NHS HAVERING
Pharmaceutical Needs Assessment
1 Document Control
Title: NHS Havering – Pharmaceutical Needs Assessment Authors: Mohamed Kanji – Senior Pharmaceutical Advisor Matthew Henry – Medicines Management Data Analyst Belinda Krishek – Chief Pharmacist Sanjay Patel – Head of Community Pharmacy Denise Baker – Community Pharmacy Administrator Approved By: NHS Havering Board Version: 2011 Final Version 1.0
2 CONTENTS PAGE Page Number 1. Executive Summary 5 2. 10 Key Points for Decision Makers 8 3. Pharmaceutical Needs Assessment 9 3.1 What is a PNA? 9 3.2 What will the PNA achieve? 10 3.3 NHS Havering Vision and Context 10 3.4 National Policy Context 10 3.5 Assessment of Needs 10 3.6 Pharmaceutical Services Covered 11 3.7 What is a Joint Strategic Needs Assessment? 11 3.8 Commissioning Arrangements 12 3.9 Characteristics of Localities 12 3.10 Applications 12 3.11 Assessment of Pharmaceutical Services and Pharmaceutical Needs 13 3.12 Process followed in developing the PNA 15 3.13 Mapping 16 3.14 Consultation 16 4. Demographics & Future Growth 17 4.1 Current Population 17 4.2 Future Growth 17 4.3 Life Expectancy 20 5. Pharmacies Key Information 21 5.1 Location of Pharmacies 23 6. GPs, Hospitals & Polysystems 25 6.1 JSNA Recommendations 25 6.2 GP Practices 25 6.3 Hospitals 27 6.4 Polysystems 27 7. Opening Hours 28 7.1 100 hour Pharmacies 30 7.2 Sunday Rota Service 30 7.3 Bank Holiday Rota Service 30 7.4 Out of Hours Access to Medicines 30 7.5 GP Opening hours 31 7.6 How Pharmacy Can Contribute? 31 8. Essential Services 32 8.1 Equality Act 2010 ( Formerly Disability and Discrimination Act) 32 8.2 Monitoring of the Community Pharmacy Contractual Framework 32 8.3 Local Support Groups 33 8.4 Language Line 33 9. Advanced services 34 9.1 Stoma Customisation & Appliance Use Review 34 9.2 Medicines Usage Reviews (MURs) 34 9.3 Advanced Service Tables 35 10. Enhanced Services 38 10.1 Summary table 38 10.2 Enhanced Services for Substance Misuse 41 10.3 Diabetes 46 10.4 Anti-coagulation Monitoring (Warfarin) 49 10.5 Smoking Cessation Service 51 10.6 Chlamydia Screening & Treatment 53 10.7 Medicines Administration Record (MAR) Service 55 3 Page Number 11. Better Management of Medicines 56 11.1 Background 56 11.2 Enhanced Medication Usage Reviews 58 11.3 Repeat Dispensing 58 11.4 Integrated Case Management 60 11.5 Improved Medicines Management in Nursing Homes 60 11.6 Other Areas 60 12. Patient Feedback 62 13. Pharmacists Survey 63 14. GP Survey 66 15. Identified Health Needs 67 15.1 Background. 67 15.2 Emergency Hospital Admissions 68 15.3 Under 18 Conception 70 15.4 Chronic Obstructive Pulmonary Disorder (COPD) 72 15.5 Obesity & Physical Activity 75 15.6 Cancer 78 15.7 Stroke 79 15.8 Hypertension 81 15.9 Healthy Eating 84 15.10 Alcohol 85 15.11 Dementia 88 15.12 Transforming Community Equipment Service (TCES) 88 16. Appendices 90 16.1 (Appendix 1) Glossary 90 16.2 (Appendix 2) Consultation Report 92 16.3 (Appendix 3) List of pharmacies 107 16.4 (Appendix 4) Patient Survey Responses 109 16.5 (Appendix 5) Opening Hours of Pharmacies 116
4 1. EXECUTIVE SUMMARY
Legislation requires that each Primary Care Trust has a Pharmaceutical Needs Assessment (PNA). The regulations set out the scope of the PNA and require a PNA to be in place by the 1st of February 2011.
NHS Havering’s PNA is a tool to help in the commissioning of pharmaceutical services. It is focused on the priorities identified locally, in particular within the Joint Strategic Needs Assessment (JSNA). DH guidance states that the PNA must be a key component of the JSNA, whilst being a separate document.
The PNA is in line with the vision in the DH White Paper Equity and Excellence: Liberating The NHS which states ‘The community pharmacy contract, through payment for performance, will incentivise and support high quality and efficient services, including better value in the use of medicines through better informed and more involved patients. Pharmacists, working with doctors and other health professionals, have an important and expanding role in optimising the use of medicines and in supporting better health. GP consortia and the NHS commissioning board will use the JSNA to inform their healthcare commissioning decisions’. The PNA is also in line with the QIPP (Quality Improvement Productivity Prevention) agenda.
Below are the key points arising from the PNA grouped into different categories.
General Pharmacy Provision • Havering has good coverage of pharmaceutical service providers and the PNA has not identified a need for any new pharmaceutical service providers
• Over 600 members of the public completed the PNA patient survey in a variety of settings. Patients are very happy with the pharmacy services and access to pharmacies
• NHS Havering will work with all pharmacies to ensure that they deliver services to the quality expected from their service contracts
• A pharmacy minor ailments scheme could address the patients’ feedback for extended GP opening hours by capitalising on the extended pharmacy opening hours. It would also bring Havering in line with all the other PCTs in North East London and the majority of PCTs nationally who commission such a service. Such schemes are a cost effective way of reducing the 18% of GP appointments that are solely for minor ailments, and are supported by patients and GPs
• PCTs are required to consider changes that take place after the publication of the PNA and decide if a supplementary statement or the publication of a new assessment is required. The Community Pharmacy Steering Group will consider changes in the health needs and in the provision of pharmaceutical services on an on-going basis and decide the appropriate revisions that need to take place
Substance Misuse Services • Substance misuse services through pharmacy offer an excellent opportunity to target hard to reach groups. NHS Havering will work with the Drug Alcohol Action Team (DAAT) and community pharmacists to maximise the number of problematic drug users in treatment through enhancement of existing services • The majority of the Havering population can access the pharmacy needle exchange and supervised consumption services easily. However consideration needs to be given to commissioning these services in specific identified wards highlighted in the PNA
5 Other Enhanced Services • Pharmacies are making a valuable contribution to meeting the health needs of the population through enhanced services commissioned by NHS Havering and the Local Authority, in particular smoking cessation and anti-coagulation monitoring
• Anticoagulation (Warfarin) service - Over 1400 patients have been transferred from secondary care to monitoring by community pharmacies. There is a high level of satisfaction with the service offered and projected savings are at least £84k in 2010/11
• Pharmacies are making a valuable contribution to helping smokers quit in Havering accounting for 53% of all the recorded, successful 4 week smoking quitters in Havering during 2009/10
• Overall there is a good distribution of pharmacies providing Chlamydia screening and treatment across Havering. However additional distribution points should be considered in Rainham & Wennington. NHS Havering will work with pharmacy providers to increase Chlamydia screening
Better Management of Medicines • National Institute Clinical Excellence (NICE) guidance indicates that between a third and half of all the medication taken for long term conditions may not be taken as directed. Over 5% of hospital admissions may be medicines related of which half are preventable
• The primary care prescribing budget in Havering is in excess of £34 million and better management of medication could help with the optimal use of this significant resource. Improving medicines taking could potentially have a greater impact on clinical outcomes than changing treatments and it could reduce hospital admissions
• Community Pharmacists have contact with patients and their carers every time they are issued with medication. Patient groups in Havering strongly support greater information and education for patients around medication. Community Pharmacists can have a greater role in the management of medicines through enhanced Medication Use Review schemes in diabetes, hypertension and stroke. Also through Repeat Dispensing, the Electronic Prescription Service (EPS) and the Medicines Administration Record (MAR) scheme
• Consideration needs to be given to improved medication management in the integrated case management work and also within nursing homes
Health Needs • The success of the pharmacy smoking cessation and anti-coagulation services demonstrate that community pharmacy can provide cost effective and highly rated services that can meet the health needs of the population
• Havering has an increasing under 18 conception rate, which is now higher than the national average. Some wards have amongst the highest rates in the country and termination rates are also above the national average. A pharmacy emergency contraception service should be commissioned, in line with the majority of PCTs in London and in line with the JSNA recommendations
• A contraceptive service through pharmacy can be piloted in the specific wards. This will help the uptake of contraceptive services as recommended in the JSNA
• A service should be commissioned in pharmacies to identify the 2.7% of the population who may have undiagnosed Chronic Obstructive Pulmonary Disease (COPD). A pilot in Havering 6 identified 7 severe COPD cases out of 126 smokers screened and potentially saved £12K in avoided hospital admissions
• Community pharmacists can help with the JSNA recommendation to increase patients on exercise referral schemes, if they are allowed direct referral to such schemes
• Pilots show that a community pharmacy weight management scheme can assist with the rising burden of obesity and the service is more cost effective in many cases than prescribing weight reducing medications
• Early roll out of NHS health checks through Community Pharmacy can help identify undiagnosed diabetics and the estimated 20% of people who have undiagnosed hypertension and is strongly supported by patients
• A community pharmacy alcohol interventions scheme is a cost effective way of targeting the estimated 49 000 people in Havering who drink above the Department of Health (DH) recommended levels and improving health outcomes
• Community pharmacy can help in the identification of patients with dementia and to maintain patients in the community through support schemes such as MAR and enhanced medication usage reviews
Public Health Information & Education • Pharmacy public health campaigns are potentially a very powerful way of promoting key health messages recommended in the JSNA, as up to 10% of the Havering population may visit a pharmacy daily
• Such campaigns can address many issues within the JSNA such as increasing the awareness of specific forms of cancer, promoting healthy eating and physical activity and reducing obesity
Consultation • Key Stakeholders were consulted throughout the development of the PNA. In addition, as required by the regulations a formal 60 day consultation was undertaken from the 5th November 2010 up to the 4th January 2011. The responses have been taken in to account within the final PNA. A consultation response summary document has been completed.
7 2. 10 KEY POINTS FOR DECISION MAKERS ARISING FROM THE PNA
1. Pharmacy minor ailments scheme could address the patients’ feedback for extended GP opening hours by capitalising on the extended pharmacy opening hours. It would also bring Havering in line with all the other PCTs in North East London and the majority of PCTs nationally who commission such a service. Such schemes are a cost effective way of reducing the 18% of GP appointments that are solely for minor ailments, and are supported by patients and GPs.
2. Havering has an increasing under 18 conception rate, which is now higher than the national average. Some wards have amongst the highest rates in the country and termination rates are also above the national average. A pharmacy emergency contraception service should be commissioned. A contraceptive service through pharmacy should also be piloted in the specific identified wards highlighted in the PNA.
3. Improved medicines management through schemes such as enhanced medicines usage reviews can help with the 30 – 50 % of medications for long term conditions that are not taken as directed. This could lead to improvements in the condition, reduce drug wastage and hospital admissions
4. Early roll out of NHS health checks through Community Pharmacy can help identify undiagnosed diabetics and the estimated 20% of people who have undiagnosed hypertension; this is strongly supported by patients.
The above four points (1-4) have been identified as a priority by the Clinical Commissioning Group for NHS Havering. Business cases will be developed for these services for possible commissioning from April 2011.
The Key Points below (5-10) will be considered for commissioning in future years.
5. Consideration needs to be given to improved medication management in the integrated case management work and also within nursing homes.
6. A service should be commissioned in pharmacies to identify the 2.7% of the population who may have undiagnosed COPD. A pilot in Havering identified 7 severe COPD cases out of 126 smokers screened and potentially saved £12K in avoided hospital admissions.
7. A community pharmacy alcohol interventions scheme is a cost effective way of targeting the estimated 49 000 people in Havering who drink above the Department of Health (DH) recommended levels and improving health outcomes.
8. Pilots show that a community pharmacy weight management scheme can assist with the rising burden of obesity and the service is more cost effective in many cases than prescribing weight reducing medications.
9. Substance misuse services through pharmacy offer an excellent opportunity to target hard to reach groups. NHS Havering will work with the DAAT and community pharmacists to maximise the number of problematic drug users in treatment through enhancement of existing services.
10. Consideration needs to be given to how the network of community pharmacies can be utilised to enhance patient care, possibly on the basis of pilots of the ‘Healthy Living Pharmacy’ concept.
8 3. PHARMACEUTICAL NEEDS ASSESSMENT (PNA)
Key Points:
• Legislation requires that each PCT has a PNA. NHS Havering’s PNA is a tool to help in the commissioning of pharmaceutical services that are focused on the priorities identified locally, in particular within the Joint Strategic Needs Assessment (JSNA) as required under the regulations • DH guidance states that although the PNA will need to be a separately identifiable document, it will also be seen as a key component of the JSNA • National and local guidance suggests that pharmacies can have a valuable role in working with local clinicians to deliver safe, sustainable and affordable health services to support NHS Havering priorities • PCTs are required to consider changes that take place after the publication of the PNA and decide if a supplementary statement or the publication of a new assessment is required. The Community Pharmacy Steering Group will consider changes in the health needs and in the provision of pharmaceutical services on an on-going basis and decide the appropriate revisions that need to take place
3.1 WHAT IS A PNA?
The PNA is a structured approach to identifying unmet pharmaceutical needs. A primary function of the PNA is to help those in NHS Havering responsible for commissioning services to manage the current and future availability of pharmaceutical services to people living and working in Havering. These services will support NHS Havering in delivering its health objectives.
Critical success factors for any PNA is to ensure that commissioning is undertaken in such a way as to provide value for money for the NHS. This includes ensuring the quality, effectiveness and efficiency of pharmaceutical services as well as ensuring appropriate management of market entry and securing value for money from existing providers of pharmaceutical services.
Section 128A of the NHS Act 2006 requires Primary Care Trusts (PCTs) to assess the pharmaceutical needs for its area and to publish a statement of its assessment and of any revised assessment. Termed a Pharmaceutical Needs Assessment (PNA), the NHS (Pharmaceutical Services) Amendment Regulations SI 2010 No. 914, provide PCTs with the minimum information that must be contained within their PNA (whilst leaving scope for the PCT to include any other details that it considers relevant) and also outlines the process that must be followed in the development of the PNA.
PNAs were first developed in 2004/5 to support the implementation of the new community pharmacy contractual framework and to determine what additional pharmacy services were needed locally. In particular, they set out the directed services to be provided by applications exempt from Control of Entry arrangements for example 100 hour pharmacies. In that respect, they were used less to commission new services.
In addition to Health Act and regulations the following DH guidance has been used in the development of the PNA: • Pharmaceutical Needs Assessments (PNAs) as part of world class commissioning – Guidance for PCTs (January 2009). • Developing Pharmaceutical Needs Assessments – A practical guide (July 2009). • Pharmacy in England: Building on strengths – delivering the future –Regulations under the Health Act 2009: Pharmaceutical Needs Assessments Information for Primary Care Trusts 9
3.2 WHAT WILL THE PNA ACHIEVE?
The PNA informs interested parties of the pharmaceutical needs within its area and enables PCTs to identify, plan and deliver possible ways in which the health needs of the population can be addressed through pharmaceutical services.
Legislation is being amended so that a PNA based market entry system will replace the current NHS “control of entry” arrangements. Further information on the “control of entry” can be found on the Pharmaceutical Services Negotiating Committee (PSNC) website (www.psnc.org.uk).
The NHS Havering PNA has used this opportunity to focus on considering how services can be commissioned against local health priorities. Enhance pharmacy’s contribution through expanded access and improved patient choice of services with a much bigger role for pharmacy in tackling health inequalities
3.3 NHS HAVERING VISION AND CONTEXT
For all people in Havering, our vision is to increase life expectancy, reduce health inequalities and improve quality of life. We will become a major influencer in creating a healthy, safer borough environment in which to live.
• To commission quality services that give choice and control to people; • Radically redesign our Primary Care provision, align targeted and open access services with the borough and operate jointly 7 days-a-week; • Empower residents to access health and wellbeing, education and training opportunities; and • To make informed evidence based investment decisions, delivering clearly defined outcomes.
3.4 NATIONAL POLICY CONTEXT
The DH White Paper Equity and Excellence: Liberating the NHS (3.22 p.26) states, ‘The community pharmacy contract, through payment for performance, will incentivise and support high quality and efficient services, including better value in the use of medicines through better informed and more involved patients. Pharmacists, working with doctors and other health professionals, have an important and expanding role in optimising the use of medicines and in supporting better health.’ This is very much integrated into the Quality Innovation Productivity Prevention (QIPP) agenda.
3.5 ASSESSMENT OF NEEDS
The regulations stipulate the PNA must have regard to the assessment of needs identified in the Joint Strategic Needs Assessment (JSNA) that is produced by the PCT with Havering Local Authority. The JSNA covers health and social care. Whilst the JSNA identifies the overall health needs and priorities for the population, the PNA will focuses on the contribution community pharmacy contractors can make in meeting these needs and priorities. It also takes into account services delivered by other providers.
For the PNA, NHS Havering has mapped the services of a range of providers. These include providers and premises within Havering but also those other providers providing services from outside Havering e.g. those on the Havering borders, those that provide services by mail order or internet, services from hospital and Out of Hours providers. This will assist the PCT in assessing whether there is still unmet need for services once its existing services have been considered.
10 Having assessed local needs and the provision of services, the PNA has identified the gaps in services. Options to provide services to meet those gaps can be assessed as part of the overall prioritisation process. This will assist the PCT to work with providers to target services to those areas where they are needed and to limit the duplication of services in areas that are already adequately provided for.
3.6 THE DEFINITION OF PHARMACEUTICAL SERVICES COVERED
In this document “pharmaceutical services” refers to provision of pharmaceutical services such as the supply of medicines and advice, support for health, well-being and better medicine taking.
This is inline with the new Part 1A and Schedule 3A of the new regulations where pharmaceutical services are defined as services of a type that may be provided by those on the pharmaceutical list (whether or not they are provided by those on the pharmaceutical list or by other providers). These are: Essential Services; and Advanced and those Enhanced Services set out in Directions.
Providers of pharmaceutical services have a crucial role to play in improving the health of local people. They are often the first point of contact, especially for those who might otherwise struggle to access health services. Effective commissioning includes assessing and prioritising population needs, focusing on strategic outcomes, procuring services, and managing providers to deliver the desired results1. Central to successful commissioning will be an ability to work in close partnership with all local community partners. Development of the PNA for NHS Havering has taken account of these principles with a view to maximising the benefits available from pharmaceutical services and to promote efficient use of NHS resources2.
PCTs’ commissioning priorities are driven by the joint strategic needs assessment (JSNA). The PNA is a key component of the JSNA.
3.7 WHAT IS A JOINT STRATEGIC NEEDS ASSESSMENT?
The Local Government and Public Involvement in Health Act (2007) placed a statutory duty on Local Authorities and Primary Care Trusts (PCTs) to undertake Joint Strategic Needs Assessments (JSNA)3. The JSNA aims to “assess the health and wellbeing needs of a local population, with the aim of establishing a shared, evidence based consensus on key local priorities to support commissioning to improve health and wellbeing outcomes and reduce inequalities”. The 2010 Government White Paper “Equity and Excellence: Liberating the NHS” proposes a continued statutory role for the JSNA, suggesting the following:
• Local Authorities will lead on the JSNA to ensure coherent and co-ordinated commissioning strategies, as part of their enhanced proposed role in health (previously was a joint responsibility between Local Authorities and the Primary Care Trust)
• GP Consortia and the NHS Commissioning board will use the JSNA to inform their healthcare commissioning decisions
• The new statutory Health and Wellbeing Boards (placed within the Local Authority) will be responsible for assessing the needs of the local population and leading the JSNA
The JSNA 2010 has been used to identify health needs within this PNA and to suggest ways in which community pharmacy can help address these needs.
1http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_080958 2 http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitalasset/dh_113807.pdf 3 http://www.hspnetwork.org.uk/links/documents/JSNA.pdf 11
3.8 COMMISSIONING ARRANGEMENTS
At the time of preparing this PNA for consultation the structure and commissioning arrangements of the NHS in England are changing. However in preparing this PNA, NHS Havering has made the judgement that the functions delivered by community pharmacies will remain necessary to promote safe and appropriate use of medicines whilst making efficient use of NHS resources.
The PNA has been prepared at a time when the NHS is being asked to reduce costs and find savings. As a result all areas of NHS spending, including pharmaceutical services will be scrutinised to ensure that money is spent to deliver the outcomes expected by patients and the public.
However, the task at hand is for the PCT to ensure that it has in place a robust PNA by 01 February 2011; this document is intended to meet that requirement.
3.9 CHARACTERISTICS OF LOCALITIES
Regulation 3G(e) refers to PCTs having regard to different needs of different localities within a PCT area. The localities used within this PNA are the electoral wards. This is in order for the PNA to be in line with the JSNA which has used wards.
In some cases such as opening hours, Polysystems have been considered as well as wards. The Polysystems are described in section 6.4.
3.10 APPLICATIONS
Standard
The DH considers that the PNA based market entry system will replace current NHS market entry with new arrangements which will:
- Make PCTs responsible for assessing patients’ needs locally - Ensure PCTs commission services against those needs and other local health priorities. - Create explicit requirements for delivery of high standards, quality and good patient outcomes for the investment made. - Enhance pharmacy’s contribution through expanded access and improved patient choice of services with a much bigger role for pharmacy in tackling health inequalities.
The 2009 Health Act outlines new arrangements for entry onto the pharmaceutical list. The act states that for applications where:
(2A) The Primary Care Trust is satisfied as mentioned in this subsection if, having regard to its needs statement and to any matters prescribed by the Secretary of State in the regulations, it is satisfied that it is necessary to grant the application in order to meet a need in its area for the services or some of the services specified in the application.
The PNA has not identified any gaps in the provision of pharmaceutical services that would require a type 2A application.
The DH will be publishing regulations and guidance around the use of PNAs to handle applications from April 2011. These will provide further information on other types of applications for pharmaceutical services. The PNA may need to be reviewed when the regulations and guidance are published.
12 Under the current control of entry regulations, provision is made for certain types of applications to be exempt from the current regulatory test. For three of these types of applications, pharmacies are required to provide a full and prescribed range of services, appropriate to local needs.
These exemptions are:
• Pharmacies based in leasehold premises in large shopping developments away from town or similar centres with more than 15,000 square metres retail leasehold gross floor space; • Pharmacies providing services of at least 100 hours per week; and • Consortia set up to establish new one stop primary care centres.
As the PNA went to consultation it had not been decided nationally whether any or all of the exemptions from the control on entry test would still be in place for the new market entry regulations. If any of these exemptions are in place then an application to provide pharmaceutical services based on one of these exemptions must include details of how it will provide the full list of advanced and enhanced services that are commissioned by the PCT or its partner organisations e.g. the Local Authority. These services must be delivered throughout a pharmacies core hours except services which may require out of normal hours access e.g. the out of hours access to medicines and rota services.
In addition, such pharmacies must be prepared to offer these services from the day they are admitted to the pharmaceutical list.
The enhanced services currently commissioned are:
• Smoking Cessation Service • Chlamydia Screening • Chlamydia Treatment service • Anticoagulation Monitoring service • Diabetes Medicines Use Review (MUR) service • Supervised Consumption Scheme • Needle Exchange Scheme • Sunday Rota Service • Bank Holiday Rota Service • Out of Hours Access to Medicines • Medicines Administration Record Service (MAR)
3.11 ASSESSMENT OF PHARMACEUTICAL SERVICES AND PHARMACEUTICAL NEEDS
The National Health Service (Pharmaceutical Services and Local Pharmaceutical Services) (Amendment) Regulations 2010 require the PCT to consider the need for pharmaceutical services in terms of: • Services currently commissioned that are necessary to meet a current need • Services that are currently commissioned which are relevant but do not constitute “necessary services”. • Services not currently commissioned that will be necessary in specified future circumstance • Services not currently commissioned that would secure improvements or better access to pharmaceutical services
Table 1 below summarises the assessment of the current and proposed services in line with the above requirement: Further information is provided in the relevant sections that discuss the individual services.
13 Table 1. Essential Services The PCT considers that access to essential services is a necessary service to meet current need for which is secured through our existing pharmacy contractors. Advanced Services
Medicines Use The PCT considers that the Medicines Use Reviews service is a Reviews necessary service to meet current need. Appliance Use The PCT considers that both the Appliance Use Review and Stoma Reviews and Customisation services are relevant but do not constitute a necessary Stoma service Customisation Current Commissioned Services
Needle and Syringe The PCT considers that the Needle and Syringe Exchange service is a Exchange Service necessary service to meet current need. Supervised The PCT considers that the Supervised Consumption service is a Consumption necessary service to meet current need. Service Smoking Cessation The PCT considers that the Smoking Cessation service is a necessary Service service to meet current need. Chlamydia The PCT considers that the Chlamydia screening and treatment services Screening and are relevant but will not constitute a necessary service Treatment Service Anti-coagulation The PCT considers that the Anti-Coagulation service is a necessary service service to meet current need. Diabetes Enhanced Enhanced medicines usage review services. The diabetes enhanced MUR service medicines usage review service will be evaluated at the end of 2010/11 and an assessment of whether this service is necessary or relevant will be made at this stage. This will also determine the assessment for other proposed enhanced medicines usage reviews services. Sunday Rota The PCT considers that the Sunday Rota service is a necessary service Service to meet current need. Bank Holiday Rota The PCT considers that the Bank Holiday Rota service is a necessary Service service to meet current need. Out of Hours The PCT considers that the Out of Hours Access to Medicines service is Access to a necessary service to meet current need. Medicines service Medicines The PCT considers that the Medicines Administration Record (MAR) Administration service is a necessary service to meet current need. Record (MAR) Service
14
Future Services the may be commissioned
Emergency The PCT believes that a community pharmacy emergency contraception Contraception service would secure improvements to pharmaceutical services. Service COPD Screening The PCT believes that a COPD screening service would secure Service improvements to pharmaceutical services.
Community The PCT believes that a community pharmacy weight management Pharmacy Weight service would secure improvements to pharmaceutical services. Management Community The PCT believes that a community pharmacy alcohol intervention Pharmacy Alcohol service would secure improvements to pharmaceutical services. Intervention Service
3.11 PROCESS FOLLOWED IN DEVELOPING THE PNA
The NHS Havering Pharmacy Steering Group was given the responsibility by the PCT board for development of the PNA.
The membership of this group includes Tim Woodman (PCT Medical Director), Mike McClean (Non Executive Director) from the PCT board and Dr Ian Humberstone from the Professional Executive Committee (PEC) and Practice Based Commissioning member. It also includes Dr Louise Dibsdall from the PCT Public Health, Andy Thornley from PCT Communications, Angela Pruss from PCT Primary Care, members from the PCT Medicines Management, Local Pharmaceutical Committee and Local Medical Committee. It also includes Dr. John Croucher the PCT patient champion as a lay member, a secondary care pharmacist and the Assistant Director of Commissioning from London Borough of Havering.
The PNA work was co-ordinated by Mohamed Kanji, Senior Pharmaceutical Adviser and Matthew Henry, Data Analyst, in conjunction with Dr Belinda Krishek, Chief Pharmacist, Sanjay Patel, Head of Community Pharmacy and Denise Baker, Community Pharmacy Administrator.
There was extensive input from Clare Ebberson, JSNA lead. Other members of the PCT from Medicines Management, Public Health, Communications, Primary care and Commissioning departments also provided valuable input. The work was supported by the LPC Secretary Hemant Patel and the LPC office.
The development of PNA was also informed by input from pharmacists at several pharmacy forums and the PNA pharmacists survey, from GPs at various prescribing forums, patients at key patient group events, LINks and from the patient survey to which over 600 patients responded. Valuable feedback was received in particular from the Havering Family Diabetes Group.
The regulations require PCTs to publish a revised PNA within three years of its previous publication. They also require a small-scale update annually. PCTs are required to consider changes that take place after the publication of the PNA and decide if a supplementary statement or the publication of a new assessment is required. If a new assessment is required then the full process for the development of the PNA need to be undertaken including the statutory 60 day consultation. The Community Pharmacy Steering Group will consider changes in the health needs and in the provision of pharmaceutical services on an on-going basis and decide the appropriate revisions that need to take place. 15
3.12 MAPPING
A number of maps within the PNA have been provided by Experian. Experian have stated the following in relation to the maps. The Experian data maps are a ‘synthetic estimate of health conditions’ modelled using a national Hospital Episode Statistics (HES) dataset. Experian™ models billions of data items to cluster every household and postcode in the England into a Mosaic Type. All records within the HES dataset can then be modelled against each Mosaic type to establish propensities to suffer from all recorded conditions and provide a rich picture of individuals and their likely health profiles. This picture can be applied to any geographic level.
Whilst frequency of occurrences of certain health conditions in HES, more likely to be reported in a Primary care arena, may be relatively low, the overall geographic shape of the profile of those conditions has been robustly tested and proves valid’.
3.13 CONSULTATION
The regulations require PCTs to consult on a draft of their PNA for a minimum period of 60 days. The consultation on the draft of the NHS Havering PNA commenced on the 5th November 2010 and ended on the 4th of January 2011.
Following the consultation, a report was published of the feedback received to the consultation and the actions taken by NHS Havering in response to the feedback.
The PNA has been modified based on the feedback received. The final version has been agreed by the Pharmacy Steering Group and signed off by the PCT board.
16 4. DEMOGRAPHICS AND FUTURE GROWTH
Key Points:
• Identified population growth in Havering does not indicate a need for any additional community pharmacy premises/contracts
• Consideration needs to be given to the contribution pharmacy can make to the increasing elderly and more ethnically diverse population in Havering
4.1 CURRENT POPULATION
• The resident population of Havering is 230 1334, • The greatest number of residents live in Romford Town, followed by Gooshays and Brooklands • Cranham, Upminster, St Andrews and Pettits have the largest proportions of residents of retirement age • Gooshays, Havering Park, Heaton and South Hornchurch are the wards with the biggest proportion of young people (aged 0-19) living in them, with nearly a third of the population of Gooshays being in this age group • Hacton, Gooshays, St Andrew’s and Upminster have the largest proportions of very elderly (85+) residents • Fig. 1 (page 19) shows the density of the population in various parts of Havering. It is important to note that the north parts of Havering Park, Gooshay’s and the southern parts of South Hornchurch, Rainham and Upminster have relatively very low population density.
4.2 FUTURE GROWTH
Since 2007, the population of Havering has been growing at a faster rate than the England average, and this is expected to continue in the future, with the population rising by 8.3% by 2020
Havering’s retirement age population is expected to grow the fastest overall in the future, increasing by 19.2% by 2025. The fastest growth is in the 90+ age group, expected to increase by 125% by 2025
The number of children and young people in Havering is also expected to show a large increase, growing by 14.5% by 2025. The fastest increase is expected to be in the 5-9 age group, growing by 22.7% by 2025
Havering’s population is becoming more ethnically diverse, and this is expected to continue in the future. The second largest ethnic group (after White) comprises those of Black ethnicity, particularly those of Black African descent. This suggests a demographic change since the census in 2001, at which time Asian/Asian British residents were the second largest ethnic group in Havering
4 ONS 2008 17 Further detailed information about the current and projected population of Havering can be obtained from the JSNA.
The JSNA recommends decision makers to consider: • Increased need for targeted health interventions and health promotion activities for Black and Ethnic Minority groups. • Prepare for large increased demand for older people’s services, particularly those for the very elderly (90+) • Prepare for increased demand in children’s services, particularly those aimed at 5-9 year olds
Consideration needs to be given the contribution pharmacy can make to increasing elderly and more ethnically diverse population in Havering.
Identified population growth in Havering does not indicate a need for additional community pharmacy premises/contracts.
18
Fig. 1
19
4.3 LIFE EXPECTANCY
Havering residents live slightly longer than the national average, with life expectancy at birth being 78.5 years (men) and 82.5 years (women). This compares to an England figure of 77.93 (men) and 82.02 (women)5. Female life expectancy is higher than male, in line with national trends. Life expectancy is increasing for both men and women in Havering, in line with national trends. Men in Havering now live 4.2 years longer and women now live 2.7 years longer than in 1991.
Life expectancy for males is highest in Mawneys ward (80.28 years) and lowest in Brooklands (74.10 years). Female life expectancy follows the same pattern for these wards with life expectancy for females also being highest in Mawneys ward (85.88 years) and lowest in Brooklands (78.53 years)6.
In Havering, residents who live in less deprived areas live longer than those who live in deprived areas. Women in the most deprived areas live (on average) 2.9 years less than women in the least deprived areas, and men in the most deprived areas live (on average) 5.1 years less than men in the least deprived years7.
Fig. 2
Life Expectancy by Ward 2003-2007 (2006-2008 for Havering average); NCHOD
88 86 Life Expectancy at Birth - Male 84 82 Life Expectancy at Birth Female 80 78 76 Havering Average - Male Life Expectancy 74 72 Havering Average - Female Life Expectancy 70 LifeExpectancy (Years) 68 Brooklands Park Havering Town Romford Heaton Gooshays Wennington and Rainham Park Elm Hornchurch South Andrew’s St Hylands Wood Harold Upminster Park Emerson Heath Squirrel’s Hacton Pettits Cranham Mawneys
Ward
5 National Centre for Health Outcomes Development, 2006-2008 6 National Centre for Health Outcomes Development, 2003-2007 7 Havering Health Profile, Association of Public Health Observatories and the Department of Health, 2009 (based on 2003-2007 data) 20 5. PHARMACIES KEY INFORMATION
Key points: • Havering has a good coverage and choice of pharmaceutical service providers in all areas. The PNA has not identified a need for any new pharmaceutical service providers
There are 47 pharmacies within Havering; the map below gives the locations: (Some premises are not shown on this map where they are in close proximity to other premises. This is being revised.)
Fig. 3
The names and full addresses of all the pharmacies within Havering are listed in Appendix 3. The table below gives a break down of the pharmacies in terms of wards and Polysystems (See section 6.4 for further information on Polysystems) Further information about the location of these pharmacies in terms of wards and Polysystems is given in the Enhanced Services section of the PNA.
21 Distribution of Pharmacies by Ward (and Polysystem) All Polysystem / Ward Pharmacies 100 Hour Pharmacies NORTH EAST 11 1+ LPS Gooshays 4 1 Harold Wood 3 1 8am – 8pm everyday (LPS Pharmacy)
Emerson Park 1
Squirells Heath 2
Heaton 1 NORTH WEST 16 2 Havering Park 1 Mawneys 2 Pettits 2 Brooklands 1 Eastbrook 1 Romford Town 7 2 Hylands 2
SOUTH 20 0
St Andrews 5 Cranham 2 Upminster 4 Hacton 2 Elm Park 2 South Hornchurch 1 Rainham & Wennington 4
TOTAL 47
NHS Havering has 20 pharmacies per 100 000 of the population8.This is in line with the national average of 20 pharmacies per 100 000 of the population9.
As of November 2009 there were 6512 prescriptions dispensed on average per pharmacy per month10, this compared with the latest available national average (November 2009) of 6129 prescriptions per pharmacy per month11.NHS Havering is slightly above the national average. This can be explained by the recommendation for 28 day prescribing by General practitioners.
As of quarter 4 2009-2010 there are now 6687 prescriptions dispensed on average per pharmacy per month12.
Approximately 5.6% of Havering’s prescriptions are dispensed by pharmacies located outside of Havering. The pharmacies that dispense significant numbers of Havering generated prescriptions have been identified where possible in the PNA in the Advanced and Enhanced services section.
8 Based on a population figure of 230133 (ONS 2008 as quoted in JSNA) 9 http://www.ic.nhs.uk/webfiles/publications/Primary%20Care/Pharmacies/pharmserv9909/General_Pharmaceutical_Servic es_in_England_1999_2000_to_2008_09.xls 10 http://www.ic.nhs.uk/webfiles/publications/Primary%20Care/Pharmacies/pharmserv9909/General_Pharmaceutical_Servic es_in_England_1999_2000_to_2008_09.xls 11 http://www.ic.nhs.uk/webfiles/publications/Primary%20Care/Pharmacies/pharmserv9909/General_Pharmaceutical_Servic es_in_England_1999_2000_to_2008_09.xls 12 NHS Information Centre 2009/10 22 5.1 LOCATION OF PHARMACIES
The map below shows that 99.56 % of the population of Havering is within a 20 minute walk time of a pharmacy. The other 0.44% is confined to areas of Havering with a relatively low population density, particularly the North side of Havering Park & Gooshays ward, the South of Upminster, Rainham & Wennington and South Hornchurch ward.
Fig. 4
23 The below map shows that 99.5% of the population can access a pharmacy from a GP premises within a 20 minute walk. In fact in most cases the time taken to access a pharmacy is significantly less.
Fig. 5
24 6. GPS, HOSPITALS & POLYSYSTEMS
Key Points:
• Community pharmacy can help with the JSNA recommendation to work with hard to reach groups to increase awareness of out of hours health services and also understand their health needs
6.1 JSNA RECOMMENDATIONS
The JSNA has the following recommendations for decision makers:
• Continue to work with hard to reach groups to understand their health needs and barriers they may have to accessing health services
• Consider activity to raise awareness of how to access out of hours health services in wards with lower awareness of this e.g. Pettits and Havering Park
6.2 GP PRACTICES
There are 54 GP practices in Havering. Five of these are geographically outside the Havering boundary although Havering residents are still able to register with these GPs. Fig. 6 shows the location of GP practices in Havering.
25 Fig. 6
26 6.3 HOSPITALS
Barking, Havering & Redbridge University Trust is the major provider of acute care for the residents of Havering. This encompasses Queen’s hospital, which is in Romford, and King George’s hospital which is in Goodmayes.
6.4 POLYSYSTEMS
The PNA was prepared at a stage when NHS Havering was working with the Polysystem/Polyclinic model. This is outlined below.
The Polysystem model envisaged a network of health and social care partners who provide and commission healthcare services for a population of between 50 and 80 thousand people. The model envisaged three Polysystems in Havering; South Havering, North East Havering and North West Havering.
Whilst the PNA was being finalised a change in the model was under discussion. However, it was felt that retaining the Polysystem geography enabled the Borough to be broken down into smaller areas. This is helpful where certain things such as opening hours on a Sunday need to be considered at a higher level than individual wards but a lower level than the Borough in its entirety. The table below gives the wards that make up each Polysystem
Fig. 7 NHS Havering Polysystems NORTH EAST NORTH WEST SOUTH Gooshays Havering Park St Andrews
Harold Wood Mawneys Cranham Emerson Park Pettits Upminster Squirells Heath Brooklands Hacton Heaton Eastbrook Elm Park
Romford Town South Hornchurch Hylands Rainham & Wennington
27
7. OPENING HOURS
Key Points:
• Analysis of the pharmacy opening hours shows sufficient provision to meet the needs across Havering during weekdays, evenings and weekends • A Pharmacy minor ailments scheme could address the patients’ feedback (as indicated in the JSNA) for extended GP opening hours by capitalising on the extended pharmacy opening hours. It would also bring Havering in line with all the other PCTs in North East London and the majority of PCTs nationally who commission such a service. Such schemes are a cost effective way of reducing the 18% of GP appointments that are solely for minor ailments, and are supported by patients and GPs • The extended opening hours of 100 hour pharmacies are valued and these extended hours should be maintained. However no gaps have been identified to indicate the need for any additional 100 hour pharmacies
This section considers the opening hours of pharmacies contracted with NHS Havering and neighbouring PCTs where relevant.
In brief
• 98% (46) of pharmacies are open on a Saturday and 21%(10) open regularly on a Sunday
• 70% (33) of pharmacies open on weekday evenings after 6pm.
• 6% (3) of pharmacies are 100 hour per week pharmacies, and are open till 11pm/midnight on weekdays and up-to 4pm/5pm on the weekends.
Details:
Fig. 39, Fig. 40 and Fig. 41 in appendix 5 list all the pharmacies in Havering and where relevant in neighbouring PCTs giving their opening hours on weekdays, Saturdays and Sundays. They also give GP opening hours. Fig 8. on page 29 shows the Sunday pharmacy provision.
28 Fig. 8
Fig. 8 above plots the provision of pharmacy services on a Sunday against the density of the population in Havering. It does not include the rota service commissioned in Cranham/Upminster. This is because the pharmacy providing the rota varies weekly and hence is not possible to map.
29 7.1 100 HOUR PHARMACIES
Currently 3 pharmacies are contractually obliged to open for 100 hours per week due to the conditions on their application. NHS Havering values the contribution made by the current 100 hour pharmacies in dispensing prescriptions, providing enhanced services and offering advice to patients, especially during early mornings, late evenings and weekends.
NHS Havering needs to maintain its distribution of 100 hour pharmacies and their current opening hours in order to maintain choice for the patients in Havering. Additionally, no gaps have been identified to indicate the need for any further 100 hour pharmacies.
7.2 SUNDAY ROTA SERVICE
NHS Havering commissions a Sunday rota service to ensure that adequate pharmaceutical service is provided on Sundays, which is appropriate to the needs of the local population. This rota service is commissioned to provide 2 hours of pharmacy service every Sunday. Currently NHS Havering commissions this service from pharmacies located in Cranham /Upminster areas as these have been identified as having a gap in service provision on Sundays. The service is designed to improve access to pharmaceutical services for the public on Sundays and to reduce unnecessary Accident and Emergencies (A&E) attendances. The PCT considers that the Sunday Rota service is a necessary service to meet current need.
7.3 BANK HOLIDAY ROTA SERVICE
A number of pharmacies now open on many Bank Holidays although not contractually obliged to do so. NHS Havering works with community pharmacies to ensure an adequate service is available for all Bank Holidays and in particular Christmas Day, Boxing Day, New Years Day, Good Friday and Easter Sunday as these are days where pharmacies are still traditionally closed. NHS Havering commissions a bank holiday rota service in Polysystems where gaps are identified on particular bank holidays. This is to ensure adequate pharmaceutical provision which is appropriate to the needs of the local population. This rota service is commissioned to provide 2 hours of pharmacy service on any identified bank holiday. The service is designed to improve access to pharmaceutical services for the public on bank holidays and to reduce unnecessary A&E attendances. The PCT considers that the Bank Holiday Rota service is a necessary service to meet current need.
7.4 OUT OF HOURS ACCESS TO MEDICINES PHARMACY SERVICE
NHS Havering commissions community pharmacists to provide the out of hours access to palliative care medicines to improve the quality of service delivery for palliative care patients and their carers, helping reducing patients presenting to A & E and preventing emergency admissions. The service is available to both healthcare professionals and out of hours organisations who would contact the on- call pharmacist to arrange for the urgent dispensing of a prescription. On-call pharmacy providers are contracted to stock an agreed list of palliative care medicines, including Controlled Drug items. Each week the on-call pharmacist is available from 6 p.m. to 8 a.m. Mondays to Fridays and at weekends from 5.30 p.m. on the Saturday evening up to 8 a.m. on the Monday morning. NHS Havering organises the rota list for on-call pharmacists and ensures that all relevant health professionals and out of hours organisations have the relevant contact details. The PCT considers that the out of hours access to medicines pharmacy service is a necessary service to meet current need.
30 7.5 GP OPENING HOURS
The JSNA recommends decision makers to explore options for increasing access to health services, including providing additional opening hours.
More than half of Havering residents would like their GP surgery to be open at additional times, with Saturdays being the preferred additional opening time. The chart below from the JSNA shows the additional hours that the patients would like GP’s to open for:
Fig. 9
Additional Times People in Havering Would Like Their GP Surgery To Be Open
% Before 8am % At lunchtime % After 6.30pm % On a Saturday % On a Sunday
7.6 HOW PHARMACY CAN CONTRIBUTE?
Analysis by IMS Health UK (IMS is a global source for pharmaceutical market intelligence-for 2006- 2007) in the UK showed that 51.4 million GP consultations per annum are for minor ailments alone. This constitutes 18% of total GP consultations.
Data from the National Information Centre shows that the vast majority (72%) of PCTs nationally commission a minor ailments scheme from community pharmacies. In London, 80% of all PCTs commission such a service and all the other PCTs in North East London commission a service.
Minor ailments schemes have been very successful in numerous PCTs at reducing GP appointments for minor ailments. Such schemes involve patients visiting their local pharmacy in the first instance for a range of short term minor ailments such as diarrhoea, constipation, coughs and colds, sore throat, and minor eye infections amongst others. Pharmacists undertake extra training and assess the patient using defined protocols agreed locally. If the patient meets the clinical criteria and does not pay for their prescriptions, then a supply of medication from an agreed list is made to the patient and the consultation is recorded by the pharmacist. The pharmacy is reimbursed the costs of the medication and paid a small fee by the PCT which is typically around £5. The IMS survey study above worked out that each GP consultation costs £29.25. In summary, patient’s feedback is for increased GP hours, however research shows that a fifth of this extra time will be used for appointments to address minor ailments. Given their success elsewhere, consideration needs to be given to a pharmacy minor ailments scheme. Over 40% of the responders to the PNA survey supported a pharmacy minor ailments scheme. There is support from GPs as well for such a service from pharmacies as indicated in the GP PNA survey.
31 8. ESSENTIAL SERVICES
Key Points:
• Pharmacy public health campaigns are potentially a very powerful way of promoting key health messages recommended in the JSNA
• NHS Havering will work with all pharmaceutical service providers to ensure that they deliver services to the quality expected from their service contracts
Essential Services must be provided by all community pharmacies in accordance with the National Community Pharmacy Framework. These services are listed below:
1. Dispensing of Medicines 2. Repeat Dispensing 3. Waste Management 4. Delivery of Public Health Campaigns 5. Signposting 6. Support for Self Care 7. Clinical Governance
Further information on these services can be found at the PSNC website (www.psnc.org.uk). However of particular relevance in many areas of the PNA is the essential service four i.e. the delivery of Public Health Campaign’s. Pharmacies are required to support the PCT in up-to 6 locally agreed campaigns every year. National data shows that approximately 1 million people visit a pharmacy daily.
8.1 EQUALITY ACT 2010 (FORMERLY THE DISABILITY AND DISCRIMINATION ACT)
Community pharmacies are required to comply with the Equality Act 2010 (Parts of which were parts of the Disability and Discrimination Act). They have to ensure that they provide access to their services for people with a disability and also make reasonable adjustments to help people who have a disability take their medicines. The PCT monitors adherence to these requirements as part of the contract monitoring process. Specific consideration has not been given to groups of people with disabilities as part of the needs assessment because of these requirements. However the PCT will continue to monitor the provision made by community pharmacies and ensure that their services are accessible by all.
8.2 MONITORING OF THE COMMUNITY PHARMACY CONTRACTUAL FRAMEWORK
NHS Havering actively monitors the Community Pharmacy Contractual Framework to ensure that pharmaceutical services are delivered to a high standard across Havering.
NHS Havering has chosen to develop a contract monitoring timetable which involves visiting each pharmacy premises at least once in a three year rolling programme. The use of a self-assessment questionnaire precedes the monitoring visits; these questionnaires acts as a helpful tool for contractors to assess their readiness and to highlight areas of service provision which may require additional attention. Following visits, an action plan is made in conjunction with contractors to highlight the areas that need more attention to ensure better service provision. On going support is provided to contractors to ensure they meet agreed actions.
32 NHS Havering will work with all pharmaceutical service providers to ensure that they deliver services to the quality expected from their service contracts.
8.3 LOCAL SUPPORT GROUPS
Feedback from the local support groups is for pharmacists to inform patients where relevant of local support groups. These groups are voluntary, free of charge and assist the patients in managing their condition. Information about self help groups can be considered as part of essential service 5 (sign posting). NHS Havering will consider distributing a list of all self help groups with contacts to the local pharmacies.
8.4 LANGUAGE LINE
Language Line is available to all community pharmacies, it is a service that offers interpreting and translating services for people accessing healthcare who struggle with their spoken English skills. The service is telephone based, where pharmacy staff, the patient and interpreters can have a three-way conversation on a special two way telephone. Interpreters are available in over 170 languages. The costs of calls are paid for by NHS Havering.
As community pharmacy is in the forefront of community areas, services like Language Line can provide good access for hard to reach people such as those with English language difficulties. As the population of Havering becomes more ethnically diverse there will be greater demand for such services.
NHS Havering is recommended to work with pharmacies to increase service provision in response to future changes in population diversity. There are potential wider savings for the NHS with services targeting those who have difficulties with English language e.g. a reduction in emergency attendances- limited English speaking patients who do not receive access to interpreting, return to emergency care more frequently than interpreted patients, increasing the cost of patient care.
33 9. ADVANCED SERVICES
Key Points:
• The PNA has not identified any significant gaps in the provision of advanced services
• NHS Havering will work with the community pharmacists to maximise the benefits of these services
Currently this covers Medicines Use Reviews (MUR) and the Prescription Intervention Service (PIS) for community pharmacies and the Stoma Customisation (SC) and Appliance Use Reviews (AUR) which can be provided by both community pharmacists and appliance contractors.
Fig. 11 on page 36 lists the advanced services offered by pharmacies within Havering and neighbouring areas where relevant.
9.1 STOMA CUSTOMISATION AND APPLIANCE USE REVIEW
Stoma customisation and appliance use reviews is a new service that has been introduced this year. Currently 3 pharmacies provide these services. Appliance usage reviews are a basic check on the usage of appliances such as catheter bags and stoma equipment by patients. Stoma customisation involves the customisation of stoma appliances to suit the needs of particular patients usually the size of the opening on bags and flanges so that they fit the stoma.
NHS Havering will work with community pharmacists to maximise the contribution these services can make to support patients with their use of medications and appliances. The PCT considers that both the Appliance Use Review and Stoma Customisation services are relevant but do not constitute a necessary service.
9.2 MEDICINES USAGE REVIEWS
Medicines usage reviews are basic checks on the usage of medication by patients. They are not to be confused with the enhanced medications usage reviews detailed in the medicine’s management section.
As of 2008-2009, the number of MURs done by each pharmacy in Havering stood at 221 on average. This compared with the latest available national average (2008/9) of 161 MURs per pharmacy13. As of 2009-2010; Pharmacies commissioned by NHS Havering now conduct on average 250 MURs per pharmacy.
It can be seen that Havering Pharmacies are providing an above average number of MURs. NHS Havering is trying to address the issue of quality of MURs through schemes such as the diabetes MUR plus scheme, where the pharmacist has to cover a pre specified number of areas, get patient feedback and share the information with the PCT. These three issues do not need to be addressed in the standard nationally agreed MUR service.
13 http://www.ic.nhs.uk/webfiles/publications/Primary%20Care/Pharmacies/pharmserv9909/General_Pharmaceutical_Servic es_in_England_1999_2000_to_2008_09.xls 34 There were 46 pharmacies able to provide MURs, 13 completed the full 400 in 2009/10; 11796 MURs were completed over the year14. This is just over 64% of the 18,400 reviews that could have been undertaken if all pharmacies had completed their maximum entitlement.
The PCT considers that the Medicines Use Reviews service is a necessary service to meet current need.
9.3 ADVANCED SERVICES TABLES
TOTAL NUMBERS OF PHARMACIES CONDUCTING MURs15
Fig. 10
WARD Number of locations for MUR service Harold Wood 2 Gooshays 3 Heaton 1 Havering Park 1 Mawneys 2 Pettits 2
Brooklands 1
Romford Town 7 Squirrels Heath 2 Emerson Park 1 Hylands 2 St. Andrews 5 Cranham 2 Upminster 4 Hacton 2 Elm Park 2 South Hornchurch 1 Rainham & 3
Wennington
14 MUR MI data April 2009 – March 2010 15 MUR MI data April 2009 – March 2010 35 Fig. 11: ADVANCED SERVICES WARD WARD FCS CODE FCS CODE POST CODE CODE POST SC SERVICE SC SERVICE POLYSYSTEM POLYSYSTEM SERVICE AUR TRADING NAME NAME TRADING SC SERVICE INTENDED INTENDED SC SERVICE AUR SERVICE INTENDED INTENDED SERVICE AUR MUR SERVICE BASED ON SURVEY SURVEY ON BASED SERVICE MUR FL514 NATIONAL CO-OP CHEMIST RM3 0BP HAROLD WOOD NORTH EAST Y FDT86 TESCO INSTORE PHARMACY RM3 0LL HAROLD WOOD NORTH EAST Y FQM30 CO-OPERATIVE PHARMACY HW POLYCLINIC RM3 0FE HAROLD WOOD NORTH EAST Y FA727 YOUR LOCAL BOOTS PHARMACY RM3 8DB GOOSHAYS NORTH EAST Y FA737 BOOTS RM3 9PH GOOSHAYS NORTH EAST Y FF297 BOOTS RM3 8DX GOOSHAYS NORTH EAST Y Y Y FW636 NEWLANDS PHARMACY RM3 9SU GOOSHAYS NORTH EAST Y Y Y FGV99 CRESCENT PHARMACY RM3 7PB HEATON NORTH EAST Y Y Y FVE89 YOUR LOCAL BOOTS PHARMACY RM5 3PH HAVERING PARK NORTH WEST Y * LASER IMPEX LTD (BRITANNIA PHARMACY) IG2 6BN ALDBOROUGH FN123 W BURDESS CHEMIST RM7 8BU MAWNEYS NORTH WEST Y Y Y FN391 LLOYDS PHARMACY RM5 3PR MAWNEYS NORTH WEST Y Y Y FKN55 NEWLANDS PHARMACY RM5 3BB PETTITS NORTH WEST Y Y FXK72 RISE PARK PHARMACY RM1 4NT PETTITS NORTH WEST Y Y FKK95 ROWLANDS PHARMACY RM7 7HH BROOKLANDS NORTH WEST Y Y Y * MASTAA CARE PHARMACY RM8 1BJ WHALEBONE * OXLOW CHEMIST RM10 7YA HEATH FDP87 SAFEDALE RM7 0TJ EASTBROOK NORTH WEST Y Y Y * FITTLEWORTH MEDICAL LTD RM10 8PS EASTBROOK NORTH WEST N/A Y Y FT893 MiM PHARMACY RM1 1DL ROMFORD TOWN NORTH WEST Y Y Y FV600 BOOTS RM1 3AD ROMFORD TOWN NORTH WEST Y FJP97 NEWLANDS PHARMACY RM11 1BH ROMFORD TOWN NORTH WEST Y Y Y FA111 SAINSBURYS INSTORE PHARMACY RM1 1AU ROMFORD TOWN NORTH WEST Y FV092 BOOTS RM1 1AU ROMFORD TOWN NORTH WEST Y FGD64 BOOTS RM1 3RL ROMFORD TOWN NORTH WEST Y FTV79 PARK LANE PHARMACY RM11 1BB ROMFORD TOWN NORTH WEST Y FGD98 ROWLANDS PHARMACY RM11 2LG SQUIRRELS HEATH NORTH EAST Y Y Y FGW82 BRITCROWN PHARMACY RM2 5JR SQUIRRELS HEATH NORTH EAST Y Y Y
KEY: * Pharmacy not contracted with NHS Havering and advanced services not known
36
Fig. 11 : ADVANCED SERVICES WARD WARD SURVEY SURVEY FCS CODE FCS CODE POST CODE CODE POST SC SERVICE SC SERVICE POLYSYSTEM POLYSYSTEM SERVICE AUR TRADING NAME NAME TRADING SC SERVICE INTENDED INTENDED SC SERVICE AUR SERVICE INTENDED INTENDED SERVICE AUR MUR SERVICE BASED ON ON BASED SERVICE MUR
FN455 SHADFORTHS CHEMIST RM2 5SU EMERSON PARK NORTH EAST Y FRF15 PHARMACARE CHEMIST RM11 1QH HYLANDS NORTH WEST Y Y Y FYN65 TESCO INSTORE PHARMACY RM11 1PY HYLANDS NORTH WEST Y Y Y FL261 YOUR LOCAL BOOTS PHARMACY RM11 3XS ST ANDREWS SOUTH Y Y FDA73 YOUR LOCAL BOOTS PHARMACY RM12 4UH ST ANDREWS SOUTH Y FX556 BOOTS RM12 4UL ST ANDREWS SOUTH Y Y Y FJM16 CHEMISTREE RM11 3UX ST ANDREWS SOUTH Y FMD27 ELM PARK PHARMACY RM12 4SD ST ANDREWS SOUTH Y FLN08 DAY LEWIS PHARMACY RM14 1RQ CRANHAM SOUTH Y Y Y FEO51 GOVANI CHEMIST RM14 1XN CRANHAM SOUTH Y FPD73 GOVANI CHEMIST RM14 2TD UPMINSTER SOUTH Y FE805 BRITANNIA PHARMACY RM14 2AD UPMINSTER SOUTH Y Y Y FXH36 BOOTS RM14 2AJ UPMINSTER SOUTH Y FCN97 PANCHEM PHARMACY RM14 3BS UPMINSTER SOUTH Y Y Y FW198 BOOTS RM12 6LL HACTON SOUTH Y FCC42 LLOYDS PHARMACY RM12 5AS HACTON SOUTH Y Y Y FXV64 NEWLANDS PHARMACY RM12 5AB ELM PARK SOUTH Y Y Y FEP91 DAY LEWIS PHARMACY RM13 7PP ELM PARK SOUTH Y FC513 DAY LEWIS PHARMACY RM13 7QX SOUTH HORNCHURCH SOUTH Y FG050 WILLIAMS CHEMIST RM13 9TR RAINHAM AND WENNINGTON SOUTH Y FTE90 CHANSONS PHARMACY RM13 9BD RAINHAM AND WENNINGTON SOUTH Y Y Y FAO52 TESCO INSTORE PHARMACY RM13 9YZ RAINHAM AND WENNINGTON SOUTH Y Y Y FJL00 BOWS CHEMIST RM13 9JR RAINHAM AND WENNINGTON SOUTH ** * SAINSBURYS INSTORE PHARMACY RM6 6PA CHADWELL HEATH * LLOYDS PHARMACY RM6 6NL CHADWELL HEATH * ALLANS CHEMIST RM6 4AL CHADWELL HEATH * TESCO INSTORE PHARMACY RM6 4HY CHADWELL HEATH * CORDEVE LTD RM6 4NP CHADWELL HEATH * ANDREW BASS PHARMACY RM8 1BP VALENCE * ASDA PHARMACY RM9 6SJ THAMES KEY: * Pharmacy not contracted with NHS Havering and advanced services not known ** Intending to provide within twelve months
37
10. ENHANCED SERVICES
Key Points:
• No major gaps have been identified in the provision of enhanced services
• There are a few areas where NHS Havering can work with pharmacy providers to improve coverage for specific enhanced services
• Pharmacies are making a valuable contribution to meeting the health needs of the population through enhanced services commissioned by NHS Havering and the Local Authority in particular smoking cessation and anti-coagulation monitoring
Enhanced Services are additional local services commissioned from community pharmacies and negotiated locally by NHS Havering. NHS Havering currently commissions 9 enhanced services as follows:
• Smoking Cessation • Chlamydia Screening • Chlamydia Treatment • Anti-coagulation service • Diabetes Enhanced MUR service • Sunday Rota Service • Bank Holiday Rota Service • Out of Hours Access to Medicines service • Medicines Administration Record (MAR) Service
A further 2 enhanced services are commissioned by the Local Authority in conjunction with NHS Havering:
• Needle and Syringe Exchange Service • Supervised Consumption Service
Each of these services is considered in further detail in the sub-sections except for Sunday Rota, Bank Holiday Rota and On Call Pharmacy Rota services which are discussed in the Opening Hours Section. The Diabetes Enhanced MUR service is discussed within the Diabetes section.
10.1 ENHANCED SERVICE SUMMARY TABLES
Fig. 12 lists the enhanced services provided by pharmacies in Havering and surrounding areas. Pharmacies outside NHS Havering have been included where they are in close proximity to the borders of Havering and dispense a significant number of prescriptions issued by GPs contracted by NHS Havering.
38 Fig. 12 ENHANCED SERVICES: This table summarises the enhanced services commissioned from pharmacies in Havering and surrounding areas EHC** EHC** WARD WARD SCHEME SCHEME SERVICE SERVICE SERVICE FCS CODE FCS CODE POST CODE CODE POST POLYSYSTEM POLYSYSTEM TRADING NAME NAME TRADING MINOR AILMENTS** AILMENTS** MINOR On Call Pharmacy Rota Rota Pharmacy On Call SUNDAY ROTA SERVICE SERVICE ROTA SUNDAY DIABETES MUR SERVICE SERVICE MUR DIABETES CHLAMYDIA TREATMENT TREATMENT CHLAMYDIA CONDOM DISTRIBUTION** DISTRIBUTION** CONDOM CHLAMYDIA DISTRIBUTION DISTRIBUTION CHLAMYDIA SUPERVISED CONSUMPTION CONSUMPTION SUPERVISED NEEDLE EXCHANGE SCHEME SCHEME EXCHANGE NEEDLE ANTI COAGULATION SERVICE SERVICE COAGULATION ANTI BANK HOLIDAY ROTA SERVICE SERVICE ROTA HOLIDAY BANK SMOKING CESSATION SERVICE SERVICE CESSATION SMOKING
FA727 YOUR LOCAL BOOTS PHARMACY RM3 8DB GOOSHAYS NORTH WEST Y Y FA737 BOOTS RM3 9PH GOOSHAYS NORTH WEST Y Y FF297 BOOTS RM3 8DX GOOSHAYS NORTH WEST Y Y Y FW636 NEWLANDS PHARMACY RM3 9SU GOOSHAYS NORTH WEST Y Y Y Y FL514 NATIONAL CO-OP CHEMIST RM3 0BP HAROLD WOOD NORTH WEST Y Y FDT86 TESCO INSTORE PHARMACY RM3 0LL HAROLD WOOD NORTH WEST Y Y Y Y FQM30 CO-OPERATIVE PHARMACY HW POLYCLINIC RM3 0FE HAROLD WOOD NORTH WEST Y Y Y Y FN455 SHADFORTHS CHEMIST RM2 5SU EMERSON PARK NORTH WEST Y Y Y FQD98 ROWLANDS PHARMACY RM11 2LG SQUIRRELS HEATH NORTH WEST Y Y Y Y Y FGW82 BRITCROWN PHARMACY RM2 5JR SQUIRRELS HEATH NORTH WEST Y Y Y Y Y Y FGV99 CRESCENT PHARMACY RM3 7PB HEATON NORTH WEST Y Y Y Y Y Y FVE89 YOUR LOCAL BOOTS PHARMACY RM5 3PH HAVERING PARK NORTH EAST Y Y * LASER IMPEX LTD (BRITANNIA PHARMACY) IG2 6BN ALDBOROUGH SEVEN KINGS Y Y Y Y Y Y FN123 W BURDESS CHEMIST RM7 8BU MAWNEYS NORTH EAST Y Y Y Y Y FN391 LLOYDS PHARMACY RM5 3PR MAWNEYS NORTH EAST Y Y Y Y Y Y Y Y FKN55 NEWLANDS PHARMACY RM5 3BB PETTITS NORTH EAST Y Y Y FXK72 RISE PARK PHARMACY RM1 4NT PETTITS NORTH EAST Y FKK95 ROWLANDS PHARMACY RM7 7HH BROOKLANDS NORTH EAST Y Y Y Y Y *** MASTAA - CARE PHARMACY RM8 1BJ WHALEBONE *** OXLOW CHEMIST RM10 7YA HEATH FDP87 SAFEDALE RM7 0TJ EASTBROOK NORTH EAST Y Y Y Y Y Y Y FT893 MiM PHARMACY RM1 1DL ROMFORD TOWN NORTH EAST Y Y Y Y Y Y Y Y FV600 BOOTS RM1 3AD ROMFORD TOWN NORTH EAST Y Y Y FJP97 NEWLANDS PHARMACY RM11 1BH ROMFORD TOWN NORTH EAST Y Y Y Y FA111 SAINSBURYS INSTORE PHARMACY RM1 1AU ROMFORD TOWN NORTH EAST FV092 BOOTS RM1 1AU ROMFORD TOWN NORTH EAST Y Y Y Y Y FGD64 BOOTS RM1 3RL ROMFORD TOWN NORTH EAST Y Y Y KEY: * Pharmacy not contracted with NHS Havering ** Service not commissioned by NHS Havering but by other PCTs ***Pharmacy not contracted with NHS Havering and enhanced services not known
39 Fig. 12 ENHANCED SERVICES: This table summarises the enhanced services commissioned from pharmacies in Havering and surrounding areas EHC** EHC** WARD WARD SCHEME SCHEME SERVICE SERVICE FCS CODE FCS CODE POST CODE CODE POST POLYSYSTEM POLYSYSTEM TRADING NAME NAME TRADING MINOR AILMENTS** AILMENTS** MINOR On Call Pharmacy Rota Rota Pharmacy On Call SUNDAY ROTA SERVICE SERVICE ROTA SUNDAY DIABETES MUR SERVICE SERVICE MUR DIABETES CONDOM DISTRIBUTION** DISTRIBUTION** CONDOM CHLAMYDIA DISTRIBUTION DISTRIBUTION CHLAMYDIA SUPERVISED CONSUMPTION CONSUMPTION SUPERVISED NEEDLE EXCHANGE SCHEME SCHEME EXCHANGE NEEDLE ANTI COAGULATION SERVICE SERVICE COAGULATION ANTI BANK HOLIDAY ROTA SERVICE SERVICE ROTA HOLIDAY BANK SMOKING CESSATION SERVICE SERVICE CESSATION SMOKING CHLAMYDIA TREATMENT SERVICE SERVICE TREATMENT CHLAMYDIA
FTV79 PARK LANE PHARMACY RM11 1BB ROMFORD TOWN NORTH EAST Y Y Y Y FRF15 PHARMACARE CHEMIST RM11 1QH HYLANDS NORTH EAST Y Y FYN65 TESCO INSTORE PHARMACY RM11 1PY HYLANDS NORTH EAST Y FL261 YOUR LOCAL BOOTS PHARMACY RM11 3XS ST ANDREWS SOUTH FDA73 YOUR LOCAL BOOTS PHARMACY RM12 4UH ST ANDREWS SOUTH Y Y FX556 BOOTS RM12 4UL ST ANDREWS SOUTH Y Y Y Y Y FJM16 CHEMISTREE RM11 3UX ST ANDREWS SOUTH Y Y Y FMD27 ELM PARK PHARMACY RM12 4SD ST ANDREWS SOUTH Y FLN08 DAY LEWIS PHARMACY RM14 1RQ CRANHAM SOUTH Y FEO51 GOVANI CHEMIST RM14 1XN CRANHAM SOUTH Y Y Y FPD73 GOVANI CHEMIST RM14 2TD UPMINSTER SOUTH Y Y Y Y Y FE805 BRITANNIA PHARMACY RM14 2AD UPMINSTER SOUTH Y Y Y Y FXH36 BOOTS RM14 2AJ UPMINSTER SOUTH Y Y Y Y Y Y FCN97 PANCHEM PHARMACY RM14 3BS UPMINSTER SOUTH Y Y Y Y FW198 BOOTS RM12 6LL HACTON SOUTH Y Y Y FCC42 LLOYDS PHARMACY RM12 5AS HACTON SOUTH Y Y Y FXV64 NEWLANDS PHARMACY RM12 5AB ELM PARK SOUTH Y Y FEP91 DAY LEWIS PHARMACY RM13 7PP ELM PARK SOUTH Y Y Y Y FC513 DAY LEWIS PHARMACY RM13 7QX SOUTH HORNCHURCH SOUTH Y Y FG050 WILLIAMS CHEMIST RM13 9TR RAINHAM AND WENNINGTON SOUTH Y FTE90 CHANSONS PHARMACY RM13 9BD RAINHAM AND WENNINGTON SOUTH Y Y Y FAO52 TESCO INSTORE PHARMACY RM13 9YZ RAINHAM AND WENNINGTON SOUTH Y Y FJL00 BOWS CHEMIST RM13 9JR RAINHAM AND WENNINGTON SOUTH * SAINSBURYS INSTORE PHARMACY RM6 6PA CHADWELL HEATH Y Y * LLOYDS PHARMACY RM6 6NL CHADWELL HEATH Y Y Y Y Y * ALLANS CHEMIST RM6 4AL CHADWELL HEATH Y Y Y Y Y * TESCO INSTORE PHARMACY RM6 4HY CHADWELL HEATH Y Y * CORDEVE LTD RM6 4NP CHADWELL HEATH Y Y Y *** ANDREW BASS PHARMACY RM8 1BP VALENCE *** ASDA PHARMACY RM9 6SJ THAMES KEY: * Pharmacy not contracted with NHS Havering ** Service not commissioned by NHS Havering but by other PCTs ***Pharmacy not contracted with NHS Havering and enhanced services not known 40 10.2 ENHANCED SERVICES FOR SUBSTANCE MISUSE
Key Points: • Substance misuse services through pharmacy offer an excellent opportunity to target hard to reach groups as they offer regular contact with substance misusers. NHS Havering will work with the DAAT and community pharmacists to maximise this opportunity to increase the number of problematic drug users in treatment • The majority of the Havering population can access the pharmacy needle exchange service within a 20 minute walk time. However consideration needs to be given to commissioning services in South Hornchurch and Rainham & Wennington • The pharmacy needle exchange scheme should be enhanced to increase the proportion of problem drug users accessing drug treatment and services to aid recovery • The majority of the Havering population has access to a pharmacy providing a supervised consumption scheme service within a 20 minute walk. However consideration needs to be given to commissioning services in South Hornchurch, Elm Park and Hacton • The pharmacy supervised consumption service should be enhanced to assist with improved drug treatment completion rates and reduce unplanned exits
10.2.1 Background
The London Borough of Havering Drug and Alcohol Action Team (DAAT) commissions both a needle exchange and supervised consumption service to assist with substance misuse and harm reduction. The service is funded by NHS Havering and there is close working with the DAAT. There is a potential to enhance current schemes and the role of community pharmacists to meet the recommendations in the JSNA.
10.2.2 Needle Exchange
The needle exchange service enables injecting drug users to have access to clean injecting equipment, to be able to dispose of used equipment safely and to have access to advice from pharmacists.
The pharmacy needle exchange scheme providers can assist with increasing the proportion of problem drug users accessing drug treatment and services to aid recovery as the scheme enables pharmacies to have regular contact with drug misusers. NHS Havering and the DAAT can work with the pharmacies providing needle exchange to maximise this opportunity where a difficult to reach group is contacting a Health Care professional on a regular basis. Improving engagement with substance misusers can help to achieve recommendations from NICE and increase the number of problematic drug users in treatment.
Fig. 13 gives the location of the pharmacies commissioned to provide a needle exchange service. This has been mapped against deprivation. Deprivation is taken here as being a surrogate marker for the need for such services. Fig. 14 alongside, gives the density of the Havering population for reference. The majority of the Havering population has access to a pharmacy providing a needle exchange service within a 20 minute walk. The areas falling outside of this 20 minute walk radius are areas with a relatively low density of population, North of Havering Park and Gooshays and the South of Rainham & Wennington, South Hornchurch, and Upminster. However consideration needs to be
41 given to a service in the North part of South Hornchurch ward which has a good density of population as well as significant deprivation and the middle of Rainham & Wennington.
Fig. 13
42 Fig. 14
At least one pharmacy in both Elm Park & South Hornchurch is interested in providing the needle exchange scheme in 2010. The PCT & DAAT need to work with pharmacy providers in Rainham and Wennington, in order to enable greater provision. The PCT considers that the Needle Exchange service is a necessary service to meet current need.
10.2.3 Supervised Consumption
This service involves pharmacists ensuring that patients in drug treatment programmes take and use their treatment as prescribed. The patient takes his/her daily treatment dose under the supervision of the pharmacist.
The JSNA states ‘The large percentage of unplanned exits from drugs treatment programmes may suggest that clients are starting formal drug treatment programmes before they are ready, and may indicate a need for more motivational work to be undertaken with clients at an earlier stage of treatment to ensure they are engaged with the treatment programme’.
The supervised consumption scheme gives the pharmacist daily contact with a drug misuser and consideration needs to be given to exploiting this opportunity further. One way is for the supervised
43 consumption service to be enhanced to meet the above finding in the JSNA. Meeting the wider health needs of this group by exploiting this daily contact also needs to be explored; for example pharmacy can play an important role in signposting and therefore increasing the number of people who can access these services.
Fig. 15 gives the location of the pharmacies commissioned to provide a supervised consumption scheme service mapped against deprivation. Deprivation is taken here as being a surrogate marker for the need for such services. Fig.16, gives the density of the Havering population for reference. The majority of the Havering population has access to a pharmacy providing a supervised consumption scheme service within a 20 minute walk. The areas falling outside of this 20 minute walk radius have a very low density of population, such as North of Havering Park and Gooshays and the South of Rainham & Wennington, South Hornchurch, and Upminster. However consideration needs to be given to a service in the North part of South Hornchurch, Elm Park and Hacton all of which have a good density of population as well as significant deprivation.
Fig. 15
44 Fig. 16
At least one pharmacy in both Elm Park and South Hornchurch are interested in providing the supervised consumption scheme in 2010. A pharmacy in St. Andrews is interested in providing the service which could cover Hacton. However the PCT & DAAT need to work with pharmacy providers in Rainham and Wennington.
The PCT considers that the Supervised Consumption service is a necessary service to meet current need.
45 10.3 DIABETES
How Pharmacy can contribute:
• Improved identification of diabetes via NHS health checks through pharmacy
• Improved medicines management in diabetes could help reduce the high morbidity and mortality associated with this condition
• Schemes such as diabetes enhanced medication usage review (Diabetes MUR+) can improve medicines management
• Explore pharmacy schemes to meet the JSNA recommendations to consider preparing for the predicted increased demand in conditions such as diabetes
If left untreated, diabetes can lead to heart disease, stroke, blindness and kidney failure, and more than 1 in 10 deaths among 20–79 year olds in England can be attributed to diabetes.
2008/2009 Quality Outcomes Framework (QOF) data suggests that in Havering, 5% of adults (aged 17 and over) registered with GPs have diabetes, equating to around 9945 individuals. This is in line with diabetes prevalence in London overall (5%) and slightly below the England prevalence (5.1%). These figures are very similar to modelled estimates of diabetes, which suggested that 5.03% of Havering residents would have diabetes in 2010.
The prevalence of diabetes is increasing both in Havering and nationally. Projections suggest that diabetes will continue to become more prevalent in Havering in the future (in line with national trends) increasing to 6.43% by 2025.
People with diabetes have a higher mortality rate then those without diabetes; it is estimated that 12.02% of all deaths in those aged 20-79 years in Havering are attributable to diabetes (around 130 people a year). This is above the England figure of 11.6%.
The JSNA highlights a discrepancy in some wards in which MOSAIC (propensity data) predicts a high level of diabetes but GP’s QOF data does not show this. The JSNA suggests that further local investigation is needed to explain the differences. These differences could be due to 'hard to reach' patients who don't normally visit a surgery. The table overleaf shows ward rankings for diabetes incidence based on QOF data versus MOSAIC data. Wards where MOSAIC predicts a high propensity but QOF is not showing relatively high incidence are Gooshays, Elm Park, Havering Park, Mawneys and Brooklands.
46 Fig 17 & 18 Type II Diabetes: Ward Rankings by QOF and by propensity
Fig.17 Ward ranking by incidence Fig. 18 Under QOF
QOF Ranking Ward 2009-2010 South Hornchurch 1 Heaton 2 Hylands 3 Rainham and Wennington 4 Hacton 5 Pettits 6 Elm Park 7 Cranham 8 Gooshays 9 St Andrew's 10 Havering Park 11 Mawneys 12 Romford Town 13 Emerson Park 14 Harold Wood 15 Upminster 16 Brooklands 17 Squirrel's Heath 18
10.3.1 NHS Health Checks
The NHS Health Check programme offers risk assessment for diseases affecting the vascular system, including diabetes and chronic kidney disease, to everyone between 40 and 74 years of age. The aim is to identify people at high risk of these diseases who are currently not diagnosed as having any of these conditions. This will enable early identification. It is currently commissioned through GP practices only in Havering. The plan for the service has always included extending the commissioning of the service through pharmacies. Given the needs identified, early roll out of the programme through Community Pharmacy would be beneficial.
A recent national survey showed that 57% of PCTs were either commissioning or piloting the commissioning of NHS Health Checks through Community pharmacy. This is with the aim of accessing the 'hard to reach' patients who don't normally visit a surgery.
The PCT considers that the NHS Health Checks service would secure improvements to pharmaceutical services.
47 10.3.2 Diabetes Enhanced Medication Usage Review Service
Enhanced medication usage reviews are explained in section 11.2 of the PNA. In summary pharmacists who have undertaken additional training undertake a detailed and structured review of the way the patients understand and use their diabetes medication.
This service was very strongly supported by the diabetes patient groups in Havering and by the NHS Havering Diabetes Network. Pharmacists who wanted to participate in the pilot scheme had to undertake three update sessions organised by the PCT Medicines Management Team. They had to successfully pass an assessment at the end of the sessions. They also had to successfully complete the national Centre for Pharmacy Post-graduate Education (CPPE) update pack on diabetes.
This pilot service has recently commenced with the pharmacists who have completed all the required training. Fig. 19 gives the location of the pharmacies that will be providing this service. This has been mapped against propensity for diabetes in the population. Fig. 20 alongside, gives the density of the Havering population for reference. The majority of the Havering population has access to a pharmacy providing this service within a 20 minute walk. The areas falling outside of this 20 minute walk radius are areas with a relatively low density of population, North of Havering Park and Gooshays and the South of Rainham & Wennington, South Hornchurch, and Upminster. This service will be evaluated at the end of 2010/11 and an assessment of whether this service is necessary or relevant will be made at this stage. This will also determine the assessment for other proposed enhanced medicines usage reviews services.
Fig. 19 Fig. 20
48 10.4 ANTICOAGULATION MONITORING (WARFARIN)
Key Points: • Over 1400 patients have been transferred from secondary care to monitoring by community pharmacies • There is a high level of satisfaction with the service offered • The projected annual saving by provision of this service through pharmacy is at least £84k, with the potential to increase as more patients are transferred
10.4.1 Background
Warfarin is used in the management of a number of clinical conditions including atrial fibrillation, prophylaxis and treatment of venous thrombosis and pulmonary embolism, and transient ischemic attacks. While it is a very safe and effective medicine, some of its side effects including haemorrhage require close monitoring.
Warfarin is an effective oral anticoagulant which is widely prescribed to treat or prevent thromboembolic disorders. Since warfarin has a narrow therapeutic range, it requires close monitor and dose adjustments to minimise the bleeding complication at the same time, to get a sufficient anti- coagulation effect.
Warfarin monitoring aims to stabilise the International Normalised Ratio (INR) within set limits to help prevent serious side effects while at the same time maximising treatment effects. The specific range of INR values depends upon the clinical condition being treated.
10.4.2 The Havering Service
NHS Havering commissions the primary care anti-coagulation monitoring service from 9 general practitioners and 16 community pharmacies. At least two clinicians from each provider have to undertake and successfully complete an accredited anti-coagulation management training programme co-ordinated by the PCT anti-coagulation service lead.
Patients are initiated on warfarin by secondary care and once stabilised are discharged from secondary care to a primary care provider. Patients with complex conditions continue to be seen in secondary care as well as those who require short term anticoagulation management.
Providers have been chosen to ensure the service is well distributed around Havering. Each provider needs a critical number of patients in order to maintain the proficiency of the clinicians in the provision of this service.
79% (1470) of all the patients who are now monitored in primary care have chosen the pharmacy service. Patients are very pleased with the service provided with 302 out of 514 respondents to a survey (59%) stating that they are completely satisfied with the service and 28% stating that they are very satisfied. This shows that community pharmacy can deliver enhanced services that meet the publics need and expectation.
49 Fig. 21 gives the location of the pharmacies and surgeries commissioned to provide the service. This has been mapped against the population density. The majority of the Havering population has access to an anti-coagulation service provider within a 20 minute walk. The areas falling outside of this 20 minute walk radius are areas with a relatively low density of population, The North of Havering Park and Gooshays and the South of Rainham & Wennington, South Hornchurch, and Upminster.
The PCT considers that the Anticoagulation monitoring service for Warfarin is a necessary service to meet a current need.
Fig. 21
50 10.5 SMOKING CESSATION SERVICE
Key Points:
• Pharmacies are making a valuable contribution to helping smokers quit in Havering accounting for 53% of all the recorded, successful 4 week smoking quitters in Havering during 2009/10
• There is a good provision of smoking cessation services across Havering and no gaps have been identified
NHS Havering Community Pharmacy Smoking Cessation Service
Smoking cessation is one of the most effective health care interventions.
NHS Havering has commissioned smoking cessation services from 29 of the 54 GP practices and from 38 of the 47 pharmacies. The specialist stop smoking service also provides support for smoking cessation and co-ordinates the service. These services are therefore available across the borough. The pharmacy smoking cessation service is provided by specially trained community pharmacy staff. Staff trained to Level 1 can provide brief advice and refer to level 2 smoking advisers/specialist clinics. The Level 2 service consists of one to one advice to support smokers in stopping smoking over a 4 week period. In many cases the pharmacist is able to supply pharmacological products directly to the patient using a patient’s group direction. Pharmacological products assist the smokers to quit.
77% (36) of pharmacies in Havering provide the level 2 smoking cessation service. These pharmacies accounted for 53% (745) of all the recorded, successful 4 week smoking quitters in Havering during 2009/10.
The JSNA states ‘that greater numbers of people quit smoking in less affluent areas of Havering e.g. Gooshays and Heaton. This suggests the stop smoking service is reaching people from less affluent areas who are more likely to smoke’. Overall, there is good provision of stop smoking services in areas where people in Havering are most likely to smoke. 46% of those who approach smoking cessation services in Havering go on to quit smoking, which is comparable to London (47%), and slightly below the national average of 50%.
Fig. 22 overleaf from the JSNA shows the percentage of smokers in the different wards of Havering. Fig. 23 shows the location where smoking cessation services are provided and the number of 4 week successful quitters.
The PCT considers that the smoking cessation service is a necessary service to meet current need.
51 Fig. 22
Fig. 23
52 10.6 CHLAMYDIA SCREENING AND TREATMENT
Key Points:
• Overall there is a good distribution of pharmacies providing Chlamydia screening and treatment across Havering. However additional distribution points should be considered in Rainham & Wennington
• NHS Havering will work with pharmacy providers to address the following issues raised in the JSNA: - Capitalise on the opportunities within pharmacies to provide easy access to Chlamydia testing and focus screening and preventative interventions on areas with high sexually transmitted infection rates
Chlamydia
Nationally, Chlamydia has been the most common sexually transmitted disease since 2000, and is 16 becoming more common, with the majority of cases being found in the under 25s . Chlamydia infection is asymptomatic in most cases. However if untreated it can have serious long term consequences in some cases including infertility.
In 2009/10, 17.3% of 15-27 year olds in Havering were screened for Chlamydia. This is below the England average of 22.1% and the London average of 26%17.
NHS Havering commissions a Chlamydia screening service from general practitioners and 29 community pharmacies. Fig. 24 gives the location of the Chlamydia screening services mapped against the population of 15-24 year olds in the ward. Fig. 25 provides information at ward level for the percentage of 15-24 year olds screened.
The JSNA states that ‘overall, distribution of the testing kits is focused in areas where there are high numbers of young people’. However, the relatively high numbers of young people in Rainham and Wennington, and the low number of distribution points in these wards (as at April 2010) suggests that additional distribution should be considered. Hence NHS Havering needs to work with pharmacy providers to increase distribution points in this area.
NHS Havering will also work with the pharmacy providers to address the following recommendations within the JSNA o Capitalise on the opportunities within pharmacies to provide easy access to Chlamydia testing and focus screening and preventative interventions on areas with high sexually transmitted infection rates
NHS Havering also commissions a treatment service from pharmacies. Fig. 12 gives further information about the locations for this service (as at April 2010). Pharmacists who have undertaken specific training, issue antibiotics for patients who have screened positive and have been referred to them by the PCT Chlamydia Screening Office. The aim is to facilitate the provision of treatment to young people without the need to see a GP. The antibiotics are issued under a Patient Group Direction (PGD). There is a good distribution of treatment sites across Havering (as at April 2010).
The PCT considers that the Chlamydia screening and treatment services are relevant but will not constitute a necessary service.
16Health Protection Agency, 2009 17 National Chlamydia Screening Programme, 2009/10 53
Fig. 24 Fig. 25 GP & Pharmacy locations as at April 2010 This only covers screening under the local NHS programme
54 10.7 MEDICINES ADMINISTRATION RECORD (MAR) SERVICE
The MAR service is a multi-organisational pilot project, led by NHS Havering, designed to enhance the medicines management role of community pharmacists in the community and the ability of Social Services-employed and/or contracted care workers to safely prompt or administer medication for their service users requiring long-term medication. The service includes joint working between health and social care and also includes the active participation of Barking, Havering and Redbridge University Hospital Trust (BHRuT). The MAR service will:
• Provide service users with more help in managing their medicines • Ensure service users take their medication appropriately and safely • Support all care workers in safely prompting or administering medication to service users • Provide all care workers with a line of communication to answer medication queries and concerns • Maintain accurate medication administration records and keep them updated
At the core of the service is the support that can be given to patients and their carers to help make better use of their medicines. There are a number of measureable outcomes that this pilot will be evaluated against:
• Reducing medicines related hospital re-admissions • Cost-Savings: - by waste reduction of medicines through medicines reconciliation e.g. unintentional discrepancies between the patients discharge prescription and the GPs held medication history - Number of short term medications identified and stopped • Practical problems and solutions associated with the administration of medicines as highlighted by the patient or their carer • Reduction in the number of compliance aids for patients
Their extended availability and medicines expertise gives community pharmacies an excellent opportunity to have a greater involvement in medicines management. Schemes such as the MAR service show that community pharmacists can be used to help better support patients and their carers, through both social and healthcare settings.
This service will be evaluated at the end of 2010/11 and an assessment of whether this service is necessary or relevant will be made at this stage.
55 11. BETTER MANAGEMENT OF MEDICINES
Key Points:
• NICE guidance indicates that between a third and half of all the medication taken for long term conditions may not be taken as directed. The estimated cost of unwanted and unused medicines in the NHS is around £100 million annually
• The primary care prescribing budget in Havering is in excess of £34 million and hence better management of medication could help with the optimal use of this significant resource and improve patients outcomes such as improvements in the condition being treated and reduced hospital admissions. Improving medicines taking could potentially have a greater impact on clinical outcomes than an improvement in treatment
• Over 5% of hospital admissions may be medicines related of which half are preventable – again better medications management could reduce these admissions
• Community Pharmacists have contact with patients and their carers every time they are issued with medication, which gives an excellent opportunity for greater involvement in medication management. This is strongly supported by patient groups in Havering who feel that greater information and education for patients around medication is required
• Community Pharmacists can have a greater role in the management of medicines through enhanced Medication Use Review schemes, Repeat Dispensing, the Electronic Prescription Service (EPS) and the Medicines Administration Record (MAR) scheme
• Consideration needs to be given to improved medication management in the integrated case management work and also within nursing homes
• Concerns have been expressed by General practice about repeat prescription schemes adopted by some pharmacies. These involve patients requesting pharmacies to order repeat medication well in advance of the due time and can lead to wastage. NHS Havering will work with the community pharmacies to ensure that these concerns are addressed. Repeat Dispensing may offer a better way of managing repeat prescriptions
11.1 BACKGROUND
The annual primary care prescribing budget for NHS Havering is in excess of £34 million. The majority of these medications are prescribed to manage long term conditions such as cardiovascular disease, diabetes, asthma etc. However NICE guidance on medicines adherence shows that between one third and a half of all medications for long term conditions are not taken as directed18. Assuming that 80% of the annual drugs budget is to treat long term conditions and that 40% of medications are not taken as directed, then approximately £10million of expenditure annually by NHS Havering is not being utilised to the best possible extent.
18 NICE clinical guideline no. 76 – medicines adherence 2009 56 It is very important to maximise the optimal use of prescribed medications by patients with long term conditions. Medicines are prescribed to patients with long term conditions based on evidence from clinical trials where the medicines have been shown to have a beneficial effect on morbidity and mortality. However if the patients are not taking their medication as directed then the full benefit of the medication is not being realised. This can lead to inadequate treatment which can in turn lead poorer outcomes. In some cases it can lead to the addition of even more medication (incurring further expense) and possible A&E presentations and emergency admission. A Cochrane review concluded that improving medicines taking may have a far greater impact on clinical outcomes than an improvement in treatment.
Furthermore studies have shown that over 5% of emergency hospital admissions are due to medication related problems and about half of these are preventable. A group which needs further attention are the ‘frequent flyers’. Enabling them to take their medication in the optimal way may help reduce re-admissions.
Pharmacists have contact with patients and carers of patients on long term conditions on each occasion that they have medication dispensed which is usually at least monthly. Hence the role of pharmacists can be enhanced to enable patients and their carers to use their medication better and hence improve outcomes and reduce costs.
NICE guidance explains that there are many causes of non-adherence with medication but they fall into two overlapping categories: intentional and unintentional. Unintentional non-adherence occurs when the patient wants to follow the agreed treatment but is prevented from doing so by barriers that are beyond their control. Examples include poor recall or difficulties in understanding the instructions, problems with using the treatment, inability to pay for the treatment, or simply forgetting to take it. Intentional non-adherence occurs when the patient decides not to follow the treatment recommendations. This is best understood in terms of the beliefs and preferences that influence the person’s perceptions of the treatment and their motivation to start and continue with it.
NICE goes on to say that to understand adherence to treatment we need to consider the perceptual factors (for example, beliefs and preferences) that influence motivation to start and continue with treatment, as well as the practical factors that influence patients such as the ability to adhere to the agreed treatment. Applying this approach in practice requires:
• a frank and open approach which recognises that non-adherence may be the norm (or is at least very common) and takes a no-blame approach, encouraging patients to discuss non-adherence and any doubts or concerns they have about treatment
• A patient-centred approach that encourages informed adherence
• Identification of specific perceptual and practical barriers to adherence for each individual, both at the time of prescribing and during regular review, because perceptions, practical problems and adherence may change over time.
The subsections below consider the various ways in which pharmacists can improve the management of medications. Medicines Management can be defined as ‘a system of processes and behaviours that determines how medicines are used by the NHS and patients’.
57 11.2 ENHANCED MEDICATION USAGE REVIEWS
Discussions with patient groups during the preparation of the PNA have shown very strong support for further assistance for patients with their medication especially in terms of information and education. These discussions also showed a strong support for an enhanced and structured medication usage review service where the patient can sit down with the pharmacist and discuss his/her medications in detail. Feedback from patient groups is that such discussions can correct any misinformation and misunderstandings that patients may have as a result of discussions with friends/relatives.
These enhanced medication reviews are based on the current medication review service (MUR), which is a nationally agreed advanced service. However there are some very important enhancements designed to improve outcomes and also enable these improved outcomes to be monitored. The differences between the normal MUR service and the enhanced MUR service are discussed below.
1. Pharmacists have to undertake special training in the conditions that the enhanced MUR is being conducted to ensure that the messages given are in line with the other clinicians locally. 2. Pharmacists adopt a structured approach set down by the PCT in conjunction with prescribers to ensure that the patient’s beliefs, as discussed above, are taken into account and all the relevant information is given. 3. Pharmacists have the opportunity to undertake a follow up in a few months, where necessary, to check if the messages have been understood adequately. For example if the pharmacist discussed with the patient that he/she does not need to use their blood glucose strips so often, the follow up enables an assessment to be made if the patient has been able to adopt the advise. 4. Data is shared anonymously with the PCT in order for the service to be monitored adequately.
11.3 REPEAT DISPENSING
Two thirds of prescriptions generated in primary care are for patients needing repeat supplies of regular medicines and as such, account for a significant workload for practices19. Many of the patients receiving these prescriptions have relatively stable conditions.
The Repeat Dispensing (RD) model offers potential benefits to prescribers, practices and patients for the safe and efficient continued supply and management of regular medicines. The model is designed to ensure clinical supervision is maintained by means of appropriate patient selection criteria and robust standard operating procedures within the pharmacy.
11.3.1 Potential benefits of repeat dispensing
• A reduction in GP practice workload issuing and re-authorising repeat prescriptions • Reduced medicines waste • Earlier detection of medicines-related problems. • Simplified one-stop process for patients obtaining next supply of medicines • Regular contact with pharmacist to discuss medicines-related issues • Pharmaceutical support for self-care and the management of long-term conditions
19 BMA, PSNC, NHS Employers. Guidance for the implementation of repeat dispensing January 2009.
58 11.3.2 Details
RD is an essential service under the Community Pharmacy Contractual Framework and all pharmacies should be able to offer the service when they receive such a prescription from a practice. The framework clearly sets out the expected service provision and the requirements for each pharmacy to have appropriate governance arrangements for the management of the service. Full information is available on the PSNC website and is summarised below.
RD is an alternative model for prescribing and dispensing regular medicines to patients on stable long-term treatment, where repeat supplies are managed by the patient’s pharmacy of choice. There are a number of differences and added benefits between the RD model and traditional repeat prescribing processes, including:
• The prescriber produces a repeatable prescription and a set of identical ‘batch’ forms.
• Each repeatable prescription can be dispensed at regular intervals, for example, monthly for a period of up to 12 months
• A dispensing interval does not have to be set by the prescriber, so that the pharmacist has maximum flexibility to make a professional decision when to dispense the next supply for the patient. This is of particular benefit for patients that may be travelling or if the prescription is for seasonal medicines or ‘when required’ medicines
• Patients will call at their chosen pharmacy for their continued supply of medicines without the need to reorder prescriptions during the life of the repeatable prescription
• The outstanding repeats left on the prescription can be cancelled and the remaining batch issues destroyed as and when required, to respond to changes in medicines, clinical condition or patient circumstances
• The batch forms can be stored securely at the pharmacy or retained by the patient
• The duration of the repeatable prescription can be aligned to a patient review, monitoring procedure or other clinical and administrative functions of the practice
• At the point of dispensing each instalment, the pharmacist will be responsible for checking patient adherence and other clinical factors that are relevant to the appropriateness of the continued supply, for example, whether there are any problems the patient may be encountering with their medicines, whether the patient has recently been in hospital or had changes made to their medication regimen. Any issues of concern to the pharmacist will be reported to the practice.
Repeat dispensing, by its very nature of being a model for people on stable, long-term medicines, will not be suitable for all patients especially those with acute conditions, a newly diagnosed or unstable condition. The need to generate batch prescriptions and concerns about ability to cancel ‘batches’ and ‘items’ has meant that only a relatively small number of prescriptions are generated under the RD system currently in Havering. Consideration needs to be given to either re-vitalising the RD scheme/ addressing the concerns. Consideration also needs to be given to the implementation of the electronic repeat dispensing discussed below which will enable RD prescriptions and items to be cancelled and monitored with greater ease.
11.3.3 Electronic Repeat Dispensing
Release 2 of the Electronic Prescription Service will provide electronic support to the repeat dispensing service. The ‘Spine’ will then manage the release of each individual prescription issue. 59 The first issue of the prescription will be available as soon as the prescription is received by the Spine, subsequent issues will be created on the Spine ready to be pulled down once a previous issue is deemed complete (that is either dispensed or marked as not dispensed).
The electronic service also supports the cancellation of prescriptions, so General Practitioners can be reassured that if the patient’s circumstances do change, they have improved arrangements to cancel and reissue a repeat prescription for a patient. It also avoids the generation of thick wads of ‘repeat batches’.
11.4 INTEGRATED CASE MANAGEMENT
Consideration needs to be given to improving the management of the medication within the Integrated Case Management work. This will help reduce re-admissions.
11.5 IMPROVED MEDICINES MANAGEMENT IN NURSING HOMES
A recent pilot undertaken by the NHS Havering Medicines Management Team in 2 nursing homes in Havering provides evidence for the benefits of improved medicines management for patients in care homes. In total over 70 medication issues were identified. Whilst many of the interventions involved improving the quality rather than reducing cost, overall a projected annual saving of £50k was achieved. Some of the interventions are listed below
• Changing unlicensed liquid medications (specials) to tablets (that can be crushed). • Review of and discontinuation of Sip feeds • Reduction of Blood Glucose testing in line with NHS Havering guidance. • Interactions between medications.
Support for improved medication management in nursing homes also comes from the CHUMS study. This high profile study considered 256 residents in 55 care homes across the UK20. It identified that about 70% of residents had at least one error with their medication. These included errors in prescribing, monitoring, dispensing and administration. In most cases these were minor errors however improved medication management can reduce such errors and improve patient outcomes.
Based on the evidence from the Havering pilot and also the CHUMS study, consideration will be given to expanding the medicines management scheme for nursing homes. The PCT considers that the medicines management scheme for nursing homes through community pharmacy would secure improvements to pharmaceutical services.
11.6 OTHER AREAS
NHS Havering and the London Borough of Havering will work with community pharmacies to identify ways in which pharmacy can contribute to new developments such as personal health budgets and tele-care.
General Practitioners have requested that pharmacists alert them in cases where they may have issued prescriptions for items that have been agreed locally as being most suitable for prescribing by secondary care.
‘Repeat prescription management schemes’- involve a community pharmacy ordering medication on behalf of the patients from the GP practice. Such schemes have worked well for a number of years and particularly benefit patients who are housebound. However some work is required to ensure that such schemes do not result in the ordering of medication that is not required by patients. Such ‘over
20 Alldred DP, Barber N et al. Care Home Use of Medicines Study (CHUMS) 2009.
60 ordering’ results in wastage and increased costs. Repeat dispensing could address some of the issues that have been raised by some General Practitioners.
Expert Patient Programme (EPP) – Consideration needs to be given to how the EPP can work with community pharmacy to improve medicines management. .
61 12. PATIENT FEEDBACK
Key Points:
• Over 600 members of the public completed the PNA patient survey in a variety of settings
• Patients are very happy with the pharmacy services and access to pharmacies
• The majority would like to see more screening services and also medications for minor ailments on the NHS from pharmacies
• Health checks and a minor ailments scheme need consideration
Over 600 members of the public completed the PNA patient questionnaire. Members of the public were requested to complete these in a variety of settings including pharmacies, GP practices, Health Centres, patient group meetings and via the web based survey on the NHS Havering website. The survey was promoted through news items on the NHS Havering website and articles in the local press including the Romford Recorder and Living Magazine.
The full results of the answers for each question are given in appendix 5; however a summary is given below.
There was a good distribution of responders from across all the wards in Havering and overall there were no substantial differences in the responses between the wards
Fig. 26 Table: Summary of responses to patient survey KEY QUESTIONS KEY RESPONSE 1.Number of responders 626 2.Additional services patients would Screening services (85%) of which like to see from pharmacies diabetes/cholesterol test (53%) and Health MOT (32%)* Medicines for minor ailments on the NHS (41%) 3.How often do you visit a pharmacy Monthly (56%) 4.Do you use the same pharmacy Every time or most of the time (89%) 5.Reasons for using a particular Proximity to home (61%) Proximity to pharmacy doctors surgery (46%) 6.Experience of using pharmacy Excellent (53%) Very good (32%) Good (11%) 7.Problems with access Yes (2.5%) – of which 50% were problems getting specific brands of medication and not access problems
*Those indicating a Health MOT may not have ticked the diabetes/cholesterol test and vice-versa so in total it could be considered that over 80% of responders would like to see more screening services from pharmacies
62
13. PHARMACISTS SURVEY Fig. 27 WARD WARD FCS CODE CODE FCS POST CODE POSTCODE POLYSYSTEM POLYSYSTEM E-MAIL ACCESS ACCESS E-MAIL TRADING NAME NAME TRADING QUIET AREA AVAILABLE AVAILABLE AREA QUIET NUMBER OF CONSULTATION ROOMS ROOMS CONSULTATION OF NUMBER NUMBER OF PMR LINKED COMPUTERS COMPUTERS LINKED PMR OF NUMBER NETWORKED COMPUTERS IN CONSULTATION ROOM ROOM CONSULTATION IN COMPUTERS NETWORKED
FA727 YOUR LOCAL BOOTS PHARMACY RM3 8DB GOOSHAYS NORTH EAST 1 Yes 2 No DAILY FA737 BOOTS RM3 9PH GOOSHAYS NORTH EAST 1 No 4 Yes DAILY FF297 BOOTS RM3 8DX GOOSHAYS NORTH EAST 1 Yes 4 No DAILY FW636 NEWLANDS PHARMACY RM3 9SU GOOSHAYS NORTH EAST 1 Yes 6 Yes DAILY FL514 NATIONAL CO-OP CHEMIST RM3 0BP HAROLD WOOD NORTH EAST 1 No 2 Yes DAILY FDT86 TESCO INSTORE PHARMACY RM3 0LL HAROLD WOOD NORTH EAST 1 No 1 No WEEKLY FQM30 CO-OPERATIVE PHARMACY HW POLYCLINIC RM3 0FE HAROLD WOOD NORTH EAST 1 No 3 Yes DAILY FN455 SHADFORTHS CHEMIST RM2 5SU EMERSON PARK NORTH EAST 1 No 3 Yes DAILY FQD98 ROWLANDS PHARMACY RM11 2LG SQUIRRELS HEATH NORTH EAST 1 No 4 Yes DAILY FGW82 BRITCROWN PHARMACY RM2 5JR SQUIRRELS HEATH NORTH EAST 1 Yes 3 Yes DAILY FGV99 CRESCENT PHARMACY RM3 7PB HEATON NORTH EAST 1 Yes 3 Yes DAILY FVE89 YOUR LOCAL BOOTS PHARMACY RM5 3PH HAVERING PARK NORTH WEST 1 No 3 Yes DAILY FN123 W BURDESS CHEMIST RM7 8BU MAWNEYS NORTH WEST 1 No 2 Yes DAILY FN391 LLOYDS PHARMACY* RM5 3PR MAWNEYS NORTH WEST 1 FKN55 NEWLANDS PHARMACY RM5 3BB PETTITS NORTH WEST 1 Yes 3 Yes DAILY FXK72 RISE PARK PHARMACY RM1 4NT PETTITS NORTH WEST 1 No 3 Yes DAILY FKK95 ROWLANDS PHARMACY RM7 7HH BROOKLANDS NORTH WEST 1 No 2 Yes DAILY FDP87 SAFEDALE RM7 0TJ EASTBROOK NORTH WEST 1 Yes 3 Yes DAILY FT893 MiM PHARMACY RM1 1DL ROMFORD TOWN NORTH WEST 1 Yes 2 Yes WEEKLY FV600 BOOTS RM1 3AD ROMFORD TOWN NORTH WEST 1 Yes 4 No DAILY FJP97 NEWLANDS PHARMACY RM11 1BH ROMFORD TOWN NORTH WEST 1 Yes 4 Yes DAILY FA111 SAINSBURYS INSTORE PHARMACY RM1 1AU ROMFORD TOWN NORTH WEST 1 No 1 No DAILY FV092 BOOTS RM1 1AU ROMFORD TOWN NORTH WEST 2 Yes 3 Yes DAILY * Relevant data not provided
63 Fig. 27 (Continued) WARD WARD FCS CODE CODE FCS POST CODE POSTCODE POLYSYSTEM POLYSYSTEM E-MAIL ACCESS ACCESS E-MAIL TRADING NAME NAME TRADING QUIET AREA AVAILABLE AVAILABLE AREA QUIET NUMBER OF CONSULTATION ROOMS ROOMS CONSULTATION OF NUMBER NUMBER OF PMR LINKED COMPUTERS COMPUTERS LINKED PMR OF NUMBER NETWORKED COMPUTERS IN CONSULTATION ROOM ROOM CONSULTATION IN COMPUTERS NETWORKED
FGD64 BOOTS RM1 3RL ROMFORD TOWN NORTH WEST 1 Yes 10 No DAILY FTV79 PARK LANE PHARMACY RM11 1BB ROMFORD TOWN NORTH WEST 1 No 2 Yes DAILY FRF15 PHARMACARE CHEMIST RM11 1QH HYLANDS NORTH WEST 1 Yes 1 No DAILY FYN65 TESCO INSTORE PHARMACY RM11 1PY HYLANDS NORTH WEST 1 No 1 No NEVER FL261 YOUR LOCAL BOOTS PHARMACY RM11 3XS ST ANDREWS SOUTH 1 No 3 Yes DAILY FDA73 YOUR LOCAL BOOTS PHARMACY RM12 4UH ST ANDREWS SOUTH 1 No 2 Yes WEEKLY FX556 BOOTS RM12 4UL ST ANDREWS SOUTH 1 Yes 3 Yes DAILY FJM16 CHEMISTREE RM11 3UX ST ANDREWS SOUTH 1 No 2 No DAILY FMD27 ELM PARK PHARMACY RM12 4SD ST ANDREWS SOUTH 1 No 2 Yes WEEKLY FLN08 DAY LEWIS PHARMACY RM14 1RQ CRANHAM SOUTH 1 Yes 2 Yes DAILY FEO51 GOVANI CHEMIST RM14 1XN CRANHAM SOUTH 1 No 1 No DAILY FPD73 GOVANI CHEMIST RM14 2TD UPMINSTER SOUTH 2 No 2 Yes DAILY FE805 BRITANNIA PHARMACY RM14 2AD UPMINSTER SOUTH 2 Yes 3 Yes DAILY FXH36 BOOTS RM14 2AJ UPMINSTER SOUTH 1 No 1 No DAILY FCN97 PANCHEM PHARMACY RM14 3BS UPMINSTER SOUTH 1 No 1 No DAILY FW198 BOOTS RM12 6LL HACTON SOUTH 1 No 2 Yes DAILY FCC42 LLOYDS PHARMACY RM12 5AS HACTON SOUTH 1 No 2 Yes DAILY FXV64 NEWLANDS PHARMACY RM12 5AB ELM PARK SOUTH 1 No 2 No DAILY FEP91 DAY LEWIS PHARMACY RM13 7PP ELM PARK SOUTH 1 No 2 Yes DAILY FC513 DAY LEWIS PHARMACY RM13 7QX SOUTH HORNCHURCH SOUTH 1 No 2 Yes DAILY FG050 WILLIAMS CHEMIST RM13 9TR RAINHAM AND WENNINGTON SOUTH 1 No 1 Yes DAILY FTE90 CHANSONS PHARMACY RM13 9BD RAINHAM AND WENNINGTON SOUTH 1 Yes 2 No DAILY FAO52 TESCO INSTORE PHARMACY RM13 9YZ RAINHAM AND WENNINGTON SOUTH 1 No 1 No DAILY FJL00 BOWS CHEMIST RM13 9JR RAINHAM AND WENNINGTON SOUTH 1 No 1 No NEVER
64 As part of the Pharmacy survey, pharmacists were asked which 6 services they saw as being priorities for Havering residents; the top 6 priorities identified by Havering pharmacists are shown in the table below:
Fig. 28 Service Ranking % of pharmacists surveyed who ranked the service in their top 6 priorities Minor Ailments 79% Emergency Hormonal Contraception (EHC) 57% Flu vaccination 40% Vascular Risk Assessment 34% Obesity management 34% Diabetes screening/monitoring 30%
65 14. GP SURVEY
At a forum meeting 25 GPs were asked which services they thought were important for Pharmacy to be providing; the following are the main responses:
• (36%) 9 mentioned minor ailments should be offered through pharmacies
• (28%) 7 mentioned about reconciling patients medicines after discharge from hospital being a brilliant idea
• (24%) 6 mentioned stop smoking services should be available
• (16%) 4 mentioned medication review services being very important
• (16%) 4 mentioned weight/obesity management
66 15. IDENTIFIED HEALTH NEEDS
Key Points:
• Community pharmacy has a significant role to play in meeting the health needs of the Havering population identified within the JSNA
• The success of the pharmacy smoking cessation and anti-coagulation services demonstrate that community pharmacy can provide cost effective and highly rated services that can meet the health needs of the population
• The PNA pharmacists survey shows a lot of enthusiasm amongst pharmacists to take on more services and help to meet the wider health needs of the population
15.1 BACKGROUND
This section considers areas of health need identified within the JSNA where pharmaceutical services can help address the needs identified
The areas considered are:
• Chronic Obstructive Pulmonary Disorder • Diabetes • Stroke • Hypertension • Emergency hospital admissions • Under 18 conception • Obesity and Physical Activity • Cancer • Healthy Eating • Alcohol • Dementia
67 15.2 EMERGENCY HOSPITAL ADMISSIONS
Key Points:
• In 2009/10, there were more than 13,800 emergency hospital admissions in Havering
• The JSNA recommends decision makers to consider targeting interventions to reduce the need for hospital admissions at those social groups and wards identified as placing the highest demand on these services
• Better management of patients medication, in particular those with cardiovascular and respiratory long term conditions, could significantly reduce emergency hospital admissions
15.2.1 Background
In 2009/10, there were more than 13,800 emergency hospital admissions in Havering. Fig. 29 below gives a breakdown of the hospital admissions by ward.
Residents of Gooshays, Romford Town and Heaton made up the largest proportions of people admitted to hospital for emergency appointments.
Fig. 29
% of Total Hospital Admissions in Havering by Ward 2009/10
8.0
7.0
6.0
5.0
Emergency Admissions 4.0 Elective Admissions
3.0 % of Total Admissions Total of % 2.0
1.0
0.0 Gooshays Romford Town Heaton Brooklands St Andrew's Harold Wood Elm Park Havering Park Mawneys Pettits Rainham and Wennington South Hornchurch Cranham Hacton Hylands Upminster Squirrel's Heath Emerson Park
Ward
The most common cause of emergency hospital admissions is injury and poisoning which accounts for 16% of admissions. This includes the side effects of medication. Other common causes are circulatory diseases (10%) and respiratory diseases (10%). Fig. 30 illustrates this further.
68
15.2.2 How community pharmacy can contribute
It is estimated that approximately 5% of hospital admissions are related to medication of which 2.5% may be preventable21. Improved medicines management could help prevent some of these admissions. Also improved management of medicines for patients with cardiovascular and circulatory disorders could prevent a significant number of admissions. NICE guidance on adherence indicates that between one-third and a half of all medication prescribed for long term conditions is not taken as directed. This in turn leads to such patients not receiving the full benefit of their treatment which in turn can lead to emergency hospital admissions. Enhanced Medicines Usage Reviews could be targeted at patients with particular risk of hospital admissions e.g. those with many medications (poly- pharmacy) and ‘frequent flyers’.
Fig. 30
Top 10 Causes of Emergency Hospital Admission in Havering 2009/10 (Grouped By Type of Disorder)
18
16
14
12
10
8
6
4
2 % of Total EmergencyAdmissions Total of % 0 . es s rs s s ers er ers ers er ses aus d rde d c ord o or ord ea is s sorder s is nal d disor dis di l Canc d y y l ic ter n di tive disorders or ar etal tem di s atory at Ski s 9. A e r kel y er ex g 7. s th Di tourin os s Parasit o ul ou 2. eni c v & 3. Circul G and 4. Respi . 5 Ner ng 6. Mus 8. oni is 10.Infectious po ,
njury I 1. Type of Disorder
21 Leendertse, A: Egberts, A: Stoker, L: and van den Bemt, P. Frequency of and Risk Factors for Preventable Medication- related Hospital Admissions in the Netherlands. Arch Intern Med/Vol 168 (No 17). Sep 22 2008
69 15.3 UNDER 18 CONCEPTION
Key Points:
• Havering has an increasing under 18 conception rate, which is now higher than the national average. Some wards have amongst the highest rates in the country and termination rates are also above the national average
• A pharmacy emergency contraception service should be commissioned, in line with the majority of PCTs in London and in line with the JSNA recommendations
• A contraceptive service though pharmacy can be piloted in the specific wards in line with successful pilots in other PCTs and in line with the JSNA recommendation to investigate ways of improving access to contraceptive services
Nationally, since the launch of the Teenage Pregnancy Strategy in 2009, under 18 conceptions have been becoming less common22. In Havering, historically, there were fewer under 18 conceptions than was the average for England or London. However, 2008 data indicates that worryingly, unlike the national trend, under 18 conceptions have become more common in Havering, having increased by 3% between 1998 and 200823.
Havering has an under 18 conception rate of 42.1 per 1000 girls, which is now above the national average of 40.4. Fig. 31 illustrates the rates of Under 18 conception by ward across the PCT. It is consistently more common for women who conceive in Havering to have a termination than the national average. In the under 18s, the highest number of terminations in 2009/10 were in the Havering Park ward, followed by the Heaton and Brooklands wards, with terminations in these 3 wards accounting for 43% of all terminations in the year24.
Gooshays and Heaton wards have under 18 conception rates which are in the highest quintile nationally.
The JSNA recommends Decision Makers to Investigate ways of improving access to contraceptive services (such as free emergency contraception for young people, introducing a community based contraceptive service and improving access to the most effective long acting reversible contraception methods).
22 Local, Regional and National Comparative Quarterly Rates Data, Teenage Pregnancy Unit, 1998-2008 23 Local Authority Teenage Pregnancy Analysis (provisional), Teenage Pregnancy Unit, 2010 (based on 2008 data) 24 NHS Havering 2009/10 70 Fig. 31 illustrates the rates of under 18 conception in wards across the PCT:
Fig. 31
15.3.1 How community pharmacy can contribute
An emergency contraception service (EHC) should be commissioned from pharmacies. This would be in line with the majority of PCTs in London who have seen a reduction in their under 18 conception levels. This could be promoted in particular in the Heaton, Gooshays, Brooklands and Havering park wards which have high incidence of under 18 conception and/or abortion. EHC would be a cost effective service for NHS Havering and should be considered with other preventative measures to reduce unwanted pregnancies, the costs of abortions and improve access to sexual health services for the young.
A contraceptive service though pharmacy can be piloted in the above wards in line with successful pilots in other PCTs. This scheme could include condom distribution as well as increasing patient’s access to the most effective Long Acting Reversible Contraceptive (LARC) methods.
Community pharmacies need to be integrated into the sexual health pathway and work in conjunction with the other providers. Pharmacies participating in sexual health services would need to be ‘young people friendly’.
The PCT believes that a community pharmacy emergency contraception service would secure improvements to pharmaceutical services.
71 15.4 CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
Key Points:
• The JSNA states that the incidence of diagnosed COPD in Havering (1.9%) is higher than the national average, however the modelling estimates the actual prevalence to be 4.6%
• A pilot community pharmacy service conducted with 126 smokers, found 29 potential cases of COPD and 7 cases of severe COPD
• The pilot potentially saved £12k in avoided hospital admissions and provides evidence to commission such a service through pharmacies in Havering
Fig. 32
72 COPD is the name for a collection of lung diseases including chronic bronchitis, emphysema and chronic obstructive airways disease. The main cause of COPD is smoking25.
Below are key messages from the JSNA
1.9% of people on GP registers in Havering are recorded as having COPD. This is above the London figure of 1% and the England figure of 1.5%.
Modelled estimates of COPD predict a much higher prevalence of COPD in Havering, stating that 4.6% of people would be expected to have COPD in 2010, which is still higher than the national estimate of 3.6%. It is possible that this difference in prevalence figures is due to many people with COPD not going to the doctor with their symptoms as they just see it as “smoker’s cough”. This may result in the number of people diagnosed with COPD on GP registers being lower than the number of people who actually have this condition.
Estimates also suggest that COPD will become more common in Havering, with prevalence rising to 4.9% by 2020.
Fig. 33 below compares wards in terms of their ranking for prevalence of COPD from QOF data vs. Mosaic modelled data. This suggests that South Hornchurch, Elm Park, Mawneys and Harold Wood are wards where there are potentially the highest numbers of undiagnosed patients with COPD
Fig. 33 COPD WARD RANKINGS
Top 6 wards of highest incidence of COPD Top 6 wards of highest incidence of COPD based on Mosaic based on QOF 1. Heaton 1. Heaton 2. Gooshays 2. Havering Park 3. South Hornchurch 3. Gooshays 4. Elm Park 4. Pettits 5. Havering Park 5. Rainham & Wennington 6. Mawneys 6. Hylands
15.4.1 How community pharmacy can contribute
As smoking is the major cause of COPD, continued work on smoking cessation schemes through pharmacy, as detailed in the smoking cessation section can be promoted.
Pharmacy can make a major contribution to the identification of patients with undiagnosed COPD. A model published in the National clinical guideline on management of chronic obstructive pulmonary disease in adults in primary and secondary care suggests that opportunistic case finding in primary care is a relatively cost effective strategy. The cost per life year gained is £713.16 and the cost per quality adjusted life year gained is £814.5626.
Further evidence of this comes from a pilot undertaken in NHS Havering. The pilot found 29 of 126 people tested using a basic hand held spirometer may have COPD, 7 of these had severe or very severe COPD. Assuming these 7 are likely to end up in hospital in the next 12 months, the pilot may have potentially avoided 7 hospital admissions at a cost of £1700per admission (£12,000) 27/28
25 NHS Choices website, http://www.nhs.uk/conditions/chronic-obstructive-pulmonary-disease/pages/introduction.aspx, 2010 26 National Collaborating Centre for Chronic Conditions. Chronic obstructive pulmonary disease. National clinical guideline on management of chronic obstructive pulmonary disease in adults in primary and secondary care. Thorax 2004;59 (Suppl I):1-232 doi 27 Disease management information toolkit (DMIT), DoH, [email protected] 73
Evidence suggests that smokers diagnosed with COPD are significantly more likely to quit smoking than those with normal lung function29, and interventions involving education around lung age may improve quit rates30. This was also shown in the pilot.
The PCT believes that a COPD screening service would secure improvements to pharmaceutical services.
28 Dr Foster Respiratory; COPD; All admissions; Q1 2009/10-10/11 29 Gorecka D, Bednarek M, Nowinski A, Puscinska E, Goljan-Geremek A, ZielinskiJ. Diagnosis of airflow limitation combined with smoking cessation advice increases stop-smoking rate. Chest 2003;123:1916-23 30 Parkes G, Greenhalgh T, Griffin M, et al. Effect on smoking quit rate of telling patients their lung age: the Step2quit randomized controlled trial. BMJ 2008; 336:598-600. http://dx.doi.org/10.1136/bmj.39503.582396.25
74
15.5 OBESITY & PHYSICAL ACTIVITY
Key Points:
• The JSNA recommends the development of appropriate care pathways for overweight and obese people and community pharmacy can play a key role
• Community pharmacists can assist with the JSNA recommendation to target future interventions at 4-5 year old children, men and local wards identified as having the highest levels of obesity. They can also help with the promotion of physical activity
• Pilots show that a community pharmacy weight management scheme can assist with the rising burden of obesity and the service is more cost effective in some cases than prescribing weight reducing medications
Key findings from the JSNA include:
• In Havering, it is more common for 4-5 year olds (reception year) to be overweight or obese than is the case nationally • Data from the Health and Lifestyles Survey suggest that 21.4% of adults in Havering are obese. • The Health and Lifestyles Survey results suggest that obesity is most common in St Andrew’s, Heaton and Gooshays wards. • When exercise and weight were examined, it was found that around half of those who were overweight, obese or morbidly obese were inactive in their daily lives • Target future interventions at 4-5 year old children, men and local wards identified as having the highest levels of obesity and develop appropriate care pathways
75 15.5.1 How community pharmacy can contribute
Community pharmacy has extensive contact with overweight people and can make a significant contribution to the development of the care pathway for overweight and obese people in Havering. There are many different ways in which pharmacies can contribute, recommendations include:
• NHS Havering and the Local Authority need to work with community pharmacists so that they more proactively provide information on local services and signpost people to sources of information • Community pharmacy public health campaigns could be used to promote physical activity and healthy eating • Community Pharmacists could refer appropriate patients directly onto physical activity schemes to take advantage of their extensive contacts with such patients • A community pharmacy based weight management service is commissioned by a number of PCTs and offers patients the advantages of easy access, extended hours and an informal environment. The skills developed and the success demonstrated by pharmacists with the smoking cessation scheme could be utilised to good effect with such a service • A behavioural change programme over 12 months was commissioned from pharmacies in Central Lancashire. Target groups were people over 18 with a BMI > 25 and < 40. The results were evaluated by the University of Central Lancashire. Statistically significant weight loss of 5% of body mass or more was maintained over 12 months. Average weight loss was 2.5kg and average reduction in BMI was 2.4. The service is more cost effective than prescribing orlistat over 12 months (£160 per patient vs £419.51 per patient). Patients liked the informal pharmacy environment for this service which made them feel comfortable. It was on their ‘doorstep’; they could be flexible about appointments/drop-ins31
The PCT believes that a community pharmacy weight management service would secure improvements to pharmaceutical services.
31 Centrallancs. Primary Care Home Integrated Leadership Development Programme 76 Fig. 34 shows the prevalence of obesity across the PCT. The wards of Gooshays, Heaton and St Andrews would be ideal places for piloting further pharmacy obesity services.
Fig. 34 32
32 NHS Havering Key Health Data 2008 77 15.6 CANCER
Key Points:
• The JSNA has identified some key health information that needs to be delivered to the public around awareness of symptoms and risk factors for specific forms of cancer
• Given that up to 10% of the Havering population may visit a pharmacy daily, pharmacy public health campaigns provide a very powerful means of promoting these key messages
Key findings from the JSNA include • Overall, it is less common for people in Havering to be diagnosed with cancer than the England average • However, the mortality rate for women in Havering who get cancer and are under the age of 65 is higher than is the case nationally • Cancer (all types) is the biggest cause of premature death causing 45% of all premature deaths in Havering • Although it is less common for people in Havering to get colorectal cancer than is the case nationally, for those that do have this, survival rates are poor • Recognition of the symptoms of cancer was low among Havering residents • Improve awareness of cancer symptoms in the population as late presentation is a significant factor in poor survival
15.6.1 How community pharmacy can contribute
The key health findings from JSNA can be considered as part of the Pharmacy Public Health Campaign’s during in the forthcoming years. As discussed in the essential services section, Community pharmacies are required to support the PCT in up-to 6 public health campaigns annually. The campaigns can focus on specific patient groups who are most at risk and in areas where there is the greatest need for the message to be delivered.
78 15.7 STROKE
Key Points:
• The JSNA has identified that Havering has a higher incidence of stroke relative to the London average and also a higher emergency admission rate compared to the national average
• Better medicines management for stroke patients through an enhanced Medicines usage review service could help prevent strokes
• Community Pharmacists can play a key part in reducing the risk factors for stroke through further work on smoking cessation, obesity and promoting of healthy lifestyles, exercise and diet
Fig. 35
79 The JSNA indicates that
• Stroke is the third most common cause of death in England and is largely preventable, with many of the risk factors able to be reduced by lifestyle changes. Around a quarter of strokes occur in people under the age of 65.
• Data suggests that 1.5% of people on GP registers in Havering have had a stroke or mini stroke (transient ischemic attack). This is below the national average of 1.7% but above the London average of 1%. QOF data suggests that the highest prevalence of strokes is in the Cranham , Petits , Emerson Park , St Andrews and Elm Park wards.
• 2007/08 data suggests that it is slightly more common for people to have emergency admissions to hospital for stroke in Havering than is the case nationally (Havering: 104 admissions per 100,000 people; England: 98 admissions per 100,000 people).
15.7.1 How community pharmacy can contribute
Community Pharmacists can play a key part in reducing the risk factors for stroke through further work on smoking cessation, obesity and promoting of healthy lifestyles, exercise and diet.
As discussed in the earlier section, better management of medications can help reduce the emergency hospital admissions associated with transient ischemic attacks. A particular area of focus is compliance with and understanding of the use of medication that prevent strokes. As these medications may not provide immediate relief there may be a perception amongst patients that these medications are not helping.
The areas with the highest prevalence of stroke could be targeted in a pilot scheme on medicines management through pharmacy. An enhanced medication review scheme for stroke should be considered.
80 15.8 HYPERTENSION
Key Points:
• Early roll out of NHS health checks through Community Pharmacy can help identify the estimated 20% of people who have undiagnosed hypertension. Early identification can prevent strokes, cardiac and renal diseases
• As hypertension is asymptomatic it is especially important to have an enhanced MUR service for patients with hypertension to ensure better understanding of the benefits of the medication
Hypertension is the generic term for raised blood pressure. Having hypertension raises the risk of stroke, heart attack, kidney problems and dementia.
Hypertension is estimated to be more common in Havering (32.1% of adults) than is the case nationally (30.5% of adults).
GP register data suggests a much lower prevalence of hypertension in Havering, with 13.4% of those of GP registers having a diagnosis of hypertension33. This is still above the national figure of 13.1% however. This data suggests that prevalence of hypertension is highest in Cranham and Heaton wards.
33 Quality and Outcomes Framework, National Health Service Information Centre for Health and Social Care, 2008/09 81 Fig. 36 gives a modelled prediction for hypertension across the wards Fig. 36
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Fig. 37 compares the top wards for incidence of stroke using QOF vs. the top wards for hypertension propensity using MOSIAC modelled data. It would appear that Gooshays, Havering Park and South Hornchurch are wards with the greatest number of undiagnosed people with hypertension.
Fig. 37 Top 6 wards of highest incidence based on Top 6 wards of highest incidence based on Mosaic QOF 1. Heaton 1. Cranham 2. Elm Park 2. Heaton 3. Gooshays 3. Rainham & Wennington 4. Cranham 4. St. Andrews 5. Havering Park 5. Elm Park 6. South Hornchurch 6. Hacton
15.8.1 How community pharmacy can contribute
Early roll out of NHS health checks through Community Pharmacy can help identify the 20% of people who have undiagnosed hypertension. Early identification can prevent strokes, cardiac and renal diseases. Gooshays, Havering Park and South Hornchurch are wards where this service would be of particular value.
As hypertension is asymptomatic it is especially important to have an enhanced MUR service for patients with hypertension to ensure better understanding of the benefits of the medication and hence improve compliance/concordance.
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15.9 HEALTHY EATING
Key Point:
• Community pharmacists can, via public health campaigns and brief interventions, help to promote healthy eating and targeted healthy eating activities
Key findings from the JSNA include:
• When young people in Havering were asked how many portions of fruit and vegetables they had eaten the previous day, only 17% had eaten 5 or more portions. This is slightly below the national figure of 19%. 70% of year 8 and 10 pupils in Havering find the information they receive at school on healthy food and lifestyles helpful, however 5% stated that they had not received any advice or information about this topic. • It is estimated that only 28.8% of adults in Havering eat 5 portions of fruit and vegetables a day, which is similar to the national average of 28.7%.
15.9.1 How community pharmacy can contribute
These key messages around healthy eating can be part of pharmacy public health campaigns. Community Pharmacists can also be encouraged to make brief interventions using these messages.
84 15.10 ALCOHOL
Key Points:
• Whilst the overall incidence of binge drinking and hospital stays due to alcohol related harm is lower in Havering compared to the national average, there are estimated to be over 49,000 people who drink above the Governments Recommended Drinking Guidelines
• A significant problem exists in Heaton, Gooshays and Brooklands wards
• A community pharmacy alcohol interventions scheme could offer advice and signposting. Pilots have been successful in showing that such schemes are cost effective
Havering has significantly fewer adults that binge drink than the England average (13.7% in Havering, compared to 20.1% in England)34.
There are also significantly fewer hospital stays due to alcohol related harm in Havering than the England average (Havering: 1420 hospital stays per 100,000 people, England: 1580 stays per 100,000 people). This relates to 4088 people a year going to hospital in Havering due to alcohol related harm (this includes admissions due to short term alcohol use e.g. alcohol poisoning, but also admissions due to long term effects of alcohol use e.g. liver disease due to alcoholism)35.
Fig. 38 shows excessive alcohol consumption across the wards in Havering. It shows that, whilst the overall Havering data for alcohol related problems is below the national average, there are at least three wards where a significant problem exists. These wards are Heaton, Gooshays and Brooklands.
34 Havering Health Profile, Association of Public Health Observatories and Department of Health, 2010 35 Havering Health Profile, Association of Public Health Observatories and Department of Health, 2010 85 Fig. 38
86 15.10.1 How community pharmacy can contribute
The access and footfall that Community pharmacy offers can make a significant contribution to reducing alcohol related harm. Pharmacists can offer brief advice and signposting to assistance for those who consume alcohol excessively. Particular wards that need to be targeted are Heaton, Gooshays and Brooklands.
A pilot scheme in Havering 2009 organised by the DAAT, involved pharmacists in offering brief and extended interventions to customers who completed a self assessment questionnaire on their alcohol use. Customers were referred or signposted to the community alcohol team where appropriate. 1676 customers were screened and 476 of these were given advice (ABI). ABI results in the reduction from higher risk drinkers (also known as harmful drinkers) to lower risk drinkers (also known as hazardous drinkers). It is further established that brief interventions can reduce drinking by between 13% and 34% resulting in 2.9 to 8.7 fewer man drinks per week with a significant effect on recommended or safe alcohol use. Hence the pilot was successful, however could not be extended due to limitations in funding.
The DH ‘Ready Reckoner’ tool shows significant cost savings can result from a reduction in A&E and hospital admissions following identification of high risk drinking and subsequent intervention36. A pilot in NHS Blackpool where pharmacists made brief interventions showed that 39% of patients screened were at ‘increasing or high’ risk. A pharmacy service has the advantage in that it can be targeted towards potentially high risk groups such as customers coming in for ‘hangover’ remedies, those with gastric problems, falls and those from vulnerable groups. Pharmacy sees a different group of people from those who may visit a GP practice. Local people maybe more open to disclosing their true behaviour to pharmacy staff who are likely to be local people, as they see them as their peers.
The PCT believes that a community pharmacy alcohol intervention service would secure improvements to pharmaceutical services.
36 www.alcohollearningcentre.org.uk 87
15.11 DEMENTIA
Key Points:
• Community pharmacy can play a significant role in preparing for the predicted rise in the prevalence of dementia of over 12% by 2015 and 49% by 2030
• Community Pharmacy can help in the identification of patients with dementia as well as to maintain patients in the community through support schemes such as MAR and enhanced medication usage reviews
GP register data suggests that in Havering 0.4% of people have dementia, the same prevalence as for England overall37. This is lower than predictions made by modelled estimates, which suggest that 1.1% of people in Havering have dementia. The difference suggests that about 65% of people with dementia in Havering are undiagnosed, equating to around 2010 cases of undiagnosed dementia in Havering38.
As is the case nationally, it is predicted that the number of people with dementia in Havering will continue to rise in the future, rising by more than 15% by 2020.
The JSNA recommends decision makers to prepare for the predicted increased demand in conditions such as dementia and diabetes
15.11.1 How community pharmacy can contribute
The significant increases in the prevalence of dementia will involve considerable additional work in primary care.
Community Pharmacy can make a significant contribution and hence needs to be involved in the development of the local Dementia Strategy. Some of the ways community pharmacy can contribute is by:
• Helping maintain patients with dementia in the community through schemes such as the MAR, where carers are supported in the administration of medication
• Enhanced medication usage reviews for dementia where pharmacists can identify the medication related needs of such patients and work with the GP and carers to simplify the medication regimes
15.12 Transforming Community Equipment Service (TCES)
The retail prescription model for Simple Aids to Daily Living (SADLs) such as aids for moving, eating, toileting and sensory needs, works on a similar basis to other types of prescription. As a general rule, the DH considers items costing less than £100 to be SADL. A prescriber will assess and identify equipment needed and instead of placing an order with a contractor, they will write a prescription for the equipment. The accredited approved retailer will then fill the prescription. Accreditation of retailers
37 Quality and Outcomes Framework, National Health Service Information Centre for Health and Social Care, 2008/09 38 ONEL Dementia Analysis, ONEL Acute Commissioning Unit 2010 88 will be against national standards, and include the capacity to deliver, fit and instruct the client on the use of the equipment where necessary.
15.12.1 How community pharmacy can contribute
Community pharmacists given their extensive contact with patients and their carers are ideally positioned to provide TCES services.
89 16. APPENDICES
16.1 (APPENDIX 1) GLOSSARY
AUR Appliance Use LTC Long Term Conditions Service Review Service
BMI Body Mass Index MDS Monitored Dosage System BP Blood Pressure MUR/PI Medicines Use Review/Prescription Intervention CHD Coronary Heart NEH North East Havering Disease Polysystem COPD Chronic Obstructive NHS National Health Service Pulmonary Disease CVD Cardio Vascular NHSIC NHS Information Centre Disease DH Department of NRT Nicotine Replacement Health Therapy EHC Emergency NWH North West Havering Hormonal Polysystem Contraception EPS Electronic ONS Office of National Statistics Prescription Service ESPLPS Essential Small PCT Primary Care Trust Services Pharmacy GP General PMR Patient Medical Record Practitioner
HbA1c Glycosylated PNA Pharmaceutical Needs Haemoglobin Assessment HES Hospital Episode PSNC Pharmaceutical Services Statistics Negotiating Committee http://www.psnc.org.uk/ HF Heart Failure QOF Quality and Outcomes Framework JSNA Joint Strategic RD Repeat Dispensing Needs Assessment LMC Local Medical SC Stoma Customisation Committee Service Service LPC Local SH South Havering Pharmaceutical Polysystem Committee LPS Local Pharmaceutical Services LTC Long Term Condition
90 NHS Appeals A special health authority that was responsible for Authority determining control of entry appeals. Subsequently replaced by the NHS Litigation Authority. Community The community pharmacy contract is made up of Pharmacy Contract three service levels: Essential Services, Advanced Services and Enhanced Services. Pharmacy contractors do not have a contract in the legal sense with Primary Care Trusts, they operate under terms of service set out in regulations. These are often referred to as the ‘community pharmacy contract’. Consultation Most community pharmacies now have an area in the Facilities pharmacy where the patient and pharmacist can have a private consultation. The design and specification of these facilities varies from pharmacy to pharmacy. Medicines Use This service is intended to improve patient’s Review understanding of their medicines; highlight problematic side effects & propose solutions where appropriate; improve adherence; and reduce medicine wastage, usually by encouraging the patient only to order the medicines they require. Pharmacist A registered pharmacist who has typically completed five years of training which includes a degree and post graduate training. Pharmaceutical These are services available from pharmacies, Services dispensing appliance contractors and dispensing GPs. Pharmacy A registered pharmacy premises that is regulated by the General Pharmaceutical Council. Prescription item(s) Each medicine on prescription is counted as one item. A prescription may have many items. Quartile One of four divisions which divide a series of data into four equal parts. Quintile One of five divisions which divide a series of data into five equal parts. Repeat Dispensing Repeat dispensing is a mechanism by which the patients GP may issue the pharmacist with a prescription to dispense at agreed intervals for on- going treatment. The benefits of repeat dispensing are that it removes the need for the patient to return to the GP practice for a repeat prescription between reviews. It allows patients to be treated for periods up to one year without returning to the GP. Around 80% of prescriptions are repeat prescriptions. Repeat dispensing also has benefits for pharmacists; it allows the workflow in the pharmacy to be shaped to match the resources in the pharmacy and smoothes out peaks and troughs demand. Secondary Care Hospital based care. Tertiary Care Specialist consultative care.
91 16.2 (APPENDIX 2) CONSULTATION REPORT
16.2.1 Formulation of NHS Havering Pharmaceutical Needs Assessment (PNA) The NHS Havering Pharmacy Steering Group was given the responsibility by the PCT board for development of the PNA.
The membership of this group includes Tim Woodman (PCT Medical Director), Mike McClean (Non Executive Director) from the PCT board and Dr Ian Humberstone from the Professional Executive Committee (PEC) and Practice Based Commissioning (PBC) member. It also includes Dr Louise Dibsdall from the PCT Public Health, Andy Thornley from PCT Communications, Angela Pruss from PCT Primary Care, members from the PCT Medicines Management, Local Pharmaceutical Committee and Local Medical Committee. It also includes Dr. John Croucher the PCT patient champion as a lay member, a secondary care pharmacist and the Assistant Director of Commissioning from London Borough of Havering.
The PNA work was co-ordinated by Mohamed Kanji, Senior Pharmaceutical Adviser and Matthew Henry, Data Analyst, in conjunction with Dr Belinda Krishek, Chief Pharmacist, Sanjay Patel, Head of Community Pharmacy and Denise Baker, Community Pharmacy Administrator.
There was extensive input from Clare Ebberson, JSNA lead. Other members of the PCT from Medicines Management, Public Health, Communications, Primary care and Commissioning departments also provided valuable input. The work was supported by the LPC Secretary Hemant Patel and the LPC office.
The development of PNA was also informed by input from pharmacists at several pharmacy forums and the PNA pharmacists survey, from GPs at various prescribing forums, patients at key patient group events, LINks and from the patient survey to which over 600 patients responded. Valuable feedback was received in particular from the Havering Family Diabetes Group.
16.2.2 Consultation
Key Stakeholders were consulted throughout the development of the PNA. The PCT consulted the following persons:
• All 47 Persons on the pharmaceutical list of NHS Havering (including 1 LPS Chemist) • London Borough of Havering Local Authority • North East London Local Pharmaceutical Committee (LPC) • All employees at NHS Havering • Barking and Havering Local Medical Committee (LMC) • All employees at Outer North East London (ONEL) Community Services • All members of NHS Havering Community Pharmacy Steering Group • NHS Havering People’s Champion • Havering Children’s Trust Executive • NHS Havering Clinical Commissioning Group (CCG) • NHS South West Essex • NHS Barking and Dagenham • NHS Waltham Forest • NHS Redbridge • NHS West Essex • Diabetes UK - The Havering Family Diabetes Group • Havering Local Involvement Networks (LINks) • Barking Havering Redbridge University Trust (BHRuT)
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In addition, as required by the regulations a formal 60 day consultation was undertaken from the 5th November 2010 up to the 4th January 2011. A total of 14 responses were received from the following persons and organisations:
• ONEL Community Services • Diabetes UK – The Havering Family Diabetes Group • The Co-Operative Pharmacy • Rowlands Pharmacy • Newlands Pharmacies • Shadforths Chemist • Boots • NHS Havering Acting Joint Director of Public Health • NHS Havering Clinical Commissioning Group • NHS Havering Community Heart Service • NHS Havering Aubrey Keep Library • NHS Havering Equality Service • NHS Havering Joint Strategic Needs Assessment Lead • North East London Local Pharmaceutical Committee
The responses have been taken in to account within the final PNA. The responses from the formal 60 day consultation are given below:
93 16.6.3. Responses completed using Consultation Reply Form
Question Number: Comments Made Number: No Comments made PCT Response Yes 1. Do you feel that the 4 Very well explained N/A purpose of the PNA has and easy to read been explained sufficiently?
Question Number: Comments Made Number: No Comments made PCT Response Yes 2. Do you feel the 2 2 1. The PNA states that 1. The PCT believes information contained provision is adequate that the mapping of within the PNA without any mapping to services is adequately reflects the support this. These maps adequately current community then need to be linked to reflected within the pharmacy provision within opening hours and PNA Havering? services. Not only does it 2. Amended in Fig. need to be shown to be 12, Appendix 16.5 easy for a patient to and Fig. 27 access a pharmacy, the branch also needs to be open and providing the necessary services that the patient requires. 2. One particular pharmacy made specific comments about their smoking cessation service, opening hours and consultation room.
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Question Number: Comments Made Number: Comments made PCT Response Yes No 3. Do you feel the 3 I feel that a lot of thought has gone in to 1 The PCT pharmaceutical needs of particular areas in Havering that need to be acknowledges the population of Havering focused on. the comment and have been adequately feels that it was reflected? not appropriate to amend the PNA.
Question Number: Comments Made Number: Comments made PCT Response Yes No 4. Are there any 1 No comment made 3 N/A pharmaceutical services currently being provided that you are aware of that are not currently highlighted within the PNA?
Question Number: Comments Made Number: Comments made PCT Response Yes No 5. Are there any gaps in 1 No comment made 3 N/A pharmaceutical services provided or that could be provided by pharmacies that you are aware of or that are not currently highlighted within the PNA?
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Question Number: Comments Made Number: Comments made Yes No 6. Are there any confirmed 4 N/A future developments that you are aware of that is not currently highlighted within the PNA?
Question Number: Comments Made Number: Comments made Yes No 7. Do you agree with the 4 N/A proposals in the PNA to help address the health needs identified?
Question Number: Comments Made Number: Comments made Yes No 8. Is there any additional 1 The PNA states that provision is adequate without any 2 The PCT believes that information that you feel should mapping to support this. These maps then need to be the mapping of be included? linked to opening hours and services. Not only does it services is adequately need to be shown to be easy for a patient to access a reflected within the pharmacy, the branch also needs to be open and PNA providing the necessary services that the patient requires.
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Question Comments Made PCT Response 9. Do you have 1. I was not personally aware that so many services were being 1 & 2 - The PCT acknowledges the comment and any further offered by pharmacies. I feel that all these ideas can only be for feels that it was not appropriate to amend the PNA. comments the good of the residents living in Havering. Screening people for diabetes is the way forward to save money in the long term. 3 – The PCT acknowledges that a pharmacy may be (We know there are many people walking around ‘non contract’ and therefore would not appear on the undiagnosed). The proposed minor ailments scheme would trusts published list, however this was not take pressure off GPs/Polyclinics/A&E, as is sometimes the incorporated in to the PNA to avoid confusion as case. Education around medication used greatly help the there are no identified ‘non contract’ pharmacies vulnerable and elderly. Substance misuse services would be within the considered area. more ‘patient friendly’ held in pharmacies. Thank you for working to improve the health of Havering residents. 2. Patients need to be made more aware of the services that pharmacies provide. This needs to be a joint effort between the PCT and pharmacy contractors to free up GP time. The average number of patients per pharmacy is not a very useful measure of adequacy when referring to suitable access for patients. It does not take in to account location, staff skill mix, number of staff, volume of scripts and size of pharmacy, all of which affect a pharmacy’s ability to dispense in a safe and timely manner. We will endeavour to work with the PCT to provide the Enhanced Services that best serve the need of the patients within this area as well as improving the awareness of patients of the services available. We have noticed that our branches do not currently provide all of the Local Enhanced Services that you commission and we would be happy to provide these. There is still the general issue of accreditation across PCTs when Locum Pharmacists are covering holidays or sickness and we are continually pressing for nationwide accreditation to make continuity of provision easier to manage. We have included our details on opening hours and services for your records. 3. The PCT have identified that EHC, MAS and NHS health checks could be delivered from pharmacies. The pharmacy workforce development group in the Northwest SHA have developed competency and training frameworks under the 97 ‘HAG’ banner for these services. www.pharmacyworkforcenw.nhs.uk (under community pharmacy). We note the concerns regarding repeat ordering. We would like to work with the PCT to further expand ‘repeat dispensing’. The definition of a pharmacy – A pharmacy can be non contract and they would not appear on the PCTs list.
16.6.8 Further consultation responses:
Any wording that would identify the respondent has been amended so that responses cannot be traced to individual respondents. Respondent Comments Made PCT Response Respondent 1 1. With regard to demographics, the JSNA now has numbers, 1. Amended in appropriate sections rather than just percentages which I think helps to quantify the 2. It was acknowledged that the language around population changes. You may wish to include this information poly-systems is ever changing, however it was felt in the PNA. that the importance of the section would be lost if 2. The PNA refers to poly-systems. This language has now re-named at the time of writing changed and you could adapt accordingly. 3. A number of maps throughout the PNA have been 3. Some of the maps are quite tricky to read. An explanation of re-drawn and re-sized to make them easier to supervised consumption would be useful for the lay person. read. Supervised consumption has been 4. The numbers on the diabetes maps should be rounded up or amended (section 10.2) down. 4. Fig. 18, 19 and 20 have been re-drawn to reflect 5. Chlamydia – performance by pharmacists is not good and I do this recommendation think we need to reflect this in the document. My view is that 5. The PCT acknowledges the comment and has the current services need to be delivered, before we can look to updated section 10.6 to reflect this expand.
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Respondent 2 6. Key points for commissioners need to be prioritised. 6. Key points are now prioritised 7. Minor ailments and EHC improve medicines management, this 7. The PCT acknowledges this and one of the aims should be worked upon. Business cases should be presented of the PNA is to highlight such areas where to show how these schemes are cost effective - and how they improvements can be made to patient care lead to savings. Also how they tie in with the polyclinics and 8. The PCT acknowledges this and one of the aims walk in centres. of the PNA is to highlight such areas where 8. Health Checks through pharmacies can improve the uptake and improvements can be made to patient care will be considered as part of QIPP. It is also a priority within the 9. The PCT acknowledges the comment and feels White Paper that this is a medicines management role for 9. Pharmacists can assist GPs by highlighting if they receive only pharmacists which have been adequately covered prescriptions for items that should not normally be prescribed in through relevant sections of the PNA. primary care. Respondent 3 10. Gap in pharmaceutical services provided – A list of Havering 10. The PCT feels that this is not a gap in service Support Groups – available during consultations with patients provision, this is covered by the essential services and as a promotional guide that all pharmacies are required to provide under 11. Good Friday should be included as a bank holiday? the signposting, support for self care and 12. Supporting MURs to allay any ‘old wives tales’ – A patient promotion of healthy lifestyles aspects of the centred approach – there should be reference to patients not pharmacy contract. listening to old wives tales and not amending their own 11. Amended in section 7.3 to reflect comment medication taking habits just because someone else takes the 12. The PCT acknowledges the comment and feels same medication differently this is adequately reflected within the relevant 13. Should state somewhere the benefits of joining their local sections of the PNA. support groups, whatever condition, support groups are a 13. Reference to various support groups has been complementary free service to the NHS and patients, and enhanced throughout the PNA and section 8.3 should be considered as being worthy of a mention has been added Respondent 4 14. Warfarin testing in pharmacies is a brilliant way of maintaining 14. The PCT acknowledges the comment; the Warfarin testing in the community and means that patients do relevant sections of the PNA were not updated. not have the hassle of clinics or hospital visits. This is something that should definitely be expanded upon if resources allow as our frailer and vulnerable patients are still expected to attend Queens for their Warfarin testing.
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Respondent 5 15. Needs to be shorter (40 pages) 15. The PCT believes that the current length of the 16. Perhaps use www.evidence.nhs.uk to find high quality evidence PNA is appropriate to reflect the relevant for particular interventions e.g. Cochrane review information needed. 16. The PCT acknowledges the comment and where appropriate has reviewed and updated a number of sections to include better referencing Respondent 6 17. Population demographic chart is hi-lighted in red, this colour is 17. The PCT has changed this section following difficult for people with a visual impairment those who have availability of new data, the aforementioned table dyslexia to read, it would be better to hi-light in yellow. has been removed 18. Maps are too small! 18. Maps have been re-drawn and re-sized 19. 8.1 The disability discrimination act is now part of the Equality 19. Section 8.1 was amended Act 2010 that brings all previous legislation into one law. 20. This service is now currently available to all 20. 8.4 Language Line -This is not available to pharmacist as I am pharmacies, therefore was not removed from the still waiting for them to give me the go ahead for this service. PNA Respondent 7 21. We welcome the comprehensive analysis of the pharmaceutical 21. – 27. The PCT acknowledges these comments distribution of services. and feels that one of the aims of the PNA is to 22. It is our view that commissioning of enhanced services within highlight such areas where improvements can be Havering, has lagged behind several neighbouring PCT’s giving made to patient care. Any future strategy for rise to postcode services across PCT boundaries, and to commissioning pharmacy services will need to be unfairness within the North East London community. Therefore mindful of the findings from the PNA it is encouraging to note, that the provision of a “Minor Ailments Scheme” has been prioritised. 23. Pharmacists are optimally suited to manage medicines, and in spite of high levels of medication related hospital admission and readmission after discharge, we believe that sufficient efforts are not directed towards addressing these, resulting in a high cost to the health economy. A number of programmes have been highlighted within the PNA, however the numbers are too small to have any significant benefit. It is a recurring feature of many programmes, that pilots are carried out without the necessary underpinning to roll them out if successful, leading to disillusionment amongst practitioners and little or no benefit to the community of the learning derived from these pilots. 24. An area of activity, which has seen considerable growth, has not been sufficiently highlighted within the PNA. The demand
100 for medication in compliance aids from pharmacies has seen exponential growth within the community. Partially led by carers wishing to reduce risks associated with medication administration, this rise has been previously linked to dementia. We believe that linking this to dementia is erroneous as it fails to recognise, a significant cohort of “confused” elderly who depend on compliance aids. This has implications for future service provision in light of the potential increase in the elderly population residing in their own homes identified within the PNA in Havering, and often under the care of agencies. It is our view that schemes that support patients in their own homes through medicines management is essential. 25. It is also our view that compliance and waste are intricately linked, and the PNA does not adequately address the issue of wasted medication. Several studies have shown, that limiting the length of prescribing, is one of the most effective ways of reducing waste – yet the evidence across Havering is that the average length of prescribing period is increasing. This has led to an increase in large quantities of returned medication, often unopened for destruction as it is not permitted for reuse. We would support a scheme to restrict the length of prescribing period to 28 days. 26. In light of the health issues highlighted with the PNA, it is clear that commissioning of services targeted on areas of need is a better use of resources, and to that effect the wards with high levels of deprivation must be adequately resourced in terms of service provision. 27. Finally, we concur with the assessment that no additional pharmacy provision is required in Havering.
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Respondent 8 28. Agrees that the PNA has not identified any gaps in the 28 – 33. The PCT acknowledges these comments provision of Pharmaceutical services that would require a type and feels that one of the aims of the PNA is to 2A application. If this changes then the LPC should be highlight such areas where improvements can be consulted in the first instance. made to patient care. Any future strategy for 29. Agrees that provision of a Pharmacy minor ailments scheme commissioning pharmacy services will need to be could address the patients’ feedback for extended GP opening mindful of the findings from the PNA hours by capitalising on the extended pharmacy opening hours. It would also bring Havering in line with all the other PCTs in North East London and the majority of PCTs nationally who commission such a service. 30. Agrees with the recommendations in the PNA around using repeat dispensing as a means for improving concerns raised by GPs in managing repeat prescriptions. We would be willing to support this from our experience nationally, and would welcome the PCTs support in addressing this across the locality. 31. Agrees that “emergency contraception service (EHC) should be commissioned from pharmacies. This would be in line with the majority of PCTs in London who have seen a reduction in their under 18 conception levels. 32. We would also support the comments from the LPC regarding the draft PNA. 33. Will support the PCT in the provision of new Enhanced Services or the extension in provision of existing ones. Keen to work closely with the PCT in conjunction with the LPC to address these needs. Respondent 9 What is the PCT trying to achieve? It would be useful to include a This has been addressed under sections 3.1 (What is statement about the PCT Vision so that the direction of travel at least a PNA), 3.2 (What will the PNA Achieve) and 3.3 is clear. (NHS Havering vision and context) We feel it is important in the PNA to clarify that pharmacy is more than This has been addressed under section 3.6 a supplier of medicines and has a contribution to make to public health (Pharmaceutical Services Covered) and community development agendas which are important in the future. Pharmacy also has a contribution to QIPP agenda and there is a need The whole document contains ways that pharmacy for further reflection on this point. What does the PCT consider are the can contribute to QIPP. contributions community pharmacy can make to the QIPP agenda?
102 What does community pharmacy offer and how is the offering different These issues have been addressed at various places from the GPs? Community pharmacy has contribution to make around in the PNA. Specific reference include four priority areas: a. this has been discussed e.g. minor ailments a). Supply of prescribed and over-the-counter medicines b. this has been addressed e.g. smoking cessation, b). Helping deliver a new momentum to public health by improving obesity, chlamydia screening health and reducing inequalities, especially when public health moves from PCT to local authority c. included in medicines management section c). Helping GP-led commissioning deliver less waste in drugs budget d. discussed under healthy living pharmacy concept - and improve patient experience, and safe and effective use of drugs under the 10 key points (the medical side); and All the above have been covered within the PNA d). Community pharmacy as an accessible high street ‘hub’ for Big Society activity (the community angle). There is a very significant need for a local strategic resource to This is covered in section 11. We have added the support medicines management, public health and clinical services. definition proposed to this section. We believe ambitions to meet the local need delivered through community pharmacy will not be realised unless there is adequate strategic support. The current Government has publicly stated that pharmacy would be developed to provide a greater range of health services due to its access (hours and locality) and expertise. Current staffing plans for the coming year seriously undermine the ambitions stated by the PCT to improve services for the Havering population. We believe and request that section 11 must clearly reflect the comments here and we refer to National Prescribing Centre Medicines management can be defined as as “…a system of processes and behaviours that determines how medicines are used by the NHS and patients.”(Modernising Medicines Management. A guide to achieving benefits for patients, professionals and the NHS. National Prescribing Centre, 2001). Good medicines management means that patients receive better, This is covered in section 11 (Better Management of safer and more convenient care. It leads to better use of professional Medicines) time and enables practitioners to focus their skills where they are most appropriate. Effective medicines management also frees up resources
103 which means that NHS money can be used where it is most effective. Good medicines management benefits everyone. There is a need for the following: A paper-based patient friendly repeat Section 11 has been revised to cover paper based prescribing and dispensing scheme (i.e. not wait for electronic repeat dispensing. scheme) There is a need for a palliative care scheme and the need increases Covered under on call out of hours service, section as the population grows old in the area. 7.4 (Out of hours access to medicines) Hospital Discharge Scheme: It is recognised that when patients move The proposed enhanced medicines usage review from one setting to another there is considerable potential for things to schemes will address some of these issues. go wrong in relation to their medicines. The PCT must take action to maximise good practice and minimise the risks associated with medicines during the transfer and discharge process. We submit that transfers between many different settings, including wards within one building, from an acute ward to a care home or intermediate care centre, to a hospice, or when a patient is admitted to hospital or discharged to their own home need examining and local hospital discharge scheme developed. The scheme should • raise awareness of patients experiences with medicines and discharge • identify the principles of good practice and illustrate these principles with examples • develop strategies and identify standards based on best practice and the available evidence • make recommendations to reduce the risks of incidents with medicines for patients moving between different care settings, and in particular patients being discharged from acute hospitals. We welcome the fact that the PCT has stated that he regulations The PNA has been revised to include this. require the PCT to consider the need for pharmaceutical services in terms of assessment of needs. The PCT needs to clarify· Services currently commissioned that are necessary to meet a current demand · Services that are currently commissioned which are relevant but do not constitute a "necessary service". · Services not currently commissioned that may be necessary in specified future circumstance. · Services not currently commissioned that would secure improvements or better access to pharmaceutical services. In reaching conclusions the PCT should outline the reasons for its Each section contains details of how a particular need 104 assessment. For the above reasons, services provided by other has been identified. Identified needs have been professions should also be listed (as requested previously) as public supported by feedback from the patient questionnaire. choice and professional competition drive standards higher. We feel that in the draft document not enough emphasis is given to co- ordination of services and integration of service with other providers like the GPs and nurses (i.e. there is a lot of working in professional silos and there is lack of joint training). Also, there is not any clarity about what is meant by access. Location of a service in the area should not equate to good access as e.g. needs of the housebound are not taken into account. There is a need to list the surgery based services which are currently not provided or commissioned by the PCT from pharmacies. Under the „any willing provider rule this information can help pharmacy to put forward proposals under the last two bullet points. We feel that it would be even more helpful if the services which are not The PNA has been revised to include this. currently commissioned from pharmacies but provided by others were categorised as not commissioned but necessary (N) and not commissioned but relevant (R). There is a need to state that pharmacy should be called to support the The PNA at various places indicates how pharmacy pathway redesign process which will allow patients to access relevant can contribute to pathway redesign which will improve services from appropriately trained healthcare professionals more patient access. locally. TRANSFORMING COMMUNITY EQUIPMENT SERVICE (TCES) We have included a new section 11.12 In addition we believe that the first wave roll out of the retail prescription model for Simple Aids to Daily Living (SADL) as part of the Department of Health (DH) TCES Programme across London, along with Havering The retail prescription model for SADLs such as aids for moving, eating, toileting and sensory needs, works on a similar basis to other types of prescription. As a general rule, the DH considers items costing less than £100 to be SADL. The prescriber – occupational therapist, district nurse – will assess and identify equipment needed (no change to this process). Instead of placing an order with the contractor (as is currently the case with Medequip), they will write a prescription for the equipment. The accredited approved retailer will then fill the prescription. Accreditation of retailers will be against 105 national standards, and include the capacity to deliver, fit and instruct the client in the use of the equipment where necessary. Decommissioning: There is a need for clarification of the process of The DH is expected to produce guidance on the decommissioning the service and appropriate consultation which has commissioning pharmaceutical service providers. not been stated here. Flu Vaccination: The Pharmacy Steering Group agreed that currently This service is could help to take some pressure of the GP service at needs were met however if a gap in service is the time of expansion of GP services and to provide choice and identified in the future, community pharmacy should competition. As a part of healthy living pharmacy scheme pharmacy is be considered as a future provider seen as a provider of this service. Individualisation of Treatments: Section 11 considers how the EPP programme can An important need has not been identified in the process but assumed help improve medicines management. by the PCT: Individualisation of treatments is important to maximise outcomes of expensive therapies and especially Long Term Conditions. Access to medicines and health advice, and support in becoming Expert Patients need pharmacists help. Apart from MUR there is also a need for EPP which can be integrated into the service. Identification of individual patients needs for medicines taking support, advice, and linking with other patients in the area has not featured in the PNA. We believe there is a need to assess this as it can significantly contribute to the QUIP agenda and patient satisfaction. Improved Medicines Management in Nursing Homes - We believe that This service is one of the key recommendations. section 11.5 needs amending so that there is a clear recommendation for action based on the facts provided. And it would be better to state the time period for the study as 70 medication issues without a time scale or total number of patients in the pilot is meaningless. A list of consultees also needs to be included for the sake of This has been included in Appendix 16.2 comprehensiveness of the document.
106 16.3 (APPENDIX 3) HAVERING PHARMACY TRADING NAMES AND ADDRESSES AS AT 1ST OCTOBER 2010
PHARMACY ADDRESS POSTCODE 1 BOOTS PHARMACY 21 Clockhouse Lane, Collier Row RM5 3PH 2 BOOTS PHARMACY 132 High Street, Hornchurch RM12 4UH YOUR LOCAL BOOTS 3 205 Station Lane, Hornchurch RM12 6LL PHARMACY YOUR LOCAL BOOTS 186 Hilldene Ave. Harold Hill, 4 RM3 8DB PHARMACY Romford 122 Petersfield Ave, Harold Hill, 5 BOOTS THE CHEMIST RM3 9PH Romford 6 BOOTS PHARMACY 171 High Street, Hornchurch RM113XS 7 BOOTS PHARMACY 120-126 High Street, Hornchurch RM12 4UL 57-59 Corbets Tey Road, 8 BOOTS PHARMACY RM14 2AJ Upminster 9 BOOTS PHARMACY 12 The Liberty, Romford RM1 3RL 12 Farnham Road, Harold Hill, 10 BOOTS PHARMACY RM3 8DX Romford 11 BOOTS PHARMACY Marketplace, Romford RM1 3AD The Brewery, Waterloo Rd, 12 BOOTS PHARMACY RM1 1AV Romford 13 BOWS CHEMIST 329 Upminster Rd North, Rainham RM13 9JR 14 BRITANNIA PHARMACY 36 Corbets Tey Road, Upminster RM14 2AD 15 BRITCROWN PHARMACY 5 Balgores Lane, Gidea Park, RM2 5JR 6 Crown Parade, Upminster Rd 16 CHANSONS PHARMACY RM13 9BD South, Rainham 17 CHEMISTREE 31 Upminster Road, Hornchurch RM11 3UX 65 Masefield Crescent, Harold Hill, 18 CRESCENT PHARMACY RM3 7PB Romford 19 DAY LEWIS PHARMACY 109 Mungo Park Rd, Rainham RM13 7PP 20 DAY LEWIS PHARMACY 113 Rainham Road, Rainham RM13 7QX 21 DAY LEWIS PHARMACY 143 Avon Road, Upminster RM14 1RQ 22 ELM PARK PHARMACY 208/212 Elm Park Ave, Elm Park RM124SD FAIRVIEW/ROWLANDS 23 3 Fairview Parade, Mawney Road RM7 7HH PHARMACY 24 GOVANI CHEMIST 64 Station Road, Upminster RM14 2TD 25 GOVANI CHEMIST 87 Front Lane, Upminster RM14 1XN 26 LLOYDS PHARMACY 12 Chase Cross Rd, Collier Row RM5 3PR 2 Tadworth Pde, Elm Park, 27 LLOYDS PHARMACY RM12 5AS Hornchurch 28 MIM PHARMACY 118 North Street, Romford RM1 1DL THE CO-OPERATIVE 29 7 Station Road, Harold Wood RM3 0BP PHARMACY THE CO-OPERATIVE Harold Wood Polyclinic, Gubbins 30 RM3 0LE PHARMACY Lane, Harold Wood 31 NEWLANDS PHARMACY 67/69 Park Lane, Hornchurch RM11 1BH 32 NEWLANDS PHARMACY 6 Station Pde, Broadway, Elm Park RM12 5AB 33 NEWLANDS PHARMACY 52 Collier Row Lane, Romford RM5 3BB
107
PHARMACY ADDRESS POSTCODE Harold Hill Health Centre, 34 NEWLANDS PHARMACY Gooshays Drive, Harold Hill, RM3 9SU Romford 35 PANCHEM PHARMACY 160 St Marys Lane, Upminster RM14 3BS 36 PARK LANE PHARMACY 1 Park Lane, Hornchurch RM11 1BB 37 PHARMACARE CHEMIST 164 Hornchurch Road, Hornchurch RM11 1QH 173 Eastern Ave East, Rise Park, 38 RISE PARK PHARMACY RM1 4NT Romford 39 SAFEDALE PHARMACY 82-84 Dagenham Rd, Romford RM7 0TJ 1-15 The Brewery, Waterloo Road, 40 SAINSBURYS PHARMACY RM1 1AU Romford 41 SHADFORTHS CHEMIST 266 Brentwood Road, Romford RM2 5CU TESCO INSTORE 42 300 Hornchurch Road, Hornchurch RM11 1PY PHARMACY TESCO INSTORE Bryant Ave,Gallows Corner, 43 RM3 0LL PHARMACY Romford TESCO INSTORE 44 Bridge Road, Rainham RM13 9YZ PHARMACY 45 W BURDESS CHEMIST 178 Mawney Road, Romford RM7 8BU WHITEROSE/ROWLANDS 100 Ardleigh Green Rd, 46 RM11 2LG PHARMACY Hornchurch 47 WILLIAMS CHEMIST 139a Wennington Rd, Rainham RM13 9TR
108 16.4 (APPENDIX 4) PATIENT SURVEY RESPONSES
626 members of the public completed the PNA patient questionnaire. Members of the public were requested to complete these in a variety of settings including pharmacies, GP practices, Health Centres, patient group meetings and via the web based survey on the NHS Havering website. The survey was promoted through news items on the NHS Havering website and articles in the local press including the Romford Recorder and Living Magazine.
The full results of the answers for each question are given below:
In the last six months, how often have you visited a pharmacy (this includes pharmacies located in bigger stores such as Sainsburys and Boots)?
8% 3% 18% 18% I haven’t visited a Pharmacy at all Less than 3 times Once a month Once a week Other
53%
Thinking about the most recent time you used a pharmacy, what did you use the pharmacy for?
To collect a prescription
5% 4%
2% To buy over the counter medicines e.g. cold remedies 11%
To buy other health related products e.g. pregnancy testing kits To ask for advice on health related matters 78% Other
109 Did you use the pharmacy for yourself and/or on behalf of a family member or friend?
600 525 500
400
300 Responses
200 121 89 100 26 39 0 For myself For someone else For someone else For someone else For someone else aged 5 years and aged 6 to 16 aged 17 to 64 aged 65 years under years old years and over
Do you always use the same pharmacy?
10%
Yes always
29% Usually I do, but not every time
61% No, I use whichever one is most convenient at the time
Thinking about the location of the pharmacy you use most, which of the following factors is most important to you?
400 370 350 282 300 250 200 150 91 103 100 50 31 50 23 0 Other shop the surgery my home It isI where It is easy to park nearby my doctor’s It is close to It is close to work placework It is close to bus/tube/trains It is to mynear
110 Do you feel that the pharmacist/assistant that you regularly see at the pharmacy knows about you and your care?
350 296 300
250
200 162 Responses 150 87 100 74
50
0 Yes, a great deal Yes, to some extent No I don’t usually see the same pharmacist
Thinking about the services that the pharmacy provides, which of the following is most important to you?
500 432 450 400 323 350 300 245 250 196 203 Responses 200 123 150 100 20 50 0 The service There is The The The The Other is quick some pharmacist pharmacy pharmacy is pharmacy privacy when or staff usually has open late or offers a I want to knows about my at weekends prescription speak to the me and my medicines in collection pharmacist medicines stock and delivery service
Which of the follow ing NHS services did you know could be provided by your local pharmacy?
350 322
300
250 201 200 176 175
150 120 121
100 84 67 57 56 50
0 Health 'MOT' Health Chlamydia tests Chlamydia Diabetes check-up Diabetes Holiday vaccinations Holiday Stop smoking services smoking Stop Diarrhoea Needle & Syringes disposal Syringes & Needle morning after pill after morning Diabetes and Cholesterol Tests Cholesterol and Diabetes Prescription collection & delivery & collection Prescription Contraceptives services e.g. condoms, e.g. services Contraceptives Medicines on the NHS for minor illness e.g. illness minor for NHS the on Medicines 111
Which of the following NHS services would you like to be provided from pharmacies?
300 276
250 243 214
200 164 169 149 150 Series1
91 100 82 74 51 50 13 0 Other Health 'MOT' Chlamydia tests Diabetes check-up Holiday vaccinations Stop smoking services Diarrhoea Needle Syringes& disposal afterpill Diabetes and Cholesterol Tests Prescriptioncollection delivery & Medicines on the forNHS minor illness e.g.
Contraceptivesservices e.g.condoms, morning
How do you rate your experience of using pharmacies?
2% 12%
Excellent Very Good 54% Good 32% Fair
112 In the last 12 months have you had any problems finding a pharmacy to get medicines or advice?
2%
Yes No
98%
Respondents Gender:
1%
35% Male Female Prefer not to say
64%
What age group are you in? 2% 4% 15% 5% Under 20 13% 20 - 24 25 - 34 35 - 44 20% 45 - 54 55 - 64 18% 65 - 74 75 or over
23%
113 Which of the following best describes your race or ethnic origin?
2%1%3%1% 4% 2% White Mixed Asian or Asian British Black or black British Chinese Prefer not to say Other
87%
Which ward do you live in?
70 65 60 50 38 40 34 33 36 35 33 33 30 28 30 Responses 24 26 25 24 27 30 22 21 20 20 10 0
N k n rk s n s h ds am r ton ds o t W n h a ays cto ood n ttit t own a n h neys g T e a s W ea w Pe in H NO okla r o Ha H n d K o C ld Hyla l's N Elm P Go o Ma en Andrew' Upminster U Br ar W St. H Havering Pa d uirre Emerson Park n Romfor a Sq m South Hornchurch a h Rain
*Wards that respondents lived in (determined using postcode)
114 16.4.1 – Additional Patient Survey Questions Asked
A) What is the street name of which pharmacy you use the most? Response
Count 465
B) Is there anything particularly good about the pharmacy you use? Response
Count 380 There were over 380 responses to this; the majority were around the friendliness, helpfulness and knowledge of the staff/pharmacist. A few examples are:
-‘They will go out of their way to help and assist with prescription errors interactions and have provided information known about the neurological medication’
-‘Very pleasant and helpful staff’
-‘Late opening hours’
-‘I can get what I want when I need it, or they can tell me where I need to go to get it’
-‘A good professional knowledge of my medical conditions aligned with good humoured reliable service’
C) Is there anything that could be improved? Response
Count 221 Only 221 out of 626 responded to this question, which in itself suggests satisfaction, out of these 221, 120 stated ‘no’, ‘not applicable’ or ‘nothing’.
115 16.5 (Appendix 5) Opening Hours of pharmacies Weekday Opening Hours of Pharmacies & GP Practices: Fig. 39 Green bar represents pharmacy opening hours, Blue bar represents GP opening hours. Blank shows provider is closed. WEEKDAY OPENING HOURS 9.00 12.00 15. 00 18. 00 21. 00 24.00
6.00 6 .30 7 .00 7.30 8 .00 8 .30 9.30 1 0.00 1 0.30 11 .00 11 .30 1 2 .30 13 .00 1 3.30 1 4.00 14 .30 1 5.30 16 .00 16 .30 1 7.00 1 7 .30 1 8.30 1 9.00 19 .30 2 0.00 2 0.30 21 .30 2 2.00 2 2 .30 23 .00 2 3.30
Pharmacy or GP name P ost c ode Wa r d P ol y sy st e m Ope n C l ose Further Information NATIONAL CO-OP CHEMIST RM3 0BP HAROLD WOOD NEH 09.00 18.30 TESCO INSTORE PHARMACY RM3 0LL HAROLD WOOD NEH 08.00 21.00 T ue & T hur : 08.00 - 19.15 HAROLD WOOD POLYCLINIC - CO-OPERATIVE PHARMACY RM3 0FE HAROLD WOOD NEH 08.00 20.00 HURLEY GROUP PRACTICE - HAROLD WOOD POLYCLINIC RM3 OFE HAROLD WOOD NEH 08.00 20.00 DR R S CHOWDHURY RM3 0PT HAROLD WOOD NEH 08.00 18.30 DR H MCDONALD RM3 0DR HAROLD WOOD NEH 09.00 18.30 T ue & Wed: 09.00 - 17.30 YOUR LOCAL BOOTS PHARMACY RM3 8DB GOOSHAYS NEH 09.00 17.30 BOOTS RM3 9PH GOOSHAYS NEH 09.00 18.30 BOOTS RM3 8DX GOOSHAYS NEH 09.00 19.00 NEWLANDS PHARMACY RM3 9SU GOOSHAYS NEH 07.00 24.00 DR M FELDMAN RM3 9PD GOOSHAYS NEH 08.30 18.30 Tuesday: 08.30 - 20.00 DR A JABBAR RM3 9SU GOOSHAYS NEH 08.30 19.00 Wednesday & T hur sday: 08.30 - 18.30 DR J KA K A D RM3 9SU GOOSHAYS NEH 08.30 20.00 Wednesday & Fr iday: 08.30- 18.00 DR N A KUCHHAI RM3 9SU GOOSHAYS NEH 08.00 20.00 T ue & T hur : 08.00 - 18.30 / Wed: 08.00 - 17.00 DR K RABINDRA RM3 9SU GOOSHAYS NEH 08.00 18.30 T ue & T hur : 08.00 - 20.00 CRESCENT PHARMACY RM3 7PB HEATON NEH 09.00 19.00 Monday: 08.30 - 20.00 DR A KA W RM3 7JJ HEATON NEH 08.30 18.30 Monday: 08.0009.00 - 20.0019.45 DR N A KUCHHAI RM3 7HR HEATON NEH 08.00 18.30 Monday: 08.30 - 20.00 DR J PARASAD RM3 7JJ HEATON NEH 08.30 18.30 YOUR LOCAL BOOTS PHARMACY RM5 3PH HAVERING PARK NWH 09.00 19.00 Mon & Fr i Alter nate Weeks: 08.30 - 20.00 DR S KULENDRAN RM5 3PJ HAVERING PARK NWH 08.30 18.30 DR G S SA I NI & DR H D PA T E L RM5 3QL HAVERING PARK NWH 08.00 18.30 Mon: 08.00 - 20.00 / T ue & Wed: 07.15 - 18.30 LASER IMPEX LTD (BRITANNIA PHARMACY) IG2 6BN ALDBOROUGH 09.00 20. 00 * Thur sday: 09.00 - 13.00 W BURDESS CHEMIST RM7 8BU MAWNEYS NWH 09.00 19.00 LLOYDS PHARMACY RM5 3PR MAWNEYS NWH 09.00 19.00 DR NK GUPTA RM7 8BU MAWNEYS NWH 08.30 18.30 Wednesday: 08.30 - 20.00 DR P JOSEPH RM5 3PR MAWNEYS NWH 08.30 19.00 Monday: 08.30 - 20.00 NEWLANDS PHARMACY RM5 3BB PETTITS NWH 09.00 19.00 RISE PARK PHARMACY RM1 4NT PETTITS NWH 09.00 18.00 Wednesday: 09.00 - 13.00 DR M MAHMOOD RM5 3BJ PETTITS NWH 08.15 18.00 Thur sday: 09.00 - 13.00 DR BURACK & DR SAUNDERSON RM1 4QJ PETTITS NWH 08.00 18.30 Mon & Alter nate Tuesdays: 08.00 - 20.00 ROWLANDS PHARMACY RM7 7HH BROOKLANDS NWH 09.00 18.30 Mon & T ues: 08.30 - 20.00 QUEENS HOSPITAL PHARMACY RM7 0AG BROOKLANDS NWH 09.00 17.00 DR P KUKATHASAN RM7 0PX BROOKLANDS NWH 08.30 18.00 * MASTAA - CARE PHARMACY RM8 1BJ WHALEBONE 09.00 19. 00 Thur : 0 9 . 0 0 - 13 . 0 0 / 14 . 0 0 - 17 . 3 0 Fri: 0 9 . 0 0 - 13 . 15 / 14 . 15 - 19 . 0 0 OXLOW CHEMIST RM 10 7Y A HEATH 09.00 19. 00 * Alter nate Mon & Fr i: 08.30 - 20.00 SA FE DA LE RM7 0TJ EASTBROOK NWH 09.00 19.00 Tuesday & Thur sday: 08.30 - 20.00 DR S POOLOGANATHAN RM7 0XR EASTBROOK NWH 08.30 18.30 DR B BEHEST I RM7 0XR EASTBROOK NWH 08.30 18.30 MiM PHARMACY RM1 1DL ROMFORD TOWN NWH 09.00 18.00 B OOT S RM1 3AD ROMFORD TOWN NWH 08.30 19.00 NEWLANDS PHARMACY RM11 1BH ROMFORD TOWN NWH 09.00 17.00 SAINSBURYS INSTORE PHARMACY RM1 1AU ROMFORD TOWN NWH 07.00 23.00 Wednesday & Fr iday: 08.00 - 24.00 BOOTS RM1 1AU ROMFORD TOWN NWH 08.30 24.00 Thur sday: 9.00 - 19.00 BOOTS RM1 3RL ROMFORD TOWN NWH 09.00 18.00 Thur sday: 9.00 - 16.00 PARK LANE PHARMACY RM11 1BB ROMFORD TOWN NWH 09.00 19.00 Thur sday: 08.45 - 18.30 DR D J BA SS RM1 3LS ROMFORD TOWN NWH 08.45 20.00 Monday: 08.30 - 20.00 DR M A RK S RM1 2SB ROMFORD TOWN NWH 08.30 18.30 Thur sday: 08.30 - 16.00 DR S H PA T E L RM1 3DQ ROMFORD TOWN NWH 08.30 20.00 ROWLANDS PHARMACY RM11 2LG SQUIRRELS HEATH NEH 09.00 19.00 T ue & Wed: 09.00 - 18.30 / T hur : 09.00 - 18.00 BRITCROWN PHARMACY RM2 5JR SQUIRRELS HEATH NEH 09.00 18.00 DR M H FLA SZ RM11 2LY SQUIRRELS HEATH NEH 09.00 18.00 DR H MCDONALD RM11 2LP SQUIRRELS HEATH NEH 09.00 18.30 T ues & Wed: 09.00 - 17.30 SHADFORT HS CHEMIST RM2 5SU EMERSON PARK NEH 08.45 18.15 Thur s: 08.45 - 17.30 DR M EDISON RM2 5SU EMERSON PARK NEH 08.30 19.00 Thur s & Fr i : 08.30 - 18.30 PHARMACARE CHEMIST RM11 1QH HYLANDS NWH 09.00 19.00 TESCO INSTORE PHARMACY RM11 1PY HYLANDS NWH 08.00 20.00
DR S S UB E ROY RM12 4AN HYLANDS NWH 08.00 18.30 Thur sday: 08.00 - 20.00
KEY * Pharmacy not contracted by NHS Havering Pharmacy lunch hours have been taken int o considerat ion, GP af t ernoon closing times have not been shown
116 Weekday Opening Hours of Pharmacies & GP Practices: Fig. 39 (continued) WEEKDAY OPENING HOURS
9.00 12.00 15. 00 18. 00 21.00 24. 00 Pharmacy or GP name P ost c ode Wa r d P ol y sy st e m Ope n C l ose 6 .00 6 .30 7.00 7.30 8 .00 8 .30 9.30 1 0.00 10.30 11 .00 1 1 .30 1 2.30 13 .00 13 .30 1 4 .00 1 4.30 15 .30 1 6 .00 1 6.30 1 7.00 17 .30 1 8 .30 1 9.00 19 .30 2 0.00 2 0.30 2 1.30 22 .00 22 .30 2 3 .00 2 3.30 Further Information YOUR LOCAL BOOTS PHARMACY RM11 3XS ST ANDREWS SH 09.00 19.00 YOUR LOCAL BOOTS PHARMACY RM12 4UH ST ANDREWS SH 09.00 17.30 BOOTS RM12 4UL ST ANDREWS SH 09.00 17.30 CHE M I ST REE RM11 3UX ST ANDREWS SH 09.00 18.30 ELM PARK PHARMACY RM12 4SD ST ANDREWS SH 09.00 19.00 Monday: 08.30 - 20.00 DT TC BLAND RM11 1XA ST ANDREWS SH 08.30 18.30 Monday: 08.30 - 20.00 DR J C F O'M OORE RM12 6PL ST ANDREWS SH 08.30 18.00 DR PM PATEL RM12 4LF ST ANDREWS SH 08.30 18.30 T hur sday: 08.30 - 20.00 T uesday: 08.30 - 20.00 DR VM PATEL RM11 3SZ ST ANDREWS SH 08.30 18.30 DR M M RAHMAN RM12 4JP ST ANDREWS SH 09.00 18.30 DR A T RAN RM11 1XA ST ANDREWS SH 08.30 18.30 T uesday: 08.30 - 20.00 DAY LEWIS PHARMACY RM14 1RQ CRANHAM SH 09.00 18.00 GOVANI CHEMIST RM14 1XN CRANHAM SH 09.00 18.30 DR C DA HS RM14 1BJ CRANHAM SH 08.30 18.30 M onday & Wednesday: 08.30 - 20.00 DR S S HA IDER RM14 1XX CRANHAM SH 08.30 14.00 DR I K SUDHA RM14 1RG CRANHAM SH 08.30 19.00 GOVANI CHEMIST RM14 2TD UPMINSTER SH 09.00 19.00 Wednesday: 08.30 - 19.00 BRITANNIA PHARMACY RM14 2AD UPMINSTER SH 09.00 19.00 BOOTS RM14 2AJ UPMINSTER SH 09.00 17.30 PANCHEM PHARMACY RM14 3BS UPMINSTER SH 09.00 18.30 Wednesday & Thur sday: 09.00 - 18.00 DR S S BA IG RM14 3DH UPMINSTER SH 09.00 19.30 DR P CHAKRAVARTY RM14 2YX UPMINSTER SH 08.30 19.00 Monday & Alter nate Fr idays: 09.00 - 20.00 DR P CHOPRA RM14 3DP UPMINSTER SH 08.00 19.00 DR C DA HS RM14 2JP UPMINSTER SH 08.30 18.30 M onday & T uesday: 08.00 - 20.00 DR S S HA IDER RM14 2YN UPMINSTER SH 08.00 19.00 DR D KWAN RM14 2HF UPMINSTER SH 08.00 19.00 Wednesday & Thur sday: 08.00 - 20.00 BOOTS RM12 6LL HACTON SH 09.00 18.00 Monday: 08.00 - 19.40 LLOYDS PHARMACY RM12 5AS HACTON SH 08.30 19.00 DR Q H A GILLET WALLER RM12 5PA HACTON SH 08.30 19.00 DR M M RAHMAN RM12 5PA HACTON SH 09.00 19.00 T uesday: 08.30 - 20.00 NEWLANDS PHARMACY RM12 5AB ELM PARK SH 09.00 19.00 Alter nate Tues & Weds: 09.00 - 20.00 DAY LEWIS PHARMACY RM13 7PP ELM PARK SH 09.00 18.00 DR S BRANDMAN RM12 4EQ ELM PARK SH 08.30 18.30 DR A R DESHPANDE RM12 5HX ELM PARK SH 08.30 20.00 Fr idays & Alter nate Mon/ Wed: 08.30 - 20.00 DR A K JAISWAL RM12 5HJ ELM PARK SH 08.00 18.30 TM uesday onday & & Wednesdays: Wednesday: 08.00 08.30 -- 19.15 20.00 DR HM VIVERS RM12 5HJ ELM PARK SH 08.30 18.30 M on & Wed: 07.30 - 18.30 / T ue: 08.30 - 20.00 DAY LEWIS PHARMACY RM13 7QX SOUTH HORNCHURCH SH 09.00 18.00 ORCHARD VILLAGE RM13 8QA SOUTH HORNCHURCH SH 10.00 19.00 DR K SUBRAMANIAN RM13 7UP SOUTH HORNCHURCH SH 08.00 18.30 Monday: 08.00 - 19.30 / T uesday: 08.00 - 19.00 DR S SUBRAMANIAM RM13 7XJ SOUTH HORNCHURCH SH 08.30 18.00 Monday: 08.30 - 20.00 DR S S UB EROY RM13 7SB SOUTH HORNCHURCH SH 08.00 18.30 DR M A WANI RM13 7XR SOUTH HORNCHURCH SH 09.00 18.30 Monday: 09.00 - 20.00 WILLIAMS CHEMIST RM13 9TRRAINHAM & WENNINGTON SH 09.00 18.00 CHANSONS PHARMACY RM13 9BDRAINHAM & WENNINGTON SH 09.00 18.30 TESCO INSTORE PHARMACY RM13 9YZ RAINHAM & WENNINGTON SH 08.00 20.00 BOWS CHEMIST RM13 9JR RAINHAM & WENNINGTON SH 09.00 19.00 DR ARM ABDULLAH RM13 9ABRAINHAM & WENNINGTON SH 08.00 18.30 DR R M ADUR RM13 9QURAINHAM & WENNINGTON SH 08.30 19.00 Wednesday: 08.00 - 20.00 DR H H HUSSAI N RM13 9ABRAINHAM & WENNINGTON SH 08.30 19.00 T uesday & Fr iday: 08.30 - 20.00 DR AKS JAWAD RM13 9RZ RAINHAM & WENNINGTON SH 08.30 19.00 Wednesday: 08.30 - 20.00 * SHAH RH (T RICOVER LTD) ALLANS PHARMACY RM6 4AL CHADWELL HEATH 09. 00 18. 00 T uesday: 08.30 - 20.00 * CORDEVE LTD RM64NP CHADWELL HEATH 09. 00 19. 00 * LLOYDS PHARMACY RM6 6NL CHADWELL HEATH 09. 00 21. 00 T hur sday: 09.00 - 17.00 SAINSBURY'S INST ORE PHARMACY RM6 6PA CHADWELL HEATH 07. 00 23. 00 * T hur sday: 09.00 - 17.00 * TESCO INSTORE PHARMACY RM6 4HY CHADWELL HEATH 08. 00 20. 00 * THE CO-OPERATIVE PHARMACY RM6 5NR CHADWELL HEATH 09. 00 18. 00 * DR J A HAMILTON SMIT H RM6 6RT CHADWELL HEATH 09. 00 20. 00 * DR S J HA SKELL RM6 6RT CHADWELL HEATH 09. 00 19. 00 * DR A N PAT EL RM6 6RT CHADWELL HEATH 09. 00 18. 30 T hur sday & Fr iday: 09.00 - 19.00 * ANDREW BASS PHARMACY RM8 1BP VALENCE 09. 00 18. 00 * ASDA PHARMACY RM9 6SJ THAMES 08. 00 22. 00
KEY * Pharmacy not contracted by NHS Havering Pharmacy lunch hours have been taken int o considerat ion, GP af t ernoon closing times have not been shown
117 Saturday Opening Hours of Pharmacies & GP Practices: Fig. 40 SATURDAY OPENING HOURS 9.00 12.00 15.00 18.00 21.00 24.00
6.00 6.30 7.00 7.30 8.00 8.30 9.30 10.00 10.30 11.00 11.30 12.30 13.00 13.30 14.00 14.30 15.30 16.00 16.30 17.00 17.30 18.30 19.00 19.30 20.00 20.30 21.30 22.00 22.30 23.00 23.30
Pharmacy or GP name Postcode Ward Polysystem Open Close Further Information NATIONAL CO-OP CHEMIST RM3 0BP HAROLD WOOD NEH 09.00 17.00 TESCO INSTORE PHARMACY RM3 0LL HAROLD WOOD NEH 08.00 21.00 HAROLD WOOD POLYCLINIC - CO-OPERATIVE PHARMACY RM3 0FE HAROLD WOOD NEH 08.00 20.00 HURLEY GROUP PRACTICE RM3 OFE HAROLD WOOD NEH 08.00 20.00 DR R S CHOWDHURY RM3 0PT HAROLD WOOD NEH DR H MCDONALD RM3 0DR HAROLD WOOD NEH YOUR LOCAL BOOTS PHARMACY RM3 8DB GOOSHAYS NEH 09.00 17.30 BOOTS RM3 9PH GOOSHAYS NEH 09.00 17.30 BOOTS RM3 8DX GOOSHAYS NEH 09.00 17.30 NEWLANDS PHARMACY RM3 9SU GOOSHAYS NEH 09.00 18.00 DR M FELDMAN RM3 9PD GOOSHAYS NEH DR A JABBAR RM3 9SU GOOSHAYS NEH DR J KAKAD RM3 9SU GOOSHAYS NEH DR N A KUCHHAI RM3 9SU GOOSHAYS NEH DR K RABINDRA RM3 9SU GOOSHAYS NEH CRESCENT PHARMACY RM3 7PB HEATON NEH 09.00 15.00 DR A KAW RM3 7JJ HEATON NEH 09.00 10.00 *This is one Saturday every month (4/5weeks) DR N A KUCHHAI RM3 7HR HEATON NEH DR J PARASAD RM3 7JJ HEATON NEH YOUR LOCAL BOOTS PHARMACY RM5 3PH HAVERING PARK NWH 09.00 18.00 DR S KULENDRAN RM5 3PJ HAVERING PARK NWH DR G S SAINI & DR H D PATEL RM5 3QL HAVERING PARK NWH * LASER IMPEX LTD (BRITANNIA PHARMACY) IG2 6BN ALDBOROUGH 09.00 20.00 W BURDESS CHEMIST RM7 8BU MAWNEYS NWH 09.00 16.00 LLOYDS PHARMACY RM5 3PR MAWNEYS NWH 09.00 18.00 DR NK GUPTA RM7 8BU MAWNEYS NWH DR P JOSEPH RM5 3PR MAWNEYS NWH NEWLANDS PHARMACY RM5 3BB PETTITS NWH 09.00 13.00 RISE PARK PHARMACY RM1 4NT PETTITS NWH 09.00 18.00 DR M MAHMOOD RM5 3BJ PETTITS NWH DR BURACK & DR SAUNDERSON RM1 4QJ PETTITS NWH ROWLANDS PHARMACY RM7 7HH BROOKLANDS NWH 09.00 13.00 QUEENS HOSPITAL PHARMACY RM7 0AG BROOKLANDS NWH 09.00 14.00 DR P KUKATHASAN RM7 0PX BROOKLANDS NWH * MASTAA - CARE PHARMACY RM8 1BJ WHALEBONE 09.00 17.30 * OXLOW CHEMIST RM10 7YA HEATH 09.00 13.00 SAFEDALE RM7 0TJ EASTBROOK NWH 09.00 13.00 DR S POOLOGANATHAN RM7 0XR EASTBROOK NWH DR B BEHESTI RM7 0XR EASTBROOK NWH MiM PHARMACY RM1 1DL ROMFORD TOWN NWH 09.00 13.00 BOOTS RM1 3AD ROMFORD TOWN NWH 08.30 13.00 NEWLANDS PHARMACY RM11 1BH ROMFORD TOWN NWH 09.00 14.00 SAINSBURYS INSTORE PHARMACY RM1 1AU ROMFORD TOWN NWH 07.00 23.00 BOOTS RM1 1AU ROMFORD TOWN NWH 08.00 24.00 BOOTS RM1 3RL ROMFORD TOWN NWH 09.00 18.00 PARK LANE PHARMACY RM11 1BB ROMFORD TOWN NWH 09.00 16.00 DR D J BASS RM1 3LS ROMFORD TOWN NWH DR MARKS RM1 2SB ROMFORD TOWN NWH DR S H PATEL RM1 3DQ ROMFORD TOWN NWH ROWLANDS PHARMACY RM11 2LG SQUIRRELS HEATH NEH 09.00 16.00 BRITCROWN PHARMACY RM2 5JR SQUIRRELS HEATH NEH 09.00 16.00 DR M H FLASZ RM11 2LY SQUIRRELS HEATH NEH DR H MCDONALD RM11 2LP SQUIRRELS HEATH NEH SHADFORTHS CHEMIST RM2 5SU EMERSON PARK NEH 09.00 13.00 DR M EDISON RM2 5SU EMERSON PARK NEH PHARMACARE CHEMIST RM11 1QH HYLANDS NWH 09.00 18.00 TESCO INSTORE PHARMACY RM11 1PY HYLANDS NWH 08.00 20.00 DR S S UBEROY RM12 4AN HYLANDS NWH KEY * Pharmacy not contracted by NHS Havering Pharmacy lunch hours have been taken into consideration, GP afternoon closing times have not been shown
118 Saturday Opening Hours of Pharmacies & GP Practices: Fig. 40 (continued) SATURDAY OPENING HOURS 9.00 12.00 15.00 18.00 21.00 24.00 Pharmacy or GP name Postcode Ward Polysystem Open Close 6.00 6.30 7.00 7.30 8.00 8.30 9.30 10.00 10.30 11.00 11.30 12.30 13.00 13.30 14.00 14.30 15.30 16.00 16.30 17.00 17.30 18.30 19.00 19.30 20.00 20.30 21.30 22.00 22.30 23.00 23.30 Further Information YOUR LOCAL BOOTS PHARMACY RM11 3XS ST ANDREWS SH 09.00 17.30 YOUR LOCAL BOOTS PHARMACY RM12 4UH ST ANDREWS SH 09.00 17.30 BOOTS RM12 4UL ST ANDREWS SH 09.00 17.30 CHEMISTREE RM11 3UX ST ANDREWS SH ELM PARK PHARMACY RM12 4SD ST ANDREWS SH 09.00 17.30 DT TC BLAND RM11 1XA ST ANDREWS SH DR J C F O'MOORE RM12 6PL ST ANDREWS SH DR PM PATEL RM12 4LF ST ANDREWS SH DR VM PATEL RM11 3SZ ST ANDREWS SH DR M M RAHMAN RM12 4JP ST ANDREWS SH DR A TRAN RM11 1XA ST ANDREWS SH DAY LEWIS PHARMACY RM14 1RQ CRANHAM SH GOVANI CHEMIST RM14 1XN CRANHAM SH 09.00 17.30 DR C DAHS RM14 1BJ CRANHAM SH DR S S HAIDER RM14 1XX CRANHAM SH DR I K SUDHA RM14 1RG CRANHAM SH GOVANI CHEMIST RM14 2TD UPMINSTER SH 09.00 17.30 BRITANNIA PHARMACY RM14 2AD UPMINSTER SH 09.00 14.00 BOOTS RM14 2AJ UPMINSTER SH 09.00 17.30 PANCHEM PHARMACY RM14 3BS UPMINSTER SH DR S S BAIG RM14 3DH UPMINSTER SH DR P CHAKRAVARTY RM14 2YX UPMINSTER SH DR P CHOPRA RM14 3DP UPMINSTER SH DR C DAHS RM14 2JP UPMINSTER SH DR S S HAIDER RM14 2YN UPMINSTER SH DR D KWAN RM14 2HF UPMINSTER SH BOOTS RM12 6LL HACTON SH 09.00 13.00 LLOYDS PHARMACY RM12 5AS HACTON SH 09.00 16.00 DR Q H A GILLET WALLER RM12 5PA HACTON SH DR M M RAHMAN RM12 5PA HACTON SH NEWLANDS PHARMACY RM12 5AB ELM PARK SH 09.00 17.00 DAY LEWIS PHARMACY RM13 7PP ELM PARK SH 09.00 13.00 DR S BRANDMAN RM12 4EQ ELM PARK SH DR A R DESHPANDE RM12 5HX ELM PARK SH DR A K JAISWAL RM12 5HJ ELM PARK SH DR HM VIVERS RM12 5HJ ELM PARK SH DAY LEWIS PHARMACY RM13 7QX SOUTH HORNCHURCH SH 09.00 13.00 ORCHARD VILLAGE RM13 8QA SOUTH HORNCHURCH SH 10.00 14.00 DR K SUBRAMANIAN RM13 7UP SOUTH HORNCHURCH SH DR S SUBRAMANIAM RM13 7XJ SOUTH HORNCHURCH SH DR S S UBEROY RM13 7SB SOUTH HORNCHURCH SH DR M A WANI RM13 7XR SOUTH HORNCHURCH SH WILLIAMS CHEMIST RM13 9TR RAINHAM & WENNINGTON SH 09.00 12.00 CHANSONS PHARMACY RM13 9BD RAINHAM & WENNINGTON SH 09.00 13.00 TESCO INSTORE PHARMACY RM13 9YZ RAINHAM & WENNINGTON SH 08.00 20.00 BOWS CHEMIST RM13 9JR RAINHAM & WENNINGTON SH 09.00 13.00 DR ARM ABDULLAH RM13 9AB RAINHAM & WENNINGTON SH DR R M ADUR RM13 9QU RAINHAM & WENNINGTON SH DR H H HUSSAIN RM13 9AB RAINHAM & WENNINGTON SH DR AKS JAWAD RM13 9RZ RAINHAM & WENNINGTON SH * SHAH RH (TRICOVER LTD) ALLANS PHARMACY RM6 4AL CHADWELL HEATH 09.00 18.00 * CORDEVE LTD RM64NP CHADWELL HEATH 09.00 17.00 * LLOYDS PHARMACY RM6 6NL CHADWELL HEATH 09.00 21.00 * SAINSBURY'S INSTORE PHARMACY RM6 6PA CHADWELL HEATH 07.00 22.00 * TESCO INSTORE PHARMACY RM6 4HY CHADWELL HEATH 08.00 20.00 * THE CO-OPERATIVE PHARMACY RM6 5NR CHADWELL HEATH * DR J A HAMILTON SMITH RM6 6RT CHADWELL HEATH * DR S J HASKELL RM6 6RT CHADWELL HEATH * DR A N PATEL RM6 6RT CHADWELL HEATH * ANDREW BASS PHARMACY RM8 1BP VALENCE 09.00 13.00 * ASDA PHARMACY RM9 6SJ THAMES 09.00 20.00 KEY * Pharmacy not contracted by NHS Havering Pharmacy lunch hours have been taken into consideration, GP afternoon closing times have not been shown
119 Sunday Opening Hours of Pharmacies & GP Practices: Fig. 41 SUNDAY OPENING HOURS 9.00 12.00 15.00 18.00 21.00 24.00
6.00 6.30 7.00 7.30 8.00 8.30 9.30 10.00 10.30 11.00 11.30 12.30 13.00 13.30 14.00 14.30 15.30 16.00 16.30 17.00 17.30 18.30 19.00 19.30 20.00 20.30 21.30 22.00 22.30 23.00 23.30
Pharmacy or GP name Postcode Ward Polysystem Open Close Further Information NATIONAL CO-OP CHEMIST RM3 0BP HAROLD WOOD NEH TESCO INSTORE PHARMACY RM3 0LL HAROLD WOOD NEH 10.00 16.00 HAROLD WOOD POLYCLINIC - CO-OPERATIVE PHARMACY RM3 0FE HAROLD WOOD NEH 08.00 20.00 HURLEY GROUP PRACTICE RM3 OFE HAROLD WOOD NEH 08.00 20.00 DR R S CHOWDHURY RM3 0PT HAROLD WOOD NEH DR H MCDONALD RM3 0DR HAROLD WOOD NEH YOUR LOCAL BOOTS PHARMACY RM3 8DB GOOSHAYS NEH BOOTS RM3 9PH GOOSHAYS NEH BOOTS RM3 8DX GOOSHAYS NEH 10.00 16.00 NEWLANDS PHARMACY RM3 9SU GOOSHAYS NEH 10.00 17.00 DR M FELDMAN RM3 9PD GOOSHAYS NEH DR A JABBAR RM3 9SU GOOSHAYS NEH DR J KAKAD RM3 9SU GOOSHAYS NEH DR N A KUCHHAI RM3 9SU GOOSHAYS NEH DR K RABINDRA RM3 9SU GOOSHAYS NEH CRESCENT PHARMACY RM3 7PB HEATON NEH DR A KAW RM3 7JJ HEATON NEH DR N A KUCHHAI RM3 7HR HEATON NEH DR J PARASAD RM3 7JJ HEATON NEH YOUR LOCAL BOOTS PHARMACY RM5 3PH HAVERING PARK NWH DR S KULENDRAN RM5 3PJ HAVERING PARK NWH DR G S SAINI & DR H D PATEL RM5 3QL HAVERING PARK NWH * LASER IMPEX LTD (BRITANNIA PHARMACY) IG2 6BN ALDBOROUGH 10.00 16.00 W BURDESS CHEMIST RM7 8BU MAWNEYS NWH 10.00 13.00 LLOYDS PHARMACY RM5 3PR MAWNEYS NWH DR NK GUPTA RM7 8BU MAWNEYS NWH DR P JOSEPH RM5 3PR MAWNEYS NWH NEWLANDS PHARMACY RM5 3BB PETTITS NWH RISE PARK PHARMACY RM1 4NT PETTITS NWH DR M MAHMOOD RM5 3BJ PETTITS NWH DR BURACK & DR SAUNDERSON RM1 4QJ PETTITS NWH ROWLANDS PHARMACY RM7 7HH BROOKLANDS NWH DR P KUKATHASAN RM7 0PX BROOKLANDS NWH * MASTAA - CARE PHARMACY RM8 1BJ WHALEBONE * OXLOW CHEMIST RM10 7YA HEATH SAFEDALE RM7 0TJ EASTBROOK NWH DR S POOLOGANATHAN RM7 0XR EASTBROOK NWH DR B BEHESTI RM7 0XR EASTBROOK NWH MiM PHARMACY RM1 1DL ROMFORD TOWN NWH BOOTS RM1 3AD ROMFORD TOWN NWH NEWLANDS PHARMACY RM11 1BH ROMFORD TOWN NWH SAINSBURYS INSTORE PHARMACY RM1 1AU ROMFORD TOWN NWH 10.00 16.00 BOOTS RM1 1AU ROMFORD TOWN NWH 10.00 17.00 BOOTS RM1 3RL ROMFORD TOWN NWH 10.00 17.00 PARK LANE PHARMACY RM11 1BB ROMFORD TOWN NWH DR D J BASS RM1 3LS ROMFORD TOWN NWH DR MARKS RM1 2SB ROMFORD TOWN NWH DR S H PATEL RM1 3DQ ROMFORD TOWN NWH ROWLANDS PHARMACY RM11 2LG SQUIRRELS HEATH NEH BRITCROWN PHARMACY RM2 5JR SQUIRRELS HEATH NEH DR M H FLASZ RM11 2LY SQUIRRELS HEATH NEH DR H MCDONALD RM11 2LP SQUIRRELS HEATH NEH SHADFORTHS CHEMIST RM2 5SU EMERSON PARK NEH DR M EDISON RM2 5SU EMERSON PARK NEH PHARMACARE CHEMIST RM11 1QH HYLANDS NWH TESCO INSTORE PHARMACY RM11 1PY HYLANDS NWH 10.00 16.00 DR S S UBEROY RM12 4AN HYLANDS NWH
KEY * Pharmacy not contracted with NHS Havering Pharmacy lunch hours have been taken into consideration, GP afternoon closing times have not been shown
120 Sunday Opening Hours of Pharmacies & GP Practices: Fig. 41 (continued) SUNDAY OPENING HOURS 9.00 12.00 15.00 18.00 21.00 24.00 Pharmacy or GP name Postcode Ward Polysystem Open Close 6.00 6.30 7.00 7.30 8.00 8.30 9.30 10.00 10.30 11.00 11.30 12.30 13.00 13.30 14.00 14.30 15.30 16.00 16.30 17.00 17.30 18.30 19.00 19.30 20.00 20.30 21.30 22.00 22.30 23.00 23.30 Further Information YOUR LOCAL BOOTS PHARMACY RM11 3XS ST ANDREWS SH YOUR LOCAL BOOTS PHARMACY RM12 4UH ST ANDREWS SH BOOTS RM12 4UL ST ANDREWS SH 10.00 16.00 CHEMISTREE RM11 3UX ST ANDREWS SH ELM PARK PHARMACY RM12 4SD ST ANDREWS SH DT TC BLAND RM11 1XA ST ANDREWS SH DR J C F O'MOORE RM12 6PL ST ANDREWS SH DR PM PATEL RM12 4LF ST ANDREWS SH DR VM PATEL RM11 3SZ ST ANDREWS SH DR M M RAHMAN RM12 4JP ST ANDREWS SH DR A TRAN RM11 1XA ST ANDREWS SH DAY LEWIS PHARMACY RM14 1RQ CRANHAM SH GOVANI CHEMIST RM14 1XN CRANHAM SH DR C DAHS RM14 1BJ CRANHAM SH DR S S HAIDER RM14 1XX CRANHAM SH DR I K SUDHA RM14 1RG CRANHAM SH GOVANI CHEMIST RM14 2TD UPMINSTER SH BRITANNIA PHARMACY RM14 2AD UPMINSTER SH BOOTS RM14 2AJ UPMINSTER SH PANCHEM PHARMACY RM14 3BS UPMINSTER SH DR S S BAIG RM14 3DH UPMINSTER SH DR P CHAKRAVARTY RM14 2YX UPMINSTER SH DR P CHOPRA RM14 3DP UPMINSTER SH DR C DAHS RM14 2JP UPMINSTER SH DR S S HAIDER RM14 2YN UPMINSTER SH DR D KWAN RM14 2HF UPMINSTER SH BOOTS RM12 6LL HACTON SH LLOYDS PHARMACY RM12 5AS HACTON SH DR Q H A GILLET WALLER RM12 5PA HACTON SH DR M M RAHMAN RM12 5PA HACTON SH NEWLANDS PHARMACY RM12 5AB ELM PARK SH DAY LEWIS PHARMACY RM13 7PP ELM PARK SH DR S BRANDMAN RM12 4EQ ELM PARK SH DR A R DESHPANDE RM12 5HX ELM PARK SH DR A K JAISWAL RM12 5HJ ELM PARK SH DR HM VIVERS RM12 5HJ ELM PARK SH DAY LEWIS PHARMACY RM13 7QX SOUTH HORNCHURCH SH ORCHARD VILLAGE RM13 8QA SOUTH HORNCHURCH SH 10.00 14.00 DR K SUBRAMANIAN RM13 7UP SOUTH HORNCHURCH SH DR S SUBRAMANIAM RM13 7XJ SOUTH HORNCHURCH SH DR S S UBEROY RM13 7SB SOUTH HORNCHURCH SH DR M A WANI RM13 7XR SOUTH HORNCHURCH SH WILLIAMS CHEMIST RM13 9TR RAINHAM & WENNINGTON SH CHANSONS PHARMACY RM13 9BD RAINHAM & WENNINGTON SH TESCO INSTORE PHARMACY RM13 9YZ RAINHAM & WENNINGTON SH 10.00 16.00 BOWS CHEMIST RM13 9JR RAINHAM & WENNINGTON SH DR ARM ABDULLAH RM13 9AB RAINHAM & WENNINGTON SH DR R M ADUR RM13 9QU RAINHAM & WENNINGTON SH DR H H HUSSAIN RM13 9AB RAINHAM & WENNINGTON SH DR AKS JAWAD RM13 9RZ RAINHAM & WENNINGTON SH * SHAH RH (TRICOVER LTD) ALLANS PHARMACY RM6 4AL CHADWELL HEATH * CORDEVE LTD RM64NP CHADWELL HEATH * LLOYDS PHARMACY RM6 6NL CHADWELL HEATH 10.00 17.00 * SAINSBURY'S INSTORE PHARMACY RM6 6PA CHADWELL HEATH 10.00 16.00 * TESCO INSTORE PHARMACY RM6 4HY CHADWELL HEATH 10.00 16.00 * THE CO-OPERATIVE PHARMACY RM6 5NR CHADWELL HEATH * DR J A HAMILTON SMITH RM6 6RT CHADWELL HEATH * DR S J HASKELL RM6 6RT CHADWELL HEATH * DR A N PATEL RM6 6RT CHADWELL HEATH * ANDREW BASS PHARMACY RM8 1BP VALENCE * ASDA PHARMACY RM9 6SJ THAMES 10.00 16.00 KEY * Pharmacy not contracted with NHS Havering Pharmacy lunch hours have been taken into consideration, GP afternoon closing times have not been shown
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