14 June 2019 REF: SHA/21094 APPEAL AGAINST NHS ENGLAND

Arena Point 14 June 2019 Merrion Way Leeds LS2 8PA REF: SHA/21094

Tel: 0203 928 2000 APPEAL AGAINST NHS ENGLAND (WEST MIDLANDS) Fax: 0207 821 0029 AREA TEAM, NHS COMMISSIONING BOARD ("NHS Email: [email protected] ENGLAND") DECISION TO REFUSE AN APPLICATION BY PHARMINSPIRE LIMITED FOR INCLUSION IN THE PHARMACEUTICAL LIST OFFERING UNFORESEEN BENEFITS UNDER REGULATION 18 ON THE B4348 BETWEEN DARK LANE AND THE VILLAGE STORES, EWYAS HAROLD, c. HRD 0EU

1 Outcome

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

1.2 The Committee determined that the application should be refused.

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

Arena Point REF: SHA/21094 Merrion Way Leeds APPEAL AGAINST NHS ENGLAND (WEST MIDLANDS) LS2 8PA

AREA TEAM, NHS COMMISSIONING BOARD ("NHS Tel: 0203 928 2000 ENGLAND") DECISION TO REFUSE AN APPLICATION Fax: 0207 821 0029 BY PHARMINSPIRE LIMITED FOR INCLUSION IN THE Email: [email protected] PHARMACEUTICAL LIST OFFERING UNFORESEEN BENEFITS UNDER REGULATION 18 ON THE B4348 BETWEEN DARK LANE AND THE VILLAGE STORES, EWYAS HAROLD, c. HRD 0EU

1 The Application

By application dated 9 April 2018, Pharminspire Limited (“the Applicant”) applied to NHS Commissioning Board (“NHS England”) for inclusion in the pharmaceutical list offering unforeseen benefits under Regulation 18 on the B4348 between Dark Lane and The Village Stores, Ewyas Harold, c HR2 0EU. In support of the application it was stated:

1.1 In response to why the application should not be refused pursuant to Regulation 31, the Applicant stated:

1.1.1 N/A there is no pharmacy provider adjacent or in close proximity.

1.2 The area surrounding the application attracts a significant number of people to access GP services. Additionally, people in the area of the application have access to community and retail services such as primary school, village store and postal services, public house, church, take away, dentist, butchers, GP Surgery.

1.3 The resident and reliant population has access to GP services but there is no pharmacy service.

1.4 Existing pharmacy providers are located a considerate [sic] distance away and therefore the significant large reliant population has no access to pharmaceutical services on a face to face basis therefore reasonable choice is not satisfied in the area of the application. This application will therefore secure better/improved access to pharmaceutical services.

1.5 On this basis this application affords better/improved access to pharmaceutical services and therefore satisfies the requirements for a Regulation 18 unforeseen benefits application.

1.6 The granting of this application will significantly improve access resulting in significantly improved availability of pharmacy services.

1.7 The application site is easily accessible by all the local and reliant population, the pharmacy will be operational for 53 hours weekly (53 core guaranteed hours) providing adequate cover and improved access for the whole area.

1.8 Services out with those commissioned but important from a strategy point of view and to be provided include:

1.8.1 Diabetes screening

1.8.2 Cholesterol testing

1.8.3 Blood pressure testing

1.8.4 Weight management services

1.8.5 Alcohol FAST interventions

1.8.6 Health checks

2 The Decision

NHS England considered and decided to refuse the application. The decision letter dated 7 March 2019 states:

2.1 NHS England has considered the above application and are writing to confirm that it has been refused.

2.2 Please see the attached report for NHS England’s reasoning behind the decision.

The decision report stated:

2.3 Pharminspire Limited – CAS Unforeseen Benefits - HR2 0EU - CAS-767596-N4Z3L3

2.4 This application for unforeseen benefits was considered by the Pharmaceutical Services Regulations as follows:

2.5 Regulation 31 is not engaged by the application. The Committee is not required to refuse the application under the provisions of Regulation 31.

2.6 Regulation 40: No information to suggest that there had been a refusal in the last 5 years.

Reserved Location Status

2.7 Regulation 41: The number of individuals residing within 1.6km of the best estimate who are on a patient list is 1043 (1030 of which are dispensing and 13 non dispensing).

2.8 There is no information or satisfactory evidence to suggest that if pharmaceutical services were provided at the relevant location, the use of those services would be similar to, or greater than, the use that might be expected if the number of individuals residing in that area who are on a patient list were 2750 or more.

Determination

2.9 The Committee determined that the location remained a reserved location and proceeded to determine the main application for unforeseen benefits.

2.10 The Committee considered that the location remains a reserved location, therefore, there was no requirement to consider the question of prejudice under Regulation 44.

Unforeseen Benefits

2.11 Regulation 18: Whilst granting the application would not detriment proper planning in the area, the application lacks details and fails to provide a cogent argument to demonstrate an unforeseen benefit. The basis of the application is to secure NHS pharmaceutical services in an area where the nearest pharmacies are located approximately 5 miles away. The Pharmaceutical Needs Assessment (PNA) is clear as to what pharmaceutical provision is available in the area. Furthermore, the PNA concludes that there are currently no gaps in provision. The applicant provides no compelling evidence as to why this position has changed since the PNA was published.

2.12 There is no evidence of any significant benefit that would be conferred by granting the application. There is no evidence that granting the application would secure innovative services for the population. The applicant makes no mention of patients with protected characteristics.

2.13 Regulation 50: Given the Committee’s considerations re reserved location status and unforeseen benefits, gradualisation is not deemed relevant.

Determination

2.14 The Committee having considered the respective Regulations, refused the application.

3 The Appeal

In a letter dated 25 March 2019, addressed to NHS Resolution, Rushport Advisory LLP on behalf of the Applicant, appealed against NHS England's decision. The grounds of appeal are:

3.1 The Applicant includes a copy of the decision letter and report.

3.2 The application is rejected on the basis of reference to the PNA. The decision report states:

‘The basis of the application is to secure NHS pharmaceutical services in an area where the nearest pharmacies are located approximately 5 miles away. The Pharmaceutical Needs Assessment (PNA) is clear as to what pharmaceutical provision is available in the area. Furthermore, the PNA concludes that there are currently no gaps in provision. The applicant provides no compelling evidence as to why this position has changed since the PNA was published.’

3.3 The Applicant is not claiming that the position in relation to the PNA has changed, what the Applicant is claiming is that the PNA is incorrect in its assumptions in relation to the application site and there is documented evidence in support of this.

3.4 The PNA is written in such a way that there is a common theme running through it, namely the assessment of pharmaceutical services in relation to improved/ better access. NHS England if they had considered the PNA strategy should have concluded that in relation to the specific location of Ewyas Harold the PNA is actually supportive that better/ improved access to pharmaceutical services would be secured by granting the application.

3.5 The PNA Pg.5 identifies pharmaceutical services provided by community pharmacists:

NHS England Core Essential and Commissioned Pharmaceutical Services

 Essential Services o Dispensing (includes electronic prescription services) and actions associated with dispensing o Repeatable dispensing o Disposal of unwanted medicines o Promotion of healthy lifestyle . Prescription Linked interventions . Public health campaigns o Signposting/support for self-care

 Advanced services o Medicines use reviews (MUR) and Prescription Intervention Service o New Medicines Service (NMS) o Appliance Use Reviews (AUR) o Stoma Appliance Customisation Service (SACS)

o New Urgent Medicines Service Advance Service (NUMSAS)

 Enhanced Services o NHS Pharmacy Fly Vaccination Service

3.6 And on Pg. 47 correctly defines a dispensing doctor as being able to ‘dispense medication’ and ‘relates only to the dispensing of medicines’

“A Dispensing Doctor is a General Practitioner (GP) who under regulation can dispense medication to patients in their care. Only the provision of those services set out in their pharmaceutical services terms of service (Schedules to the 2013 Regulations) is included within the definition of pharmaceutical services and relates only to the dispensing of medicines.

Dispensing doctors provide primary healthcare to people in rural areas. Only certain people are eligible to receive dispensing services from a dispensing doctor. Many live away from a community pharmacy and so dispensing doctors are allowed to dispense prescribed medicines.”

3.7 This being correct therefore means that the population at the application site do not have any access to any pharmaceutical service other than a dispensing service. To be clear there is no availability of:

3.7.1 Repeat dispensing

3.7.2 Disposal of unwanted medicines

3.7.3 Promotion of healthy lifestyles

3.7.4 Public health campaigns

3.7.5 Signposting

3.7.6 Self-care

3.7.7 Advanced and enhanced pharmaceutical services

3.8 NHS England surely cannot have confirmed that the presence of a dispensing doctor is satisfying access to pharmaceutical services!!! [sic]

3.9 The PNA includes a strategy for health needs and improvements in the population Pg. 11-16 and includes:

3.9.1 Smoking

3.9.2 Poor diet

3.9.3 Physical activity

3.9.4 Alcohol misuse

3.9.5 Sexual behaviour

3.9.6 Cardiovascular disease and stroke

3.9.7 Diabetes

3.9.8 Cancer

3.9.9 Chronic respiratory disease

3.9.10 Hospital admissions

3.9.11 Substance misuse

3.9.12 Mental health

3.9.13 Older people

3.9.14 Disability

3.9.15 Flu

3.10 Each of these strategic health concerns can be improved if there was better/ improved access to pharmaceutical services in the area of the application rather than the current scenario where there is no access to pharmaceutical services.

3.11 PNA Pg.25 clearly shows the services that pharmacy can provide supporting health improvement needs locally. (see Appendix A for the table extracted from the PNA).

3.12 PNA Pg. 91 shows the vision for pharmacy and highlights the lack of access to these services in and around the application site. (see Appendix A for the table extracted from the PNA)

3.13 PNA Pg. 26 identifies principles in determining pharmaceutical services as being ‘necessary’ and the importance and principles in relation to ‘choice’. (see Appendix A for the table extracted from the PNA)

3.14 The PNA concludes in relation to patient choice on Pg.60:

Patient Choice. Patients should have a choice on where they access pharmaceutical services and where their prescriptions are dispensed and this should be articulated clearly by all providers. Options for ordering prescriptions electronically when they receive medicines via community pharmacy should be increased.

3.15 There is no pharmacy and therefore no choice in terms of accessing pharmaceutical services in the area of the application.

3.16 The PNA Pg. 60 defines the distribution of pharmacies and access to pharmaceutical services in terms of people travelling more than a mile and access by car within 20 minutes. (see Appendix A)

3.17 People in the area of the application must travel c. 11 miles and can’t access inside 20 minutes even when travelling by car.

3.18 On foot is not possible and via public transport takes 50 minutes in each direction requiring 2 buses to reach the destination. (see Appendix A)

3.19 The PNA Pg. 29 identifies the area ‘Golden Valley to Mortimer’ where access to pharmacies is poor due to travelling 5 miles.

However, there is a corridor running through the Golden Valley to Mortimer where access to pharmacies is poor with residents needing to travel more than 5 miles to the nearest pharmacy but receive dispensing services from dispensing practices. (Map 3).

3.20 Again, at the application site requires an 11-mile journey.

3.21 The Golden Valley is the area where the applicant has submitted this pharmacy application and therefore NHS England by granting this application would have resolved the documented poor access to pharmaceutical services.

3.22 NHS England has failed to remedy this poor access issue and has failed to recognise the published limitations in terms of access to pharmaceutical services within its own PNA document.

3.23 Map PNA Pg.35 Golden Valley location. (see Appendix A)

3.24 The PNA Pg. 61 concludes in terms of essential pharmaceutical services (the Applicant notes defined as ‘current need’):

Current Need where improvements could be made in the immediate future

 Additional pharmacy opening hours would be advantageous between 7-9 am on weekdays, in all localities, to ensure alignment with GP opening hours and to promote timely access to dispensing

3.25 This application satisfies this current need - there are no opening hours in the area surrounding Ewyas Harold (Golden Valley) hence the PNA defining the area in terms of poor accessibility to pharmaceutical services.

3.26 PNA Pg. 61 current improvements or better access.

Current and Future Improvements or Better Access

 In all localities, additional opening hours on weekday mornings (before 9am), weekday and Saturday evenings and on Sundays, would improve access, convenience and choice to dispensing and other essential services, both now and in the future. This would be beneficial for residents who work full time and who prefer to use a pharmacy outside of working hours; and would facilitate ensuring there is sufficient capacity to meet the future pharmaceutical needs of a growing population.

 More pharmacies could provide support for people with disabilities, particularly those with hearing impairment

3.27 Again, this application satisfies this documented current improvement/ better access in the defined Golden Valley area.

3.28 PNA Pg.98 describes improvements/ better access in relation to essential and advanced pharmaceutical services plus improving needs for those with disabilities. Again, this application satisfies these improvements/ better access in the Golden Valley area. (see Appendix A)

3.29 The decision report makes mention of innovation and shared characteristics as below:

‘There is no evidence of any significant benefit that would be conferred by granting the application. There is no evidence that granting the application would secure innovative services for the population. The applicant makes no mention of patients with protected characteristics.’

3.30 The applicant disagrees with this statement in relation to patients sharing a protected characteristic. The PNA itself identifies shared characteristics on Pg. 59. The relevant shared characteristics in relation to access to pharmaceutical services being:

3.30.1 Age

3.30.2 Disability

3.30.3 Gender

3.30.4 Race

3.30.5 Religion or belief

3.30.6 Pregnancy and maternity

3.30.7 Gender reassignment

3.31 Also documented Pg. 59 is how pharmacy can meet the needs of these groups. However, as per the documented ‘poor access’ to pharmaceutical services for those residing through the Golden Valley it must be concluded that people sharing protected characteristics are not able to secure reasonable choice/ access to pharmaceutical services. This application secures access for these groups to pharmaceutical services.

3.32 The decision report makes NO mention whatsoever of Reasonable Choice. The Applicant therefore must conclude that Reasonable Choice; Regulation 18(2)(b)(i); has not been considered by NHS England in its deliberations even though this is a main theme in the application and reply to representations submitted (attached for completeness, see Appendix A).

3.33 [Regulation 18(2)(b)(i) quoted in full]

3.34 The Applicant notes that the LPC is supportive of this application specifically in relation to better and improved access and therefore reasonable choice.

The applicant is offering better access to pharmaceutical services, from 2005 the over- riding principle has been to improve access to, and the quality of, pharmaceutical services for people in rural areas by encouraging new services, whilst retaining the existing need of some people to access medicines from their GP.

3.35 LPC comments submitted to NHS England following consultation.

3.36 The Applicant has clearly proven that Regulation 18 is satisfied in relation to this application and look forward to hearing further in due course.

4 Summary of Representations

This is a summary of representations received on the appeal.

4.1 HEREFORDSHIRE AND WORCESTERSHIRE LPC

4.1.1 Herefordshire and Worcestershire LPC have no further representations on the appeal other than the comments previously made in their letter dated 20 August 2018, enclosed for reference.

In a letter dated 20 August to NHS England, the LPC stated:

4.1.2 Thank you for informing Herefordshire and Worcestershire LPC of the application from Pharminspire Ltd, Herefordshire and Worcestershire would like to make the following representations.

4.1.3 The premise are not yet secured.

4.1.4 This is an application for a pharmacy within a controlled locality and must be considered under Part 7 of the NHS (Pharmaceutical and Local

Pharmaceutical Services) Regulations 2013. NHS England must now consider whether the proposed pharmacy is within a reserved location as defined under Regulation 41(3), whereby the area within a 1.6km radius of a relevant location is a “reserved location” if –

(a) the number of individuals residing in that area who are on a patient list etc. is less than 2,750 and

(b) The NHSCB is not satisfied that if pharmaceutical services were provided at the relevant location, the use of those services would be similar to, or greater than, the use that might be expected if the number of individuals residing in that area who are on a patient list were 2,750 or more.

4.1.5 As quoted the number of patients residing within 1.6km of the proposed site above is 1043 and therefore the area should be deemed a reserved location. Herefordshire and Worcestershire LPC notes that this routine application has been brought under Regulation 18 – Unforeseen Benefits. Herefordshire and Worcestershire LPC notes that the current PNA, published May 2018, concludes that the assessment made in terms of accessibility, locations and population density suggest that there is satisfactory access to NHS pharmaceutical services in this area.

4.1.6 The applicant is offering better access to pharmaceutical services, from 2005 the over-riding principle has been to improve access to, and the quality of, pharmaceutical services for people in rural areas by encouraging new services, whilst retaining the existing need of some people to access medicines from their GP.

4.1.7 Herefordshire and Worcestershire LPC believe that if the area is determined not to be a reserved location, and that, if after consideration of Regulation 44, prejudice is not found then consideration of granting the application should be given, notwithstanding the postponement of dispensing rights under Regulation 50 (2).

4.2 VEAL WASBROUGH VIZARDS ON BEHALF OF GOLDEN VALLEY PRACTICE PARTNERSHIP

4.2.1 These representations are submitted on behalf of the Golden Valley Practice partnership, comprised of Drs Champ, Milsom and Scotland (the Practice). The Practice operates from two sites, as follows:

4.2.1.1 Ewyas Harold, Herefordshire, HR2 0EU; and

4.2.1.2 Peterchurch Surgery, Closure Place, Peterchurch, Hereford, HR2 0RS.

4.2.2 The Practice holds dispensing rights at both sites.

4.2.3 The Practice employs a full time pharmacist, whose role includes dispensing medicines, providing ad hoc advice and guidance to patients on request, reviewing new medication prescribed to patients by secondary care providers and carrying out medication reviews.

4.2.4 Many of the Practice's patients live in Wales (currently 751 out of a total patient list size of 5,827). Those that do are entitled to free NHS prescriptions. These patients make very little use of the Practice's dispensing service and are extremely unlikely to visit a pharmacy in England.

4.2.5 The Practice strongly objects to the granting of the application submitted by Pharminspire Limited (Pharminspire) and supports the decision of NHS England to reject the application.

4.2.6 Enclosed at Annex 1 is a copy of the Practice's representations of 20 August 2018, submitted to NHS England in response to Pharminspire's original application. The Practice invites the Pharmacy Appeals Committee to read its letter of 20 August 2018 in full.

Regulation 18 - unforeseen benefits

4.2.7 Pharminspire's application is made pursuant to regulation 18 of the NHS (Pharmaceutical and Local Pharmaceutical Services) Regulations 2013 (the Regulations).

4.2.8 In summary, the Practice's position is that Pharminspire has failed to demonstrate that granting its application would confer significant benefits on persons in the area of the relevant HWB which were not foreseen when the relevant pharmaceutical needs assessment was published.

4.2.9 Pharminspire alleges that the population at the application site do not have access to pharmaceutical services other than a dispensing service. This is incorrect. Pharminspire lists services which it specifically alleges are not available to the population. The Practice's response is set out in the table below.

Services which Pharminspire The Practice's response claim are not available Repeat dispensing The Practice offers repeat dispensing. This service is available to 100% of patients of the Practice. Disposal of unwanted medicines The Practice offers disposal of unwanted medicines. The Practice has a DUPE bin available for disposal of unwanted medicines and has an arrangement in place with a company that regularly picks up the waste for safe disposal. Promotion of healthy lifestyles Herefordshire Council fund a Healthy Lifestyles Trainer. All Practice staff are able to refer patients to this service (including the Practice's reception team who have all received training to signpost patients to different care professionals). The Practice is in a better position than a pharmacy to make appropriate referrals to this service as they know the patient's family history, have access to their medical records and can check height and weight opportunistically. Appointments with the Healthy Lifestyles Trainer are held in the Practice. The Practice also offers NHS Health Checks (which include a vascular check). The Practice employs two Health Care Assistants (HCAs) who carry out the checks. There are a large number of appointments available for this service each week. The Practice has high uptake for the NHS health checks. It offers 8 appointments per week and carried out over 150 checks last year.

The Practice nurse carries out healthy lifestyle promotion in local schools and local community groups. For example, she has visited the local scout and cub groups and held meetings with Golden Valley Stitches and Compass Group. In relation to the latter two organisations, the Practice Nurse was invited by the organisations to provide health promotion. She spoke about a number of healthcare issues including breast examinations and cervical smears. The fact that the Practice nurse was invited to speak to these organisations demonstrates that it is known in the community that the Practice is a source of healthy lifestyles advice. The Practice waiting room is full of brochures and posters promoting healthy lifestyles. The Practice receives the same promotional material as an NHS pharmacy does. Public health campaigns The Practice is notified of any NHS public health campaigns and promotional material is provided. The Practice displays posters in the waiting room and makes brochures available to patients. Signposting The entire Practice team is trained to signpost patients to other services. As mentioned above, all of the Practice receptionists have received care navigation training. NHSE provides a social prescriber, who works in the Practice, and who can signpost patients to services outside of healthcare. Self-care The Practice is aware that a current nationwide NHS priority is to encourage its staff to promote self-care to patients. It actively does so and has the benefit of access to the patient's notes when doing so. For example, the clinical staff at the Practice, in particular the doctors and pharmacist actively encourage patients to purchase over the counter medications (for example paracetamol and hay fever treatments) rather than issuing patients with prescriptions. Self-care promotion applies to healthcare services as well as medication. For example, the Practice offers an ear syringing service (many practices do not offer such a service but there is a need for this service as the Practice is so rural). Where appropriate, the Practice encourages patients who use the service to self-care. The Practice's pharmacist is able to advise patients in relation to simple ailments. Advanced and enhanced pharmaceutical Pharminspire aspires to offer a number of services. advanced and enhanced services but it has not Pharminspire has not specified within its appeal produced any evidence to demonstrate that it will the advanced and enhanced pharmaceutical do so. services that it intends to provide. Any pharmacy's provision of enhanced services However, within its application, it specifies its is entirely dependent on them actually being intention to provide the following services (albeit commissioned. Pharminspire has produced no they have not been commissioned from it): evidence to demonstrate the commissioner's intention to commission any particular enhanced  MUR service.

 AUR Pharmacy funding in general was cut significantly  NMS in the last year. Allowing the pharmacy to open  Smoking cessation would be a huge drain on already scarce NHS  EHC resources.  Needle Exchange Any pharmacy's provision of advanced services  Supervised consumption is dependent on that pharmacy meeting the relevant criteria. Pharminspire has produced no NUMSAS is mentioned on page 2 of evidence of its ability to meet the relevant criteria. Pharminspire's appeal of 25 March 2019, as a MUR (Medicines Use Reviews) pharmacy service provided by community The Practice has employed a full time pharmacist pharmacies. However, Pharminspire has not since May 2018. stated that it intends to provide the service. He is available to speak to patients if they have any questions or concerns about medication. He also carries out medication reviews and holds 3- 4 clinics per week for this purpose. The Practice's doctors also carry out medication reviews. They have plenty of capacity to see patients and are able to carry out such MURs with the benefit of having access to the patient's medical notes. The Practice is signed up to the DSQS (Dispensary Services Quality Scheme). The Practice is required to carry out a high level of medication reviews to comply with this scheme and so it is a service that the Practice offers as a matter of course. The Practice has an automatic record on its EMIS computer system which alerts the Practice if a patient has not had a review in the past twelve months. The next review due date is also given to the patient on each prescription. The Practice doctors carry out medication reviews when visiting patients in the local residential home (visits are carried out once a week). When the Practice team carry out medication reviews, they have the added benefit of having the patient’s notes in front of them and therefore knowing why each medication was started, previous drug allergies/adverse effects and recent blood results (e.g. knowing a patient’s renal function is important for a significant amount of medications). AUR (Appliance Use Reviews) The vast majority of appliances that are prescribed to the Practice's patients are either applied or reviewed on a regular basis by the Practice nurses, district nurses or specialist nurses (for example: dressings, catheters and stomas). While the Practice does not carry out formal AURs, it does support patients in relation to their use of appliances. NMS (New Medicine Service) New medicine reviews are performed by the Practice doctors and pharmacist when a new medication is prescribed by them to a patient, and the patient wishes to have a review.

The Practice's patients receive support from the pharmacist, doctors and nurses in relation to newly prescribed medicines. Any letter received from a hospital detailing new medication prescribed to a patient is seen by the Practice pharmacist for review. In particular, the pharmacist will consider interactions with existing prescribed medication. The pharmacist has full access to the patient's records and will liaise with the patient if there are any concerns. Smoking cessation The Practice was previously commissioned to provide the smoking cessation service (up until April 2017). Since then, the contract to provide the service in our area has been held by Healthy Lifestyles. The reception team (as well as the clinicians in the Practice) can refer patients to the smoking cessation service. The Practice understands that much of the smoking cessation service is provided online, for example, through the use of a smoke free app. The Practice further understands that the smoking cessation service is not commissioned from pharmacies in its area. Given that the Practice previously provided this service and its staff retain the relevant skills/training, the Practice could provide it again if the service was recommissioned. EHC (Emergency Hormone Contraceptive) Patients can access EHC from the Practice. Emergency appointments with doctors are available every day and the prescription can be dispensed from the Practice. The doctors at the Practice have the advantage of knowing the patients and having access to their medical notes. They are in a better position than a pharmacist to discuss the patient's future contraception options. Needle exchange The Practice has never had any patients who need this service but it could assist patients with needle exchange if the service was required. The Practice currently has a number of four diabetic patients. It provides the patients with sharps bins for their used needles and the patients return full sharps bins to the Practice for safe disposal. Supervised consumption The Practice has never had any patients who need this service. Diabetes screening Most of the Practice's diabetes screening is done opportunistically. The Practice clinicians follow appropriate guidelines for testing for diabetes if the patient has risk factors (age/weight/family history etc.). The Practice's treatment of diabetic patients (and other long term conditions) is monitored as part of the Quality Outcomes Framework (QOF). The

Practice is a high QOF achiever, as shown by its most recent QOF results, enclosed at Annex 2. The high score demonstrates that the Practice provides good support to patients with a number of long term conditions, including diabetes. It also means that the practice is paid by NHSE to complete reviews on long term conditions. If a pharmacy was also paid, this would represent a duplication of costs. This comment applies to each of the long term conditions listed in Annex 2. The Practice records show that it carried out blood tests for HbA1c on 1557 patients during the last year. This represents 26% of the Practice population. The Practice can refer patients to the Diabetes Prevention Programme which is funded by our local CCG. It is a 9 month educational support programme for patients at risk of developing diabetes. It is designed to help patients to change their lifestyles to seek to avoid developing diabetes. The programme is provided by Healthier You. NUMSAS The purpose of this service is to be able to provide urgent medications in an out of hours setting, via NHS 111, without the need to see an A&E or out of hours GP. For example, if a patient had ran out of their usual medication. As Pharminspire's proposed pharmacy opening hours are virtually the same as Golden Valley’s opening hours, they offer negligible benefit.

4.3 Within its original application dated 9 April 2018, Pharminspire Limited stated that it would also intend to provide the following further services which would provide unforeseen benefits. The practice already provides each of those services, as detailed below.

Service that Pharminspire states that it Service already provided by the Practice intends to offer Cholesterol testing As mentioned above, the Practice offers NHS Health Checks. These include vascular checks which include cholesterol testing. The NHS Health Checks are automatically offered to every patient aged 40 to 74 years. Repeat checks are offered every five years. The Practice also offers new patient medicals. Every new patient over 40 years old would be offered a cholesterol check. Cholesterol testing is also carried out opportunistically. The Practice's clinicians are well placed to know whether patients should be tested because they have access to patient records. Blood pressure testing Blood pressure testing is part of the vascular check which is included in NHS Health Checks and so the comments above in relation to Cholesterol testing apply to blood pressure testing.

In addition, the Practice has a blood pressure testing machine in our waiting room in both practices. Patients can self-test using this machine. Blood pressure testing is often carried out opportunistically during appointments at the Practice. The testing can be carried out by doctor, nurses, HCAs and the pharmacist. The Practice also owns two blood pressure testing machines that can be loaned out to patients so that they can carry out 24 hour testing. This is the "gold standard" for blood pressure testing. Weight management service The Healthy Lifestyles Trainer described in the table at paragraph 2.3 above provides a weight management service. The service involves seeing patients on a regular basis (often starting with weekly appointments but moving to monthly appointments) and the provision of advice and relevant information leaflets. The Practice nurses also offer weight management support. Alcohol FAST interventions The Practice screens patients for alcohol dependency as part of its new patient screening and NHS Health Checks. Screening is also carried out opportunistically. Health checks As mentioned in the table above, the Practice provides NHS Health Checks. Pharmacies are not commissioned to undertake NHS health checks and so it is unclear what Pharminspire is suggesting that it will offer.

4.4 Pharminspire goes on to list a number of health needs and improvements in the population.

4.5 It claims that these strategic health concerns can be improved if there was better/ improved access to pharmaceutical services. No detail is supplied regarding the pharmaceutical services that would be provided to address the strategic health concerns. The Practice sets out below its current offering to address the strategic health concerns listed by Pharminspire.

Smoking Please see the Practice's comments with regard to the smoking cessation service set out in the table at above. Poor diet The Practice's HCAs provide dietary advice as part of the NHS Health Checks. The Practice nurses also provide dietary advice. The Healthy Lifestyles Trainer provides dietary advice. A health visitor operates from the Practice and provides dietary advice to parents of babies and small children. The local midwifery team provide dietary advice to pregnant women. Dietary advice is provided on an opportunistic basis to patients, and patients can be referred to the Healthy Lifestyles Trainer if further support is required.

Physical activity Advice regarding physical activity is provided opportunistically but is also provided as part of NHS Health Checks. The Healthy Lifestyles Trainer provides advice regarding physical activity. Practice nurses provide physical activity advice as party of providing weight management support. Alcohol misuse The Practice's comments regarding alcohol FAST interventions, set out in the table at paragraph 2.3 above are repeated. When the Practice identifies alcohol misuse /dependency it refers patients to Addaction, the local drug and alcohol misuse clinic. Sexual behaviour The Practice provides family planning advice, prescription and dispensing of EHC and other contraceptives, fitting of coils and administration and removal of contraceptive implants. STI screening is offered by the Practice. The Practice does not believe that such screening is commissioned from pharmacies in the area. Advice is provided opportunistically by the whole Practice team. Cardiovascular disease and The Practice's comments regarding NHS Health stroke Checks, new patient checks, cholesterol testing and blood pressure testing are repeated. The Practice has a recall system which automatically issues letters to patients with a diagnosis of cardiovascular disease, inviting them to attend the practice for an annual check. A 30 minute review appointment is provided with the Practice nurse. The yearly review ensures that medication is optimized and risk factors managed. The Practice has the added benefit of having patient’s notes so can access history, blood results etc. The Practice also has close links to hospital/secondary care and specialist nurses. The Quality Outcomes Framework incorporates health checks for all chronic disease management (and the Practice results therefore illustrate that it is meeting the requirements). The Practice also carries out vascular checks opportunistically, based on the patient's medical history and current symptoms. Diabetes The Practice's comments regarding screening for diabetes, set out in the table above, are repeated. The Practice reviews its diabetic patients every six months. The recall system automatically issues letters to diabetic patients to invite them for a review. The patients attend a 30-40 minute appointment with the practice nurse. Bloods are taken the results are reviewed by a doctor. If the results are complicated then the patient is given a follow up appointment with the doctor. Cancer The Practice offers screening for breast, cervical and bowel cancer. The Practice also offers blood tests for PSA (an indicator for prostate cancer).

As described in the table above, the Practice nurses deliver educational talks in the local community, covering cancer advice. The Practice carries out screening for cancer opportunistically, with the benefit of having access to the patient's medical history and full medical notes. The Practice holds bi-monthly meetings with the palliative care team in our multi-disciplinary team. Chronic respiratory disease The practice's automatic recall system invites patients with Asthma/COPD to attend the Practice for a yearly review. Patients are offered 30 minute appointments with the Practice nurse. The nurse checks breathing function, gives smoking cessation advice (making referrals to the smoking cessation service provided by Healthy Lifestyles where appropriate). Both branches of the Practice have a spirometer (which means that patients do not need to be referred to hospital for testing). Hospital admissions The breadth of the Practice's team (doctors, nurses, HCA's, pharmacists, receptions trained in care navigation, social prescriber) helps the Practice to achieve low Accident & Emergency admissions. The Practice's low Accident and Emergency admissions rates are demonstrated by its GP Practice Data for Q4 2017/18, enclosed at Annex 3. It has the lowest rates in the CCG. The Practice has access to virtual hospital beds, a service provided by the local hospital trust. The Practice shares this service with other practices but 8 virtual beds are specifically allocated to the Practice. Patients at risk of admission to hospital can be referred to the community team. The community matron will visit the patient at home, when needed, with the aim of keeping the patient out of hospital. The Practice believes that this scheme has a significant impact in reducing hospital admissions. Substance misuse The Practice currently has no patients suffering from substance misuse. As described above, patients with alcohol or drug dependency can be referred to Addaction. Mental health The Practice doctors can refer patients to see a dementia nurse (who attends the Ewyas Harold branch once a month) and a Primary Care Mental Health Worker (who attends the Practice, alternating between the two branches, once a week). Both clinicians have access to patient medical records. The appointments are made via the Practice. Referrals to the community mental health worker are for patients whose mental health condition is too severe for the patient to wait for low intensity CBT. For example, referrals are made for patients who are suicidal and those who suffer from chronic mental health conditions such as long term schizophrenia.

The Primary Care Mental Health Worker is part of the local mental health service, the 2Gether trust, and liaises with other members of that team, including the area psychiatrist. They are therefore well placed to escalate the treatment provided if appropriate. The Practice also receives regular (monthly) visits by a psychiatrist and a Community Psychiatric Nurse to see patients. The Practice has a close working relationship with colleagues and able to share information/advice. The local CCG has commissioned the Lets Talk service which offers CBT. There are a number of courses available, including depression and anxiety. Patients are signposted to the service (by clinicians and also by the reception team) and can access the service directly. Older people Home visits to elderly patients are regularly carried out by the Practice's doctors. The Practice's comments regarding the dementia nurse, set out in this table, are repeated. The virtual hospital beds, described in this table above, are particularly useful for older people. A Practice doctor visits the local residential home once a week. Care Hereford operates from premises approximately one mile from the Practice. It is a non-profit charity that helps older people. For example, they offer a delivery service and will pick up prescription medication from the Practice and deliver to patients. They also offer holistic support in the community, designed to support the older population from becoming isolated. For example, they hold lunch clubs. The Practice is able to provide holistic care to older patients for all their health needs as it has access to their notes and knows their history. The Practice often has a relationship with the patient that has built up over many years The Practice has strong knowledge of local services (for example: occupational therapy/3rd sector availability) which means that appropriate sign posting can be given and referrals made. The Practice holds bi-monthly MDT meetings (district nurses/palliative care/occupational therapy/physio). Disability The Practice reviews certain disabled patients yearly. The Practice has excellent awareness of local resources for patients with disabilities. The Practice has good disabled access. The Ewyas Harold branch is all on one level. It has disabled car parking spaces and a disabled toilet. There are ramps to assist accessibility. There is a hearing loop available in the dispensary/reception area. Flu The Practice offers all vaccinations. A flu clinic is held once a year for each branch in their local village hall. The Practice advertises in local village magazines, on its website and by

displaying posters in local shops, the Practice waiting rooms and a large poster outside the Practice. The Practice also issues letters inviting 'at risk' patients to attend the clinic. For example, all patients who had turned 65 last year received a letter. If a patient is unable to attend the flu clinic, they can book an appointment with the HCA or nurse to receive their flu vaccine at a time which is convenient to them. The Practice works closely with the district nurses to ensure house bound patients get vaccinated. It also provides flu vaccines opportunistically during home visits. The Practice also opportunistically offers and administers vaccinations.

4.6 Within its appeal, Pharminspire claims that the local population cannot access a pharmacy within 20 minutes. This contradicts the claim that it made in its letter of 18 September 2018, which related to its original application. In that letter, it confirmed that pharmacies could be accessed within 18 minutes. It would appear that Pharminspire have simply used the journey time search engine at a time of day when traffic is busier to suggest that journey times are over 20 minutes.

4.7 The PNA confirms that pharmacy access is within 20 minutes (page 91). The PNA does not identify poor access.

4.8 The application relates to a rural area and so Pharminspire's suggestion that granting its application would improve choice only applies to the few patients who live very close to the site.

4.9 The PNA identifies a current need for additional pharmacy opening hours, between 7 and 9 am on weekdays. The Practice dispensary is open from 8 am each weekday. Pharminspire proposes to open from 8.30 am and so it does not offer an improvement.

4.10 Pharminspire proposes to open a pharmacy in the same postcode as the Practice. The Practice has not been able to identify suitable premises for a pharmacy. There are no available buildings with the necessary space and parking facilities. The Practice is in a rural area and adequate parking is therefore essential.

4.11 Pharminspire provide no evidence regarding any services that they will provide to meet the specific needs of people who share protected characteristics or any innovative approaches that it intends to take with regard to delivery of pharmaceutical services.

4.12 Pharminspire has therefore failed to provide sufficient evidence to demonstrate that granting the application would confer significant benefits on persons in the area of the relevant HWB which were not foreseen when the relevant pharmaceutical needs assessment was published.

Regulation 31

4.13 No evidence has been supplied to suggest that regulation 31 applies to this application.

Regulation 40(2)

4.14 No evidence has been supplied to suggest that regulation 40(2) applies to this application.

Regulation 40(1)

4.15 The application relates to a controlled locality.

Regulation 41

4.16 No evidence has been supplied to suggest that, if pharmaceutical services were provided at the relevant location, use of those services would be similar to, or greater than, the use that might be expected if the number of individuals residing in that area who are on a patent list were 2750 or more. The Practice therefore agrees with NHS England's assessment that the application relates to a reserved location.

Regulation 44

4.17 If the Pharmacy Appeals Committee were to disagree with the Practice's assessment that the application relates to a reserved location in a controlled locality, the Practice's position is that the granting of the application would prejudice the proper provision of primary medical services in the area of the Health and Wellbeing Board because of the financial impact on the Practice, which relies on its dispensing income. If the application were to be granted, the Practice believes that its dispensing income would be severely affected and that, as a consequence, it would be forced to terminate its contract to provide primary medical services, or at very least cut a significant amount of the services it currently provides to the local population. If the Practice is incorrect in its belief that its dispensing income would be significantly affected, then it is concerned that the pharmacy itself would not be financially viable.

R v North Yorkshire Family Health Services ex parte Dr Michael Wilson and others

4.18 Within its letter of 18 September 2018, Pharminspire suggests that the Practice's dispensing revenue is subsidising its provision of medical services and refers to the above case.

4.19 The case is 23 years old. Its comment that 'it is desirable for pharmaceutical services to be provided by pharmacists and that provision by doctors [i.e. GP practices] is the exception' is outdated. GP practices are encouraged to engage clinical pharmacists and NHS funding has been made available to assist practices to do so.

4.20 The Practice does not argue that it relies on its pharmaceutical services income to underpin its medical services. It does rely upon its dispensing revenue for financial survival, however, it provides the pharmaceutical services as part and parcel of providing a good, safe service to its patients. For example, if the Practice is prescribing medication then it needs to be carrying out yearly medication reviews. The Practice's reliance on its dispensary income is not an uncommon situation.

4.21 The partners' drawings at present are not much greater than its salaried doctors (and the role involves a lot more stress/work/ responsibility). The partners' drawings are less than its long term locums. A drop in the Practice's income due to a loss of dispensing revenue would seriously jeopardise the Practice's ability to continue.

5 Observations

5.1 RUSHPORT ADVISORY LLP ON BEHALF OF PHARMINSPIRE LTD

5.1.1 There is no need to respond to the LPC letter which portrays a continued support for the Applicant’s application and therefore Rushport respond below in rebuttal of the points submitted by letter from VWV on behalf of Golden Valley Practice dated 1 May 2019.

5.1.2 In relation to VWV:

The practice employs a full time pharmacist, whose role includes dispensing medicines providing ad hoc advice and guidance to patients on request, reviewing new medication prescribed to patients by secondary care providers and carrying out medication reviews.

5.1.3 Whether the practice employs a pharmacist or not has no bearing on the determination of this application. The practice is not included on the list of providers of pharmaceutical services as held by the Local Authority; therefore; no provision of essential pharmaceutical services is available at the practice or in the immediate area of the Applicant’s application. VWV are confusing the employment of a pharmacist and the provision of contractual essential pharmaceutical services.

5.1.4 In relation to VWV:

In summary, the Practice’s position is that Pharminspire has failed to demonstrate that granting its application would confer significant benefits on persons in the area of the relevant HWB which were not foreseen when the relevant pharmaceutical needs assessment was published.

5.1.5 With respect, Rushport refer the appeals unit to the Grounds for Appeal submission by the Applicant where the PNA Pg.29 identifies the application area as having poor access to pharmacies.

5.1.6 Again, at the application site requires an 11 mile journey

The Golden Valley is the area where the applicant has submitted this pharmacy application and therefore NHS England by granting this application would have resolved the documented poor access to pharmaceutical services.

5.1.7 As there is documented proof of poor access to pharmacies this application by offering full essential, advanced and enhanced pharmaceutical services must confer a significant benefit on people in the area as they currently have no access at the application site to pharmaceutical services; discounting all services provided by Golden Valley practice as not being pharmaceutical services; and the access issues to pharmacies further afield which have not been challenged by VWV.

5.1.8 In relation to VWV

Pharminspire alleges that the population at the application site do not have access to pharmaceutical serives other than a dispensing service. This is incorrect. Pharminspire lists services which it specifically alleges are not available to the population. The Practice’s response is set out in the table below.

(table not copied)

5.1.9 The Applicant has listed services in terms of pharmaceutical services, again the Golden Valley Practice is not providing pharmaceutical services and is not listed by the Local Authority as a contractual provider of pharmaceutical services.

5.1.10 The PNA describes the benefits conferred on people in the area by way of availability to pharmaceutical services: These benefits are also conferred

across the total core hours that the pharmacy will be required to provide contractually.

5.1.11 The PNA page 5 identifies pharmaceutical services provided by community pharmacists (see table at 3.5 above and Appendix A).

5.1.12 And on page 47 [of the PNA] correctly defines a dispensing doctor as being able to ‘dispense medication’ and ‘relates only to the dispensing of medicines’. (see paragraph 3.6 above and Appendix A).

5.1.13 The PNA describes the benefits conferred on people in the area by way of availability to pharmaceutical services. (See page 25 of the PNA, included at Appendix A).

5.1.14 These benefits are also conferred across the total core hours that the pharmacy will be required to provide contractually.

Monday Tuesday Wednesday Thursday Friday Saturday Sunday Total

08:30am– 08:30am– 08:30am– 08:30am– 08:30am– 09:00am – 53 6:30pm 6:30pm 6:30pm 6:30pm 6:30pm 12:00pm

5.1.14.1Satisfies the PNA Pg.61 re: additional pharmacy opening hours

5.1.14.2The PNA page 61 concludes in terms of essential pharmaceutical services (the Applicant notes defined as ‘current need’)

Current Need where improvements could be made in the future

 Additional pharmacy opening hours would be advantageous between 7-9am on weekdays, in all localities, to ensure alignment with GP opening hours and to promote timely access to dispensing.

5.1.14.3The Golden Valley Practice does not open Saturdays hence this application allows access to full pharmaceutical services when the GP practice is not providing General Medical Services.

5.1.14.4The Golden Valley Practice closes as 6pm [sic]

5.1.14.5There is no requirement for an appointment at the proposed pharmacy and therefore pharmaceutical services will be readily accessible throughout the 53 core hours. An appointment is required to access GMS at the Golden Valley Practice.

5.1.15 In relation to VWV:

Within its appeal, Pharminspire claims that the local population cannot access a pharmacy within 20 minutes. This contradicts the claim that it made in its letter of 18 September 2018, which related to its original application. In that letter, it confirmed that pharmacies could be accessed within 18 minutes. It would appear that Pharminspire have simply used the journey time search engine at a time of day when traffic is busier to suggest that journey times are over 20 minutes.

5.1.16 The authors of the PNA use ‘mapping tools’ as described on Pg. 60

Distribution of Pharmacies

 Herefordshire has below average number of pharmacies but the distribution of these is relatively consistent with population density and deprivation.  There is correlation between deprivation and the number of pharmacies per 100,000 which does vary between localities which needs to be noted.  There are some densely populated areas where residents may have to travel more than a mile to access a pharmacy.  There is a choice of pharmacy in all localities. We have estimated (using mapping tools) that all residents may access a pharmacy within 20 minutes by car, when all 27 pharmacies are open.

5.1.17 The fact being that access to pharmacy is NOT within 20 minutes by car as evidenced in the grounds for appeal document submitted by the Applicant and therefore the PNA is not accurate in relation to the application address.

5.1.18 The applicant has described access to pharmacy on foot and by public transport, VWV has not challenged this and therefore Rushport must conclude that on foot and public transport is not a viable option for people living in the area of the application.

5.1.19 Rushport also note that PNA Pg.35 map (as shown in Appendix A) shows Ewyas Harold considerably outside the PNA definition in terms of reasonable access to pharmacy. Ewyas Harold

5.1.20 In relation to VWV:

The PNA confirms that pharmacy access is within 20 minutes (page 91). The PNA does not identify poor access.

5.1.21 The statement in relation to 20 minutes is Pg. 60 and as evidenced in the grounds for appeal the application site is NOT within 20 minutes by car. The PNA is therefore incorrect in relation to Ewyas Harold.

5.1.22 And PNA Pg.29 does describe poor access

5.1.23 VWV are incorrect in both points they raise within this point.

5.1.24 In relation to VWV

The application relates to a rural area and so Pharminspire’s suggestion that granting its application would improve choice only applies to the few patients who live very close to the site.

5.1.25 This is incorrect, the PNA describes poor access to pharmacies running through Golden Valley to Mortimer. The map (at Appendix C) shows the Golden Valley area from Ewyas Harold to Mortimer and this pharmacy will be sited within the area described as having poor access to pharmacy.

5.1.26 Rushport refer the NHS Resolution to the practice catchment area/ map with the application postcode highlighted (see Appendix C).

5.1.27 This clearly shows the pharmacy will be central to the GP catchment area and therefore the pharmacy will be easily accessible; compared to the current 11- mile distance; for the vast majority of the Golden Valley patient list.

5.1.28 In relation to VWV

The PNA identifies a current need for additional pharmacy opening hours, between 7 and 9 am on weekdays. The Practice dispensary is open from 8am each weekday. Pharminspire proposed to open from 8:30am and so it does not offer an improvement.

5.1.29 Rushport refer NHS Resolution to the above in relation to core guaranteed hours and improvements compared to the availability of GM services.

5.1.30 In relation to VWV:

Pharminspire proposes to open a pharmacy in the same postcode as the Practice, the Practice has not been able to identify suitable premises for a pharmacy. There are no available buildings with the necessary space and parking facilities. The Practice is in a rural area and adequate parking is therefore essential.

5.1.31 This is an application for ‘best estimate’ location and as such the applicant is not required to determine which premises it will open in until they need to inform NHS England of an actual address prior to opening. The statement can have no bearing on the determination of this application.

5.1.32 In relation to VWV:

The Practice does not argue that it relies on its pharmaceutical services income to underpin its medical services. It does rely upon its dispensing revenue for financial survival, however, it provides the pharmaceutical services as part and parcel of providing a good, safe service to its patients. For example, if the Practice is prescribing medication then it needs to be carrying out yearly medication reviews. The Practice’s reliance on its dispensary income is not an uncommon situation.

5.1.33 Firstly, VWV describe ‘pharmaceutical services’ which again it does not provide and, secondly, the Practice confirms ‘it relies on pharmaceutical services income to underpin it medical services’. Therefore, Rushport include Mr Justice Carnwath judgement that ‘It is not part of the scheme of those regulations, or indeed of the statute, that pharmaceutical services should be relied upon to provide financial underpinning for medical services, which are intended to be financed in other ways’. This has not been superseded by any subsequent judgement. (see Appendix C).

5.1.34 The Applicant has clearly proven that Regulation 18 is satisfied in relation to this application and we look forward to hearing further in due course.

6 Additional Observations

6.1 VEAL WASBROUGH VIZARDS ON BEHALF OF GOLDEN VALLEY PRACTICE PARTNERSHIP

6.1.1 The Committee noted the comments received from Veal Wasbrough Vizards on behalf of the Golden Valley Practice Partnership, however the Committee disregarded them and placed no weight on the additional submissions.

7 Consideration

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

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

7.3 On the basis of this information, the Committee considered it was not necessary to hold an Oral Hearing.

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

7.5 Ewyas Harold is in a controlled locality and the application was based on securing improvements or better access to pharmaceutical services in that controlled locality.

7.6 The Committee considered that the correct course was to first consider if the application must be refused pursuant to Regulation 31. The Committee will then consider if the application must be refused pursuant to Regulation 40. If the Committee is not so required to refuse the application, it will consider the issue of reserved location pursuant to Regulation 41. The Committee will then consider the application under Regulation 18. If the Committee has determined that the Applicant is seeking the listing of pharmacy premises which are in a part of a controlled locality that is not in a reserved location, it will consider the issue of prejudice under Regulation 44 last. The reason for this staged approach and in particular for dealing with prejudice last is that if the application does not meet the requirements of Regulation 18 the Committee is required to refuse it and prejudice cannot arise. The potential for prejudice only arises if the Committee has concluded that the application meets the requirements of Regulation 18 and may be granted. It is then for the party asserting prejudice to satisfy the Committee that this provides a reason to refuse an otherwise valid application. Depending on the determinations of the Committee in respect of the above as well as taking into consideration of whether NHS England has considered Regulation 50(1), the Committee will then consider Regulation 50(1) Discontinuance of arrangements for the provision of pharmaceutical services by doctors.

Regulation 31

7.7 The Committee first considered Regulation 31 of the Regulations which states:

(1) A routine or excepted application, other than a consolidation application, must be refused where paragraph (2) applies.

(2) This paragraph applies where -

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

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

(ii) adjacent premises; and

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

7.8 The Committee noted that the Applicant had stated, in their application form, that Regulation 31 was not applicable as there is no pharmacy provider adjacent or in close proximity. The Committee noted that NHS England, in their decision letter, had 24

determined that Regulation 31 was not engaged by this application. The Committee further noted that no party had provided any information to the contrary to indicate that Regulation 31 would require the refusal of this application. Given the information available to the Committee it determined that it was not required to refuse the application under the provisions of Regulation 31.

7.9 The Committee noted that, if the application were granted, the successful applicant would - in due course - have to notify NHS England of the precise location of its premises (in accordance with paragraph 31 of Schedule 2). Such a notification would be invalid (and the applicant would not be able to commence provision of services) if the location then provided would (had it been known now) have led to the application being refused under Regulation 31.

Regulation 40

7.10 In those circumstances, the application (which is made under Regulation 18 of the Regulations) must be assessed against the provisions of Part 7 of the Regulations and, in particular Regulation 40 which reads:

(1) This paragraph applies to all routine applications—

(a) for inclusion in a pharmaceutical list as an NHS pharmacist; or

(b) from an NHS pharmacist included in such a list—

(i) to relocate to different pharmacy premises in the area of the relevant HWB, or

(ii) to open, within the area of the relevant HWB, additional pharmacy premises from which to provide pharmaceutical services,

where the applicant is seeking the listing of pharmacy premises which are in a controlled locality.

(2) If the NHSCB receives an application (A1) to which paragraph (1) applies, it must refuse A1 (without needing to make any notification of that application under Part 3 of Schedule 2), where the applicant is seeking the listing of premises at a location which is—

(a) in an area in relation to which outline consent has been granted under these Regulations, the 2012 Regulations or under the 2005 Regulations within the 5 year period—

(i) starting on the date on which the proceedings relating to the grant of outline consent reached their final outcome, and

(ii) ending on the date on which A1 is made; or

(b) within 1.6 kilometres of the location of proposed pharmacy premises (other than proposed distance selling premises), in respect of which—

(i) a routine application under these Regulations or the 2012 Regulations, or

(ii) an application to which regulation 22(1) or (3) of the 2005 Regulations (relevant procedures for applications) applied,

was refused within the 5 year period starting on the date on which the proceedings relating to the refusal reached their final outcome and ending on the date on which A1 is made,

unless the NHSCB is satisfied that since the date on which the 5 year period started, there has been a substantial and relevant change of circumstances affecting the controlled locality.

(3) For the purposes of paragraphs (1) and (2), if no particular premises are proposed for listing in A1, the applicant is to be treated as seeking the listing of pharmacy premises at the location which is the best estimate that the NHSCB is able to make of where the proposed listed pharmacy premises would be, having regard to the best estimate given by the applicant under paragraph 1(7)(a)(ii) of Schedule 2.

(4) Paragraph (2)(b) does not apply where the NHSCB is satisfied that there are reasonable grounds for believing the person making the refused application was motivated (wholly or partly) by a desire for that application to be refused.

(5) The refusal of an application pursuant to paragraph (2)(b), or regulation 40(2)(b) of the 2012 Regulations (applications for new pharmacy premises in controlled localities: refusals because of preliminary matters), is to be ignored for the purposes of the calculation of a 5 year period pursuant to paragraph (2)(b).

7.11 The Committee noted that there was no information to suggest that the instant application was in respect of a location where outline consent had been granted or there had been a refusal for a previous application within the last 5 years.

Regulation 41

7.12 Based on its conclusion above, the Committee went on to consider the application in light of the remainder of Part 7 of the Regulations and, in particular, regulation 41 which reads:

(1) This paragraph applies to any routine application—

(a) for inclusion in a pharmaceutical list as an NHS pharmacist; or

(b) from an NHS pharmacist included in such a list—

(i) to relocate to different pharmacy premises in the area of the relevant HWB, or

(ii) to open, within the area of the relevant HWB, additional pharmacy premises from which to provide pharmaceutical services,

where the applicant is seeking the listing of pharmacy premises which are in a controlled locality and the NHSCB is required to notify the application under Part 3 of Schedule 2.

(2) If paragraph (1) applies to an application (referred to in this regulation and regulation 42 as “A1”), subject to paragraph (5), the NHSCB must determine whether or not the “relevant location”, that is—

(a) the location of the premises for which the applicant is seeking the listing; or

(b) if no particular premises are proposed for listing in A1, the location which is the best estimate that the NHSCB is able to make of where the proposed pharmacy premises would be, having regard to the best estimate given by the applicant under paragraph 1(7)(a)(ii) of Schedule 2, 26

is, on basis of the circumstances that pertained on the day on which A1 was received by the NHSCB, in a reserved location.

(3) Subject to regulation 43(2), the area within a 1.6 kilometre radius of a relevant location is a “reserved location” if—

(a) the number of individuals residing in that area who are on a patient list (which may be an aggregate number of patients on more than one patient list) is less than 2,750; and

(b) the NHSCB is not satisfied that if pharmaceutical services were provided at the relevant location, the use of those services would be similar to, or greater than, the use that might be expected if the number of individuals residing in that area who are on a patient list were 2,750 or more.

(4) Before making a determination under paragraph (2) (referred to in this regulation and regulation 42 as “D1”), the NHSCB must—

(a) notify the persons notified under Part 3 of Schedule 2 about A1 that the NHSCB is required to make D1 (and it may make this notification at the same time as it notifies those persons about A1); and

(b) invite them, within a specified period of not less than 30 days, to make representations to the NHSCB with regard to D1 (and the period specified must end no earlier than the date by which the person notified needs to make any representations that they have with regard to A1).

(5) The NHSCB must not make a determination under paragraph (2) in respect of A1 in circumstances where an earlier application which was in respect of the relevant premises and to which paragraph (1), regulation 44 of the 2012 Regulations (prejudice test in respect of routine applications for new pharmacy premises in a part of a controlled locality that is not a reserved location) or regulation 18ZA of the 2005 Regulations (refusal: premises which are in a controlled locality but not a reserved location) applied was refused—

(a) for the reasons relating to prejudice in—

(i) regulation 44(3),

(ii) regulation 44(3) of the 2012 Regulations, or

(iii) regulation 18ZA(2) of the 2005 Regulations; and

(b) within the 5 year period starting on the date on which the proceedings relating to the refusal reached their final outcome and ending on the date on which A1 is made, unless the NHSCB is satisfied that since the date on which the 5 year period started, there has been a substantial and relevant change of circumstances affecting the controlled locality.

(6) For the purposes of paragraph (5), the “relevant premises” are—

(a) the premises which are proposed for listing; or

(b) if no particular premises are proposed for listing in A1, premises at the location which is the best estimate that the NHSCB is able to make of where the proposed listed pharmacy premises would be, having regard to the best estimate given by the applicant under paragraph 1(7)(a)(ii) of Schedule 2.

7.13 The Committee considered the issue of reserved location for premises described in the application.

7.14 The Committee noted that the appellant had not challenged NHS England's position that Ewyas Harold is a reserved location.

7.15 The Committee noted that NHS England had stated that the number of individuals residing within 1.6km of the best estimate who are on a patient list is 1,043. The Committee noted that no party had sought to dispute this figure.

7.16 The Committee noted that NHS England had further gone on to conclude that there was no information or evidence to suggest that the use of pharmaceutical services would not be similar to, or greater than, the use that might be expect if the number of individuals residing in that area who are on a patient list were 2,750 or more. The Committee noted that this had not been disputed by any party.

7.17 On the basis of the information before it, the Committee determined that the use of pharmaceutical services would not be similar to, or greater than, the use that might be expected if the number of individuals residing in that area who are on a patient list were 2,750 or more.

7.18 The Committee noted that as the number of individuals residing in that area who are on a patient list is less than 2,750, the area is therefore in a reserved location. The Committee did not need to go on to consider prejudice. The Committee therefore next considered whether the application met the requirements of Regulation 18.

Regulation 18

7.19 The Committee noted that this was an application for “unforeseen benefits” and fell to be considered under the provisions of Regulation 18 which states:

"(1) If—

(a) the NHSCB receives a routine application and is required to determine whether it is satisfied that granting the application, or granting it in respect of some only of the services specified in it, would secure improvements, or better access, to pharmaceutical services, or pharmaceutical services of a specified type, in the area of the relevant HWB; and

(b) the improvements or better access that would be secured were or was not included in the relevant pharmaceutical needs assessment in accordance with paragraph 4 of Schedule 1,

in determining whether it is satisfied as mentioned in section 129(2A) of the 2006 Act (regulations as to pharmaceutical services), the NHSCB must have regard to the matters set out in paragraph (2).

(2) Those matters are—

(a) whether it is satisfied that granting the application would cause significant detriment to—

(i) proper planning in respect of the provision of pharmaceutical services in the area of the relevant HWB, or

(ii) the arrangements the NHSCB has in place for the provision of pharmaceutical services in that area;

(b) whether, notwithstanding that the improvements or better access were not included in the relevant pharmaceutical needs assessment, it is satisfied that, having regard in particular to the desirability of—

(i) there being a reasonable choice with regard to obtaining pharmaceutical services in the area of the relevant HWB (taking into account also the NHSCB’s duties under sections 13I and 13P of the 2006 Act (duty as to patient choice and duty as respects variation in provision of health services)),

(ii) people who share a protected characteristic having access to services that meet specific needs for pharmaceutical services that, in the area of the relevant HWB, are difficult for them to access (taking into account also the NHSCB’s duties under section 13G of the 2006 Act (duty as to reducing inequalities)), or

(iii) there being innovative approaches taken with regard to the delivery of pharmaceutical services (taking into account also the NHSCB’s duties under section 13K of the 2006 Act (duty to promote innovation)),

granting the application would confer significant benefits on persons in the area of the relevant HWB which were not foreseen when the relevant pharmaceutical needs assessment was published;

(c) whether it is satisfied that it would be desirable to consider, at the same time as the applicant’s application, applications from other persons offering to secure the improvements or better access that the applicant is offering to secure;

(d) whether it is satisfied that another application offering to secure the improvements or better access has been submitted to it, and it would be desirable to consider, at the same time as the applicant’s application, that other application;

(e) whether it is satisfied that an appeal relating to another application offering to secure the improvements or better access is pending, and it would be desirable to await the outcome of that appeal before considering the applicant’s application;

(f) whether the application needs to be deferred or refused by virtue of any provision of Part 5 to 7.

(g) whether it is satisfied that the application presupposes that a gap in pharmaceutical services provision has been or is to be created—

(i) by the removal of chemist premises from a pharmaceutical list as a consequence of the grant of a consolidation application, and

(ii) since the last revision of the relevant HWB's pharmaceutical needs assessment other than by way of a supplementary statement.

(3) The NHSCB need only consider whether it is satisfied in accordance with paragraphs (2)(c) to (e) if it has reached at least a preliminary view (although this may change) that it is satisfied in accordance with paragraph (2)(b)."

7.20 The Committee considered that Regulation 18(1)(a) was satisfied in that it was required to determine whether it was satisfied that granting the application, or granting it in respect of some only of the services specified in it, would secure improvements, or better access, to pharmaceutical services, or pharmaceutical services of a specified type, in the area of the relevant HWB

7.21 The Committee went on to consider whether Regulation 18(1)(b) was satisfied, i.e. whether the improvements or better access that would be secured if the application was granted were or was included in the PNA in accordance with paragraph 4 of Schedule 1 of the Regulations.

7.22 Paragraph 4 of Schedule 1 requires the PNA to include: “a statement of the pharmaceutical services that the HWB had identified (if it has) as services that are not provided in the area of the HWB but which the HWB is satisfied (a) would if they were provided….secure improvements or better access, to pharmaceutical services… (b) would if in specified future circumstances they were provided…secure future improvements or better access to pharmaceutical services…” (emphasis added).

7.23 The Committee considered the Pharmaceutical Needs Assessment ("the PNA") prepared by Herefordshire Health and Wellbeing Board, conscious that the document provides an analysis of the situation as it was assessed at the date of publication. The Committee bears in mind that, under regulation 6(2), the body responsible for the PNA must make a revised assessment as soon as reasonably practicable (after identifying changes that have occurred that are relevant to the granting of applications) unless to do so appears to be a disproportionate response to those changes. Where it appears disproportionate, the responsible body may, but is not obliged to, issue a Supplementary Statement under regulation 6(3). Such a statement then forms part of the PNA. The Committee noted that the PNA was dated May 2018 and that no supplementary statements had been issued.

7.24 The Committee noted that Herefordshire had been split into different localities for the purpose of the PNA and that this was based on the CCG locality model. The Committee noted that the proposed site was within the South and West locality. The Committee noted that the PNA had looked at areas as a whole, based on the trends towards similar demographics within the localities and had not split the localities down into smaller areas. The Committee noted the one reference in the PNA to the Golden Valley which is where the site of the proposed pharmacy is situated, however this is mentioned as part of the consideration of population density.

7.25 The Committee noted that the PNA had provided, section 5 “The Assessment” at 5.1 “Conclusions – Summary of Gaps” showing “Needs and Improvements” and had considered the gaps in pharmaceutical provision in the area of the PNA. The Committee noted that there were improvements or better access listed but that no specific details had been provided in the PNA for any of the localities and that these were general statements for the area covered by the PNA as a whole.

7.26 The Committee noted that the Applicant seeks to provide unforeseen benefits to the residents of Ewyas Harold and the surrounding villages. The Committee noted that the improvements or better access that the Applicant was claiming would be secured by its application were not included in the relevant pharmaceutical needs assessment in accordance with paragraph 4 of Schedule 1.

7.27 In order to be satisfied in accordance with Regulation 18(1), regard is to be had to those matters set out at 18(2). The Committee's consideration of the issues is set out below.

Regulation 18(2)(a)(i)

7.28 The Committee had regard to

"(a) whether it is satisfied that granting the application would cause significant detriment to—

(i) proper planning in respect of the provision of pharmaceutical services in the area of the relevant HWB"

7.29 The Committee noted that NHS England had concluded that the application, if granted, would not detriment proper planning in the area. The Committee noted that no party had sought to argue or produce any information which would support a finding that significant detriment would be caused if the application was granted.

7.30 On the basis of the information available, the Committee was not satisfied that, if the application were to be granted and the pharmacy to open, the ability of the NHS England thereafter to plan for the provision of services would be affected in a significant way.

7.31 The Committee was therefore not satisfied that significant detriment to the proper planning of pharmaceutical services would result from a grant of the application.

Regulation 18(2)(a)(ii)

7.32 The Committee had regard to

"(a) whether it is satisfied that granting the application would cause significant detriment to— …

(ii) the arrangements the NHSCB has in place for the provision of pharmaceutical services in that area"

7.33 The Committee noted that NHS England had not addressed the provisions of Regulation 18(2)(a)(ii) in its decision letter and had not provided any representations on this matter. The Committee noted that no party had sought to argue, or produce any information, which would support a finding that significant detriment would be caused. On the basis of the information available, the Committee was therefore not satisfied that significant detriment to the arrangements currently in place for the provision of pharmaceutical services would result from a grant of the application.

7.34 In the absence of any significant detriment as described in Regulation 18(2)(a), the Committee was not obliged to refuse the application and went on to consider Regulation 18(2)(b).

Regulation 18(2)(b)

7.35 The Committee had regard to

"(b) whether, notwithstanding that the improvements or better access were not included in the relevant pharmaceutical needs assessment, it is satisfied that, having regard in particular to the desirability of—

granting the application would confer significant benefits on persons in the area of the relevant HWB which were not foreseen when the relevant pharmaceutical needs assessment was published"

Regulation 18(2)(b)(i) to (iii)

7.36 The Committee noted the comments from the Applicant that there is no pharmacy within Ewyas Harold and therefore there is no choice of pharmaceutical services for those within the village and surrounding area. The Committee was mindful that consideration needs to be given as to whether there is a reasonable choice in obtaining pharmaceutical serives within the area of the relevant HWB. The Committee noted the information from NHS England with regard to the nearest pharmacy, which is located approximately 5 miles away, as well as the map, provided by NHS England, which showed the location of pharmaceutical provision as well as the location of medical provision in the area. The Committee noted the comments with regard to the GP practice in Ewyas Harold also being a dispensing practice and whilst noting the service that was provided the Committee was mindful that a GP dispensing practice is not a pharmacy and as such does not provide the full range of services that a pharmacy does.

7.37 The Committee noted the distances to the nearest pharmacies as quoted by both NHS England and the Applicant. Given the information with regard to distance and from viewing the map provided, the Committee was of the view that it was unlikely that those in Ewyas Harold would choose to access pharmaceutical services outside of the village on foot, however the Committee was of the view that difficulties of access on foot did not of itself indicate that there was not reasonable choice in obtaining pharmaceutical services. The Committee went on to consider the ease of access to the nearest pharmacies by private and public transport.

7.38 The Committee noted the statement from the Applicant with regard to public transport; that it takes 50 minutes in each direction and that 2 buses are required to reach the destination. The Committee noted that the Applicant had not expanded upon this statement and further had not provided any bus time tables in support of this assertion. The Committee further noted that the Applicant had not stated where or what the “destination” that they were referring to was or if this was the journey to the nearest pharmacy. The Committee was mindful the nearest pharmacy in distance might not be necessarily be the easiest to access, however no further information had been provided by the Applicant in support of this assertion. Given the lack of information before it, the Committee concluded that for those who relied on public transport there was nothing provided by the Applicant to demonstrate that they were currently having difficulties in accessing the existing pharmaceutical provision in the area of the HWB.

7.39 The Committee noted that the PNA had defined the distribution of pharmacies and access to pharmacies in terms of people travelling more than a mile and access by car within 20 minutes. The Committee noted that the Applicant had quoted this statement from the PNA but had provided no information with regard to car ownership levels in the area. Further, the Committee noted that the Applicant had not expanded upon the information given in the PNA in the context of this application and why, for those living in Ewyas Harold, a journey of approximately 20 minutes meant that they were currently having difficulties in accessing the existing pharmaceutical provision in the area. The Committee concluded that for those who did have access to private transport there was nothing provided by the Applicant to demonstrate that they were currently having difficulties in accessing the existing pharmaceutical provision in the area of the HWB.

7.40 The Committee was of the view that the applicant has not demonstrated that there is not already reasonable choice with regard to obtaining pharmaceutical services in the

area of the relevant HWB, such that it was not satisfied that, having regard to the desirability of there being a reasonable choice with regard to obtaining services, granting the application would confer significant benefits on persons.

7.41 In considering Regulation 18(2)(b)(ii) the Committee reminded itself that it was required to address itself to people who share a protected characteristic having access to services that meet specific needs for pharmaceutical services that are difficult for them to access. The Committee was also aware of its duties under the Equality Act 2010 which include considering the elimination of discrimination and advancement of equality between patients who share protected characteristics and those without such characteristics. The Committee noted the comments from the Applicant in response to the decision letter from NHS England and quoted from the PNA in respect of those patients who share a protected characteristic. The Committee accepted that there were always people in an area who share a protected characteristic and was of the view that whilst a pharmacy located at the proposed site may be a benefit to some people, there was no information provided by the Applicant to indicate why this was a significant benefit or how those with a protected characteristic were currently experiencing any difficulties in accessing pharmaceutical services. The Committee was therefore not satisfied that, having regard to the desirability of people who share a protected characteristic having access to services that meet specific needs for pharmaceutical services that are difficult for them to access, granting the application would confer significant benefits on persons.

7.42 In considering Regulation 18(2)(b)(iii) the Committee had regard to the desirability of innovative approaches to the delivery of pharmaceutical services. In doing so, the Committee would consider whether there was something more over and above the usual delivery of pharmaceutical services that might be expected from all pharmacies, some ‘added value’ on offer at the location. The Committee noted that the Applicant had provided no information with regard to innovation in their application form or on appeal. The Committee was not satisfied that, having regard to the desirability of there being innovative approaches taken with regard to the deliverability of pharmaceutical services, granting the application would confer significant benefits on persons.

Regulation 18(2)(b) generally

7.43 The Committee noted that the Applicant is proposing to open for 53 hours a week and that all of these would be core hours. The hours were arranged so that provision would be available from 8:30am to 6:30pm Monday to Friday and from 9am to 12 noon on a Saturday. The Committee noted that the Applicant was not proposing to provide any hours, either core or supplementary on a Saturday afternoon or a Sunday. The Committee was of the view that there was no information provided to support a finding that pharmaceutical services are not currently provided at such times as needed and therefore it was not satisfied that, having regard to the desirability of there being a reasonable choice with regard to obtaining services, granting the application would confer significant benefits (in relation to opening hours) on person.

7.44 The Committee noted that there was currently a dispensing GP practice located in the village in the vicinity of the site of the proposed pharmacy. The Committee was mindful that these are dispensing services and therefore do not offer the same level and range of services that a full pharmaceutical service would offer, however there were dispensing services being provided in the area. The Committee further noted the other services provided by the GP practice as documented above, but was again mindful that these are not pharmaceutical services in the context of these Regulations. The Committee accepted that whilst there was some provision in the area this could not be considered in the context of the Regulations.

7.45 The Committee was of the view that in accordance with Regulation 18(2)(b) the granting of this application would not confer significant benefits on persons in the area of the HWB which were not foreseen when the PNA was published.

Other considerations

7.46 Having determined that Regulation 18(2)(b) had not been satisfied, the Committee did not need to have regard to Regulation 18(2)(c) to (e).

7.47 No deferral or refusal under Regulation 18(2)(f) was required in this case.

7.48 The Committee considered whether there were any further factors to be taken into account and concluded that there were not.

7.49 The Committee was not satisfied that the information provided demonstrates that there is difficulty in accessing current pharmaceutical services such that a pharmacy at the proposed site would provide better access to pharmaceutical services.

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

7.50.1 confirm NHS England’s decision;

7.50.2 quash NHS England’s decision and redetermine the application;

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

7.51 In those circumstances, given that NHS England had not considered all parts of Regulation 18, the Committee determined that the decision of NHS England must be quashed.

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

7.53 The Committee noted that representations on Regulation 18 had been sought from parties by NHS England and representations had already been made by parties to NHS England in response. These had been circulated and seen by all parties as part of the processing of the application by NHS England. The Committee further noted that when the appeal was circulated representations had been sought from parties on Regulation 18.

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

8 DECISION

8.1 The Pharmacy Appeals Committee (“Committee”), appointed by NHS Resolution, quashes the decision of NHS England, for the reasons given above, and redetermines the application.

8.2 The Committee determined that the application should be refused.

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

8.4 The Committee concluded that Ewyas Harold is in a controlled locality and that the site of the application is in a reserved location.

8.5 The Committee has considered whether the granting of the application would cause significant detriment to proper planning in respect of the provision of pharmaceutical services in the area covered by the HWB, or the arrangements in place for the provision of pharmaceutical services in that area and is not satisfied that it would;

8.6 The Committee determined that the application should be refused on the following basis:

8.6.1 In considering whether the granting of the application would confer significant benefits, the Committee determined that –

8.6.1.1 there is already a reasonable choice with regard to obtaining pharmaceutical services;

8.6.1.2 there is no evidence of people sharing a protected characteristic having difficulty in accessing pharmaceutical services; and

8.6.1.3 there is no evidence that innovative approaches would be taken with regard to the delivery of pharmaceutical services;

8.6.2 Having taken these matters into account, the Committee is not satisfied that granting the application would confer significant benefits as outlined above that would secure improvements or better access to pharmaceutical services.

Jill Jackson Case Manager Primary Care Appeals

A copy of this decision is being sent to:

Rushport Advisory LLP on behalf of Pharminspire Limited VWV LLP on behalf of The Golden Practice Partnership Herefordshire and Worcestershire LPC PCSE on behalf of NHS England – West Midlands Area Team