PHARMACY PRACTICES COMMITTEE MEETING Wednesday, 26 March, 2014 at 2pm Seminar Room, Caithness General Hospital, Bankhead Road, Wick, KW1 5NS Application by SANJAY MAJHU of APPLE PHARMACY GROUP for the provision of general pharmaceutical services at Castletown Fish & Chip Shop, 13 Mackay Street, Castletown, Caithness, KW14 8UQ

PRESENT Elaine Wilkinson (Chair) Margaret Thomson (Lay Member) Maureen Thomson (Lay Member) Michael Roberts (Lay Member) Dr Susan Taylor (GP Sub Committee Nominate) Fiona Thomson (APC Non Contractor Nominate) Catriona Sinclair ( APC Contractor Nominate) Caroline Morgan (APC Contractor Nominate)

In Attendance Andrew J Green (Area Regulations, Contracts & Controlled Drugs Governance Pharmacist) Helen M MacDonald (Community Pharmacy Business Manager) Sanjay Majhu, Apple Pharmacy Group Dr Hercules Robinson, GP Sub Committee Dr Wilma Macleod, GP Sub Committee Support

Apologies Area Pharmaceutical Committee of NHS Highland

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

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

Case No: PPC – Castletown Apple Pharmacy Group, Castletown Fish & Chip Shop, 13 Mackay Street, Castletown, Caithness, KW14 8UQ

The Chair asked each Committee member if there were any interests to declare in relation to the application being heard from Sanjay Majhu of Apple Pharmacy Group. No interests were declared.

3. The Committee was asked to consider the application submitted by Sanjay Majhu of Apple Pharmacy Group to provide general pharmaceutical services from premises sited at Castletown Fish & Chip Shop, 13 Mackay Street, Castletown, Caithness, KW14 8UQ under Regulation 5(10) of the National Health Service (Pharmaceutical Services) (Scotland) Regulations 2009, as amended.

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

The Committee, having previously been circulated with all the papers regarding the application from Sanjay Majhu of Apple Pharmacy Group, agreed that the application should be considered by oral hearing.

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P1 Prior to the hearing, the Committee had, as a group, visited the vicinity surrounding the applicant’s proposed premises and that which was the catchment area for the dispensing practice, currently providing a dispensing service to patients within the neighbourhood defined by the applicant. The route followed was laid out in advance and directed by the Chair of the Pharmacy Practices Committee from Westerloch to John O’Groats on the A99, then following the A836 through Castletown to Thurso and through the villages on this road, but also turning off to Canisbay and Scarfskerry. On returning to Castletown they then took the B876 to Wick. In doing so, the Committee visited the medical practice dispensaries at Canisbay and Castletown and the locus of each of the three pharmacies, currently listed on the NHS Highland Pharmaceutical list in the town of Thurso.

It was particularly noted the village of Castletown was sited six miles from the town of Thurso where a full range of amenities and services were located, including supermarkets, petrol filing stations and the High School and College.

The Committee visited the boundaries of the neighbourhood as defined by the applicant and the residential area, noting the former Icetech freezer factory which had recently closed down, removing the main employing body from the village. The bus stops were noted, as was the Stagecoach bus service which was seen travelling through the neighbourhood.

Housing was viewed to be a mix of social and private housing. Services noted within the neighbourhood comprised a filling station, garage, general grocers, butcher shop, garden centre, post office, bank, hair and beauty salon, takeaway restaurants, primary school, churches, community hall and police station scattered throughout the village accessible by walkways and footpaths. There was a play park. No developments, housing or otherwise were noted.

The Committee then visited the proposed premises where the Manager of the current business – Castletown Fish & Chip Shop was on hand to guide the Committee around the premises. The applicant was not present and there were no plans available to the Committee, other than the one submitted for the purpose of the application. The Manager of the current business was unable to answer any questions regarding the proposed fit out of the premises, but was however helpful in explaining that the land to the right of the premises between the Chinese Takeaway was part of the site and could be developed to accommodate further parking if required. The Committee was satisfied with the arrangements for accepting deliveries to the premises. The premises were sizeable and deemed by the Committee could accommodate a pharmacy, and all the facilities required under terms of the NHS contract, from within it.

The Committee were saddened to hear that the community had boycotted the business as it stood since mention of the pharmacy application was made to operate from the premises and that as a result had experienced loss of business to the detriment of 80% per day which was unsustainable for the owner.

The Committee drove by 13 Mackay Street, which they could clearly see was a residential property.

Health Board officials had previously sought assurance from the Central Legal Office of NHS Scotland regarding the validity of the application in terms of the proposed premises which had been identified, as the street number and postcodes sometimes differed. The Health Board officials were advised that insofar as the Committee could be assured that the premises could be identified beyond reasonable doubt, that the fact there had been some confusion over the postcode and street number would not invalidate the application.

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P2 Presented with all the evidence and information the Committee absolutely agreed that there could be no doubt at all that the premises referred to in the application, were easily identified as Castletown Fish & Chip Shop, Mackay Street, Castletown on two counts. One, that it was an operational business on Mackay Street providing the product equivalent to that of a fish and chip takeaway shop and also that there was a gargoyle in the form of a fish protruding from the front gable end of the premises, on Mackay Street but that neither the Committee, nor the Health Board Officials, were able to identify a street number for the property, nor, in fact was the letting agent on his letter of intent to the applicant.

The Committee then returned to the Seminar Room, Wick General Hospital, Bankhead Road, Wick, KW1 5NS, where the hearing was to be held.

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

The Applicant, Interested party and support were invited into the meeting at around 2.30 pm.

4. The Chair apologised to all in attendance for the late start of the hearing and welcomed:-

The Applicant, Sanjay Majhu of Apple Pharmacy Group and the Interested Party who had submitted written representations during the consultation period and who had chosen to attend the hearing, Dr Hercules Robinson, GP Sub Committee and Dr Wilma Macleod, GP Sub Committee support.

The Chair then invited the Committee members and Board officials to introduce themselves to the Applicant and all other parties and vice versa.

The Chair explained that this was her first hearing as Chair of the NHS Highland Pharmacy Practices Committee and, as a result, may require to seek technical assistance from Mr Green and Mrs MacDonald to support her in this throughout the hearing. The Chair explained the roles of Mr Green and Mrs MacDonald in providing accurate clerking, administration and technical advice which they also could seek throughout the hearing but that Mr Green and Mrs MacDonald would not be present during the private deliberations of the Committee and would be invited back into the hearing, only after all parties had been dismissed and the decision was made.

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

5. The Chair reminded everyone that the meeting had been convened to hear the application from Sanjay Majhu of Apple Pharmacy Group for the provision of general pharmaceutical services from Castletown Fish & Chip Shop, 13 Mackay Street, Castletown, KW14 8UQ. The application would be considered against the legal test contained in Regulation 5(10) of the National Health Service (Pharmaceutical Services) (Scotland) Regulations 2009, as amended.

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P3 6. Regulation 5(10) was read out:

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

7. The Chair advised that all present were probably aware that the Cabinet Secretary for Health and Well Being had made clear his intention to bring forward amended legislation as a priority that would aim to address concerns raised by many people, including the community of Castletown about the Control of Entry arrangements and dispensing GP practices, however, he had been clear in correspondence with the NHS Highland Board Chairman that existing Regulations remain in force until such time as that legislation came into force.

The Chair then described the format of the hearing, reminding those attending that no new evidence could be introduced at the summing up, explaining that it would be the sole responsibility of the Lay Members to decide whether or not to grant the application. Only after the decision had been made would NHS Highland Board officials rejoin the Committee to enable the decision and reasons to be recorded.

The procedure adopted by the Committee at the hearing was that the Chair asked the applicant to make his submission. There followed the opportunity for the Interested Party and the Committee to ask questions. The Interested Party would then make its submission. There followed the opportunity for the applicant and the Committee to ask questions of the Interested Party. The Interested Party and the applicant were then given the opportunity to sum up.

The Chair then asked the applicant to give his statement.

7.1. The Applicant’s Case

Mr Majhu of Apple Pharmacy Group stated “Firstly, congratulations on picking an easy case to be heard. I would like to thank you all for coming to this application hearing. Our proposition is to apply for an NHS pharmacy contract in the neighbourhood of Castletown. Castletown is a village situated near Dunnet Bay, in the northern most tip of the Scottish Highlands. The village is linked to John O’Groats and Thurso via the A836 and the town of Wick which is about 20 miles away via the B876.

So, the north boundary of the neighbourhood of Castletown is Dunnet Bay. To the west, Dunnet Bay heading south along Battery Road, cutting through the main road the A836, continuing southeast to Stangergill burn. To the east, running to Dunnet Bay south to the junction of Harbour Road and the A836, continuing south west to the junction of Harland Road and the B876. To the south from the southern tip of Castletown Primary School to Stangergill burn, which if you pick the tips of encompass the Village of Castletown.

I have tried to apply the legal test in my definition of the neighbourhood within the guidelines within which a neighbourhood has to be defined, which has been my biggest problem. I have had sleepless nights over it and I still couldn’t define it.

At present there is no pharmacy within the neighbourhood supplying pharmaceutical services. There is, however, a dispensing doctors’ practice within the GP surgery of Castletown which resides in Murrayfield. This practice, along with its satellite in Canisbay, dispenses 7,000 items per month and this is growing. We present the case today to the PPC that already this is above the national average for even a pharmacy and will not be sustainable, in our opinion, in moving forward.

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P4 For the purpose of definition we have chosen Castletown as our defined neighbourhood as this is where local people believe they are from – they believe they are from Castletown but I am bound by definition. The GP practice of this village has a larger patient base which covers the full triangle from Thurso, to Wick and to John O’Groats, and for this reason has a substantial catchment area, linked by a satellite surgery. So if we look at where we see it, there are no pharmacies within the area. You would need to go to Wick or Thurso to access pharmaceutical services as there are none within the triangle as there is no pharmacy. So, Castletown is a unique neighbourhood, like no other. I believe it has a significant transient population who travel from all four corners of Castletown to John O’Groats to just above Wick to access the GP practice at Castletown Health Centre. This is a large catchment area which is unique in Highland but with very fine GPs. I would urge the PPC to consider this neighbourhood in the context of the findings of Lord Nimmo Smith in his consideration of Judicial Review of Boots Chemists, in Inverness in 1999:

Neighbourhood is not defined in the Regulations and must therefore be given the meaning which would normally be attributed to it as an ordinary word of the English language. As the word is ordinarily understood, it has the connotations of vicinity or nearness…the word “neighbourhood” in regulation 5(10) of the 1995 Regulations means an area which is relatively near to the premises in question, which need not have any residents, and which can be regarded as a neighbourhood for all purposes.

Thus although we have a population no greater than 1000 people, we have all the elements of a neighbourhood. A school, post office, church, shops and a butchers shop, petrol station, a recreational park for children, chinese takeaway, hotel, bank, a small garden centre - and also a very busy GP practice.

Though I agree people may leave the neighbourhood to access the larger supermarkets, perhaps monthly, for their large supplies. On a day to day basis this is a neighbourhood for all purposes. Also, and more importantly, this neighbourhood has a large influx of patients who access the GP practice in Murrayfield – that is Castletown Medical Practice. Thus, though the resident population is low, there is evidence available from script numbers that in fact, at least 2,000 people access this neighbourhood to visit their GP – that is as well as the population of Castletown – well they have a very good GP Practice!

Castletown Practice has a dispensing doctors’ practice. Last year combined scripts for Castletown and Canisbay produced 83,165 items – that’s information which is direct from the NHS website - or just under 7,000 items per month. The NHS payment for 2012/13 was £719,288. NHS figures show the combined numbers and we have no access to split the figures. That’s £720,000 income from medicines alone!

We believe the split is majority Castletown as there are two resident doctors there and one for Canisbay. We believe at the time of application, both Castletown Doctors were covering Canisbay due to a doctor being off sick. Already this is stretching the current medical delivery and a pharmacy will have no other effect but to ease this burden.

There was a meeting organised on the 20th November which was attended by 500 very angry and very anxious local residents. It is never easy taking on an application in a dispensing practice area. This was backed by the setup of a website “Save Our Surgery” – and I don’t know if any of you have read this - as a platform for those who oppose this application to keep abreast of the situation. The issue here is that the message given to all was that the Surgery may be threatened by this application and may in time have to close.

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P5 It was called the “Save Our Surgery” and you can see from the picture here that during the “Save Our Surgery” campaign this is backed up by the doctors and staff pictured wearing a t- shirt (the applicant holds up a photograph of the doctors and staff each wearing a t-shirt with the words “Save our Surgery” printed on them) as well as posters being placed in all windows. We received three letters anonymously from residents who though wished to back us, could not, because they were afraid.

Once you start an application in a dispensing practice area you start an uphill struggle to try and liaise with anyone and I came from head on. I asked the Community Council if I could meet with 20 representatives from the community on 26th November so I could put my view forward.

My view is that a doctor should never have a dispensing pad as a cheque book and that this should not line doctors’ pockets as income and that where there is a need then this should trigger a pharmacy being put in place.

The owner of the unit we propose to place the pharmacy into was himself subject to a large influx of abuse and boycott, resulting in his sales halving and his business on the verge of collapse. The reason for this is clearly the message to the locals is this application may result in closure of the medical practice, yet as we will see, this is not true. So, he got a hard time.

I don’t come with a lot of support. I come with none.

I’ll go back to the legal test:

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

Now, if I wanted to be tactful what I’d do is I’d take the whole practice area and try to get you not to agree to my neighbourhood, even though folk could move to Canisbay

So, in summary; members of the committee; I cannot show you desirability as I have not received any letters of support that I can offer you today a neighbourhood. I can’t show you that as those people are too terrified to be named and I won’t put people in that position but I can clearly show you that granting this application is necessary whatever.

At a meeting on the 26th November in which I asked the Community Council to bring 20 persons to represent the community as well as both Dr Macleod and Dr Robinson, and this meeting is audio taped. Dr Robinson was very nice and refused to let me walk into that meeting on my own. Dr Robinson stated the following and I quote:

“…there is no question that should this contract be granted, viability will not be affected, business will continue. We plan to oppose the application, but should we lose (meaning that I will win), we will look at all opportunities”.

Applicant: I have asked that we move forward together – he can take it forward – or not.

“We agree we will be under threat and one of the options is we apply ourselves to keep the threat away”.

“It is true that both dispensaries are busy with increasing scripts and it will be harder to maintain a 48 hour turnaround. As the NHS request, we write monthly scripts, hence we have many dispensers. It will be difficult to argue, if dispensing load continues, the current situation will become harder to maintain”

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P6 Ref: Save Our Surgery Website (Track 7)

I am saying today that Dr Robinson himself agreed that he may not be able to secure services himself, should the rise occur.

When I met on the same day with both Dr Robinson and Dr Wilma Macleod, the main concern seemed to be the attraction of a third partner, thus not really a pharmacy issue, it’s a financial incentive. I don’t know if it’s the same today.

I could not reconcile this to the “Save Our Surgery” campaign, which has all the connotations that the GP may have to close which is not true. There is no reconciliation other than to get three GPs. It seems to be that to get doctors to work in the sticks you have to give them a good offer in monetary terms.

Dr Robinson assured me that this was not the case currently, but may be later, as attracting GPs to this neighbourhood was easier with the income generated from the dispensing practice. I hope he will agree to that conversation today. So where I am trying to be fair to apply the legal test, I find myself battling against the message of dispensing doctors that the practice will close. If you don’t grant the application then at what point should a dispensing pad not be used as a cheque book?

I also discussed with Dr Robinson that knowing dispensing doctors were under threat from pharmacy contracts applications then why did Castletown and Canisbay not a apply for a pharmacy contract themselves. The reason given was one that budgets did not allow.

Thus if average GP salaries without dispensing are well over £100k, why a cheque for £719,000 at a GP of 32% would not allow a pharmacist to be afforded, I can only conclude that the money is either ring fenced for other services or GPs get more here than should be afforded by them. Dispensing doctors were never given the right to cream more money from the NHS, they were set up in rural areas where viability was an issue, and with 7,000 items per month I can deduce quite clearly, this is not an issue and, I don’t know how you do your sums but with £210,000 gross profit, a pharmacy could be triggered with no argument once legislation goes through.

I find myself saying, as a businessman – “why haven’t they applied for a contract? They have told me finances did not allow for this but dispensing doctors earn the same as everyone else. If they are dispensing 7,000 items per month then they are earning above average salaries – which was confirmed to me by Dr Robinson himself.

Our services would comprise dispensing NHS prescriptions, private and vet scripts, advice and consultations, display of public health material, chronic medication service, minor ailment service, emergency hormonal contraception, smoking cessation service and an unconditional delivery service within a twenty mile radius.

Subject to granting of the application this will happen and the pharmacy will open within 3 months. Apple Pharmacy will need this time to invest and build a £150,000 new, state of the art pharmacy with consultation room, private consultation areas, over the counter service area with minor ailment terminals, fully fitted dispensary, repeat service software and seating area.

The pharmacy would be open 49 hours a week and no appointment would be necessary.

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P7 Apple Pharmacy would TUPE (meaning Transfer of Undertaking of Permanent Employment) all dispensary staff with no redundancies. There will be a creation of at least three new jobs to service the catchment area the GPs cover. There will be investment in a 4x4 vehicle to adequately cover severe weather conditions and make sure patients receive their medication – not a taxi service.

We would encourage the PPC when considering this application to consider the wider transient population who travel in every day to access a very good GP Surgery. They are a very good surgery but sorry, we won’t agree. If I thought it would make their business unstable I would walk away. A dispensing practice cannot be considered in the same vein as a pharmacy and therefore those persons travelling into Castletown to access the surgery and other services would benefit immensely from having their own chemist which would cover CMS, eMAS, PHS and much, much more, reducing the burden on GPs which is a Scottish Government initiative. The net result will be an offloading for an already strained pharmacy service which is inadequate for those accessing this practice on a daily basis.

Recently Dispensing practices awarded an NHS Contract are Drymen (population 900), Bonar Bridge (population 1000). Our population is not far away from these numbers. If the Committee awarded a contract for Drymen then you have got to award this application!

The dispensing practice at Castletown dispenses more than double than any of those above that were awarded. We have met and agreed with the doctors that should the PPC see in our favour, they will work with us to support the new pharmaceutical provision which will immensely help those in remote and rural areas by providing first line healthcare thus reducing waiting times in the surgery, cos, I can’t work without them. I want them to be stakeholders and work together. We have sat down together and discussed the options.

If you reject this application today then there will be many applications behind me to come. Can you imagine – if there was not a dispensing doctors here then I would have been celebrated but I am not because of the perceived threat of closure of the doctors’ surgery.

The practice in Castletown is therefore unique. It is the busiest dispensing doctor in Scotland. Whichever way the PPC defines the neighbourhood, this practice in this location will not be overall able to support future growth, and that is an agreement between us and Dr Robinson. He said this himself at the “Save our Surgery” meeting.

The issue here is to entice doctors to the area with extra income. It that was the test then we would not have applied. Doctors in this practice already receive a higher than average income, supported even more by the extra income of drugs profit. This practice is not the aim of the future delivery of healthcare. It is all about incentivising them.

Our unit is 1,300 square feet with a proposed Investment of £150,000. Parking is ample outside the shop, and we will have an unconditional delivery service to patients over a twenty mile radius. Though we do not suggest this is core contractual, it will provide a service in this remote area that will revolutionise how people with travelling issues, disability issues or in times of severe weather will always have access to pharmaceutical healthcare provision over 49 hours per week without closing – we don’t take appointments.

The community were warned that the doctors’ surgery would close down – they are not going to close – this simply will not happen.

The doctors can use this service to enhance their service to patients – that is my belief. We would hope that at the meeting the doctors will agree to work with us should you see the light of my application.

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P8 The unit will have full disabled access and will be far more prepared than the existing dispensary, taking the workload from them. There will be a state of the art consultation room with a good supply of over the counter medicines which currently, those accessing this surgery, do not have”.

The Chair thanked Mr Majhu of Apple Pharmacy Group for his statement and invited the Interested Party and members of the Committee to ask questions of him.

7.2 Questions from Dr Hercules Robinson, GP Sub Committee to the Applicant

Q. Are you aware that Canisbay is not a satellite surgery?

A. It was one name so I never thought it wasn’t.

Q. Why did you choose the neighbourhood you chose?

A. Because your surgery is very busy and people have to come from far away to access services, there is a wide catchment of population coming to Castletown to access GP and other services.

Q. Why didn’t you choose the area covered by the practice as your neighbourhood?

A. I am not allowed to.

Q. How do you justify viability based on your neighbourhood?

A. If you said that two thirds of the Joint Practice access dispensing at Castletown, that would be 3,500 items and I am hoping that a transient population will access pharmacy services.

Q. Do you agree that if the pharmacy application is granted then the surgery, as it is, will close?

A. No

Q. Do you provide blood tests for medication monitoring?

A. I never said I would do that. We will provide services such as the minor ailments service.

Q. Are you aware that the practice provides a chronic medication service, although it cannot be said that this is a pharmacy chronic medication service?

A. No.

7.3 Questions from the Committee to the Applicant

Dr Susan Taylor, GP Sub Committee

Q. You described how you had a meeting with invited individuals, when did you approach people regarding your application to set up a pharmacy?

A. About a month before?

Q. Who did you consult with?

A. At the time of the public consultation, I approached the doctor to ask for his views.

Q. Did you speak directly to anyone before the invited meeting?

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P9 A. Yes, I spoke to Brenda at the Community Council and a few of the folk who wrote in at the time of the public consultation.

Q. As you have mentioned, you obviously feel Castletown is transient. How would you see patients in Dunnet Head and Canisbay receiving their medication?

A. From the pharmacy.

Q. So they would visit their doctor and then they would visit the pharmacy would they?

A. Hopefully if they were patients from Canisbay they would attend the Canisbay surgery for their medicines. We would need to sit down and discuss this.

Q. So, someone from Canisbay would still get their acute medicines from Canisbay. What if they chose to take their prescription elsewhere?

A. I hope that wouldn’t happen. But if I was sitting here today and the “Save our Surgery” campaign didn’t exist things would be different. If I knew it (meaning the surgery) would fold then I wouldn’t have put the application in.

Q. Many get their medicines from pharmacies in Wick and Thurso. What if they felt that was adequate for them?

A. If you think it’s OK to travel 6 miles to Thurso and 20 to Wick then don’t grant this application.

Q. Where are the secondary schools based?

A. The population goes into Castletown which is a neighbourhood for all purposes. It has a post office, bank, church and a garden centre.

Q. Did you not mention that Castletown is less populated?

A. At the moment you should be looking for better investment from operators like me. Working with the GPs to create a fantastic service and three new jobs.

Q. You mention that you had to transfer staff across. Why is that and is that in Castletown only?

A. It’s the Law.

Q. But the practice is joint. Wouldn’t you have to transfer the lot?

A. And there lies the problem! We would want to work with the doctor to provide services. It looks as though there are separate staff at each site but then if it is being said that the staff are for one dispensing practice and there is only one pharmacy service in the area can all staff be TUPED across? That is a question for the Committee today.

Q. You have stated that dispensing doctors use their dispensing pad as a cheque book. Do you have any evidence that the costs are higher to the NHS via a dispensing doctor than a pharmacy?

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P10 A. Why would I have that? The evidence is there and it’s quite clear. Doctors get paid very well for what they do. They only dispense when it’s not viable to have a pharmacy in the area. That is why they do it but when they start earning excessive amounts I think it’s horrendous that doctors use that prescription pad as a bolt on to their earnings. If you have evidence to the contrary let me know. I am happy not to take this contract. I don’t want to make any money from the contract and give it back by the GPs. It is a disgrace and it should stop.

Caroline Morgan, APC Contractor

Q. You have said that you thought that 6 miles was excessive to travel to Thurso from Castletown but what about those resident in Canisbay if they were to travel to your pharmacy in Castletown?

A. Look, Canisbay is not under threat. Would you want your elderly grandmother to travel in?

Q. How many people would travel into Canisbay?

A. It’s the pharmaceutical services we want to provide in Castletown that’s being considered here. The roads between Thurso and Wick are better - I don’t think!

Q. Is the applicant expecting travel to be better into the pharmacy then?

A. We are on the doorstep if they are travelling into Castletown anyway. This is much better than present but by throwing in unconditional delivery service - then that is even better.

Q. Tell my about your delivery service?

A. It will be 6 days a week.

Q. Would that be for delivering prescriptions only or for over the counter medicines or other medicines and supplies?

A. If someone wants something delivered, we will deliver it. Within legal domains.

Catriona Sinclair, APC Contractor

Q. You said it you would provide an unconditional delivery service, within a 20 mile radius, tell me about that?

A. I picked Dunnet Bay as I wanted to include that triangle.

Q. How often would you be delivering? Would it be for acute or repeat prescriptions also and how often would it be out there?

A. There would be a shift in morning and a shift in the afternoon which is standard in all our shops.

Q. Are you already providing a rural delivery service in an area such as this?

A. No.

Q. I just want to make sure it’s been evaluated so have you costed it?

A. We distribute for 30 miles so understand that that is slightly different here, but its in the profit and loss and it would be a different cost base, as economies of scale. I have 16 drivers.

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P11 Fiona Thomson, APC Non Contractor

Q. I wonder, have you anticipated any problems in recruiting a pharmacist for this area?

A. No. Perhaps 10 years ago that would have been an issue but not now, as there is an overprovision of pharmacists. I have 30 applicants applying for each post and recently 25 applicants for a new pharmacy in Inverness. I do not envisage any problem in recruiting one for Castletown.

Q. You mentioned you had a number of shops. How many are in rural areas?

A. None, but I am opening a pharmacy soon in Inverness so may get some experience there. I have stores in Shieldhill and Gartcosh but this area is extreme rural. I am ready for Triple X Rural!

With some of the questions people are asking me, I am beginning to wonder if people are wondering what I am letting myself in for but this would be a fabulous service for patients, if granted.

Maureen Thomson, Lay Member

Q. How much did you understand about the working of the Canisbay and Castletown Practice when you decided to put in the application and did you understand they dispensed at both sites?

A. Yes.

Q. Can you clarify the model you are looking to achieve and explain about what is going to happen in Castletown and Canisbay as I am struggling to understand your model, as are perhaps, some other members of the committee?

A. Well, that’s difficult. I don’t have information on split numbers. I called Canisbay a satellite earlier as it looks to be separate. People won’t need an appointment to be seen in the pharmacy. I know they say they provide a type of chronic medication service and nicotine replacement therapy but you need an appointment to access these services, which you don’t to access the chronic medication service and minor ailments service in pharmacy.

Q. I want to hear how you anticipate what would happen in Canisbay? This is critical. Every other application has been in an area where there is a single practice location but you are choosing to apply to open a pharmacy in an area where there are two locations for dispensing.

A. When I apply the legal test – and I had sleepless nights over this! When defining the neighbourhood – and I must define a neighbourhood and both of the Thomsons are very clever ladies - I would have to define the whole area as a neighbourhood and open a fabulous pharmacy in Castletown!

The difficulty I have - and I cannot answer for Canisbay - that is your decision; is that we cannot presume Canisbay is going to close so I would ask the doctors to close the dispensing arm of Canisbay,

Q. How do you explain to the patients that they would have to access pharmaceutical services in Castletown?

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P12 A. Patients in the east will be affected. I am not suggesting this Committee make the decision. Your definition will decide what ultimately is happening in Canisbay.

Q. Do you know that it is not possible to split the prescription data?

A. Yes, but the doctors have said today that 4,000 items are from Castletown. How many go to the GP is not relevant as the pharmacy is more than viable on this basis if just for Castletown. I am not one to take on doctors who are upset. Other contractors have been but the whole idea relies on discussion with the GPs and working together.

Q. So, are you saying that you are relying on the doctors to be the conduit to calming the community?

A. Yes.

Q. Do you anticipate they (patients) would vote with their feet?

A. I anticipate that the doctors will become very good stakeholders in a pharmacy in Castletown. They are great doctors who look after the patients very well.

Q. How many years training does it take to become a pharmacist?

A. 5 years.

Margaret Thomson, Lay Member

Q. In relation to your delivery service, assuming that the contract was granted, how would you cope with a young mum who would needto get out to the pharmacy in the winter if the weather was bad?

A. Well there would be a better chance of them getting their medicines in the winter as we have a 4x4 vehicle.

Q. Do the doctors not have to go out to visit their patients anyway? Is that not more normal than for a pharmacist?

A. That’s what we should be letting the doctors get on with it.

Q. I haven’t heard any mention of residential facilities which might be serviced by pharmacies. Do you know of any residential units which might be using the services of a pharmacy i.e, small nursing homes?

A. That would be right across the board included as information forming part of our business development plan which we are yet to look at. We believe we have enough information to start off.

Michael Roberts, Lay Member

Q. The legal test, you will agree, described the neighbourhood but it doesn’t define an area, so you are defining your neighbourhood as Castletown?

A. Correct.

Q. Within it there is there a GP dispensing practice?

A. Yes.

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P13 Q. So, are you not concerned with anything outwith the neighbourhood?

A. I never said that. I am concerned with the transient population and Canisbay but I can only provide the neighbourhood I have defined. Look, I’m between a rock and hard place, certain definitions of neighbourhood double up to the catchment area of the practice.

Q Where would someone from John O’Groats , Canisbay and Castletown say they came from?

A. Well, if you were from John O’Groats you would say you were from John O’Groats; if you were from Canisbay, you would say you were from Canisbay and if you were from Castletown, you would say you were from Castletown.

Q. So have you defined a separate neighbourhood in that answer?

A. Yes - for that answer.

Q. Would there be no job losses at the surgery if you were successful?

A. Correct.

Q. So how many staff are there?

A. Well, we don’t know how many service the 7,000 items and how the staff area split. We would TUPE the staff in Castletown.

Q. If you are talking about two thirds of the 7,000 then that would be viable?

A. Pharmacies have been granted on a lot less.

Q. You keep saying you want to work with the GPs. Is that true?

A. Yes

Q. Why did you pick Castletown?

A. It sticks out like a sore thumb. Castletown sitting and growing and growing and growing and then it caught my eye and I was wondering why no-one has applied so therefore I did.

Q. Would you move to Castletown?

A. No, I won’t.

Q. So, would your pharmacist be equitably amenable.

A. Helen works out of Inverness. That doesn’t mean she has to move to do her job. Look, don’t grant this application if you believe you need me to move up here as that’s not part of the legal test.

Elaine Wilkinson, Chair

Q. I understand the difficulties you have in defining the neighbourhood but the Committee also have to define a neighbourhood. You have said you want the GP to become a stakeholder. What I cannot understand is the thought process you went through and the vision for the business model you had prior to submitting the application in the neighbourhood you define without information from the GP. Can you explain this to me?

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P14 A. He refused first time round. I asked him, and we discussed it. His preference is to keep the dispensing practice the way it is and to fight it but, should it be awarded, he would look at any discussions with me.

I defined Castletown as I knew I couldn’t say someone from John O’Groats would consider themselves neighbours of Castletown. If people boycott the pharmacy in Castletown to go to Canisbay to empower the doctors then so be it.

The perfect situation would be to retain that part of the practice but as a pharmacy and with the GPs on board as stakeholders.

Susan Taylor, GP Sub Committee

Q. How would you define each pharmacy as separate businesses for Apple Pharmacy?

A. You can do separation – it’s very easy. If the doctors are the stakeholders by 50% then that could be done.

Q. I have a slight point on the proposed opening hours. You mention you would provide EHC (emergency hormonal contraception) and open on Saturday morning but is it not the case that there is more call for that on a Saturday afternoon?

A. Do you have evidence of that? No (answers Dr Taylor). Then I rest my case!

Fiona Thomson, APC Non Contractor Pharmacist

Q. As your current pharmacies are in urban areas, your previous experience of defining neighbourhoods would have been in an urban area. Did you consult anyone about definition of the neighbourhood in a rural area?

A. No, who would I consult? I cannot phone up the Scottish Office and ask! A neighbourhood is a neighbourhood - what makes it different here than in any other area?!

Michael Roberts, Lay Member

Q. What would you do if the doctors don’t come on board?

A. I would have a problem. But, if they dominate what is happening then there is a massive problem and I dread to think what the budget would do.

Margaret Thomson, Lay Member

Q. With the introduction of the Chronic Mediation Service is there not more working required face to face with the doctors. How would you see that working out?

A. If the doctors don’t work with me then this pharmacy will not open - if that’s what they want to happen. If this is granted, that’s the first part. If the doctors want to tell everyone this is a big man coming from Glasgow and terrible things are going to happen here then let them carry on dispensing. I don’t want hardship for the patients or doctors. I am trying to do the right things if he wasn’t dispensing then it would be the right thing to have a pharmacy, but he is so it’s not!

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P15 Catriona Sinclair, APC Contractor

Q. Your application is based on the definition of the neighbourhood. How can you say it wasn’t a challenge when you had sleepless nights? That is why it’s important we have an understanding of the neighbourhood as you have defined it. What actually is it?

A. The people of Castletown and John O’Groats know who their neighbours are. Someone from Castletown wouldn’t think they are from Canisbay, however, the GP practice scoops in people from a larger area, however, the neighbourhood won’t let me.

Q. Is it not the case that you can put the neighbourhood anywhere you would like?

A. That is right but I am bound by the legal test.

Q. You have said you will create three new jobs to service the catchment area that is covered by the GP. Would you do this on top of up to a dozen or who knows the number that you would have to TUPE over?

A. Yes, we will TUPE all those members of staff, and a pharmacist and two drivers.

8. The Interested Party’s Case – Dr Hercules Robinson, GP Sub Committee

Dr Robinson stated “thank you for the opportunity to present, on behalf of the GP Sub Committee, the case opposing the application by Apple Pharmacy to open a pharmacy in Castletown.

Can I just make a couple of points of clarification, we don’t have an NHS funded delivery service but the practice will make arrangements for patients would cannot access the practice and get a taxi and pay for that ourselves if necessary.

We do different things as GPs but cover the same area – we don’t do pharmaceutical services as we are not a pharmacy but we do some of the things that a pharmacy does.

Clinical work such as blood tests, renal and urine function tests are all things not done by a pharmacy, therefore there would be no saving for the practice as suggested.

Mr Majhu has stated correctly that the practice would continue (if the application were to be granted) as the Health Board has a legal obligation to do so but I would say that this would not be in the form currently offered.

The NHS Constitution states that the NHS belongs to the people. It is there to improve our health and well-being, supporting us to keep mentally and physically well, to get better when we are ill and, when we cannot fully recover, to stay as well as we can to the end of our lives. It touches our lives at times of basic human need, when care and compassion are what matter most.

An opinion of the Court of Session delivered by Lord Drummond Young in 2004 was that the decision maker must approach the application in two stages. Firstly it must consider whether the existing provision of pharmaceutical services in the relevant neighbourhood is adequate, then if it decides that the provision is adequate, that is the end of the matter.

However if it is deemed that the provision is not adequate, then the decision maker needs to decide whether the provision as stated in the Application is ‘necessary or desirable’, and the opinion stated that adequacy is a simple concept, in the sense that there is no room for different degrees of adequacy. Either the pharmaceutical services are adequate or not.

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P16 The applicant has defined the neighbourhood under consideration and has limited the neighbourhood to only part of Castletown village itself,

The population, according to the last Scottish Neighbourhood Statistics available, is less than 500 people in just over 200 households.

With regards to adequacy, at present, there are three pharmacies in Thurso and between them they provide a very full range of services including minor ailments and chronic medication services and smoking cessation.

Due to the rurality of our practice area, almost all residents have a car or access to a car. The pharmacies in Thurso are approximately 5-6 miles away from Castletown, well within the limit defined by NHS Highland for access to pharmacy services. This time being 30 minutes travel time – and that information comes from the 2012/13 Pharmaceutical Care Services Plan of NHS Highland. The main centres of commerce in the county are Thurso and Wick and most households do their main shopping in either Thurso or Wick.

We know from many patient contacts, that patients have attended pharmacies in Thurso and Wick to try to deal with symptoms themselves, before making a GP appointment. This would indicate that these existing pharmacy services are easily accessible and are being accessed regularly by patients and therefore it is suggested that the neighbourhood residents do have access to adequate pharmacy services.

In terms of adequacy, the question must be asked, adequate for whom? We would suggest that the people and patients in the area should be the main arbiter of that decision, as fundamentally all the NHS services are for the people.

In the NHS (Pharmaceutical Services) (Scotland) Amendment Regulations 2011, Annex 2, 5 it is said

“the NHS needs of the local community are to be the main determinant of whether an additional community pharmacy is to be approved”; and again

“our overarching aim is to ensure that the public are involved in the process where they wish to be”; and yet again

“the Board should seek information from the public which would aid their decision”; again

“the key questions for the public could cover: their views as to whether the pharmaceutical services provided…. are currently adequate”.

In the Review of NHS Pharmaceutical Care of Patients in the Community in Scotland (Wilson and Barber) it is said to be “focusing primarily on the needs of patients”; again

“ care will be delivered to the highest standards of quality and safety, with the person at the centre of all decisions”; again

“person centred care”.

In the document “Your Health, Your Rights” it is written that “the Health Board must take account of your needs when providing health services”;

“you have the right to be involved, directly or through representatives, in the planning, design and provision of services in your area”

“you have the right to ask for your needs and preferences to be taken into account”.

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P17 In addition, the judgement of the Committee should be “based upon the facts of the local services rather than just adopting a mechanistic quota driven approach to the application”. That is from the Amended Regulations 2011.

Given the above situation, we would suggest that the current pharmacy services are adequate for the population in question.

A petition launched by a patient was signed by 1,515. The petition confirmed the view of people that there was an excellent provision of pharmacy services in the locality and also that the signatories indicated they did not feel that it was either necessary or desirable to have a pharmacy in Castletown.

In our opinion, taking these factors into account, the current pharmacy services are adequate and the application should fail at this point.

With regard to the application and before dealing with the necessary, desirable and viable elements of the application, we would like to advise of some concerns with regards to the application itself.

Our interpretation of the Regulations indicate that notice of the application needs to be in place for a continuous period of 20 days, rather than a single advert placed in one edition of a local newspaper.

The next point I was going to raise was regarding the discrepancy in the address and I have accepted that the Committee have taken advice and accepted that this is no longer relevant.

The advert also stated that public consultation is required to be carried out to see if “people think this service would be of benefit to the health of the population” rather than addressing the issue of establishing whether the neighbourhood has adequate provision.

The applicant did organise a meeting but stipulated that a maximum of 20 people only should attend. The overwhelming opinion at that meeting was that the pharmacy was not wanted nor was it necessary.

There were some contradictions within the application with regards the neighbourhood and the number of likely prescription items.

Now, regarding the issue of necessity, if the current pharmacy services for this neighbourhood are deemed to be inadequate, then the decision must be made with regards to whether the proposed pharmacy services are necessary.

As indicated earlier, this neighbourhood is served by three pharmacies within the 30 minute travel time considered by NHS Highland to be a factor in pharmacy provision. These pharmacies provide a full range of pharmaceutical services.

In addition, the patients in this neighbourhood, and the rest of the practice population, already have services available to them.

The surgeries provide a one-stop provision for acute prescriptions where following the GP consultation; patients can receive the necessary prescriptions on site, without having to visit a pharmacy as well.

In addition they can order and receive all their repeat prescriptions from the surgeries. In addition to the GP experience, the computer system used flags up possible problems with the prescription with regards to interactions, allergies, adverse events and factors relating to renal function and other clinical problems.

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P18 The dispensaries in both areas have trained dispensers provided by Buttercup, who are a leading trainer, to level NVQ 2 and 3 and all newly employed staff are required to undertake appropriate training.

Each step in the provision of drugs and appliances to patients is governed by Standard Operating Procedures. Each prescription is dispensed and then checked by another dispenser.

There is a system of monitoring for any errors, with regular review to consider if there should be a change to the Standard Operating Procedures via the use of a Significant Event Analysis.

We have a complaint system. In addition, the Health Board allocates pharmacy advisers to review prescribing which increases the level of clinical governance.

There is absolutely no evidence from large scale trials comparing the dispensing error rates between community pharmacies and dispensing practices that any one system is safer than the other.

In addition, the surgeries actively manage repeat prescribing with regular reviews which include disease monitoring as well as medication review. There is also provided contraceptive services, public health services, nicotine replacement therapy, minor ailments, immunisation and travel vaccination. We also provide a medication and sharps disposal service.

Once again, a poll organised by a patient concerned about the application, addressed the question of necessary and desirable revealed a significant number of signatures -1,515 - from people who felt that there was already a good provision of pharmacy services in the area and that a new pharmacy in Castletown was neither necessary nor desirable.

The Committee also needs to look at the issue of desirability. There is overwhelming evidence that the local population do not desire there to be a pharmacy in Castletown. The great majority of responses to Apple Pharmacy were against the pharmacy application. There have also been numerous letters sent to the Health Board, MP, and MSPs by local people stating their opposition to the application.

There was a public meeting held by the Community Council which over 500 people attended and the overwhelming feeling of attendees were that the current services were adequate and that a pharmacy was not wanted in Castletown.

Whilst the Regulations indicate that any effect on the dispensing doctors’ income should be ignored, there is no prohibition to consider the overall NHS services available to patients if the application were to succeed.

We are anticipating advertising for a third replacement GP. It would be difficult to attract candidates to the post as it is extremely difficult to recruit for rural practices in Highland.

We know that the practice would be unsustainable with only two GPs and it is likely that the two current GPs would be forced to resign. If the application succeeds it would be costly for NHS Highland to provide locum cover for the two sites and the lack of continuity would adversely affect the quality of the care provided.

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P19 The current service, highly valued by our patients, would be lost. This situation may persist long-term in view of the current difficulties of GP recruitment in Caithness. In Thurso, all six GPs at the local practice left, leaving the Health Board to obtain locum cover at costly expense. This is not a theoretical concern, there are five recent examples where there has been a loss of services to patients.

Millport, on Isle of Cumbrae; an island community of approximately 1,400 residents. When a pharmacy opened, all three GPs left as the practice was not viable without dispensing. The practice remains and is currently covered by a series of locums paid for by the Health Board which is extremely expensive and there is no longer an Out of Hours service run by the practice. At present, there has still not been a GP appointed.

Bowmore on Islay where the practice became economically unviable and has now become a branch surgery of another practice.

Scalloway in Shetland. The practice is continuing with emergency funding from the Health Board as a temporary measure and it is likely that the partners will leave and that the practice will be staffed with salaried and locum GPs.

Carstairs. This practice has changed and has now been merged with a neighbouring practice. The new merged practice is trying to recruit a GP.

In our opinion, the addition of extra pharmacy services to patients will be significantly outweighed by the loss of other services to patients.

We do not feel that this is desirable firstly for the population and also there is evidence which indicates that the population do not desire additional pharmacy services.

With regard to Regulations, as you will be aware and as it was referred to at the start of the meeting, the Scottish Government has accepted that the current Regulations governing community pharmacy services are not fit for use. Alex Neil stated in response to a parliamentary question that the current legislation is absurd. The government is aware of the unintended consequences of loss of dispensing for practices, especially those in rural settings. There is a current consultation taking place about amendments to the current Regulations. There is no doubt that these changes are designed to protect rural dispensing practices so they can continue to provide services to their communities.

Finally the question of viability and sustainability needs addressing. Apple Pharmacy’s application used a figure of 7000 items per month for an entire practice. This relates to all prescriptions from both sites. Apple Pharmacy has chosen a very limited neighbourhood and this means that the number of prescription items should be significantly reduced in considering whether the plan is viable. The viability is extremely doubtful given the neighbourhood chosen by Apple Pharmacy.

It is very unlikely that there would be any significant increase in the population of the neighbourhood chosen, or in fact unlikely for the entire practice area itself, and therefore sustainability would also be in question.

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P20 In conclusion, we feel that these issues raised, show that:

• The current pharmacy services are adequate for the neighbourhood; • The application process was flawed with regards a number of aspects; • That the additional pharmacy services are not necessary; • That the additional pharmacy services are not desirable; • Given the neighbourhood stated in the Application, a pharmacy in Castletown would not be viable or sustainable; • Granting the Application would mean an overall reduction in quality of NHS services available to the patients of the practice; and • The intention of future government legislation is to protect rural dispensing practices, such as ours, from the damage caused to communities by granting pharmacy applications.

In our opinion, the Application should fail”.

“Can I just say also that it was a patient who set up the “Save our Surgery” website and the meetings referred to were set up outwith the business of the practice. GPs did wish to monitor the website to ensure there was no adverse reaction expressed towards Ian, the owner of the Chip Shop, as we realised this is not a problem he was creating, to protect him.

I don’t want to start on “dispensing cheque book practice” referred to. All items prescribed are because of a clinical need and just because the numbers of items are higher or less higher, does not imply the standard of care is any worse. In fact, you could say it was better as these patient’s issues are being dealt with. I totally understand that it is being considered under current legislation but it should be recognised that the Cabinet Secretary has said the current legislation is unfit for purpose.

Regarding reference to the earnings of the practice, unfortunately, two practices mean no economy of scale. With two practices, you have two sets of nurses and also two sets of dispensers. Loss of income, though you cannot consider this, although you have a duty to consider the services delivered to patients linked to the income loss and I think I should leave it at that. I am happy to answer any questions.

The Chair thanked Dr Robinson for his statement and asked Mr Green to clarify the point made by Dr Robinson in his statement regarding his understanding of the Regulations being that the advertisement publicising the application required to be in place for a continuous period of 20 days, rather than a single advert placed in one edition of a local newspaper. Mr Green advised that when the NHS (Pharmaceutical Services) (Scotland) Regulations 2009 were amended in 2011, they were released with Scottish Government Circular letter PCA (P) 2011 (7) within which there were some inaccuracies, one of them in regard to the 20 day period.

For clarification, Mr Green advised that within the NHS (Pharmaceutical Services) (Scotland) Regulations 2009, as amended under Paragraph 5 2 (A), (c) the consultation must be advertised (ii)….”through publication in a newspaper circulating in the neighbourhood in which the applicant intends to provide services”;

Which then go on to advise that the consultation must last (d) …for a continuous period of not less than 20 days from the date of the advertisement under sub-paragraph (c)”.

Therefore, it was the consultation that must last for the continuous period of 20 days, not the posting of an advertisement every day for 20 days, as had been misunderstood.

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P21 This misunderstanding had not been helped by the fact that the Circular accompanying the amended Regulations in 2011 held inaccuracies, however, it is the Regulations which define legislation and not the Circular. The Circular remains uncorrected to this date.

Dr Robinson and the Chair thanked Mr Green for his clarification of the issue.

The Chair then invited the applicant and then members of the Committee to ask questions of him.

8.1 Questions from the Applicant to Dr Robinson, GP Sub Committee

Q. Is it right to say that between the two practices, that Castletown would take roughly two thirds of the 7,000 items which would be 4,000 items?

A. That is as correct as we could say.

Q. Can you also confirm that leaflets from the practice with the “Save our Surgery” intention were printed out and handed to patients and that these had your photographs on it, wearing the t-shirts, which make them a scare tactic?

A. No, I don’t accept that, particularly when we spoke to the 500 to say that the Health Board would continue the practice but that that would not be as it is currently done, as it is their legal requirement. We differentiated between the loss of surgery as it currently runs from the surgery closing.

We had a patient who provided stickers and t-shirts. We did have to ask them to change the stickers from “Save our Pharmacy”. We did a notice board regarding progress of the application and leaflets and also had a petition that made it clear it was run by a specific patient.

Q. Do you believe that patients had already formed an opinion that this application threatened the surgery and that it would not be viable.

A. I am absolutely sure that the patients realised that the surgery as they understood it would be no more and viability was not the issue.

The buildings and doctors provided by the Health Board will remain in Castletown and Canisbay whatever happens, the practice as it is run currently will not continue.

Q. You brought up situations like Millport. This did not happen because the pharmacy opened, it was because the GPs retired. Do you agree it’s sort of blackmail to say that “if we’re not earning £X then we’re off”!?

A. You may take that view but I wouldn’t. It would be a practical decision and if the application succeeds then the practice as it currently exists will be different. Q. Did you say at the meeting that the current trend could not be sustained and in the future this would be hard to maintain?

A. I certainly accept that the demand for GP services is increasing but we would need to make changes to how we do things, e.g. would we really need the same size dispensary in Canisbay as we do in Castletown?; could we shift the dispensing function to Canisbay to dispense items and then deliver back to Castletown for collection?, etc.

Q. I am trying to sell you and I as friends. It will be difficult to do but if we win would you resign?

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P22 A. I haven’t decided yet as that question is dependant on whether we recruit a third partner. If we fail to do that the practice will not continue to be in its current form.

Q. By opening a pharmacy do you not agree that this would reduce the burden?

A. It would make no difference at all because of the fact that we have two surgeries and a large area within which we cannot manage with only two doctors.

Q. You also stated if you win, meaning I loose, you may have to apply for a pharmacy license yourself. Would you have the same arguments then?

A. We have discussed that prospect ourselves, however, that is not an option as it would recreate the problem. Sadly, I am 64, we don’t have a third partner and whilst it might seem an attractive option we would have to have extra premises, a pharmacist and an extra pharmacist to cover. It would be difficult for a pharmacy to cover the same area as our catchment area with a pharmacy in Castletown and patients in Canisbay and John O’Groats and we would not have the luxury of saying that these patients are not in our area.

Q. What would your argument be if you were to apply for a pharmacy – the same of mine? In terms of value.

A. I think in general I, as other GPs, welcome colleagues in pharmacies for the additional work and expertise they provide but instead of adding to the overall services which was the purpose of the legislation very orientated to succeeding pharmacy applications, and rightly so, except in areas such as ours, pharmacy services are great, but in this particular area services to patients would suffer.

Q. Do you agree by having a pharmacy patient waiting times would be reduced i.e. they access them before the GP?

A. Well, there must be some truth in that as we know that some patients do attend adequate pharmacy service in Thurso and then sometimes see us if they need to after. Yes, I would agree.

Q. Is it the income from dispensing services which would be what attracts a third partner?

A. My main argument in opposing the application is that there would be serious harmful effects on patients to services in the area by the opening of a pharmacy. I am certain that is not what you or the Regulations intend but this is why this is so fervent.

We have a lifetime of service to the NHS. It is important to us that services are delivered to patients to the best of our ability. Despite all that you are trying to achieve a reduction in services would occur.

Q. Why then do you need the extra £720k? Is this required and how dispensing income should be used?

A. The dispensing income is included in the whole far more than half of it is expenditure. We don’t get discounts. There is a residual pot. We don’t get the discounts like you do but because we are at two sites we have two sets of everything.

If this application were in an area of a single practice they might be in a more fortunate position. What you are saying is right but it is not separate. Our costs are significant. Quite rightly, you did confirm our income is above average, which is compensation in the hope that we can recruit a third partner.

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P23 That aside to put things into perspective; if we don’t recruit a third doctor then we cannot run a surgery this size on two doctors.

Q. Is it then more logical to close down Canisbay?

A. I said we can’t make the decision to close Canisbay. It is for the Health Board to make that decision. If the pharmacy application succeeds, then we cannot continue to maintain a service across two sites. We would then need to decide what to do. One of the surgeries would remain open under Health Board management. Unfortunately, the care for patients without continuity of care delivered by locums is lesser, despite their best efforts.

Q. By some horrible event, how would you run the practice if you became ill?

A. If it were a matter of illness, then the Health Board would contribute to the employment of locums. If it is down to two doctors then there can be no assistance from the Health Board and it is for the surgery to seek to employ a third doctor.

Q. You seem to be able to cover with a GP locum if you are sick but then say it is different to entice a doctor if it is for permanent work. Is it?

A. Locum doctors, sadly, are expensive to employ at a cost of around £2,500 per week, plus a car, plus expenses. If the Health Board accepts two GPs and there is no funding for a third, then the practice has to incur the costs.

Q. If you didn’t have a dispensing practice in Castletown would you have said the same?

A. Yes as valuable addition to the NHS. Whatever the outcome, if the Committee decide in favour of the application, Dr Macleod and I and any locums or a third partner would work with the pharmacy. That is not an issue and we currently do this with pharmacies in Thurso more so, as Wick is further away. So we would agree pharmacy services are a good thing, however, in exceptional circumstances, where a pharmacy application has the consequences of destabilising services is a concern and why this is being addressed under the Consultation recently undertaken by Scottish Government.

Q. If it is destabilising services in Carstairs and Millport then is this not a tactic that if doctors are not receiving the money, they’re off and why the community are scared?

A. I would take issue that this is not the situation we are currently in.

8.2 Questions from the Committee to Dr Robinson, GP Sub Committee

Dr Susan Taylor, GP Sub Committee

Q. Do you provide dosette boxes?

A. Yes

Q. Do you have any nursing homes?

A. No.

Q. Are the surgeries privately owned or owned by the Health Board?

A. They are privately owned by a third party but the Health Board would be committed to ensuring continuity of services. The Health Board has stated publicly that they would continue to have GP services at Castletown and Canisbay.

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P24 I am aware of the arguments regarding loss of dispensing income on the back of the comment of GPs all get paid the same.

Q. Do you have a GMS Contract?

A. Yes

Q. Were any of the practices under inducement scheme prior to 2004?

A. Both were.

Q. Given the GP Contract in Scotland in 2004 was slightly different and based on capitation does that prove a challenge to a rural practice like yours?

A. Yes, in two ways. We don’t have a choice in the practice area as we are the only practice in the area of John O’Groats and Canisbay. We had to take these patients and again, because of the capitation fee have a problem of running over two sites.

Catriona Sinclair, APC Contractor Pharmacist

Q. You have said you don’t have economies of scale because you operate over two sites, however, do you have staff who work in both sites?

A. Yes we do, mainly the practice nurses, most of the admin staff are surgery based and the dispensary staff are surgery based. Practice nurses work at both sites as they work different hours. The only people working over the two sites are the GPs, nurses and Practice Manager for both surgeries. It is one practice but it just happens to have two sites and this is due to its rurality.

Q. What are your patients waiting times?

A. For routine appointments usually less than 48 hours, sometimes 24 hours but we also ensure we have a number of appointments available each day on our system so there are slots for those who need them to access them. Flexibility is fitted into nursing appointments and if, for example, a child is ill, we can usually slot them in.

Q. You talked about adequacy of pharmaceutical services in the neighbourhood. What neighbourhood are you talking about?

A. Our practice area. This may not fit the legal definition and not the neighbourhood chosen by Sanjay. The provision is in the practicality. I personally need to use a GP in Thurso. I can’t prescribe for myself. We know that 99% of our patients go weekly to Thurso or Wick for shopping and so pharmacies in Thurso, of which there are 3 are accessed and within NHS Highlands own definition of 30 minutes drive time, therefore people from Sanjay’s neighbourhood are reaching services there..

Patients from John O’Groats will not access services, perhaps from Wick within that drive time and that would not change, even if Sanjay opened a pharmacy in Castletown.

Fiona Thomson, APC Non Contractor Pharmacist

Q. You have stated that the current services provided by the surgery would not continue if the pharmacy contract was granted, can you explain what the differences in services would be?

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P25 A. If granted and the dispensary in Castletown ceases to be, I cannot believe the reduction in salary would attract a GP to come to fill the third post. We haven’t as yet discussed our options, but there would be options, one of which might be that it would be untenable. I am 64 and would look at my retirement options. We would definitely have to close one of the surgeries that we would not provide services to although the Health Board would have to provide a service. Two thirds of patients are in Castletown, so we could abandon patients in Canisbay and keep Castletown. We simply could not keep two surgeries open if there were only two GPs.

Q. Is recruitment an issue for practices which dispense and also those who do not?

A. Yes, it is an enormous issue. I came here 9 years ago and was the only applicant for the post and all the doctors have left Riverbank in Thurso.

Q. In your statement you have given examples of practices where a pharmacy contract has affected services. Was there a reason for selecting these examples?

A. They are examples on the Dispensing Doctors Association website.

Q. Are they similar to your surgery e.g. same list size, geography?

A. No, they are all different but the effect of losing their dispensing has affected their services.

Q. What about other ones where it has been successful and not affected their services? Can you tell me about those?

A. I don’t know about those but I do know about Drymen.

Q. Are you aware that Bowmore is still a separate practice?

A. I am only aware of what the DDA (dispensing doctors association) advised so I thought that they were not.

Elaine Wilkinson, Chair

Q. You said the change in services would come about if you couldn’t recruit a third GP. Do you agree that this is a scenario which might happen whether or not the application is granted?

Yes, unfortunately, I think that is a possibility. A. Do you think it would be more likely that you could recruit a third partner if you retained the Q. dispensing element?

A. Yes.

Maureen Thomson, Lay Member

Q. You have said that you have had problems as you are working over two sites. Were you aware that you were two practices historically and chose to become one practice over two sites?

A. That was before I arrived. I understand that the joining of the two practices was for the reason of improving administration and out of hours support.

Q. Are you providing an out of hours’ service?

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P26 A. No.

Q. Are there other models which could apply, other than using locums to run these practices, which could be used?

A. There are indeed and they (meaning the Health Board) have looked at this for Riverbank in and the other big practice in Thurso but these places are not where doctors want to go. It would seem they would prefer to take large patients lists without the facilities.

Q. Did you say that 90-95% of patients from the practice area can access a pharmacy within 30 minutes?

A. No, I said they go to Wick on a regular basis. Castletown is within the 30 minute drive time and probably Dunnet but probably nowhere in the north east corner is within 30 minute travel time so it does not meet the current advisory regulations within the NHS Highland Pharmaceutical Care Services Plan for pharmacy.

Q. So are you arguing that you do not need to dispense?

A. We dispense at the grace and favour of the Health Board to dispense where they feel there is a need for a dispensing service.

Q. Do you dispense because the provision of a pharmacy is not viable?

A. I have no idea but that is the reason why GP dispensing practices dispense.

Q. Correct me if I am wrong, but should there not be a cross subsidy of dispensing and GMS services.

A. We are a business and don’t view this income stream as separate.

Q. What level of prescribing carried out by you is generic?

A. Pretty high, only where there is no generic equivalent. Bioavailability can be a problem where the patient needs to stick to a brand.

Q. If part of any argument was to get dispensing doctors into a buying group to achieve economies of scale or anything which keeps costs reduced to NHS, would that have a bearing on you?

A. No.

Margaret Thomson, Lay Member

Q. If you are going to recruit another doctor would it be of any benefit to you to recruit a pharmacist instead of a doctor?

A. None at all.

Q. So you need a third doctor?

A. Yes.

Q. So how would the dispensary aspect help recruit a third doctor?

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P27 A. In order to run both surgeries we need three prescribing doctors. What we cannot do is run two surgeries with only two doctors.

Q. Describe for me as you have talked about, the doctors carrying out medical care and prescribing and the staff in the dispensary. Do they make up the prescriptions and then you check them?

A. No, we have a system whereby two dispensers check and for an acute prescription, the doctor checks the prescription as well as the dispenser.

Q. So the dispensing is not checked at any point in time by a pharmacist?

A. Correct, but the dispenser is trained.

Q. It seems that pharmaceutical input is missing but are you saying that this is done through the trained dispensers?

A. Yes.

Maureen Thomson, Lay Member

Q. Have you had any time to actually read the service specifications required in terms of the requirements of providing pharmaceutical services in Scotland in respect of CMS, EHC, and MAS?

A. I have looked at the amended Regulations and the services from that point of view, yes.

Q. Would you accept that dispensing from a dispensing doctor practice is not a pharmaceutical service?

A. Yes – by definition.

Q. So in terms of the neighbourhood that has been presented are there adequate pharmaceutical services?

A. Yes, as determined in NHS Highlands own definition from Thurso which is within a 30 minute drive time.

Q. How much training do you undertake on medicines in your training?

A. It is continuing, through learning about disease specific requirements.

Q. Would you accept - or not - that pharmacists have a greater knowledge and understanding of medicines?

A. Absolutely, they will but I have a greater knowledge of the effects of medicines on the human body than the pharmacist so we need to work together.

Michael Roberts, Lay Member

Q. Are you searching for a third partner to cover your post for when you retire?

A. No we need three GPs to run the two surgeries.

Q. Do you agree a pharmacy would reduce the demand on the surgery?

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P28 A. That is possible but it will not solve our problem of having two sites.

Q. Why would you need to close two sites because of a pharmacy? A. The loss of the dispensing income in terms of the services will have the effect that we will not be able to recruit three doctors. In terms of the current medical management of patient services we are unable to sustain two sites by only two doctors.

Catriona Sinclair, APC Contractor Pharmacist

Q. You have said that recruiting GPs in the north is a particular challenge. Do you think that dispensing is a recruitment tool for obtaining GPs?

A. No.

Q. What do you think would be a possible option to attract GPs to remote and rural areas?

A. It’s with great difficulty and I cannot see a solution to it. The same applies to the Hospital here but if Government were to induce services to work in areas that they cannot attract people to that might be the only solution I can see in the long term.

Q. So taking dispensing out of the equation, is it a problem full stop?

A. It is a problem. I came here and if you offer a package which is very attractive, they will come. What I am clear about is offering a poorer contract than the average makes a difficult situation poorer.

Q. Do you think this is a matter for higher powers?

A. Yes, I don’t think GPs can deal with it.

Dr Susan Taylor, GP Sub Committee

Q. Are there currently three partners?

A. Yes.

Margaret Thomson, Lay member

Q. Has there recently been an increase in attempts to try to recruit young medics during training to rural areas?

*Mrs Thomson in asking her question looks towards Dr Susan Taylor to answer. Dr Taylor gestures with her hands towards Margaret Thomson that she cannot speak as the question is directed to Dr Robinson*

The applicant interjects, raising his voice to strongly object that he had seen Dr Taylor make gestures with her hands which he felt were in the direction of Dr Robinson to assist him in answering the last question posed by Margaret Thomson.

He went on to say that in his opinion this type of behaviour by a member of the Pharmacy Practices Committee was disgraceful and that should he so choose, which he would not, he could say that he had not had a fair hearing as a result of.

Dr Taylor explained that her nature was that she “spoke with her hands” and that when Margaret Thomson had looked to her for an answer had crossed her arms and hands in front of each other to sign to Margaret Thomson that “I can’t answer that question”.

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P29 Dr Robinson goes on to answer the question posed by Margaret Thomson prior to the misunderstanding over the hand gestures.

A. Yes, but it’s not working very well.

9. Summing up

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

9.1 Dr H Robinson, GP Sub Committee stated “current pharmaceutical services in the area are adequate. Additional pharmacy services are not seen to be either neither necessary nor desirable by us nor our patients. Given the neighbourhood stated in the application, a pharmacy would not be viable or sustainable. Granting of the application would result in an overall reduction in the quality of NHS services available to patients.

The intention of future government legislation is to protect rural dispensing practices such as ours from the damage caused to the communities caused by granting pharmacy applications”.

9.2 Mr S Majhu of Apple Pharmacy Group stated “It is never an easy process applying for a pharmacy license near a dispensing doctor. The doctor is the most important member of the community and with the extra income coming in we can see it is being used for their recruitment budgets. Much as they are fabulous doctors, here I am today.

How could 4,000 prescription items not lead to a pharmacy being viable as 2,000 items make it viable for other pharmacies in other locations. If Dr Robinson and Dr Macleod move their patients to other parts of the neighbourhood then this would not make the pharmacy viable but if you want to empower the GPs with £2,500 per week, a company car, expenses, spa nights – where do you stop - don’t grant this application. If you want more doctors then train more students and get more students to sort the recruitment problem that way.

In other areas, we hear of surgeries closing under the guise of a pharmacy opening and not for the real reason that the doctors were about to retire. Three doctors wanted to retire. They were the ones who decided to destabilise their own patients. The situation in Carstairs was unique because they walked away to another place with their patient list destabilising the pharmacy. When a doctor threatens he wants to retire, we cannot get a locum, you are going to take my drug money away!

You have seen the hand signals from dispensing doctor PPC member”.

The Chair interjected advising she had not noticed any gestures coming from the direction of Dr Taylor towards Dr Robinson, at the point previously referred to by the applicant.

The applicant continued “I am not going to say I have had an unfair hearing - though I could. If you are not getting enough to pay for a doctor then ask for more money! Their actions will result in a pharmaceutical service being lost. We have GPs wearing t-shirts saying we are going to lose our surgery and I’m being told I am the “city boy”.

You did well for the first time Chairman!

All of a sudden you are making us not relevant. Everything will change if you open a pharmacy. No appointments at a pharmacy - CMS, MAS. We are being told the GP service is insecure.

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P30 What happens when Dr Robinson retires and we are left only with Dr Macleod? A pharmacy is open 49 hours a week, no appointment is required, serving the public with the vast services we were trained to deliver, will simply enhance the healthcare delivery to patients.

£2,500 a week, a company car and expenses for a locum GP. Dispensing figures in two years time up to 10,000 – are you dispensing doctors going to look after each other? We cannot get locums, we are covering with a locum and can’t do everything. Slight doctor laziness there. I urge you, please, don’t be dictated to by doctors!

He (Dr Robinson) is already confused by neighbourhood. If patients can go to Thurso, then why dispense? I have talked to him saying that he can have a stakeholder and made that commitment so I urge you I will not appeal this nor will I say it’s an unfair hearing – although certain members of the Committee have been unfair today. When you make the decision that will be your final decision but behind me there will be many people. I have urged Dr Robinson to apply for a contract but he has said he is trying to get a doctor.

In both doctors I have nothing but the utmost respect for them. Their work is fantastic and if there is any risk of destabilisation then I urge you to look at this and start considering how we put in place pharmaceutical services or do we let dispensing doctors make all the decision.

If Dr Robinson was holding hands with me then it would be a great report.

The information you were given about Millport was wrong – the doctors there retired.

In Carstairs – the doctor moved and took his patients and the practice has closed. Then we are at the hands and the mercy of dispensing doctors. So I hope you make the right decision to the whole of the neighbourhood. I don’t want to make this application because of the money. Pharmacy adds value but only if we make it workable and efficient. The GPs should not be using their dispensing profits from GPS to help their GMS contract. It should be allowed to be split otherwise. How are you going to stop what happens after this!

Thank you Chair and thanks doctors for a fair hearing”.

At this point the Chair asked the applicant and interested party if they considered that they had had a fair hearing. Mr Majhu replied “yes, very fair” and the Doctors Robinson and Macleod replied “yes” (meaning that they had).

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

10. Private deliberations of the Committee

After conclusion of the summing up, at around 5.20pm, the Chair asked the applicant, interested party and Board officials if they would exit the hearing, inviting them to take a seat in the allocated waiting area until such time as they had concluded their private deliberations; after which they would be advised that they would be free to leave.

All parties were agreeable to this request and Mr Majhu, Doctors Robinson and Macleod, Mr Green and Mrs MacDonald departed to the waiting areas as requested to enable the Committee to make their decision in private.

The meeting then became closed with only members of the Pharmacy Practices Committee remaining.

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P31 11. DECISION Having considered all the evidence presented to it, and the Committee’s observations from their visits to the proposed pharmacy site, and the Canisbay and Castletown Medical Practice catchment area boundaries including the two surgeries, the Committee had firstly to decide, the question of the neighbourhood in which the premises to which the application related were located.

The Committee considered the neighbourhoods proposed by the Applicant and the Interested Parties in relation to the application, as well as comments received during the public consultation.

They noted that the Area Pharmaceutical Committee (APC) in their letter of 5 February 2014 accepted the neighbourhood as defined by the Applicant.

They also recognised that Dr Robinson in presenting the case on behalf of the GP Sub Committee at the oral hearing did not disagree with this neighbourhood, only highlighting that it was limited to only part of the village of Castletown and not to the much wider rural and sparsely populated area that comprises the medical practice catchment area.

The Committee took into account a number of factors in defining the neighbourhood including who resides there, neighbourhood statistics, the natural and man-made boundaries, the presence or otherwise of schools, shops, health services, land use and topography, and the distances over which and by how residents are required to travel to access existing pharmaceutical and other services.

They also took into consideration their obligations in terms of the Equality Act 2010:

• the need to eliminate unlawful discrimination, harassment and victimisation and other conduct prohibited by the Act; • advance equality of opportunity between people who share a protected characteristic and those who do not; • foster good relations between people who share protected characteristics and those who do not

Castletown had most of the features that a neighbourhood would be expected to have, including a medical centre, a primary school, churches, a bank, a post office, a community hall, a filling station and garage, a convenience store, a butcher, a garden centre, a hair and beauty salon, takeaway restaurants and a police station.

There was a mixture of housing both private and social and also a play park, but no evidence of new developments. The former Icetech freezer factory adjacent to the medical practice was noted.

The businesses and housing were all easily accessible not only by road but via walkways and footpaths throughout the village.

Most of the businesses were situated either by or close to the A836 trunk road from John O’Groats to Thurso running through the village from east to west.

The Committee decided that the residents of Castletown would be able to meet most of their everyday needs in the village but that they would generally have to leave the neighbourhood for their main shopping in either Thurso or Wick.

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P32 11.1 Neighbourhood:

The Committee decided that the village of Castletown is a neighbourhood in its own right and unanimously agreed with the Applicant and the Area Pharmaceutical Committee that the neighbourhood should be defined as follows:

North: The natural boundary of the sea along the coast line at Dunnet Bay from Battery Road to the west and where Stangergill Burn meets the sea on the east near the car park.

East: From Dunnet Bay at Stangergill Burn following the natural boundary of the burn to the junction of Harbour Road and the A836 continuing south through the small wood to the junction of the minor road at Tansfield on the B876 beyond Harland Road at the edge of the village. Beyond this is open countryside and farm land.

South: The southern tip of the primary school wall beyond which is mostly fields and open countryside on the minor road from the junction of the B876 road to Bower to Borgie House to the junction for the minor road at Tansfield on the B876 which is effectively the edge of the village.

West: From Dunnet Bay in the north heading down Battery Road to the village boundary on the A836, Main Street past the disused quarry heading east past the rear of the former freezer factory at Ruther Myre to the south wall of the primary school at Stangergill beyond which is open countryside.

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

Having reached that decision, the Committee was then required having made reference to the Pharmaceutical Care Services Plan to consider the adequacy of pharmaceutical services within that neighbourhood, and whether the granting of the application was necessary or desirable to secure adequate provision of pharmaceutical services within the defined neighbourhood.

The Committee noted that the Pharmaceutical Care Services Plan does not currently identify significant gaps in pharmaceutical care provision in the neighbourhood. They also noted a reference to a Highland-wide study which indicated that most participants were satisfied with their current model of obtaining medicines, and using travel time to community pharmacies as a proxy measure for access, advised that 94% of the population of NHS Highland are within a 30 minute travel time of a community pharmacy. This means that it is the remaining 6% of the population who experience difficulty in accessing pharmaceutical care services through a community pharmacy.

The Committee noted that within the neighbourhood as defined there are no community pharmacies. However there are three pharmacies within the adjacent town of Thurso some 5-6 miles distant, the Co-operative, Sutherlands and Williamsons, which are all well within the travel time above, and in addition there are an additional three pharmacies in Wick about 16 miles away. In fact on the day of the oral hearing the Committee were able to travel from the proposed neighbourhood in Castletown to Thurso within 6 minutes and estimated that total travel time including parking and walking to any of the Thurso pharmacies would take no more than 15 minutes by car. The Stagecoach bus timetables show that travel time via public transport from the primary school in the south of the neighbourhood to the centre of Thurso where the pharmacies are located takes under 20 minutes.

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P33 Within his presentation the applicant has acknowledged that the practice boundaries of Canisbay and Castletown Group Practice take in a much larger area, as seen by the Committee during their journey around the area in the morning. In addition he recognises that the patient base of his neighbourhood within Castletown is significantly smaller then the wider practice population base. He also correctly indicated that the population of this neighbourhood is no greater than 1000 people.

However the Committee disagree with his definition that Castletown is a unique neighbourhood which has a significant transient population which he likens to the Inverness Retail and Business Park neighbourhood in Lord Nimmo Smith’s findings of 1999 in favour of Boots the Chemists. Although this large retail park in Inverness without residents does draw a transient population to its large shops and businesses from all over the Highlands the same cannot be said of Castletown where the movement of the resident population is not in, but generally out. They also disagree with his assessment that the residents leave the neighbourhood approximately monthly only to access supermarkets as the location of Tesco in Thurso would allow them to do this relatively easily.

There is no supermarket or secondary school in the village and the population generally travel to Thurso for their main shopping and post-primary education. In addition many people have to travel out with the neighbourhood to go to work, particularly since the closure of the Icetech freezer factory in 2013 with the loss of around 100 jobs.

Castletown is no longer a village with a major employer and the number of residents has declined. In 2011 Datazone information showed that 61% of the population were of working age and 22% were children. Only 17% of the population were of pensionable age. This is a village with a mobile population and it is acknowledged that as Dr Robinson stated almost all residents have access to a car.

The Committee have carefully considered the applicant’s presentation today and the supporting documentation and consider that he has failed to prove that pharmaceutical services to this neighbourhood are inadequate and to make a case for providing pharmaceutical services within the neighbourhood. In addition he demonstrated a poor knowledge of the local area and had not considered the wider catchment area of the medical practice and the scattered population served by one practice but located in two separate premises at Castletown and Canisbay.

Most of the emphasis of his presentation dwelt not on pharmaceutical services but on the income derived by and the viability of dispensing GPs which the Regulations do not allow the PPC to consider.

The Committee were all in agreement that Dr Taylor had not tried to assist Dr Robinson in answering the question about recruiting young medics to rural areas and in fact, again this is not something that was relevant to the PPC since it has no bearing upon the adequacy of pharmaceutical services.

There have been no complaints to NHS Highland about a lack of pharmaceutical services within the neighbourhood.

The Committee are of the opinion that if the residents of the neighbourhood wish to access pharmaceutical services then they can do so relatively easily at the three pharmacies in Thurso where the Minor Ailment Service, Chronic Medication Service, Public Health Service and Acute Medication Service aspects of the pharmacy contract are all available.

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P34 The Area Pharmaceutical Committee in its response has not advised that a community pharmacy is necessary to secure adequate pharmaceutical services only desirable and raised concerns about the long-term sustainability and hence adequacy of a new pharmacy given the small population in the neighbourhood.

The Committee took into consideration the very large combined number of responses to the applicant and the Health Board during the public consultation when considering desirability.

There had been absolutely no support for a pharmacy in this neighbourhood. The applicant has suggested that the reason for this is that those persons who might have been supportive were too frightened to be named and the Committee did acknowledge that the public response may have been influenced by the fear of losing the medical practice which clearly the Health Board would not allow.

However the fact remains that there were no letters of support at all. There had been 270 letters, emails and postcards from members of the local community, all objecting in some way to the application, including from the following:

• Highland Councillors: Gail Ross, Gillian Coghill & Matthew Reiss;

• Community Councils: Castletown & District Community Council, Bower Community Council & Dunnet & Canisbay Community Council;

• House of Lords & Commons: The Rt. Hon. Lord Maclennan of Rogart & Lord John Thurso, MP;

• Scottish Parliament: John Finnie, MSP & Rob Gibson, MSP;

• the Lyth Arts Centre; and

• Traill Hall Community Trust.

Additionally, the Committee was aware there had been much communication received by various Board members and officials as a result of local publicity, including the Save Our Surgery website towards the end of 2013; however, they did not have access to this for consideration in their deliberations. The reason for this was that this communication was received prior to receipt of the application which was outwith the regulatory timeframe within which they were able to consider such responses.

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P35 11.3 In accordance with the statutory procedure the three pharmacists Fiona Thomson, Catriona Sinclair and Caroline Morgan and Dr Susan Taylor the GP Sub Committee nominate were excluded from the decision process:

DECIDED/-

The Committee acknowledged that there are currently no pharmaceutical services within the defined neighbourhood. Taking into account the evidence provided and made available from other sources they concluded that the level of existing pharmaceutical services from outwith the neighbourhood were adequate and are accessed with little difficulty and the application is not necessary. In considering desirability again they took account of the evidence presented and provided and also noted the complete absence of support for this application from the public and their representatives.

They agreed that it would not be necessary or desirable to grant the application in order to secure adequate provision of pharmaceutical services within the neighbourhood.

The Chair invited the lay members of the Committee to vote on the application by Sanjay Majhu of Apple Pharmacy Group to provide pharmaceutical services at the Fish & Chip Shop, Mackay Street, Castletown, Caithness. The Committee unanimously agreed to refuse the application.

The non-voting members and Board officials were then invited into the room and were advised that the application had been refused.

The Hearing was then closed.

Elaine Wilkinson as Chair of the PPC:

Date: 7 April 2014

Apple Pharmacy Group Castletown _ PPC 26 March 2014 NOTES.doc P36