Report to Steering Group May 2017 Review of Dispensing GP Practices

APPENDIX 3

1. Purpose

The purpose of this report is to detail the findings and recommendations of the group instructed to review the current arrangements for dispensing GP practices within NHS Grampian. These findings and recommendations will initially be presented to the Dispensing GP Practices Steering Group before presentation to NHS Grampian Board for further consideration.

The review group would like to acknowledge and thank all those who contributed to the formal consultation and/or attended to make representation to the review group itself.

2. Background

2.1 Following the judicial review of dispensing medicines by the Haddo Medical Group completed in 2015, NHS Grampian’s Board accepted the recommendation to conduct a review of general practices providing a dispensing service to patients within Grampian and to ensure patients have access to the most appropriate services to meet their clinical needs.

2.2 The mechanism for Medical Practices to provide dispensing of medicines are set out in the National Health Service (General Medical Services Contracts) (Scotland) regulations 2004, Part 3 Prescribing and Dispensing - paragraph 44 Provision of Dispensing Services. Paragraph 44 allows NHS Boards to require a GP Practice to undertake dispensing for their patients:

Where the Health Board is satisfied, after consultation with the area pharmaceutical committee, that a person, by reason of:

a) Distance; b) Inadequacy of means of communications; or c) Other exceptional circumstances,

will have serious difficulty in obtaining from a pharmacist any drugs; medicines or appliances, other than scheduled drugs, required for that person’s treatment.

2.3 The review is intended to determine which patients of the practices currently providing a dispensing service, will have ‘serious difficulty’ in obtaining any drugs, medicines or appliances, other than scheduled drugs, from a pharmacist required for treatment. Criteria for this review is based on those outlined in paragraph 44(2) of the National Health Service (General Medical Service Contracts) (Scotland) regulations 2014. The review process is based on those patients who are presently registered with practices, and who will be registered in the future.

2.4 For the vast majority of patients in NHS Grampian, medicines are prescribed by GPs and dispensed by Community Pharmacists. Where a patient has a serious difficulty in obtaining any drugs, medicines or appliances, other than scheduled drugs from a pharmacist the NHS Board shall require or authorise the patient’s GP to supply the dispensed medicines direct to the patient. Presently NHS Grampian requires or authorises nine GP practices to supply to such patients. In some practices the Board requires or authorises the GP to dispense to all patients, whilst in others the Board has defined a geographical boundary where patients living beyond a set distance from the practice can get their dispensed medicines from their practice. The term serious difficulty is not defined in law or regulation, but the Board can consider distance, the inadequacy of means of communication and other exceptional circumstances.

2.5 The Review was undertaken in relation to the requirements of Paragraph 44 of the GMS regulations. For a patient, who requires any drug, medicine or appliance, not being a Scheduled drug, and where such provision is needed for the immediate treatment of that patient before a provision can otherwise be obtained; this scenario is covered for all practices providing GMS, regardless of dispensing contractor status, under Paragraph 45 of the regulations. This provides a route of access for the patient to treatment that needs to be available immediately directly from the Practice. Therefore, scenarios such as those where a patient is required to begin immediate treatment where the patient is unable to get to a community pharmacy, or it is after the opening hours of a pharmacy, are covered by Paragraph 45 of the regulations and do not form part of this review.

2.6 This review has been triggered by the need to make sure that the Board is continuing to act legally in requiring or authorising these GP Practices to supply to their patients. NHS Grampian is required to assure itself that it is operating within its legal authority i.e. only requiring or authorising GPs to dispense to a person that it has defined as having a serious difficulty in obtaining any drugs, medicines or appliances other than scheduled drugs, required for that person’s treatment.

2.7 The NHS Grampian Board has previously renewed its requirement or authorisation for the practices of Strathdon, Glenlivet and Rinnes at Tomintoul to supply to all of their registered patients living within their agreed practice boundary. In renewing this requirement the Board concluded that all the patients of the aforementioned practices formed a group of patients or class of patients who qualify as having a serious difficulty in obtaining from a pharmacist any drugs, medicines or appliances other than the scheduled drugs required for their treatment by reason of distance from a pharmacy. Each of these practices serve populations that are designated remote and rural (based on the Scottish Government Urban/Rural classifications), are in the lowest deciles for geographical access deprivation, have a travel distance from the practice to the nearest pharmacy of eleven miles or more and have generally poor public transport links.

2.8 NHS Grampian agreed to the proposed review for the remaining six dispensing practices in Grampian. These are Rhynie Medical Practice, Portlethen Medical Centre, Skene Medical Group, Gardenstown Branch Surgery, Udny Station Branch Surgery and Auchenblae Medical Centre.

3. Public Consultation

3.1 A public consultation process was undertaken from 4th July until 1st October 2016. Information events took place in communities. Postal feedback forms and email responses were also available. Representatives from groups, organisations, elected public representatives and independent contractors to the NHS such as community pharmacies or medical practices were invited to respond during the public consultation to the question:

“If dispensing of medicines was not available at a specific GP practice in this review, do you think that patients who currently get, or are eligible to get, their medicines from these practices will have serious difficulty in getting their dispensed medicines from a community pharmacy?”

If the answer was yes, respondents were asked to describe what these difficulties would be and to whom they would apply.

As part of the public consultation, six advertised public drop-in sessions took place so that NHS Grampian could engage with all interested parties and to keep them well informed and up to date with the consultation process. This enabled all stakeholders the opportunity to be actively involved in the review. NHS Grampian representation was also present at meetings organised by the Community Councils representing Rhynie and Udny Station residents. Both of these events were very well attended.

3.2 Individual responses to the consultation were collated and thematically analysed by the NHS Grampian Public Involvement Team (available in appendix 1 of this report). From the feedback received it was clear from those who felt they would experience serious difficulty, that this was due to distance from alternative community pharmacies and the time required for this journey. Poor or non-existent public transport was also mentioned with high frequency. Concern was also expressed regarding health conditions, being elderly and/or having mobility problems.

3.3 The public consultation was also open to any organisation, representative or body including local NHS contractors. The consultation included feedback forms for such groups and bodies to comment on the serious difficulty of affected patients, communities and populations. Awareness was raised amongst local contractors with letters to individual GP Practices affected and information about the review and consultation provided in the community pharmacy newsletter to all community pharmacies across Grampian, in addition to the wider efforts to raise awareness through the professional advisory structures and the NHS Grampian website. Local contractors responded through the local consultation in written form and also through the opportunity to make representations directly to the Review Group at public events in each of the practice areas. The Review group had access to and reviewed the response of each of these groups and bodies as part of its deliberations.

4. Review Group

4.1 The Review Group was set up to carry out this review, under the direction and guidance of the NHS Grampian Dispensing GP Practices Steering Group and has been provided with details of the consultation responses and key themes provided by individual groups and respondents.

4.2 The remit of the Review Group was to identify those individuals, receiving General Medical Services from Practices, who by reason of distance or inadequacy of means of communication or other exceptional circumstances, will have serious difficulty in obtaining from a pharmacist any drugs, not being scheduled drugs, or appliances required for this treatment in accordance with the National Health Service (General Medical Services Contracts) (Scotland) Regulations 2004 Paragraph 44 of Part 3.

4.3 The Group was also open to presentations from any party, organisation or individual who wished to present their case verbally to the panel. Written submissions and appointments were to be arranged in advance and those presenting were given a clear timeframe for their contributions.

4.4 Although all interested parties were requested to make an appointment, the group, in the spirit of best practice and active engagement, welcomed those who arrived without appointment and their comments formed part of the deliberations.

4.5 Although the Review Group acknowledged people’s concerns relating to other aspects, for instance, potential impact of termination of dispensing for practices, their deliberations adhered to the question of the review; ‘ if dispensing was not available at the GP practice would there be a serious difficulty in getting dispensed medicines from a community pharmacy.” This issue of impact was raised at all of the sessions and reassurance was given that this would be considered separately.

4.6 The Review Group have concluded their deliberations and this report will outline their findings. A full record of submissions, oral presentations, questions and responses along with a summary of the group’s deliberations and recommendations is available on request

4.7 The Review Group comprised of the following membership:-

Mr Christopher Dawson Area Pharmaceutical Committee Dr Janet Fitton GP, Clinical Governance Lead, NHS Grampian Mrs Sue Kinsey Public Representative Mrs Trish Morgan Service Manager, Primary Care Contracts Mr Miles Paterson Public Representative Dr Annabel Ross Associate Medical Director Mr Scott Sim Interim General Manager, eHealth Mr Sandy Thomson Pharmacy Lead, Moray Health & Social Care Partnership Mrs Angie Wood (Chair) Partnership Manager for Central Aberdeenshire, Aberdeenshire Health and Social Care Partnership

4.8 Details of number of people who contributed to each part of the review process is as follows:-

Public Drop in sessions Review group Consultation sessions Auchenblae 600 130 29 Gardenstown 18 8 29 Portlethen 84 10 3 Rhynie 360 25* 12 Skene 35 0 1 Udny Station 251 28* 7

*denotes that additional events were arranged in Rhynie and Udny Station by the local Community Councils.

5. Additional information available to the Review Group

5.1 The Review Group has a substantial amount of information at their disposal, including data from the formal consultation process, Geographical Information System (GIS) relating to:-

1. Distance from each patient to their dispensing practice 2. Distance from each patient to their nearest pharmacy 3. Distance from each dispensing practice to the nearest pharmacy 4. Distance and travel time isochrones from each dispensing practice covering all the patient addresses 5. Distance and travel time isochrones from each pharmacy covering all the patient addresses 6. Distance and travel time isochrones from each dispensing practice covering all pharmacies

This information can be found within appendix 2 of this document.

5.2 Information relating to the availability of public transport/bus timetables was made available to the Review Group. Information regarding the availability of prescription collection and delivery services for dispensed medicines and appliances that community pharmacy contractors are willing to provide to the patients served by the six practices under review was also provided and considered.

Community Pharmacy collection and delivery services are provided by many community pharmacies. However, it is recognised that this is not a contractual requirement or part of their national terms of service. Whilst subject to professional best practice guidance these private services are subject to the will of the contractor in terms of who they are available to, when they are available and can be instigated, suspended or withdrawn at any time, without notice. The review group considered the information gathered from contractors regarding such collection and delivery services for each of the areas. In each of the areas under review the Review Group considered whether collection and delivery services available from community pharmacy provided mitigation for serious difficulties in obtaining dispensed medicines. The Review Group found that there was an absence of collection and delivery services from community pharmacies that could be relied upon to consistently supply medicines to those patients defined as having a serious difficulty in obtaining from a pharmacist any drugs, medicines or appliances other than scheduled drugs required for treatment. It was also noted by the review group that such services are specifically designed for repeat medicines and do not readily support the collection, dispensing and supply of acute prescriptions.

6. Common themes identified by the Review Group

There were several themes shared by the majority of representations across all areas.

These included:-

1. Distances to community pharmacy provision 2. Availability of public transport impacting on travel time and accessibility 3. Concerns about adverse weather and the impact on travel 4. The current and predicted demographic within these communities 5. Being fit and able to travel at the moment but concerned about future years and health status 6. Issues of confidentiality within small communities. There was particular concern regarding this issue for young adults and their ability to access community pharmacy without own transport.

It is clear that within many communities, the primary care service is viewed as a key service within the community. In several of the communities, the review group was told of how local services have been reduced over recent years and there was significant concern regarding any potential changes to their current service. Within all of the areas, many patients spoke highly of the service they received from their practice.

7. Defining serious difficulty

Serious difficulty was considered and commented upon by Lord Doherty in 2012 following judicial review. He stated that “the relevant qualifying class /or classes might include patients in a defined part of practice area who have serious difficulty by reason of distance from a pharmacy; or patients residing in defined areas who have serious difficulty because they are dependent on public transport to travel to a pharmacy and public transport provision is inadequate; or patients whose mobility is impaired by reason of age or other bodily impairment. These are simply possible examples. In each case it is for the Health Board to define the relevant qualifying class or classes of persons”.

The review group have used distance from a community pharmacy as a factor in establishing serious difficulty. The Board considered that if a person or persons were within a defined part of a practice area then that person or those persons were considered as forming a qualifying class of persons who have serious difficulty by reason of distance from a pharmacy. This distance has been considered alongside the availability of public transport and where applicable, the topography of the area and potential for impact of adverse weather conditions on travel (within the category of inadequacy of means of communication). In only one area did the review group feel there was a “qualifying class” with exceptional circumstances. This is described in the findings for the Auchenblae Medical Centre.

The Review group considered each dispensing practice as a separate entity and as such there are 6 reports on the group’s findings and recommendations.

Auchenblae Medical Centre

The Auchenblae Medical Centre practice boundary includes the main centres of Auchenblae, Fordoun, Drumlithie, Fettercairn and the surrounding rural area. It has a list size of approximately 1965 patients. The practice is currently able to dispense medicines to all of its population (the Practice List).

During the period of March 2016 to August 2016, the Auchenblae Medical Centre prescribed a total of 16522 items of which they dispensed 15082 items (91%).

Consultation response

NHS Grampian received 600 feedback responses to the public consultation from the Auchenblae area. In response to the question “if dispensing of medicine was not available at your GP practice, would you have serious difficulty in getting your dispensed medicines from a community pharmacy?” a total of 592 respondents (98.7%) stated they would have serious difficulty with 8 respondents (1.3%) stating they would not have serious difficulty. Written responses were also received from local independent contractors.

A public information event was held in Auchenblae on 15th September 2016 to which 130 people attended. The Review Group Session was held in Auchenblae Hall on 22nd November 2016 when 29 people/organisations attended. Representations were made by individuals, local independent contractors, elected members and local community groups.

It should be noted that in addition to the NHS Grampian consultation, Auchenblae Medical Centre developed and distributed its own consultation paperwork. An information sheet titled “Auchenblae Surgery – NHS Grampian Review of Continued Dispensing” was distributed together with a response form, requesting the name, address and postcode of the patient responding. The key question on this response form was: “Please state the reasons you think you would have serious difficulties in obtaining prescriptions if dispensing was not available at the Auchenblae”

Respondents were asked to send their completed form to the Freepost address at NHS Grampian with a second copy of the form to be handed into the practice or to the shop at Drumlithie or Fettercairn. Those who responded by e-mail to the generic e-mail address of the Public Involvement Team at NHS Grampian were asked by the Surgery to copy their e-mail to the administrator at Auchenblae Surgery.

The vast majority of Auchenblae respondents used the Surgery response form. The Public Involvement Team collated responses and where duplicate submissions were provided the Team removed the duplicate and where more than one response from an individual was provided the Team collated the responses as they undertook the thematic analysis i.e. duplicate responses / additional responses were not double counted / entered.

The Review Group were conscious of the slight difference in the wording of the question between the Surgery form and the NHS Grampian response form, as the Surgery form asked to state the difficulty rather than establish whether there was a difficulty. As the vast majority of respondents had used this form it was agreed not to exclude these responses. Responses indicating no difficulty represented 1.3% in Auchenblae compared to 1.7% in Rhynie, 9.2% in Udny Station rising to 57.1% in Portlethen and 65.7% in Skene. The Group felt that the best comparison was with Rhynie and Udny Station. The Review Group were of the opinion that the slightly different wording, although unfortunate, did not materially affect the themes expressed but were aware that responses from patients to say they did not have a serious difficulty may be very slightly under-represented.

As full addresses were not required on the NHS Grampian response forms (just full postcodes), all Auchenblae Surgery response forms received by the Public Involvement Team had the patient’s address redacted.

The Review Group considered all written and verbal submissions and found the following:

Distance

Auchenblae Medical Centre dispenses to a dispersed patient population, who reside in a remote and rural part of Aberdeenshire. The topography of the area makes it vulnerable to transport problems particularly during the winter months. There is one community pharmacy in Laurencekirk, within 5 miles of the practice and 2 within 10 miles at Inverbervie and Stonehaven. The Review group noted that due to the dispersed population there was a variation in the distance that an individual patient would have to travel from home to the nearest community pharmacy due to the location of the settlements.

The Review Group found that those patients living in Laurencekirk did not have a serious difficulty in obtaining from a pharmacist any drugs, medicines or appliances, other than scheduled drugs required for treatment. There is no qualifying class of patients living in Laurencekirk who have serious difficulty by reason of distance, or by reason of inadequacy of means of communication. It is the understanding of the review group that currently the practice does not dispense repeat prescriptions to patients living in Laurencekirk. The Review group concluded that this should be more clearly reflected in the requirements to dispense for patients within the practice to ensure that these patients who do not have serious difficulty are not provided with prescribed medicines under Paragraph 44 of the GMS Regulations.

There appears to be a small number of patients living in DD10 postcode area which is out with the practice boundary. The Review Group recognise there are a number of reasons why patients out with the recognised boundary are registered with a practice. There is however no qualifying class of patient within the DD10 postcode who have serious difficulty in obtaining from a pharmacist any drugs, medicines or appliances, other than scheduled drugs required for treatment by reason of distance, or by reason of inadequacy of means of communication.

It is considered that patients living outside Laurencekirk fall within the definition of the qualifying class who do have serious difficulty by reason of distance in obtaining drugs from a pharmacist required for treatment.

Communication

Public transport in this area is limited. Although there is currently an hourly public transport service between Laurencekirk and Stonehaven, with bus stops in Auchenblae, Fourdon and Drumlithie, getting to these bus stops proves difficult for those living in farms and glens that are not in the main settlement areas. The weather conditions in the area have the capacity to interrupt journey times and could potentially add further time to the round trip to attend a community pharmacy. It is considered that those patients defined as living outside Laurencekirk are all patients who satisfy the criteria of the qualifying class of patients who have serious difficulty.

Exceptional Circumstances

Auchenblae has a large community of temporary residents living and working on local farms. These workers are employed locally for approximately 6 months of the year and appear reluctant to engage fully with primary health care provision. The Group tend to present only when experiencing acute health problems and there is a higher frequency within this group of failure to attend for follow up appointments. A requirement for the practice to dispense to this group may increase the likelihood that they will comply with treatment provided. The additional travel associated with a visit to a community pharmacy may reduce the level of compliance with required treatment and impact on health outcomes. This group of patients are considered to fall within the definition of the qualifying class and the Board is satisfied these particular patients falling within the definition will have serious difficulty in obtaining from a pharmacist any drugs, medicines or appliances, other than scheduled drugs required for treatment.

Additional Factors

The review group received representation from the community pharmacy in Laurencekirk expressing concern that they may not have the capacity to provide a service to additional patients of Auchenblae Medical practice that currently receive dispensed medicines from the Practice. Whilst the Review Group noted this information it did not consider that this was an exceptional circumstance in this particular situation.

The Review Group had received no evidence of collection and delivery services being provided to patients of this practice by community pharmacies nearest to Auchenblae.

Review Group Findings and Recommendation

The Review Group recommends that Auchenblae Medical Group should be required or authorised to continue to supply such drugs, medicines or appliances to those patients defined in the above qualifying classes who have a serious difficulty in obtaining their medication from a pharmacist. This requirement should be limited to the classes specified who are considered as having serious difficulty due to:

a) Distance from a pharmacist. This is defined by the Review Group as those patients on the practice list residing in post code areas of AB301 excluding the town of Laurencekirk (defined as the area between the railway line and A90), AB392 south of A92 and AB393 south of unclassified road running East to West through Tewel. The surgery should not be required to dispense to patients within the DD10 postcode.

b) An inadequacy of means of communication due to inadequate public transport provision. Consideration has been given to the topography of area and the potential for weather disruption which, further exacerbates the serious difficulty relating to distance for the patients defined in (a).

c) Being a temporary worker, registered with the practice and employed and living on a local farm.

Gardenstown Branch Surgery

In April 2016 following longstanding recruitment and retention issues, the practice population of Banff & Gamrie Medical Practice was merged with the Macduff Medical Practice. Gardenstown patients have been registered and receiving care from Macduff Medical Practice since that time.

When requested, Macduff Medical Practice provide prescriptions to a community pharmacist, which are then uplifted and taken to Gardenstown Surgery for collection by patients. The surgery building is manned on two occasions (2 hours on 2 days) a week for patients to pick up prescription medication. In addition to this a community pharmacy delivery service is in situ for residents at a sheltered housing complex in Gardenstown.

Consultation responses

NHS Grampian received 18 feedback responses to the public consultation from the Gardenstown area. In response to the question “if dispensing of medicine was not available at your GP practice, would you have serious difficulty in getting your dispensed medicines from a community pharmacy?” a total of 15 respondents (83.3%) stated they would have serious difficulty with 3 respondents (16.7%) stating they would not have serious difficulty.

A public information event was held in Gardenstown on 22nd September 2016 which 8 people attended. The Review Group Session was held in Gardenstown on 28th November 2016 where 29 people/organisations attended. Representations were made by individuals, local independent contractors, elected members and local community groups.

For the Review Group’s visit, Gardenstown Village Action Committee (GVAC) developed and distributed its own feedback form. A total of 41 completed forms were handed in on the day. A written request to the Spar store in Gardenstown, which was a drop off point for GVAC forms, for any additional forms did not produce a response or any extra responses.

It should be noted that all forms submitted to the Review Group on 28th November, would not have met the criteria for inclusion had they been submitted during the public consultation as not all forms contained names and no respondents gave the required postcode. However, the Review Group was satisfied on the day that these forms were from bone fide residents of Gardenstown representing patients who received services from the Medical Practice.

The Review Group considered all written and verbal submissions and found the following:

Distance

There are no community pharmacies within 5 miles of Gardenstown and 4 within 10 miles. The nearest community pharmacist is in Macduff, 7 miles from Gardenstown.

Communications

Those patients without cars reported finding it difficult to visit the community pharmacist in Macduff. There is an infrequent public transport service with few stops near to the community pharmacist, which can leave patients needing to walk some distance. People stated that the infrequent transport service can mean that patients have lengthy waiting periods between buses with no appropriate shelter from the weather.

The bus service can be affected in the winter months due to unsafe road conditions in the area. The weather conditions in the area have the capacity to interrupt journey times and add further time to the round trip, to attend the community pharmacy.

Exceptional Circumstances

There were no exceptional circumstances elicited by the Review Group.

Additional Factors

Although there is clearly difficulty for some of the population, the current collection service does appear to mitigate some of this difficulty. However many others do not make use of this service and so must have alternative provision in place.

There is currently no community pharmacy collection and delivery service available for all residents of Gardenstown however there is delivery to the sheltered housing complex.

Review Group Findings and Recommendation

The Review Group acknowledge the difficulties that the area has faced with regard to the delivery of primary care services. There are issues with regard to the distance to nearest community pharmacy. However this appears to be mitigated to some extent by the availability of the collection service and also by the fact that some patients are making the journey to Macduff to attend GP appointments and could access the pharmacy there if they choose to. It was noted that knowledge of the collection service was not universal and the Review Group would recommend that any such arrangements are made widely known to the residents.

A dispensing service is not available at this current time in Gardenstown but the review group would recommend that the Health and Social Care Partnership continue to work with the community in the planning of primary care provision within this community. The Review group concluded that until the future provision of GP Medical Services is clarified it is not possible to assess whether there are any individual patients, or class of patients who qualify as having serious difficulty in obtaining drugs, medicines or appliances, other than scheduled drugs from a pharmacist.

Portlethen Medical Centre

Portlethen Medical Practice includes the main centres of Portlethen, Newtonhill, Muchalls and the surrounding urban area and has a list size of approximately 15009 patients. The Medical Centre has the provision to dispense medicines to those patients living more than a one mile from the practice. This arrangement is a historic one and was in place prior to the urban growth of Portlethen and surrounding areas which brought increased services to the area.

During the period of March 2016 to August 2016, the Portlethen Medical Centre prescribed a total of 97802 items of which they dispensed 12556 items (12.8%).

Consultation responses

NHS Grampian received 84 feedback responses to the public consultation from the Portlethen area. In response to the question “if dispensing of medicine was not available at your GP practice, would you have serious difficulty in getting your dispensed medicines from a community pharmacy?” a total of 36 respondents (42.9%) stated they would have serious difficulty with 48 respondents (57.1%) stating they would not have serious difficulty. Written responses were also received from independent contractors, local community groups and elected members.

A public information event was held in Portlethen on 12th September 2016 which 10 people attended. The Review Group Session was held in Portlethen Academy on 22nd November 2016 where 3 people/organisations attended.

The Review was also discussed at a meeting of the Newtonhill, Muchalls & Cammachmore Community Council, where the question of ‘serious difficulty’ was considered. The Community Council agreed that the answer was ‘No’ as good alternative facilities are available to the residents in the Community Council area who will predominantly be registered at the Portlethen Medical Centre.

The Review Group considered all written and verbal submissions and found the following:

Distance

There is a Community Pharmacy situated adjacent to the Medical Centre, sharing the same building. There are 11 Community Pharmacists within an approximate 5 miles radius of the practice and a further 56 within a 10 mile radius.

Communication

There is a comprehensive public transport service to and from Portlethen which provides good communication links to areas surrounding the practice population area. This operates within surgery times. The Review Group did hear that although

15 there is an hourly bus service, some patients who do not drive, may find some difficulties travelling to and from Muchalls area.

Exceptional Circumstances

There were no exceptional circumstances elicited by the Review Group.

Additional Factors

A community pharmacy provides a collection and delivery service to patients resident south of the practice, in the vicinity of the pharmacy. Another community pharmacy works with a volunteer group to provide a delivery service to housebound patients.

Review Group Findings and Recommendation

The Review Group concluded that as there is a community pharmacy co-located with the medical practice and the fact that there are community pharmacists within the surrounding areas, with good communication systems, that there are no individual patients, or class of patients who qualify has having serious difficulty in obtaining prescribed medicines and appliances from a community pharmacist.

The Group therefore recommends that Portlethen Medical Group is no longer required to dispense from the practice.

Rhynie Medical Practice

Rhynie Medical Practice serves a remote and rural part of Aberdeenshire and has a list size of approximately 1079 patients. The practice currently dispenses medicines to its population, the vast majority of whom reside in rural and remote settings.

During the period of March 2016 to August 2016, the Rhynie Medical Practice prescribed a total of 9808 items of which they dispensed 9727 items (99%).

Consultation responses

NHS Grampian received 360 feedback responses to the public consultation in the Rhynie area. In response to the question “if dispensing of medicine was not available at your GP practice, would you have serious difficulty in getting your dispensed medicines from a community pharmacy?” a total of 354 respondents (98.3%) stated they would have serious difficulty with 6 respondents (1.7%) stating they would not have serious difficulty. Written responses were also received from local elected members including Marr Area Committee, local community groups and healthcare providers.

The Tap o Noth Community Council organised an event on 30th August which was very well attended with a further public information event held in Rhynie on 15th September 2016 which 25 people attended. The Review Group Session was held in Rhynie on 18th November 2016 where 12 people / organisations attended. Representations were made by individuals, local independent contractors, elected members and local community groups.

The Review Group considered all written and verbal submissions and found the following:

Distance

Rhynie Medical Practice dispenses to a dispersed patient population, who reside in a remote and rural part of Aberdeenshire. The topography of the area makes it vulnerable to transport problems particularly during the winter months. There is no community pharmacy within 5 miles of the practice and 4 within 10 miles, with the closest being approximately 8 miles from the practice in Huntly. The Review group noted that due to the dispersed population there was a variation in the distance that an individual patient would have to travel from home to the nearest community pharmacy and this was of particular relevance to those living in Huntly.

The Review Group found that those patients living in Huntly (AB548 and AB546) did not fall into the qualifying class of patients who have a serious difficulty in obtaining from a pharmacist any drugs, medicines or appliances, other than scheduled drugs required for treatment by reasons of distance from a pharmacist These patients represent a very small number of patients out with the practice boundary. The group acknowledges there can be a variety of different reasons why someone out with the

17 practice boundary might be registered with a particular practice. This group of patients would however have access to the community pharmacy provision in Huntly and therefore it is considered that those persons do not fall within the aforementioned qualifying class of patients who have a serious difficulty by reasons of distance from a pharmacist.

Communication

Patients without cars reported finding it very difficult to attend appointments owing to the public transport service being reduced in recent years and the infrequency of the bus service, which does not synchronise with surgery hours. This difficulty had led to the local community forming the charity Car Aid to help patients attend GP appointments. The review Group heard that the bus service can be cancelled in the winter months because of unsafe road conditions in the area. The weather conditions in the area have the capacity to interrupt journey times and add further time to the round trip of approximately 16 miles, to attend a community pharmacy.

The local charity Car Aid, presently provides a transport service for Rhynie patients to attend GP appointments. It operates with around 10 volunteer drivers and came in to existence to assist in lowering the number of patients who were missing appointments due to transport difficulties getting to and from the surgery. Representatives from members of the Car Aid organisation reported that they would be unable to cope with the extra demand on the service if more patients required transport and support to attend both appointments at the surgery and a subsequent visit to a community pharmacy.

Exceptional circumstances

There were no exceptional circumstances elicited by the Review Group.

The review group is not aware of any community pharmacy delivery services to patients in the practice catchment area.

Review Group Findings and Recommendation

The review group recommends that Rhynie Surgery should be required to continue to dispense to those patients, as individuals or those who fall within the defined qualifying class of patients who will have serious difficulty in obtaining their medication from a community pharmacist. This requirement is limited to those with serious difficulty due to:

a) Distance from a pharmacist. This difficulty applies to all patients registered with the practice residing within the agreed boundary of the practice but excludes those patients living in Huntly (AB548 and AB546).

b) An inadequacy of communication due to public transport provision. Consideration included the topography of the area and the potential for weather disruption, which further exacerbates the serious difficulty relating to distance for the patients defined in (a).

Skene Medical Group

Skene Medical Group provides services to the population of Westhill and some of the surrounding area and has a practice list size of approximately 15330 patients. Skene Medical Group are currently required or authorised to supply drugs, medicines or appliances other than scheduled drugs to patients living more than 2 miles from the practice. These patients are generally rural patients who have been registered with the practice for some time. This arrangement is a historic one and was in place prior to the urban growth of Westhill and surrounding areas which brought increased services to the area.

During the period of March 2016 to August 2016, the Skene Medical Practice prescribed a total of 86269 items of which they dispensed 10775 items (12.5%).

Consultation responses

NHS Grampian received 35 feedback responses to the public consultation from the Westhill area. In response to the question “if dispensing of medicine was not available at your GP practice, would you have serious difficulty in getting your dispensed medicines from a community pharmacy?” a total of 12 respondents (34.3%) stated they would have serious difficulty with 23 respondents (65.7%) stating they would not have serious difficulty. A written response was received from an independent contractor.

A public information event was held in Westhill on 5th September 2016 to which no one attended. The Review Group Session was held in Westhill on 24th November 2016 where 1 person / organisation attended. Representation was made by an independent contractor.

The Review Group considered all written and verbal submissions and found the following:

Distance

Skene Medical Practice is co-located with a Community Pharmacy at Arnhall Business Park. There are 12 community pharmacists within an approximate 5 miles radius of the practice and a further 59 within a 10 mile radius.

Communication

Westhill has an A2B bus service which is open to the general public. The service operates door to door, in and around the Westhill area on Monday to Friday 9.00a.m. until 5.00 p.m. and Saturday between 9.30 and 2.00 p.m. There is also a public transport service from Westhill which provides good communication links to areas surrounding the practice population area.

Exceptional Circumstances

There were no exceptional circumstances elicited by the Review Group.

Additional Factors

A number of community pharmacies provide collection and delivery services to patients registered with Skene Medical Group.

Review Group Findings and Recommendation

The Review Group concluded that as there is a community pharmacy co-located with the medical practice and the fact that there are pharmacists within the surrounding areas that there are no individual patients or a qualifying class of patients who will have serious difficulty in obtaining from a pharmacist any drugs, medicines or appliances other than scheduled drugs required for treatment.

The Group therefore recommends that Skene Medical Practice is no longer required to dispense from the practice.

Scotstown Medical Group – Udny Station Branch Surgery

In November 2016, Scotstown Medical Group had 12453 patients on their practice list. This includes those patients who receive their care from Udny Station Branch Surgery. The Udny Station Surgery provides services to residents in a geography of approximately 30 square miles and includes Potterton, Balmedie, Udny Green and Pitmedden.

Udny Station surgery is required to dispense to all registered patients, many of whom live in a remote and rural area of Aberdeenshire. The review group were unable to gain figures for the percentage of prescribed items dispensed by the practice. The figure can only be presented as a percentage of the whole Scotstown practice list. The review group felt this may be misleading and so have not included this figure in this report.

Consultation responses

NHS Grampian received 251 feedback responses to the public consultation from the Udny area. In response to the question “if dispensing of medicine was not available at your GP practice, would you have serious difficulty in getting your dispensed medicines from a community pharmacy?” a total of 228 respondents (90.8%) stated they would have serious difficulty with 23 respondents (9.2%) stating they would not have serious difficulty. Written responses were also received from local elected members, local community groups and independent contractors.

Udny Community Council held a meeting in August 2016 attended by over 135 people. A further public information event was held in Udny Station on 26th September 2016 which 28 people attended. The Review Group Session was held in Udny Station on 29th November 2016 when 7 people attended. Representation was made by individuals, local elected members and local community groups.

The Review Group considered all written and verbal submissions and found the following:

Distance

There are 4 Community Pharmacies within 5 miles of the practice in Tarves, Newmachar and Ellon (2) with a further 18 within 10 miles. There is however, a variance in the distance that a patient would have to travel from home to the nearest community pharmacy based on the spread of settlements. The Review Group considered that registered patients living outside of the postcode areas AB410 south of A920 and west of A90, AB419 south of A920 and west of A90 and AB210 east of A947 will not have a serious difficulty in obtaining drugs, medicines or appliances other than scheduled drugs required for treatment as there is a community pharmacy within these areas.

Communication

There is an infrequent public transport service with many of the settlement areas not on the bus route. Of the four community pharmacies closest to the surgery, only Tarves is accessible by direct bus route. The bus timetable is such that it is likely a patient may have to wait up to 2 hours for a return bus if they were to have their medication dispensed at the pharmacy. The bus service can be affected in the winter months and this has the capacity to impact on journey times and add further time to the round trip, to attend the community pharmacy.

Exceptional Circumstances

There were no exceptional circumstances elicited by the Review Group.

Additional Factors

Community pharmacy collection and delivery schemes are currently available within the Udny Station/Scotstown Medical Group practice boundary area. It is possible these could be developed to benefit more patients.

Review Group Findings and Recommendation

The review group recommends that Udny Station Surgery should be required to continue to dispense to individuals, and patients who fall within the definition of the qualifying class of patients, who will have serious difficulty in obtaining any drugs, medicines or appliances required for treatment from a community pharmacist. This requirement should be limited to those individual patients or those who fulfil the criteria of the qualifying class of patients who will have serious difficulty due to:

a) Distance from a pharmacist. Dispensing should continue from the Udny Station surgery for those patients residing in postcode areas AB410 south of A920 and west of A90, AB419 south of A920 and west of A90 and AB210 east of A947.

b) An inadequacy of communication due to public transport provision, further exacerbates the serious difficulty relating to distance for those patients defined in (a).