NHS Pharmaceutical Care Services Planning. Aberdeen City Community Health Partnership. Pharmaceutical Care Services Plan.

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1 NHS Pharmaceutical Care Services Planning Aberdeen City Community Health Partnership Pharmaceutical Care Services Plan December 2012 This document is also available in large print and other formats and languages on request. Please call NHS Grampian on or or

2 Aberdeen City Community Health Partnership Pharmaceutical Care Services Plan December 2012 Contents Page No 1. Introduction to Aberdeen Community Health Partnership NHS Grampian Strategic Vision For Primary Care Services Geography of Aberdeen City CHP Population of Aberdeen City CHP 4 2. Description of Primary Care Pharmaceutical Service 7 Provision in Aberdeen City CHP 2.1. Overview of Pharmacy Services Premises Standards Interface with Other Providers Core Services Additional Services Unscheduled Care Accessibility of Pharmaceutical Services Description of General Medical Service Provision in the 16 NHS Board Area 3.1. General Medical Services Relationship with Community Pharmacy Dispensing Practices Analysis of Pharmaceutical Needs Within Aberdeen City 18 CHP 4.1. The Need for Additional Premises The Need for Additional Pharmaceutical Services from 19 Existing Providers 5. Planning and Action Plan Primary Care Redesign Chronic Medication Service Closer working between Community Pharmacy and the 21 CHP 5.4. Appropriate Prescribing for Patients Reducing 21 Polypharmacy (Scottish Government, 2012) 5.5. New National Initiatives Patient Centred Care Sexual Health Palliative Care Expansion of minor illness service Provision of Vaccinations References 26 Appendix 1 Aberdeen City Datazones 27 Appendix 2 - Community Pharmacy Locations Travelling Time By Road Networks 28 Aberdeen City Community Health Partnership Pharmaceutical Care Services Plan - 1 -

3 1. Introduction to Aberdeen City Community Health Partnership (CHP) 1.1. NHS Grampian Strategic Vision For Primary Care Services The overall health of the people of Grampian is described in documents such as the NHS Grampian Health Plan 2010 (NHS Grampian 2010) and the vision for future service delivery in the Health and Care Framework. The Health Plan gives details of how the Board aims to improve the health of the population. It focuses on patient-centred, safe and effective working and Pharmacy is one sector of healthcare trying to achieve this. Medicines continue to be the most common treatment provided by the health service throughout Scotland. Getting the most benefit from these medicines, and reducing the harm associated with medicines, is a core function of the pharmacy services in Grampian. Pharmacy in 2020: Directors View outlines a vision for pharmacy, where patients would register with a community pharmacy, akin to the way they are currently registered with a GP practice for medical services. Community pharmacy would be a primary source of medicines information and would have a more clinically focussed role, with the majority being qualified as independent prescribers, which will allow them to contribute to the management of long term conditions. Most community pharmacies would have dedicated space for other members of the health and social care team. Pharmacy assistants would be trained in health promotion as well as advising on minor ailments and general medicines and healthcare advice, pharmacy technicians will be checking technicians able to manage the whole dispensing process, and with pharmacists only performing clinical checks on prescriptions, releasing time for other clinical roles. All of this aims to provide better outcomes for patients, with improved compliance with medicines leading to efficiencies in the healthcare systems Geography of Aberdeen City CHP Overview The majority of Aberdeen City is classified as a large urban area with the remainder being accessible small towns or accessible rural areas (NHS Grampian 2012b) For community service planning and delivery, Aberdeen CHP is divided broadly into four geographical areas (clusters), initially organised around natural communities and the location of GP practices. These clusters are emerging as the vehicle for more collaborative working across health and social care. See section In order to support a number of strategic aims, the CHP continues to work with GP practices to critically review and refine practice boundaries. This will result in GP practices becoming more embedded within defined communities; limiting the time GPs spend travelling for home visits and establishing closer links with other primary care contractors, health and social care providers. Complementary to this, a recent review of community nursing has led to the establishment of direct delivery teams (DDTs) who have responsibilities for looking after patients within a clearly defined geographic area, with corresponding links to the relevant GP practice(s). Aberdeen City Community Health Partnership Pharmaceutical Care Services Plan - 2 -

4 Whilst GP practices operate with a defined patient list and within geographical boundaries, the position is clearly different for Community Pharmacy. This may raise questions about access and equity of services. Patients may use several pharmacies and their choice may depend on a range of factors such as: proximity to work or home, opening hours, parking or ease of access via public transport or availability of local enhanced services. Recognising the above, future planning for pharmaceutical services will require balancing the needs of the surrounding community (e.g. cluster) as well as providing services for the population at large Cluster Working The CHP is divided into four clusters that vary in size and in health needs. Each cluster currently has a focus on a key strategic theme (see list below) in which they take a lead, developing services or projects, and trying out new ways of working on behalf of the rest of the CHP. See also Section 3.1. o o o o North Care of the elderly (specifically leading on embedding the introduction of Anticipatory Care Plans 1 ); Central North Health inequalities (focus on areas of deprivation, ethnic groups) Central South Children / early years South Pathways (focus on key orthopaedic pathways / musculo-skeletal) All four clusters have a working group called a Cluster Integrated Group, which incorporates wide representation from: Each practice in the cluster (GP & Practice Manager) Cluster Clinical Lead CHP aligned staff (including management, nursing, pharmacy, public health, Allied Healthcare Professional) Social Work 3 rd Sector (voluntary organisations) Each cluster also has a Cluster Operational Group, which is responsible for taking forward projects on behalf of the Cluster and actions delegated to the Cluster by the overarching CHP Cluster Management Group (CMG). The operational group is comprised of the CHP staff aligned to the particular cluster (see above). 1 Anticipatory care planning encourages people to adopt a thinking ahead approach and to have greater control and choice by planning for what their preferred support and care interventions would be in the event of a future flare-up or deterioration in their condition, or a carer crisis (Scottish Government, 2013) Aberdeen City Community Health Partnership Pharmaceutical Care Services Plan - 3 -

5 1.3. Population of Aberdeen City CHP Unless otherwise stated, data in this section has been sourced from NHS Grampian: Pharmaceutical Care Services Plan: Technical Information and Analysis for NHS Staff and Contractors (Phase One). (NHS Grampian, 2012b.) Age Mid year population estimates of 2010 indicate that Aberdeen has a population of 217,120 (NHS Grampian 2012b), which equates to 39.4% of the Grampian population. The percentage of the population aged 0-15 is the third lowest of all the CHPs in Scotland; The percentage who are of working age is the third highest; The percentage of the population aged 75 plus is 7.4% (Scotland 7.7%). Projections - over the 25 year period , the 75+ age group is projected to increase the most (52% increase) (NHS Grampian 2012b), in keeping with Scotland as a whole. During the same period, the population aged under 16 years in Aberdeen City is projected to decline by 4.9 per cent The rate of in- and out-migration in Aberdeen is well above the Scottish average; this is partly due to the two universities and Aberdeen College attracting young people to the city. Most migrants are in the age group Sex Mid year population estimates of 2010 indicate that overall there is an even ratio of males: females, however a difference is notably apparent in the 75+ age group. Total population: 49.5% male, 51.5% female 75+ : 37.9% male, 62.1% female Ethnicity 1.63% of the Grampian population is made up of ethnic minority groups and in Aberdeen City, National insurance registrations for migrant workers are the second highest of all council areas. From mid 2010 to mid 2011, a total of 13,541 in-migrants moved to Aberdeen, while 10,872 outmigrants left the city. All of Aberdeen s migration gain in 2010/11 was due to overseas migration, where there was a net increase of 3,738 people. The number of births to non-uk born mothers has risen steadily since 2004; by 2011, these births accounted for 32% of all births in Aberdeen. The number of school pupils in Aberdeen from a minority ethnic group rose from just under 1,400 in 2006 to over 2,000 in After English, Polish is the most common home language of school pupils in Aberdeen, followed by Arabic and Malayalam (Aberdeen City Council, 2012). Aberdeen City Community Health Partnership Pharmaceutical Care Services Plan - 4 -

6 Deprivation There is a wide variation in deprivation across Aberdeen City. Whilst the oil and gas industry has brought significant wealth to the City, there remain significant pockets of deprivation clustered around the Tillydrone, Middlefield, Kings Links and Torry areas (see Appendix 1). In terms of the Scottish Index of Multiple Deprivation categorization, the City has a significantly higher proportion of most deprived areas / datazones compared to Aberdeenshire and Moray Summary of Health Indices Male and female life expectancies are significantly better than the Scotland average Mortality rate from coronary heart disease (CHD) is significantly better than Scotland All-cause mortality (all ages) is not significantly different to Scotland. Approximately 25% of adults are smokers (same as Scotland average) The death rate from alcohol related conditions is significantly below average but the number of people hospitalised for these conditions is significantly higher than average. The proportion of the population hospitalised with drug related conditions is higher than average. 22.9% of older people with increased care needs are looked after at home rather than in formal care settings compared with the Scottish average of 31.7% The under-18 teenage pregnancy rate is significantly higher than Scotland (47.4 per 1000 women compared to Scottish average of 41.4 per 1000 women) In terms of chronic disease burden (based on Quality Outcomes Framework (QOF) prevalence estimates): o Prevalence of asthma is less than Grampian average (5.73% v 5.81%) o Prevalence of chronic obstructive pulmonary disease (COPD) is greater than Grampian average (1.48% v 1.42%) o Prevalence of CHD is less than Grampian average (3.77% v 3.99%) o Prevalence of diabetes is less than Grampian average (3.56% v 3.89%) o Prevalence of mental health issues is greater than Grampian average (0.84% v 0.74%) Relevance to Delivery of Pharmaceutical Services Clusters remain in the relatively early stages of development. However, it is clear they will increasingly act as the vehicle to bring about significant changes at community level, in the way services are planned, organised and delivered. A key feature of clusters will be their increasing role in enabling the provision of more co-ordinated and where appropriate more integrated services. It is clear that opportunities exist to create improved links between the CHP and Community Pharmacy. Some of these opportunities are highlighted within this document. With regards to the demographics of Aberdeen as detailed in this section (1.3) there are potential opportunities for community pharmacies to help deliver NHS Grampian s health plan. The following are key issues that need to be considered in any service development. An ageing population will require enhanced pharmaceutical advice / guidance on managing medicines in order to support people to remain in their own homes for as long as possible. Aberdeen City Community Health Partnership Pharmaceutical Care Services Plan - 5 -

7 Within a generally, very affluent city, there are still significant pockets of deprivation which result in greater health needs. There is a relatively high proportion of ethnic minority groups who may have difficulty accessing health services in general. These populations tend to be within certain communities in the city. Community pharmacy may be an easier point of access for healthcare advice. Substance misuse of both alcohol and drugs result in higher than average morbidity, some of which could be addressed within community pharmacy. Community pharmacy may be able to contribute to the improvement of young people s sexual health. Aberdeen City Community Health Partnership Pharmaceutical Care Services Plan - 6 -

8 2. Description of Primary Care Pharmaceutical Service Provision in Aberdeen City CHP 2.1. Overview of Pharmacy Services Community pharmacies are independent contractors who provide a service to the NHS in accordance with national regulations and locally negotiated contracts. Premises must be registered with the General Pharmaceutical Council (GPhC) and a registered pharmacist must supervise the supply of medicines. Community pharmacies are very accessible, providing a no appointment necessary service for advice on managing illness and improving health. There are 51 pharmacies in Aberdeen city: 6 single outlets 24 are part of an independent chain 21 are part of a National Multiple chain Last year nearly 3.2 million prescription items were dispensed in the city, equating to a total medicines cost of approximately 36.5 million Premises Standards The GPhC is responsible for the regulation of pharmacists, pharmacy technicians and pharmacy premises. They have recently issued new Standards for Registered Pharmacies, one of which relates specifically to the physical environment of the pharmacy (General Pharmaceutical Council, 2012): Principle 3: The environment and condition of the premises from which pharmacy services are provided, and any associated premises, safeguard the health, safety and wellbeing of patients and the public. The responsibility for meeting the standards lies with the pharmacy owner and the GPhC are developing a new way of inspecting pharmacies to ensure that they are being adhered to. The GPhC also state The standards can also be used by patients and the public so that they know what they should expect when they receive pharmacy services from registered pharmacies Interface with Other Providers Secondary Care The interface between community pharmacy and secondary care is an area of increasing focus as Scotland pursues its policy of more integrated care. One of the opportunities for closer working between the two sectors is exploring the potential for the supply of medicines from community pharmacy which have historically only been supplied from hospital pharmacy. At present, this is being trialled on a relatively small scale with one medicine (Imatinib used in treating some cancers) and is expected to develop over time. Aberdeen City Community Health Partnership Pharmaceutical Care Services Plan - 7 -

9 The hospital pharmacy department has already established a system for contacting community pharmacists when patients, who are receiving their medicines in a compliance aid, are discharged form hospital. An Information Transfer Pilot is due to commence in January The pilot is designed to establish whether enabling access to community pharmacy Patient Care Records (PCRs) will facilitate medicines reconciliation on admission to acute services. It is envisaged that the PCR would provide useful additional information, which would complement that already available in Emergency Care Summaries or Anticipatory Care Plans. Frail Elderly in the Community Community Pharmacy provides an interface between frail elderly in the community and those living in sheltered, supported or residential accommodation. Increasingly this cohort of the population is the focus of integrated working between the acute sector, the GP and the provider of care in the community. Currently the majority of care homes in the city are supplied via one large contractor and to date the service is largely based on a supply function. All care homes in the city have an aligned GP practice and there may be benefit in aligning to a pharmacy contractor in the local neighbourhood in the future. GMED / NHS24 Community pharmacists have direct access to GMEDS/NHS 24 through the professional-to professional phone line. This facility is used in order to refer a patient directly to a medical doctor for confirmation of diagnosis and treatment of a minor illness. NHS 24 will also refer patients to a service provided by a pharmacy, where appropriate e.g. Community Pharmacy Urgent Supply (CPUS), Minor Ailment Service (MAS) or Emergency Hormonal Contraception (EHC) Core Services All pharmacies are required to provide all 4 core pharmaceutical care services Minor Ailment Service Public Health Service. Acute Medication Service Chronic Medication Service Minor Ailment Service (MAS) Minor ailments can generally be described as common, often self-limiting conditions. They normally require little or no medical intervention and are usually managed through self-care and the use of appropriate products that are available to purchase, over the counter, without a prescription. This service aims to support the provision of direct pharmaceutical care within the NHS by community pharmacists. The service allows eligible people to register with the community pharmacy (of their choice) for the consultation and treatment of common self-limiting conditions Aberdeen City Community Health Partnership Pharmaceutical Care Services Plan - 8 -

10 with over-the-counter medicines, free of charge. The pharmacist advises, treats or refers the person (or provides a combination of these actions) according to their needs. A person must be registered with a Scottish GP practice and belong in a previous exemption category to be eligible for the Minor Ailment Service. Patients who are not eligible for MAS can still access advice and treatment from any community pharmacy. There is evidence of variation in MAS registrations and number of items issued across the city, which may be partly explained by the differing underlying health needs and levels of deprivation amongst patients accessing individual pharmacies. However, it is possible that the lower uptake of MAS in some pharmacies is due to insufficient promotion by pharmacy staff. All children are entitled to MAS and this is reflected in the types of medication being issued via MAS e.g. paracetamol suspension. MAS data also highlights where there has been a significant shift of practice from GP treatment to self care (e.g. treatment of head lice) Community Pharmacy - Public Health Service (PHS) There are two patient service elements of the public health service Smoking Cessation Services This consists of the provision of a smoking cessation service comprising advice and supply of nicotine replacement therapy (NRT) and other smoking cessation products over a period of up to 12 weeks, in order to help smokers successfully stop smoking. As part of the core PHS, a new scheme to provide a medicine called varenicline under Patient Group Direction is being rolled out locally. This is very much in the early stages and only three pharmacies in Aberdeen are currently providing this service Sexual Health Services There is only one pharmacy within Aberdeen City that does not provide EHC, however there are alternative pharmacies in the neighbourhood who do provide the service. All community pharmacies can provide supplies of contraceptives under the Community Pharmacy Urgent Supply (CPUS) service. However, there is an anomaly whereby women who receive their contraceptives under Patient Group Direction (PGD) from Sexual Health Services (e.g. Square 13) cannot technically be given an emergency supply under CPUS. A City-centre pharmacy is currently running a pilot contraceptive clinic on a Thursday evening (Scottish Government funding). The aim is to try and relieve the pressure on the evening surgery provided by Sexual Health Service, allowing them to deal with more vulnerable young women Acute Medication Service (AMS) The Acute Medication Service represents the provision of pharmaceutical care services for acute episodes of care and supports the dispensing of acute prescriptions and any associated counselling and advice. This remains a significant part of the daily workload of all community pharmacies. Aberdeen City Community Health Partnership Pharmaceutical Care Services Plan - 9 -

11 Chronic Medication Service (CMS) CMS provides personalised pharmaceutical care by a pharmacist to patients with long term conditions. The aim is to improve a patient s understanding of their medicines and to work with the patient to maximise the clinical outcomes from the therapy. There are three stages to CMS: Stage 1. Reviewing patients medicines Stage 2. CMS patient care record and plan Stage 3. Serial prescriptions All community pharmacies within Aberdeen city should be participating in Stages 1 and 2, although there is evidence of varying levels of involvement. Currently, data is available on current registrations for CMS and number of Patient Care Records (PCR) completed. However, at this time, it is hard to draw meaningful conclusions about service provision as it is not possible to relate this data to health need. One GP practice and 10 surrounding pharmacies are involved in the early adopter project for Stage 3 - Serial prescriptions. Serial dispensing has the potential to both improve services for the patient and reduce GP workload and the aim is for this to be implemented across the city during In order for this to be achieved, the Pharmacy & Medicines Directorate and the CHP pharmacy team will need to provide support to both Community Pharmacies and GP practices Additional Services Certain additional services are negotiated at Board level but may not necessarily be available from all community pharmacies within Aberdeen city. Current additional services available within the city are detailed below. With the exception of travel medicine clinics and chlamydia testing and treatment services, all residents of Aberdeen city are within a 20-minute travelling time of a pharmacy that provides these additional services. Some pharmacies choose to provide other services (such as blood pressure testing, blood glucose testing or weight management advice) but provision of these services is not directed by the Health Board Substance Misuse Services (SMS) Within Aberdeen city, only two pharmacies are not signed up to the Local Enhanced Service (LES) to provide methadone or buprenorphine containing products. There are other pharmacies that do provide this service within walking distance of both. Of the pharmacies that are signed up to the LES, only two do not provide consume on the premises (COTP) dispensing. Within the near future this will be resolved for one pharmacy as a planned relocation to new premises will provide them with a suitable environment to offer COTP dispensing. In a minority of pharmacies, concerns have been raised that some patients have to wait excessive durations of time to receive their methadone instalment. Although rare, the majority Aberdeen City Community Health Partnership Pharmaceutical Care Services Plan

12 of these reports arise in pharmacies that are also very busy with walk in patients (not necessarily pharmacies dispensing a high volume of methadone prescriptions). NHS Grampian is currently reviewing the pharmacy substance misuse Service Level Agreement to shift the emphasis from the existing task orientated payment to recognise the important clinical role provided by community pharmacies for this patient group. It aims to ensure that patients receive a uniform standard of treatment that is not dependent on which pharmacy they use. Flexible access to community pharmacy SMS service supports the delivery of the current Scottish Government s Road to Recovery strategy (The Scottish Government, 2008). This is particularly important for those patients at the start of treatment who require close monitoring and more frequent supply and also for those who are more stable and are successfully engaged in full-time work Injecting Equipment Providers (IEPs) There are currently 5 pharmacies providing injecting equipment across the city. This service contributes to NHS Grampian s aim to reduce the risk of Blood Borne Viruses (BBVs) in substance misusers. The pharmacies are supported by a specialist IEP (Drugs Action) which operates a base and five outreach IEP centres within the city. Injecting equipment is also available from the Middlefield Project (The Healthy Hoose). Most areas of the city are adequately covered by this arrangement. However the north of the city has fewer sites and needs analysis would be beneficial. Not all pharmacies that provide injecting equipment participate in the Condom Distribution Service (see section ). There may be opportunity to increase distribution of free condoms to this at risk client group as part of the BBV strategy Participation in Out of Hours Rota There is no Out of Hours rota in Aberdeen city. See section for further information on accessibility of pharmaceutical services (during core hours and out of hours ) Participation in Palliative Care Network (PCN) Scheme There are 10 pharmacies in Aberdeen city that participate in the PCN. As a member of this network, the pharmacies are obliged to keep a core stock of specific palliative care drugs. In terms of accessibility: The pharmacies are well distributed across the city In addition to normal working hours, four of these pharmacies provide a service up until 8pm, Monday to Friday. All 10 pharmacies are open on Saturday (6 morning only, 4 all day) 4 pharmacies are open on Sunday G-MED and Aberdeen Royal Infirmary (ARI) Pharmacy team hold home contact details of PCN pharmacists who can be called out of hours to facilitate supply of palliative medicines when required. Aberdeen City Community Health Partnership Pharmaceutical Care Services Plan

13 Oxygen Provision With the transition of the supply arrangements for Domiciliary Oxygen to a single integrated national route, community pharmacies will no longer hold or provide oxygen cylinders as part of a Domiciliary Oxygen Service. A small number of pharmacies will, in the meantime, continue to hold a limited stock of oxygen cylinders as part of local contingency planning, should the national supply route fail. It is likely that between 2 and 4 pharmacies in Aberdeen city will participate in this service, chosen on the basis of geographical accessibility and flexibility of opening hours i.e. to include a least one pharmacy with opening hours 7 days a week. A need has also been identified for local provision of portable oxygen concentrators in hours for short term use in acutely unwell, hypoxaemic patients where admission to hospital is not in a patient s best interest (e.g. care home patient). In the city, this requirement will most likely be met by provision of concentrators by the Early Supported Discharge team in Aberdeen Royal Infirmary Advisory Services to Care Homes Advisory Services to Care Homes is listed in the Scottish Drug Tariff as a service that can be locally negotiated, however this is currently under review at a national level Carer Workers Medication Management In order for some adults to remain living safely in their own home, assistance with managing and taking prescribed medication is required. For a minority of adults, support from paid care workers will be required to ensure they organise and take their medication correctly. Medication Management support is commissioned by Aberdeen City Council after the service user is assigned one of 2 levels: Level 2: The service user still has capacity to make informed decisions about their medication. Minimal support is required (generally just a prompt or assistance in opening packaging) although some Level 2 service users may require their medication to be administered. Medication can be in compliance aids or original packs. The service provider s caser file is used to record activity. Level 3: The service user does NOT have the capacity to make informed decisions about their medicines. Care at home workers administer prescribed medication. Medication must be supplied in original packs with a Medication Administration Record (MAR) chart. Care workers record all administration on this MAR chart. The guideline for the service is in the process of being updated and will be available January The CHP has a Service Level Agreement (SLA) in place to pay contractors who provide MAR charts for Level 3 service users. Not all contractors have signed up to the SLA and some contractors do not have the software/ hardware to actually produce MAR charts. To date, the numbers of Level 3 service users has been minimal. This may change with the launch of the new guidelines in January Aberdeen City Community Health Partnership Pharmaceutical Care Services Plan

14 In the future, it would be beneficial to the service if all contractors were able to produce MAR charts for any of their patients who required Level 3 medication management support. It would also be of benefit if community pharmacies could provide medication charts for Level 2 service users who receive original packs (as a prompt for care at home workers). See Section 5 (Planning and Action Plan) Influenza Vaccination Services There are 8 pharmacies across Aberdeen city who are signed up to the NHSG PGD for administration of influenza vaccine. Under this PGD they may administer vaccination to occupational health groups (e.g. NHS and Local Authority staff) or to private patients, without the need for the patient to consult their GP. NHS eligible groups are referred to their GP for immunisation. Other community pharmacies (e.g. some national chains) may provide a service for private patients only, working under their own PGDs Stoma Appliance Services All community pharmacies in Aberdeen are registered to provide a stoma appliance service and they must abide by the service standards stipulated by NHS Scotland (NHS Scotland, 2011) Independent Prescribing by Community Pharmacists Currently, there are six community pharmacy prescriber clinics running in Aberdeen city covering: respiratory (3 clinics), hypertension (1 clinic), substance misuse (1 clinic), and contraception (1 clinic). (See also Section ). Developing or extending these services is challenging due to unpredictable national funding streams and issues with sustainability of service due to the availability of pharmacist prescribers. Pharmacist prescribing will evolve with the continued roll out of CMS and, in time, is likely to become embedded as a core part of the pharmacists role (as opposed to a clinic based activity) Keep Well One community pharmacy provides health checks for some of the core Keep Well patients registered with one of the GP practices in the city. The pharmacy has agreed to pilot health checks for a small cohort of eligible SMS patients (identified as one of the new vulnerable groups under Keep Well). The service has not been rolled out to other community pharmacies in the city as it is not yet clear whether this is a cost-effective way of supporting the delivery of the Keep Well program Travel Medicine Clinics Four pharmacies are signed up to NHSG PGDs for the supply of Prescription Only Antimalarials. In addition, one pharmacy is providing a full private travel medicine service including immunisations (with the exception of yellow fever vaccination). A charge is made to patients for all services, even those that would be free of charge if provided by a GP practice. Aberdeen City Community Health Partnership Pharmaceutical Care Services Plan

15 Chlamydia Testing And Treatment There are 6 pharmacies in Aberdeen city that supply chlamydia-testing kits and can also, if indicated, supply treatment. They are located in central Aberdeen (City Centre, Tillydrone, Woodside, King Street) and south Aberdeen (Garthdee, Torry), and cover many of the more deprived areas in the city. Chlamydia test & treat is also available from other community settings in the city such as Square 13 and the Healthy Hoose Condom Distribution Service There are 15 pharmacies in Aberdeen city who currently participate in the Condom Distribution Service which provides access to free condoms across a number of settings, along with information and advice on health promotion in relation to sexual health. The service is overseen by Public Health and the sites have been chosen on the basis of local need (NHS Grampian 2012a) 2.6. Unscheduled Care Community pharmacies provide an important access route for people requiring unscheduled care, particularly during weekends and public holidays. One of the tools available to pharmacists is the National PGD for the Urgent Supply of Repeat Medicines and Appliances. Community pharmacies can directly refer to local Out of Hours services when the patient requires a more specialist consultation with another healthcare professional. A project based in a city-centre pharmacy, funded by the Scottish Government, has confirmed that the public find it acceptable to be treated for minor injuries by a nurse within a community pharmacy setting. Plans to extend this type of service into other community pharmacies need to be considered in the wider context of availability of unscheduled care Accessibility of Pharmaceutical Services Location of Community Pharmacies Many GP practices have historically been located in the city centre and, over time, a corresponding concentration of community pharmacies has emerged in what is a relatively small geographical area. Whilst this has resulted in some areas of the city appearing to have less equitable access to a local community pharmacy, this has to be balanced with the fact that all city residents are well within a 20-minute travelling time of a pharmacy (in-hours) (NHS Grampian 2012b) (See Appendix 2). Patients may use several pharmacies. Their choice may depend on a range of factors e.g. proximity to work or home, opening hours, parking or ease of access via public transport. Aberdeen does have good transport links, including free bus travel for pensioners. The 2010 City Voice survey indicated that almost 90% of respondents found it very easy or easy to access a pharmacy (Community Planning Aberdeen, 2010). Aberdeen City Community Health Partnership Pharmaceutical Care Services Plan

16 In terms of consideration of any proposed new pharmacy premises or relocations, cognisance would be taken of the CHP Premises Strategy, which is currently being developed (see Section 4) Opening Hours Core Times By the terms of their contract, community pharmacies are required to provide NHS services during the hours agreed with the Health Board. The contracted hours may not necessarily be the actual hours of opening as they represent the minimum service provision. Hours of opening can be found in the Pharmaceutical List: Pharmaceutical List. Currently the Pharmaceutical List is only available to NHS staff (on the NHS Grampian intranet), but it will be made available on the internet in the future. Members of the public can find their local pharmacy on the NHS 24 website: Evening and Weekends There is no rota provision across Aberdeen city, because the out of hours access provided by supermarkets and multiples is considered adequate. It is important to note that these services are accessed by significant numbers of the population who reside out with the city: Seven pharmacies provide services after 6pm on weekdays (one until 7pm, 3 until 8pm and 3 until 9pm). They are spread across the city: Dyce, Danestone, Bridge of Don in the North; Berryden, King Street, Union Square in the city centre and Garthdee in the South. All have easy parking and are accessible by public transport. The majority of pharmacies provide services on a Saturday; 3 are closed all day, 26 close at lunchtime. 9 pharmacies provide services on a Sunday; 5 are open until 6pm. The pharmacies opening on Sundays are the same pharmacies that provide extended hours on weekdays (see above), with the addition of one pharmacy in the city centre (Bon Accord) and another in the south of the city (Holburn St). Where pharmaceutical services are not accessible in the evening, weekends or public holidays, emergency medical care is provided via the out of hours GP services (G-MED). G-MED staff can provide medication to treat a patient in an emergency or can issue a prescription to be dispensed on the next working day when pharmacies are open. With the completion of the Emergency Care Centre (ECC) on the Foresterhill site, NHS 24, GMEDs and the Emergency Department (previously known as Accident & Emergency) will be located together. They will operate a re-direction policy whereby patients presenting at the ECC who do not need to be seen with in the acute setting are re-directed to a more appropriate service. This will include community pharmacies. Aberdeen City Community Health Partnership Pharmaceutical Care Services Plan

17 3. Description of General Medical Service Provision in the NHS Board Area 3.1 General Medical Services There are currently 30 medical practices in Aberdeen city. Details of GPs and contact numbers are available from the NHS Grampian public website: NHS Grampian - General Practitioners The city GP practices have been grouped into clusters (as detailed below) and each cluster has a nominated GP cluster lead. NORTH CENTRAL NORTH CENTRAL SOUTH SOUTH Brimmond Calsayseat Albyn Carden Medical Bucksburn Denburn Camphill Garthdee Danestone Elmbank Cults Holburn Gilbert Road Links Great Western Kincorth Old Aberdeen Northfield / Mastrick Hamilton Marywell (homeless practice) Old Machar Rosemount Peterculter Rubislaw Place Scotstown Westburn Victoria St Torry Woodside Whinhill c. 65,000 patients c. 53,000 patients c. 70,000 patients c. 63,000 patients Many of the practices in Aberdeen are sited in the west end of the city (historical reasons). Scotstown Medical Practice, Bridge of Don, has a satellite surgery in Udny (Aberdeenshire) and dispenses medication for the patients registered at Udny. The nearest pharmacies to Udny are Balmedie (8 miles away) and Tarves (6 miles away.) The Haddo Medical Group based in Pitmedden dispenses at its Pitmedden and Methlick surgeries. No other practices in the city dispense for their patients. The situation at Haddo is still under review. Until resolved, no review of other dispensing doctors can be taken (see Section 3.3). A significant minority of patients registered with practices in the north cluster live in Aberdeenshire, and may therefore choose to access pharmacy services in Balmedie, Newmachar and Inverurie. The planning process for new premises for the Woodside Medical Practice is underway. The new surgery will be built in 2014 near to the Woodside Community Centre on Marquis Road. This is unlikely to affect the local pharmacies. 3.2 Relationship with Community Pharmacy The relationship between pharmaceutical and medical services varies across the city. In areas such as Cove, Torry and Dyce, which have well defined/discreet natural communities, the situation is more conducive to inter professional liaison. However, in general, local communities in the city are not as well defined as they are in Aberdeenshire. Aberdeen City Community Health Partnership Pharmaceutical Care Services Plan

18 Many of the city centre pharmacies deal with prescriptions and queries from almost all the city s GP surgeries. Most pharmacies have regular contact with GP surgeries through repeat prescription collection services. The range and quality of these prescription collection services varies and the sustainability (due to lack of remuneration for community pharmacies) is always under question. The continuation of primary care re-design (which reflects greater involvement of CHPs with all contractor groups) is a catalyst for the increased involvement and role of community pharmacy. The Chronic Medication Service (CMS) has already commenced in community pharmacy, through early adopters, and its roll out will accelerate over the coming year. Medication reviews and serial dispensing will radically change the relationship between pharmacies and GP surgeries. The number and organisation of community pharmacies and GP practices in the city will create challenges in establishing enhanced relationships. The Electronic Transfer of Prescriptions (ETP) has begun (through barcoded prescriptions). Once electronic signatures allow for a fully electronic prescriptions (i.e. no paper prescriptions) the issues of lost prescriptions, faxed or phoned in prescriptions will hopefully disappear and allow for more timely supply of medicines. 3.3 Dispensing Practices General Medical Services (GMS) regulations make allowance for an NHS Board to request a GMS practice to dispense medicines, in certain circumstances. This can occur only if the Board, after consultation with the Area Pharmaceutical Committee, is satisfied that a person, by reason of distance or inadequacy of means of communication or other exceptional circumstances, will have serious difficulty in obtaining from a pharmacist any drugs, not being scheduled drugs or appliances required for his treatment under these (GMS) regulation. Currently, only one practice in the city (Scotstown Medical Group) provides a dispensing service to its patients registered at its Udny Surgery and living with Aberdeenshire. The Udny Surgery dispenses medication prescribed by the GPs. No over the counter medicines are sold and only the advice stated by the doctor on the prescription will be provided to the patient at the point of dispensing. No delivery service is available, though medicines can be collected at the Potterton Post Office or the surgery. Additional services such as smoking cessation, CMS, MAS are not provided. Whilst it is important that patients in Udny are able to obtain their prescribed medicines without undue inconvenience, it is also essential that they are not disadvantaged by being unable to access the additional services a pharmacy has to offer. The need for dispensing practices should be reviewed at a corporate level rather than a CHP level and guidance is awaited following a recent appeal, which successfully reinstated dispensing from a GP practice. Aberdeen City Community Health Partnership Pharmaceutical Care Services Plan

19 4. Analysis of Pharmaceutical Needs Within Aberdeen City CHP 4.1. The Need for Additional Premises The Aberdeen Local Development Plan sets out ambitious plans for potential residential and commercial property developments across the city, and around the periphery. The plan describes the areas within the city boundary that have been designated for the different types of developments. Whilst it is important to note that developments are subject to economic variables, and as such cannot be guaranteed to progress, the plan provides important prospective information which can help inform service planning. The key residential developments are outlined below (where a unit refers to a house or flat). North Areas within the north part of the city are earmarked for considerable potential growth. Most notably: Grandhome Development (off Whitestripes area) +5,000 units; Newhills and Dyce Drive +2,500 units: Stoneywood +1,000 units; Dubford and Murcar circa, 500 units. Central North The Plan outlines two key developments in this area: Greenferns 750 units; Maidencraig 320 units. Central South A development of 1,200 units is proposed for Countesswells (circa. 200/250 units per annum from 2015). A smaller development of around 300 units is proposed for the Friarsfield area over the same time period. Peterculter is outlined for a development of 400 units for a similar period. South A significant development is proposed for the Loirston area of Cove, equating to 3,750 units. Both residential and commercial designation reflects the plans for the Western Peripheral Route (WPR), which has recently been confirmed. It is anticipated that this confirmation will act as a catalyst for further requests from developers to designate additional areas of land for development, close to the WPR location. Ensuring close liaison with NHSG Physical Planning colleagues will be crucial in order for the potential of the Aberdeen Local Development Plan to be realised. Changes to GP Practice Premises/Sites The CHP is currently in the process of developing a new strategy for GP premises. This will set out, in strategic terms, the medium term aspirations and plans for GMS provision in Aberdeen. The GP Premises Strategy will be an important point of reference in the needs assessment of pharmaceutical services. On the two-year horizon, the Woodside Medical Group development is unlikely to create a significant impact on existing community pharmacy service delivery, due to the close proximity of the new build to existing practice premises. Aberdeen City Community Health Partnership Pharmaceutical Care Services Plan

20 Within a two to three year window, Denburn Medical Practice will be re-located within the city. Work is ongoing with Physical Planning colleagues to secure a development site and options for future service delivery. Subject to what is agreed, this may impact on pharmaceutical service needs, particularly if the practice does not relocate within the Rosemount area. Currently pharmaceutical premises are considered appropriate to meet the needs of Aberdeen city and its environs. However, the potential changes outlined above, together with the associated investment (eg. construction investment associated with WPR) is likely to impact on the ability of current premises to cope with demand The Need for Additional Pharmaceutical Services from Existing Providers Core Services Opening Hours Changes (Acute Medication Service) There will always be a requirement for an acute dispensing service. Proposed changes to existing opening hours should be discussed with CHP to ensure that availability of pharmaceutical services to patients is not compromised. Serial Dispensing (Chronic Medication Service) CMS, which in itself incorporates an element of anticipatory care planning, is a key component of the multi-professional approach to managing chronic disease. Although Aberdeen is perceived as a wealthy city, chronic disease burden varies across the city and there are areas with significant deprivation. In these areas there is high prevalence of diseases such as COPD, Ischaemic Heart Disease (IHD) and diabetes. The attitude and responsibility of patients towards self-management of long-term conditions is variable. Support for the elderly with significant co-morbidities is currently very challenging due to lack of care in the community. Once fully implemented CMS, should improve communication between GPs and community pharmacy and ensure pharmacological management of long-term conditions is effective. When serial dispensing is established for appropriate patients, not only will obtaining repeat prescriptions will be more convenient for patients but, in addition, GP practices and Pharmacies will be able to manage their workload more efficiently. Currently the delivery of CMS is variable across the city. Work to engage community pharmacies and GP practices to develop a plan for implementation is planned for early Public Health Prevention strategies such as smoking cessation are key to reducing morbidity and mortality in areas of deprivation. Provision of smoking cessation services is variable but at this time it is unclear whether this is due to patient demand or pharmacy performance. Development of systems for performance monitoring under the auspices of redesign (see Section 5) will support further assessment of service provision. Aberdeen City Community Health Partnership Pharmaceutical Care Services Plan

21 M AS There is a need to ensure that this service is being provided equitably across the city, particularly with the increased likelihood of patients being re-directed from the ECC. There does appear to be variability in the provision of MAS but again it is not clear whether this is due to a variation in demand or if pharmacies are not pro-actively offering this service Locally Negotiated Services These should continue to be negotiated at Grampian level (as with other contractor services) as there is a need to have a consistency of approach in order that payments are standardised across the Health Board area. At present there appears to be no obvious gaps in locally negotiated services. A methadone space audit is currently underway and provision of services will be reviewed when the results become available. Fundamentally, if new services are being introduced or existing services modified within limited resource, the CHP will need to consider where best to target these resources in order to reduce the inequalities of health within the population. Aberdeen City Community Health Partnership Pharmaceutical Care Services Plan