where patients might start their journey, road layout, levels of congestion etc, was an assurance that for those patients using private transportation either following a visit to the GP Practice or for those patients wishing to access pharmaceutical services outwith a visit to their GP, the proposed site was not significantly less accessible.

5.1.53 The data provided is significantly more robust with this application

5.1.54 Evidence has now been provided in relation those using a car to access pharmacy in relation to journey start points, distance travelled, congestion, parking and plans at the new premises.

5.1.55 Contrary to objecting parties’ comments, this application is not to be rejected due to a previous appeal decision. Although nothing in the area has changed the applicant has provided evidence specific to Reg 24 the evidence relates to what NHS Resolution felt was missing with SHA/19973 application.

5.1.56 In relation to the Regulatory tests:

5.1.57 Regulation 31 - is not in play in relation to this application.

5.1.58 Reg 24(1)(a) - The evidence provided clearly shows the location of the new premises is not significantly less accessible for those accustomed to accessing pharmaceutical services at the existing premises.

5.1.59 Reg 24(1)(b) - no evidence has been provided by any party to prove a significant change in arrangements.

5.1.60 Reg 24(1)(c) - no evidence has been provided by any party to prove significant detriment to proper planning

5.1.61 Reg 24(1)(d) - The applicant confirms services to be provided at the new premises are to be the same as those provided at the existing premises

5.1.62 Reg 24(1)(e) - The applicant confirms that pharmaceutical services will not be interrupted.

5.1.63 The applicant has provided comprehensive evidence to support its application. On the contrary, the objecting parties have not provided evidence to support their representations, which are generic and not particularised. None of the objecting parties have considered the opinion of the applicant’s patient group which ought to be a key consideration of this application. The patients who are accustomed to accessing Pelican Pharmacy have provided their opinion, which is that they do not find the new location less accessible. The objecting parties’ views must not be considered in place of the applicant’s existing patients views. If there is any conflicting view, the patients view must prevail.

5.1.64 In the last appeal SHA/19973, NHS Resolution stated that Regulation 24(1)(a) had not been met but Regulation 24(1)(b), (c), (d) and (e) had been met. The Committee had the following observations in its previous decision:

5.1.64.1the length of the previous survey and that the Committee did not consider Summer time representative of footfall. Whilst the applicant is of the view that such decision is irrational and is not evidence based, the applicant has addressed this issue in its recent survey which took place over a three-month period in the winter months from December 2018 to February 2019.

5.1.64.2The Committee stated that the applicant did not have evidence indicating where the patients started their journey. This has been addressed as each patient who participated in the applicant’s recent survey gave their starting position before their visit to Pelican Pharmacy. The result analysis has been provided with the applicant’s appeal and reveals that most patients who use Pelican Pharmacy live near the proposed site.

5.1.64.3The Committee was concerned how patients on foot would access the proposed site as a walk between the two sites was considerable and could possibly have barriers to access. This concern has been addressed as the survey analysis shows that the patients who are accustomed to using Pelican Pharmacy live closer to the proposed location and they do not think the

proposed location is less accessible. The patient’s view must be taken into account and not replaced by the Committee’s view.

5.1.64.4The Committee was concerned about accessibility by car at the proposed site as not enough information had been provided regarding parking and levels of congestion. This has been addressed in the evidence provided. Patients who are accustomed to using Pelican Pharmacy by car have confirmed through the survey that they do not find the proposed location less accessible. Evidence of pictures and parking places for the current and the proposed site has been provided to show that the proposed location has better parking facilities for cars and bikes. Traffic data provided by Trafford Council shows that the current location (A Road) has at least three times of vehicle passing by as compared to the proposed location (B Road). The current location is more prone to heavy traffic and flooding when compared to the proposed location.

5.1.65 The applicant has clearly proven that Regulation 24 is fully satisfied in relation to this application and reserves its right to apply for judicial review in the event that this appeal is not successful.