Pharmaceutical Care Services Plan. July Version 2

Transcription

1 Pharmaceutical Care Services Plan July 2013 Version 2

2 This document is also available in large print and other formats and languages on request. Please call NHS Grampian Pharmacy and Medicines Directorate on or e- mail Pharmaceutical Care Services Plan Review Date: 2015 Version 2 - i -

3 Pharmaceutical Care Services Plan July 2013 Contents Page No 1. Introduction 2 2. NHS Grampian Strategic Direction 3 3. NHS Grampian Geography 5 4. Ethnicity 6 5. NHS Grampian Pharmaceutical Care Services Plan 6 6. What Is Community Pharmacy? 6 7. Pharmaceutical Care Services 8 8. Difficulties In Access To Pharmaceutical Services 9 9. What Is The Process For the NHS Grampian Pharmaceutical 10 Care Planning? 10. Who Should Read The NHS Grampian Pharmaceutical Care 11 Services Plan? 11. Key Findings From The Plan Recommendations And Actions Community Health Partnership Section - Aberdeen Community Health Partnership Section - Aberdeenshire Community Health and Social Care Partnership Section - Moray Further Information Steering Group And Working Group Membership 98 Appendix A - Pharmaceutical Care Services Plan Public Consultation Response Form Pharmaceutical Care Services Plan Review Date: 2015 Version 2-1 -

4 Pharmaceutical Care Services Plan 1 Introduction Welcome to the new NHS Grampian (NHSG) Pharmaceutical Care Services Plan for The previous NHSG Pharmaceutical Care Services Plan May 2012 consisted of three documents: Pharmaceutical Care Services Plan (Phase One) May NHS Grampian: Pharmaceutical Care Services Plan: Technical Information and Analysis for NHS Staff and Contractors (Phase One) May NHS Grampian Services from Community Pharmacies May These documents have been used to inform and develop the 2013 plan and to take forward the work started in The new plan will include more comprehensive Community Health (and Social Care) Partnership (CHP/CHSCP) information, opinion and recommendations in order to introduce a more comprehensive strategic approach to Pharmaceutical Care Services planning. Excerpts from the individual CHP/CHSCP area plans for Aberdeen City (section 13), Aberdeenshire (section 14) and Moray (section15) are provided in this document. The complete versions of this and each CHP plan are available from _applic=ccc&p_service=content.show& and for community pharmacists from dicines_directorate/pcsp.html. One of the key components of the NHS Grampian 2020 Vision is the development of a population based approach to health and health care supported by the creation of 11 clusters/areas across Grampian allowing services and resources to be integrated for the delivery of care as close to the service user as possible; at home, a homely setting or in the local community. There are 4 clusters in Aberdeen City, 6 areas in Aberdeenshire and one in Moray. Populations range from 40,000 to 90,000 (Moray) with a similarly wide geographical range; relatively compact geography in Aberdeen City to a significantly greater spread in Aberdeenshire. Furthermore the 2020 Vision describes a significantly higher degree of integration (than currently) between service users, providers, health & care agencies, 3rd (voluntary) and private sectors. Clusters/areas will facilitate this integration and become the route through which transformation of services will occur. Each cluster/area has dedicated GP leadership supported by aligned CHP management and functional areas (pharmacy, public health, nursing, Allied Healthcare Professionals (AHP), etc). Formal structures exist for regular cluster/area meetings (all stakeholders NHS/Council), clinical leadership meetings (GP Leads/local senior management) and Grampian-wide senior clinical and executive leadership meetings. Pharmaceutical Care Services Plan Review Date: 2015 Version 2-2 -

5 It is envisaged that dedicated pharmacy clinical lead posts will be developed and appointed in the near future to join the appropriate multidisciplinary groups in order that community pharmacy is represented to a greater extent within the cluster/area groups. 2 NHS Grampian Strategic Direction The overall health of the people of Grampian is described in documents such as the NHS Grampian Health Plan 2010 and the vision for future service delivery in the Health and Care Framework. The Health Plan gives details of what the Board is trying to do to improve health and the way in which people are treated. It focuses on patient-centred, safe and effective working and pharmacy is one sector of healthcare trying to achieve this. In the Health Plan, Richard Carey, Chief Executive for NHS Grampian outlined the vision for improving services, including community pharmacy; Our plans for delivering the best possible services for a healthier Grampian will focus on "shifting the balance of care". In other words, moving care to where it is most appropriate, and putting more emphasis on what happens outside hospitals. Our aim is to ensure the care you receive is high quality, which means, safe, with good clinical outcomes and improved patient experiences. This is what we mean by putting people at the centre of everything we do. At the same time, the services we provide and the way in which we work must be efficient and affordable. This does not mean one-off savings, but long term financial stability. Shifting the balance of care will mean ongoing changes to how we deliver health and healthcare services in the future. In Grampian we will improve public access across primary care, making greater use of all service providers, pharmacy, dentistry, optometry and general medical services Medicines continue to be the most common treatment provided by the health service in NHS Grampian. Getting the most benefit from these medicines, and reducing the harm associated with medicines, is a core function of the Grampian Pharmacy Service. Pharmacy in 2020: Directors View outlines a future vision for pharmacy in 2020, 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. Pharmaceutical Care Services Plan Review Date: 2015 Version 2-3 -

6 All of this aims to provide better outcomes for patients, with improved compliance with medicines leading to efficiencies in the healthcare systems. To assist non-english speaking members of our local ethnic communities, work is underway to roll out the Language Line telephone interpretation system to all community pharmacies in Grampian. Language Line gives staff access to expert interpreters, on the telephone, in seconds, for over 170 different languages. Material in translation can also be provided. In addition a pilot scheme has recently been launched whereby pharmacists can tick the appropriate boxes on bi-lingual information sheets, to give non-english speaking patients written information on the safe use of their medicines and treatments. For people with a communication disability, accessible/pictorial material, large print and other formats can be provided. A roll out programme providing Portable Induction Loops (PIL s) to every community pharmacy to help people who use a hearing aid is also underway. Pharmaceutical Care Services Plan Review Date: 2015 Version 2-4 -

7 3 NHS Grampian Geography Figure 1. Scotland Map - NHS Grampian Boundaries Pharmaceutical Care Services Plan Review Date: 2015 Version 2-5 -

8 The geographical area covered by NHS Grampian extends to approximately 3,500 square miles of North East Scotland. The Grampian area population mid-year estimate in 2010 was 550,620 persons, representing 10.5% of the population of Scotland (National Records of Scotland). 4 Ethnicity The demographic information collected on a joint basis with the Grampian Regional Equality Council (GREC), suggests, that there are still substantial numbers of mostly Eastern European migrant workers and their families settling in Grampian. The NHS Grampian Language Line Usage Monitoring Report, January to December 2012 indicates that the most commonly requested ethnic community languages are Polish, Lithuanian, Russian, Mandarin and Latvian. 5 NHS Grampian Pharmaceutical Care Services Plan The planning process aims to assess the need for, and the provision of pharmaceutical care services in the community setting within NHS Grampian in more detail than the previous plan to ensure that the services are meeting the needs of the Grampian resident population. The purpose of the plan documentation is to inform service users, providers and planners about the care services provided by community pharmacies across NHS Grampian. Consideration can then be taken of this when designing future service. The Community Health Partnership (CHP) specific sections of the plan have been prepared under the direction of the CHP Manager, by a multi-stakeholder group within the individual CHP in order that local expertise was used to inform the plan. Guidance and support has been provided by the Pharmacy and Medicines Directorate. The Pharmacy and Medicines Directorate has coordinated the collation of the CHP sections and prepared the complete NHS Grampian Pharmaceutical Care Services Plan for publishing. It is accepted that the planning process will be flexible and ongoing and there is a commitment to update the plan annually with a full review of Pharmaceutical Care Services most likely occurring on a 3 year cycle to fit with other NHS Grampian Planning processes. 6 What is Community Pharmacy? Community pharmacy is probably better known to most people as the local or High Street Chemist. Historically the central role of the community pharmacy has focused on supply to the patient, i.e. supplying medication in response to prescriptions or over-thecounter requests, and providing advice on taking these medicines. The provision of pharmaceutical services is dependent on community pharmacies being registered with the General Pharmaceutical Council. They must also be included in the Grampian Health Board Pharmaceutical List, a process governed by legal regulations Pharmaceutical Care Services Plan Review Date: 2015 Version 2-6 -

9 set by UK and Scottish Government and managed by the Primary Care Contracts Team (PCCT). Individual pharmacists must be registered with General Pharmaceutical Council (GPhC), before they can legally practice. Pharmacy Technicians are key support staff. The title of pharmacy technician is a protected title and can only be used by those appropriately trained pharmacy staff who are registered with the GPhC. This recent development means that the opportunities for community pharmacies to develop and employ more highly skilled and trained staff are gradually increasing. There are 131 Community Pharmacies in NHS Grampian, 51 in Aberdeen City, 54 in Aberdeenshire and 26 in Moray which together act as a network providing Pharmaceutical Care Services across the Health Board area. All provide NHS dispensing services under agreement with NHS Grampian. In Grampian, community pharmacy contractors (those who own the community pharmacy) fall into 3 main groups Type of Contractor Associated number of Contracts Individuals or partnerships with only one 20 pharmacy ( also known as Independents ) Individuals or partnerships with more than 68 one pharmacy (also known as Independents ) National companies (also known as 43 Multiples ) Total Number of pharmacies 131 This shows a decrease in the number of single outlet independents and an increase in both multi outlet independents and national multiples in the last 12 months. As private contractors, community pharmacies often also provide other goods and private services to purchase in addition to their contracted NHS service provision. In the year April 2011 to March 2012, over 8.5 million prescription items were dispensed in Grampian at a gross ingredient cost of almost 92million Although this historical supply function continues to be provided, as part of a national Pharmacy Contract, community pharmacies now have a wider role in delivering pharmaceutical care for patients with chronic conditions, improving access to pharmaceutical care services in general, and to prescribed and over-the-counter medicines in particular. They also have an expanding clinical role in health improvement. Community pharmacies are very accessible to individual patients and research in Scotland demonstrates that for the vast majority of people access to a local community pharmacy is good. Patients are seen regularly when they come in to collect prescriptions, and a no appointment necessary service for provision of advice on managing illness and improving health is always available. Pharmaceutical Care Services Plan Review Date: 2015 Version 2-7 -

10 The provision of advice to patients and their carers on over-the-counter, pharmacy only or prescription only medicines is an important and increasing aspect of self care. Pharmacies have been identified by the Scottish Government as the future walk-in healthy living centres for Scotland. 6.1 Premises Standards Pharmacy premises must be registered with the General Pharmaceutical Council (GPhC), and supervised by a pharmacist. The GPhC has recently issued new Standards for Registered Pharmacies. Principle 3 of the Standards relates specifically to the physical environment of the pharmacy (General Pharmaceutical Council, 2012): 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 standards are being adhered to. The GPhC also states 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. 7 Pharmaceutical Care Services 7.1 National Core Services In addition to NHS prescription dispensing services, all community pharmacies in Scotland provide and the following Core NHS Pharmaceutical Care Services directly from their premises: The Minor Ailment Service (MAS) provides appropriate advice, treatment, or onward referral to another NHS healthcare practitioner free of charge to eligible individuals (those who previously were exempt from prescription charges). The Chronic Medication Service (CMS) provides ongoing pharmaceutical care support for patients with stable long-term conditions (including dispensing of prescriptions, counselling, and advice). The Public Health Service (PHS) aims to encourage the pro-active involvement of community pharmacists and their staff in supporting self-care, offering suitable interventions to promote a healthy lifestyle and establishing a health-promoting environment. The Acute Medication Service (AMS) covers the dispensing of acute prescriptions but also relates to the electronic management of those prescriptions from writing at the GP practice through the dispensing process, to the submission to Practitioner Services Department for coding of the items and subsequent reimbursement to the Pharmacy Contractor for the items. These Core Services are provided by all community pharmacies in Grampian. Pharmaceutical Care Services Plan Review Date: 2015 Version 2-8 -

11 7.2 Locally Negotiated Services Additional locally negotiated services which may be available from some community pharmacies have been introduced over time in response to national and local population needs. These include support for palliative care, methadone supervision, or syringe and needle exchange. These services are provided under contract to NHS Grampian and are managed by the Primary Care Contracts Team (PCCT). The contracting process itself is being reviewed updated and as a result individually contracted services are also being reviewed. Each Community Health Partnership (CHP) section identifies the services within its area. The Grampian Community Pharmacy list includes details of all pharmacies and the services they provide and is available from the Scottish Health on the Web Community Pharmacy Website under NHS Grampian ( 8 Difficulties In Access To Pharmaceutical Services Where NHS Grampian Health Board has assessed that patients requiring NHS prescriptions have difficulty in accessing a community pharmacy to obtain their dispensed medicines, there have historically been a number of options available to ease these difficulties in access: a. Essential Small Pharmacy Scheme The Essential Small Pharmacy Scheme (ESPS) is intended for pharmacy contractors who have a steady state of dispensing low volumes of prescriptions. It provides an allowance to those pharmacies that are providing essential services to communities in areas where access to the nearest alternative pharmacy would present patients with considerable difficulties. The ESPS in Scotland is currently suspended from new applications and is being reviewed nationally but can applies to the 12 existing EPS pharmacies in Grampian by virtue of the following criteria: turnover is less than 1400 prescription items per month on a regular basis the contractor is located more than 2 miles from another pharmacy there are special circumstances which suggest that if the above two conditions are not met that ESP status should still be awarded / maintained. b. Dispensing by General Practice For the vast majority of patients in NHS Grampian, medicines are prescribed by GPs (General Practitioners) and dispensed by community pharmacists. The NHS (General Medical Services) (Scotland) Regulations 2004 allow for the provision of arrangements for supply of drugs and appliances to be undertaken by doctors where 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 Pharmaceutical Care Services Plan Review Date: 2015 Version 2-9 -

12 drugs, not being scheduled drugs, or appliances required for his treatment under these Regulation. In these cases the NHS Board can require the general medical practice that is responsible for the treatment of the person to supply drugs and appliances to that person until further notice. There are currently 10 GP dispensing practices in Grampian. c. Local systems for collection and delivery of batches of prescriptions NHS Grampian has historically contracted a very small number of community pharmacies, in areas of significant difficulty of access, to collect prescriptions from a local general practice and deliver these to designated collection points within the local community. These systems are different from the collection and delivery systems for individual patients and care homes that are operated by many community pharmacies as a private service to their clients. There are currently 6 community pharmacies providing collection and delivery services to 6 different sites within Grampian. As part of Pharmaceutical Care Service Planning NHS Grampian will review how it provides improved access to pharmaceutical services in areas where access is deemed difficult. This review will cover services provided through community pharmacies designated as an essential small pharmacy, dispensing doctor practices and NHS Grampian contracted collection and delivery services. This review will begin in early In certain circumstances, some products such as stoma appliances, elastic hosiery and some other specialist hospital medicines may be supplied by external companies either under a direct contract to the NHS or by dispensing an NHS prescription. 9 What Is The Process For NHS Pharmaceutical Care Planning? The NHS (Pharmaceutical Care Services) (Scotland) Amendment Regulations (2011) require each NHS Scotland Health Board to prepare an annual Pharmaceutical Care Services Plan comprising of a summary of the pharmaceutical care services provided by the Health Board together with an analysis of the areas where a lack of adequate provision has been identified. The NHS Grampian Pharmaceutical Care Services Plan has been prepared by a multistakeholder Working Group in each CHP in conjunction with guidance from the Pharmacy and Medicines Directorate. The previous phase of the NHS Grampian pharmaceutical care services planning process (September 2011 to March 2012) focused on describing and characterising the local needs for core and additional pharmaceutical care services delivered in the community setting. Information has been sourced from the National Records of Scotland, the Scottish Public Health Observatory (ScotPHO) databases to describe variations in demography Pharmaceutical Care Services Plan Review Date: 2015 Version

13 (age, sex, and deprivation) and other health-related characteristics across the population of Grampian. Linking specific geographical populations to specific community-based pharmaceutical care services is difficult. Previous research in Scotland suggests that access to current community pharmacy locations is appropriate and convenient for the majority of individuals. Using a 20 minute travel time threshold, variation in travelling times by motor vehicle to community pharmacy locations and specific pharmaceutical services across Grampian has been examined to assess gaps in geographical access to community pharmacy services. This current planning process considers future service development and care pathways in the context of the agreed NHS Grampian strategic direction for community-based pharmaceutical care and other primary care services. 10 Who Should Read The NHSG Pharmaceutical Care Services Plan? The NHS Grampian Plan documents are available as a resource for all public, professional and policy stakeholders within Grampian. The documentation will be used to inform the development of a strategic vision for Pharmaceutical Care Services within Grampian, and support the prioritisation of available resources. Community Health Partnerships (CHPs), defined groups of GP practices (known as Clusters) and individual contractors will be able to use the documentation to inform planning for local pharmaceutical care services. Individuals will be able to use the planning documentation to find out about pharmaceutical care services in their local community. 11 Key Findings From This Plan From a Health Board-wide perspective and on the basis of the available information and analyses: The vast majority of people living in Grampian have access to a community pharmacy less than 20 minutes travel time, by road, from where they live. In terms of additional services provided by community pharmacies, it was assessed that the general level of geographical access to most services was reasonable. Where people have a serious difficulty in accessing a pharmacist (specifically in rural areas), NHS Grampian has made and will review provision of access by a variety of means. Pharmaceutical Care Services Plan Review Date: 2015 Version

14 12 Recommendations And Actions From the information gathered and assessed within this planning process it was concluded that the current level of geographical access to pharmaceutical services provided by community pharmacies is generally acceptable. Recommendations for future pharmaceutical services should be in line with NHS Grampian strategy and will require pharmacy to: Work with partners in healthcare, social care, third sector, carers and patients to deliver high quality pharmaceutical care in a more integrated way, developing a more seamless continuity of care to the patients of Grampian. Have an increasing emphasis on encouraging patients to register with their community pharmacy for services like Chronic Medication Service to help ensure patients are on the right medicines and understand how to get the best out of their medicines. Aim to provide medicines supply and other services with a patient centred focus within primary care wherever this is possible, sustainable and clinically appropriate. Focus activity on where it adds best health value and where it can contribute to the broader health strategy for services as laid out in the health and care framework through integrated working and more effective contracting processes. Improve quality, patient experience, efficiency, safe systems and information transfer through the use of technology Develop staff to maximise service outputs and make best use of the resources available. Develop new areas of work and new ways of working to contribute to service aims, e.g. expansion of pharmacist prescribing. Pharmaceutical Care Services Plan Review Date: 2015 Version

15 12.1 Key Board-Wide Actions From The Plan The following actions identified through the primary care redesign process or within the pharmaceutical care service planning process have Grampian wide implications, however each CHP will have additional actions based on local needs and projects. Action Process Timescale Lead Reasoning Primary Care Redesign Ongoing Review of access to services To maximise the opportunities for local CHP based management of Community Pharmacy Services provision in line with other contractors Introduction and development of Community Pharmacy Clinical Leadership within the CHPs Review of Dispensing Doctor Provision Ongoing Ongoing CHP Managers and Pharmacy and Medicines Directorate (P&MD) CHP Managers and P&MD Short life working group to be confirmed To ensure that planning and delivery of community pharmacy services is undertaken within an integrated approach to primary care delivery. To bring pharmacy service delivery in line with other contractors. To support the integration of community pharmacy services and develop a sustainable model of local contractor clinical leadership. To represent Community Pharmacy contractors in line with other contractors with regard to representation within the management structure. Following the review of dispensing services from the Haddo Medical Group in Pitmedden the NHS Grampian Board has made a commitment to review all of its requirements placed on GP practices to dispense prescribed medicines. Review of Essential Small Pharmacy Scheme Ongoing Scottish Government and Primary Care Contracts Team (PCCT) The Essential Small Pharmacy Scheme (ESPS) is intended for pharmacy contractors who dispense low volumes of prescriptions and/or who provide essential services to communities in areas where access to the nearest alternative pharmacy would present patients with considerable difficulties. Pharmaceutical Care Services Plan Review Date: 2014 Version

16 Review of Collection and delivery service April 2013 PCCT and P&MD It is intended to combine the ESPS review with the review of dispensing through GP practices. NHS Grampian has historically contracted a very small number of community pharmacies, in areas of significant difficulty of access, to collect prescriptions from a local general practice and deliver these to designated collection points within the local community. These systems are different from the collection and delivery systems for individual patients and care homes operated by many community pharmacies as a private service to their clients. Chronic Medication Service New Contracting Process Implementation of roll out plan Structured quarterly contracting meeting process implemented fully Annual letter for sign up December 2013 April 2013 February 2013 CHP leads / Information Management and Technology (IM&T) facilitators PCCT and P&MD PCCT As part of ongoing PCSP planning these services will be reviewed. NHS Grampian, via Primary Care Integrated Management Group (PCIMG), has made a commitment to the roll out of CMS, as required by Scottish Government as part of Community Pharmacy Core Contract activity. CHP plans have been developed and are being implemented for the roll out of serial dispensing. To provide opportunities for strategic development and monitoring of the contracting process and associated services To ensure Community Pharmacy contractors are supplied with an up to date list of services they are signed up to provide and the requirements of those services. This will also give contractors the opportunity to review the Service Level Agreement for each service and to express interest in other services that they currently do not provide. Pharmaceutical Care Services Plan Review Date: 2014 Version

17 Use of building planning information Updated Service Specifications Update of Substance Misuse Service provision Update of Compliance Aids Service Provision Shared information re Property and asset management and planning information January 2013 to March 2014 April 2013 PCCT and P&MD PCCT, P&MD, Substance Misuse Specialist Pharmacists As above To update current contract and move to a more clinically based patient-centred service. April 2013 PCCT, P&MD To ensure pharmacy resources are directed towards supporting the most appropriate patients. Ongoing Property and To ensure appropriate pharmaceutical service is Asset included in future planning programmes where Health Management Care requirements are being considered. Team and Pharmacy and Medicines Directorate Pharmaceutical Care Services Plan Review Date: 2014 Version

18 13 Community Health Partnership (CHP) Section Aberdeen City 13.1 Introduction To Aberdeen City Community Health Partnership (CHP) 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). 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 North Care of the elderly (specifically leading on embedding the introduction of Anticipatory Care Plans); Central North Health inequalities (focus on areas of deprivation, ethnic groups) Central South Children / early years Pharmaceutical Care Services Plan Review Date: 2014 Version

19 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) 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 Midyear 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 inward and outward 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 Midyear population estimates of 2010 indicate that overall there is an even ratio of males to 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 Pharmaceutical Care Services Plan Review Date: 2014 Version

20 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 out-migrants 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) Deprivation There is a wide variation in deprivation across Aberdeen City. Whilst the oil & 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 Aberdeen City Datazones by 2012 SIMD Quintiles). 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%) Pharmaceutical Care Services Plan Review Date: 2014 Version

21 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 coordinated 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 (13.1.2) 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. 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 Description of Primary Care Pharmaceutical Service Provision in Aberdeen City CHP Overview of Pharmacy Services 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. Pharmaceutical Care Services Plan Review Date: 2014 Version

22 Last year nearly 3.2 million prescription items were dispensed in the city, equating to a total medicines cost of approximately 36.5 million 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 multiple cancers) and is expected to develop over time. 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 GMED / 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: Pharmaceutical Care Services Plan Review Date: 2014 Version

23 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 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. Pharmaceutical Care Services Plan Review Date: 2014 Version

24 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 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. Pharmaceutical Care Services Plan Review Date: 2014 Version

25 Locally Negotiated 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 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 a needs analysis would be beneficial. Pharmaceutical Care Services Plan Review Date: 2014 Version

26 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 & 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 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. Pharmaceutical Care Services Plan Review Date: 2014 Version

27 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 careworkers 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 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 13.5 (Planning and Action Plan) Influenza Vaccination Services There are 8 pharmacies across Aberdeen city who are signed up to the NHS Grampian Patient Group Direction (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. 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). Pharmaceutical Care Services Plan Review Date: 2014 Version

28 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 NHS Grampian 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 Chlamydia Testing & 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) Pharmaceutical Care Services Plan Review Date: 2014 Version

29 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 Community Pharmacy Locations: Travelling Times by Road Network). 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). 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: pdf Pharmaceutical Care Services Plan Review Date: 2014 Version

30 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). These 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 (GMED). GMED 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. Pharmaceutical Care Services Plan Review Date: 2014 Version

31 Description of General Medical Service Provision in the NHS Board Area General Medical Services There are currently 30 medical practices in Aberdeen city. Details of GPs and contact numbers are available from the Family Health Services section of the intranet 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 ). 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 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 Pharmaceutical Care Services Plan Review Date: 2014 Version

32 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. 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 bar-coded 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 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 Pharmaceutical Care Services Plan Review Date: 2014 Version

33 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 Analysis of Pharmaceutical Needs Within Aberdeen City CHP 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 its 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 NHS GRAMPIAN Physical Planning colleagues will be crucial in order for the potential of the Aberdeen Local Development Plan to be realised. Pharmaceutical Care Services Plan Review Date: 2014 Version

34 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. 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 (e.g. construction investment associated with the Western Peripheral Route (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 Pharmaceutical Care Services Plan Review Date: 2014 Version

35 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 13.5) will support further assessment of service provision. 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 Emergency Care Centre (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 Planning and Action Plan The following highlights the key areas for future development. The Wilson report is expected to be published in 2013 and this may provide more direction/clarity on key areas Primary Care Redesign CHPs, the Pharmacy & Medicines Directorate (P&MD) and the Primary Care Contracts Team (PCCT) are currently working through the implications of the NHS Grampian Primary Care Organisation Redesign (NHS Grampian, 2012c). Key work- Pharmaceutical Care Services Plan Review Date: 2014 Version

36 streams of; Strategic Leadership, Clinical Leadership, Clinical Governance and Performance Management have been identified. One of the opportunities of the Primary Care Organisation (PCO) redesign will be to enable closer working of community pharmacies within the cluster. Currently pharmacy champions, funded by NHS Scotland, are supporting the implementation of the new pharmacy contract. In order to develop the role of Community Pharmacy contractors working with CHPs, one proposal is to enhance the champion role to one with a greater leadership focus. The CHP is keen to explore the role of a community pharmacy clinical lead, as there are already similar roles in optometry and dentistry, however there are resource implications that would need to be considered. There is also a need to develop robust systems for the monitoring of both core and locally negotiated services through PCCT. This will be addressed through the Performance subgroup of the redesign process Chronic Medication Service The Scottish Government vision for CMS is that during 2013: All systems are in place which will allow all patients in Scotland to have access to the benefits of pharmaceutical care delivered thorough CMS. During early 2013 the CHP will work with Community Pharmacists, GP practices and other key stakeholders (e.g. Information Management and Technology team (IM&T) to develop an implementation plan for the roll out of CMS across Aberdeen City, building on the experience of the early adopter GP practice and pharmacies in the North of the City Closer working between Community Pharmacy and the CHP Development / implementation of additional or extended services will be easier to manage when community pharmacy services are integrated more fully into the CHP once CMS is fully embedded. For example, links with social care can be developed further to support the Medication Management Support Service with the ultimate aim of supporting patients to remain in their own home. Consistent provision of MAR charts and compliance aids will be key Appropriate Prescribing for Patients Reducing Polypharmacy (Scottish Government, 2012) The review of patients on polypharmacy is a priority for all clinicians. Community pharmacists are ideally placed to highlight pertinent issues to GPs and to support patients and informal carers to manage medicines safely New National Initiatives Scottish Patient Safety Program (SPSP) (Healthcare Improvement Scotland, 2012) The SPSP is a national evidence based programme that aims to reduce the number of events which could cause avoidable harm from healthcare delivered in primary care setting. Following very successful work in the acute sector, the programme is Pharmaceutical Care Services Plan Review Date: 2014 Version

37 being out incrementally in primary care from March 2013 onwards. The initial focus of the programme will be on GP Practices followed shortly by Community Nursing Teams and Community Pharmacies (after pilot work has been completed). Dental and Optometry will follow at a later date. Although patient safety is an integral part of delivering healthcare, the SPSP has developed a range of resources, such as care bundles which are a structured way of improving specific processes of care (e.g. prescribing / monitoring of high risk medicines). Part of the potential clinical lead role would be to drive the patient safety agenda Patient Centred Care This programme aims to put the person at the centre of services. Community pharmacies are ideally located within communities to offer services that are convenient, easily accessible and enable self-care. Pharmacies are also key to supporting self-management of long term conditions by effective use of evidence based treatments. Pharmacists not only support patients, they support informal carers and paid care workers by providing advice on all aspects of managing medicines. The roll out of CMS will contribute to integration of service provision across primary care enabling direct transfer of clinical information between pharmacists and GPs to improve care Sexual Health The possibility of developing School Hubs' in secondary school across the city is being explored. The aim would be to ensure professional links between the school nurse and the community pharmacist to ensure referrals for Emergency Hormonal Contraception (EHC) can be dealt with in a seamless way. Currently there is one contraceptive clinic being run in a city centre community pharmacy but without identified long term funding, the service cannot be developed further Palliative Care Living & Dying Well will continue to be a priority for the health service and there will continue to be a focus on Anticipatory Care planning. Options to expand the palliative care network should be explored, for example; asking more pharmacies to stock the small number of core drugs required for the Just In Case boxes, which are used to manage end of life symptoms in a homely setting (NHS Grampian, 2011). Pharmaceutical Care Services Plan Review Date: 2014 Version

38 Expansion of minor illness service Evidence gathered from GMED audits confirms that a significant number of the professional to professional calls to the Out of Hours (OOH) service are requests for treatment of minor illnesses such as simple urinary tract infection in women. The possibility of providing an enhanced service in community pharmacies (for example through the use of PGDs) should be explored, as this could reduce the workload for the OOH service, enhance the role of the pharmacist and improve access for patients Provision of Vaccinations Many community pharmacies have now established services to provide annual flu vaccinations for NHS staff, paid care workers and any member of the public who wishes to pay. Provision of flu vaccination to at risk groups may be considered in the future. In addition two pharmacies provide a private service for travel vaccinations and supply of malaria prophylaxis. Extension of these services to other community pharmacies would improve patient access and could be considered. Pharmaceutical Care Services Plan Review Date: 2014 Version

39 Prioritisation of Action for Aberdeen CHP Topic Actions Timescale Facilitating link between CHP management, GP cluster leads, GP practices and pharmacy contractors Implementation of Stage 3 of CMS (serial dispensing) Re-launching NHS Grampian/ Aberdeen City Council Medicines Management Guidelines Explore the potential for a Community Pharmacy Clinical Lead role Facilitate links between local community pharmacies and the sexual health hubs being proposed for the Tillydrone area. Explore community pharmacy representation on Cluster Integrated Groups. Implementation plan to be developed Phased roll-out across the City throughout 2013 All GP practices & community pharmacies to be able to offer serial dispensing to appropriate patients Revised guidelines to be finalised and agreed (CHP & Council) Awareness sessions Review and reissue SLA Develop a role profile Explore cost implications and identify recurring funding Initial scoping exercise with NHS G Sexual Health Service Discussion with local community pharmacies April depending on resource availability (see Clinical Lead topic below) End of Jan 2013 During 2013 By end of 2013 End of Jan 2013 Feb-Apr 2013 Feb-Apr 2013 Jan 2013 Jan-Feb 2013 (subject to Scottish Government confirmation of funding for 2013/14) Scoping exercise dependent on Sexual Health Service provisionally Sep 2013 Pharmaceutical Care Services Plan Review Date: 2014 Version

40 Topic Actions Timescale Scottish Patient Safety Initiative Provision of information to CPs Updates on progress within GP practices Roll out to CP Minor Illnesses Analyse professional to professional requests OOH & identify situations where treatment could be provided by community pharmacy Explore the possibility of a PGD to treat uncomplicated UTI in women Palliative Care Explore the potential for developing the palliative care network to facilitate the timely supply of Just in Case Boxes Apr-May 2013 Ongoing from Sep 2013 TBC depending on pilot work being undertaken in CPs TBC, need to allow time for new systems and processes in ECC to be embedded Nov 2013 Substance Misuse / IEPs / Condom Distribution Review of Enhanced Service Contract currently underway Led by NHS G Enhanced Services Group. TBC (?April 2013) Expansion of IEP / Condom distribution Ethnic Minority Groups Explore how access to healthcare via community pharmacies can be improved (e.g. availability of patient information in languages other than English, use of language line, developing links with migrant support workers etc) Service developments will be led by Substance Misuse Service / Public Health with CHP involvement as appropriate Dec 2013 Pharmaceutical Care Services Plan Review Date: 2014 Version

41 13.5 References Aberdeen City Council, Migration Report, Aberdeen. Briefing Paper 2012/06 [online]. Aberdeen: Aberdeen City Council. Available from: Community Planning Aberdeen, Aberdeen City Voice Report 19 [online]. Aberdeen: Community Planning Aberdeen. Available from: port19.pdf General Pharmaceutical Council, Standards for Registered Pharmacies [online]. London : GPhC. Available from: %20pharmacies%20September% pdf HealthCare Improvement Scotland, Scottish Patient Safety Programme [online]. Edinburgh : HIS. Available from: NHS Grampian, Healthfit > caring. listening. improving. NHS Grampian s Health Plan [online]. Aberdeen: NHS Grampian. Available from: NHS Grampian, Just in Case Boxes [online]. Aberdeen: NHS Grampian. Available from: NHS Grampian, 2012a. Free Condoms Distribution Handbook [online]. Aberdeen: NHS Grampian. Available from: NHS Grampian, 2012b. NHS Grampian: Pharmaceutical Care Services Plan: Technical Information and Analysis for NHS Staff and Contractors (Phase One) [online]. Aberdeen: NHS Grampian. Available from: rs_final_may_2012.pdf NHS Grampian, 2012c. NHS Grampian Primary Care Organisation Redesign. Redesign of Pharmacy Contractor Services in Grampian. NHS National Services Scotland, Specification of requirements for dispensing and supply of stoma appliances to patients in the community for NHS Scotland [online]. Edinburgh: NHS NSS. Available from: pecification_requirements_stoma2011.pdf The Scottish Government, The Road to Recovery. A New Approach to Tackling Scotland s Drug Problem [online]. Edinburgh: The Scottish Government. Available from: The Scottish Government, Appropriate prescribing for patients and polypharmacy guidance for review of quality, safe and effective use of long- term medication [online]. Edinburgh: The Scottish Government. Available from: Pharmaceutical Care Services Plan Review Date: 2014 Version

42 APPENDIX 1 Pharmaceutical Care Services Plan Review Date: 2014 Version

43 APPENDIX 2 Pharmaceutical Care Services Plan Review Date: 2014 Version

44 14 Community Health Partnership Section - Aberdeenshire 14.1 Introduction To Aberdeenshire CHP Area Geography Figure 1: Areas within Aberdeenshire Pharmaceutical Care Services Plan Review Date: 2014 Version

45 5 year age bands Population Aberdeenshire has a population around 245,780 based on the 2010 mid-year population estimates which equates to 44.6% of the Grampian population.. 90 and over Aberdeenshire CHP population pyramid ( 2010 mid -year estimates ) ,000 20,000 15,000 10,000 5,000 0,000 5,000 10,000 15,000 20,000 25,000 Number of Males Number of Females Data Source- National Records of Scotland (NRS). By 2033 the population is projected to be 295,353, an increase of 22.3 per cent compared to the population in The population of Scotland is projected to increase by 7.3 per cent between 2008 and Aberdeenshire has a higher than average prevalence of people with specific long term conditions, namely dementia, obesity, hypothyroidism and chronic kidney disease. There is a lower than average prevalence of diabetes, Chronic Obstructive Pulmonary Disease (COPD), chronic heart disease and stroke compared with Scotland, but cardiovascular disease rates are still poor compared with many European countries. Pharmaceutical Care Services Plan Review Date: 2014 Version

46 Components of projected population change for Aberdeenshire and Scotland, (2008-based projections). Population growth of older people ranges from 40% to 185% in the over 75s in the next 12 years in towns and localities within Aberdeenshire, which must be factored into future provision. Immigrant workers need also to be planned for as numbers grow. The Aberdeen City and Aberdeenshire Council Structure Plan highlights the requirement for 75,000 new homes in Aberdeen and Aberdeenshire. Significant growth is expected in the Stonehaven, Portlethen, Westhill and Inverurie corridor. Already 2,000 new homes have been approved in Portlethen. The effect on practitioner services is expected to be significant. Early work with the local authority is underway to ensure joint opportunities are explored and planning gain maximised, despite the current economic downturn Age Over the 25 year period, the age group that is projected to increase the most in size in Aberdeenshire is the 75+ age group. This is the same as for Scotland as a whole. Life expectancy is 79.7 years, compared to a Scottish average of 77.8yrs. Pharmaceutical Care Services Plan Review Date: 2014 Version

47 Sex Aberdeenshire GP Practice Population Charts as at 1 st October 2012 (Practitioner Services Department) Age Group Male Female Total Age Group Male Female Total 0 To To 4 2.8% 2.7% 5.6% 5 To 5 To % 5.4% 11.2% 15 To To % 5.5% 11.4% 25 To 25 To % 12.7% 25.5% 45 To To % 14.5% 29.2% 65 To 65 To % 5.0% 9.7% 75 To To % 3.0% 5.4% 85 Up Up 0.7% 1.3% 2.0% Total Total 50.0% 50.0% 100.0% Aberdeenshire 85 Up 75 To To 74 Age 45 To To To 24 5 To 14 0 To 4 Male Female Percent of the Population Ethnicity The main areas of settlement in Aberdeenshire for recent migrant workers and their families is the Buchan coast around the Peterhead/Fraserburgh areas (Consultation Draft, NHS Grampian Equality) Outcomes ). The NHS Grampian 2011 involvement and consultation events with the local ethnic communities in Fraserburgh and Aberdeen report indicated the respondents had no difficulty in Pharmaceutical Care Services Plan Review Date: 2014 Version

48 accessing community pharmacy services, but there were concerns about the lack of interpreting services Deprivation The most deprived areas on the overall Scottish Index of Multiple Deprivation (SIMD) 2009 in Aberdeenshire can be found in Banff and Fraserburgh (Banff and Buchan), Peterhead (Buchan) and Huntly (Marr) (see figure 1 page % of the Aberdeenshire population is classified as a rural with 21% living in small towns and 26% living in urban areas (see Technical document p17as described in ) Information Sources A key information source is the Phase One of the Pharmaceutical Care Service Plan and the Technical Document available at: _FINAL_May_2012.pdf rs_final_may_2012.pdf ScotPHO Health and wellbeing profiles General Registrar of Scotland website which presents population and demographic information: The Scottish census website SCRoL Information and Statistics Division (ISD) website: The Scottish Government Urban/Rural Classification: ation. Information regarding deprivation may be sourced at Description of Primary Care Pharmaceutical Service Provision in Aberdeenshire CHP Overview of Pharmacy services Community Pharmacy There are 131 Community Pharmacies ( Chemist shops ) in NHS Grampian, and of these 54 are in Aberdeenshire providing Pharmaceutical Care Services across the CHP. All provide NHS dispensing services under agreement with NHS Grampian. Pharmaceutical Care Services Plan Review Date: 2014 Version

49 For Aberdeenshire the dispensed items were over 3.6 million and the gross ingredient cost around 38.2 million. The 54 community pharmacies in Aberdeenshire can be subdivided into (a) individuals or partnerships with one outlet (11), (b) individuals or partnerships with more than 1 outlet (29) or (c) national multiples that generally have many outlets (14) Interface with other providers Many of the community hospitals provide diagnostic and treatment services, some of which are staffed by secondary care colleagues, and some by primary care healthcare staff who have undertaken additional training. Some examples of this are Minor Surgery, where GP s have been trained to perform vasectomies and this is now carried out locally, Diabetic clinics and Ear, Nose and Throat (ENT) clinics where consultants come to the community hospitals, rather than patients travelling to Aberdeen. Where medicines are required, patients are required to take the consultant recommendations to the GP practice to obtain a prescription (GP10 prescription) for dispensing at the community pharmacy/dispensing doctor practice. There is one example where the Hepatitis C nurse meets with patients in a consultation room in the community pharmacy. Community hospitals offer in-patient care, but without dispensary facilities, the prescriptions for discharge are provided by means of GP10 prescriptions that normally dispensed at the patients usual community pharmacy. This requires communication and co-operation between the community pharmacy, the ward staff and often patient s relatives/carers/guardians. There is a consultation exercise underway relating to the integration of health and social care for adult services. This will have wide reaching implications for the CHP, but some examples of close working relationships between community pharmacy, primary care and local authority are already in place around supporting patients with managing their medicines and enabling them to remain independent in their own homes for as long as possible/practical with support. Community pharmacies often support patients by filling compliance aids (Monitored Dosage Systems), and many are involved with Medicines Management for Home Carers, where home care workers are trained to administer medicines to clients using Medicine Administration Charts and original packs of medicines. Community pharmacies provide a valuable service to care homes and often work closely with them to support medicines management. There is currently a national review of the care home contract. The current contract remunerates community pharmacy for providing advice to staff and residents as appropriate around storage and administration of both prescribed medicines and those used for minor ailments. There is scope for further involvement of community pharmacy that may include reducing medicine waste, medication reviews etc. In Grampian there is a project underway to dispense Imatinib (used for treatment of multiple cancers) from community pharmacy or dispensing doctors that was previously only supplied from hospital pharmacy. This involves close communication between the consultant and secondary care pharmacy team with the community Pharmaceutical Care Services Plan Review Date: 2014 Version

50 pharmacy. The community pharmacist undertakes to dispense an Hospital prescription (HBP prescription) provided by secondary care and also to counsel patient on the dosage, side-effects and action to be taken in the event of an adverse reaction. Support is available from the haematology pharmacist. Should the patient not collect a prescription for Imatinib as planned the community pharmacy is obliged to contact secondary care. It is anticipated that similar projects involving different medicines will be provided in this way in the future. Community Pharmacy has developed links with Optometrists in recent years through the Eye Health Network where community pharmacies can supply certain medicines on the recommendation of the optometrist via a voucher scheme and work is ongoing around a referral form. Community pharmacy has some links with dental practitioners in that they will dispense both NHS and private prescriptions issued by dentists 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 A description of each service has been provided in the Technical Document developed as part of Phase One but is summarised below Minor ailment service (MAS) Minor ailments can be generally 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 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 with over-the-counter medicines, free of charge. The pharmacists 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 current exemption category to be eligible for the service. There is variation in the number of patients registered to each pharmacy to obtain treatment under the minor ailment service and also variation in activity of provision of treatments for minor ailments. Pharmaceutical Care Services Plan Review Date: 2014 Version

51 Aberdeenshire MAS August CP MAS Number of Patients Paid CP MAS No. of Line Items Paid Contractor Public Health Service (PHS) There are two patient service elements of the public health service Smoking Cessation Services This service 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. There is considerable variation in the level of activity as shown in the graph below. Pharmaceutical Care Services Plan Review Date: 2014 Version

52 Aberdeenshire NRT items dispensed ,200 1, NRT Items Contractor A further development of this service is the supply of varenicline under a Patient Group Direction. 7 pharmacies in Aberdeenshire (Fraserburgh, Mintlaw, New Deer, Cruden Bay, Inverurie, Huntly and Newtonhill) provide this service with further roll out planned. Pharmaceutical Care Services Plan Review Date: 2014 Version

53 Sexual Health Services This service comprises of the provision of a sexual health service comprising the supply of emergency hormonal contraception (EHC) to women 13 years and above. Where a contractor decides not to supply emergency hormonal contraception (EHC), they should give notice in writing to the Health Board and advise the Agency of their decision and ensure prompt referral of patients to another provider who they have reason to believe provides that service. In addition, a pharmacist who chooses not to supply EHC on the grounds of religious, moral or ethical reasons must treat the matter sensitively and advise the client on an alternative local source of supply (such as another pharmacy, GP or sexual health service). There is one community pharmacy in the Peterhead area that has opted out of the provision of emergency hormonal contraception but there are alternative pharmacies within the town that are able to provide the service Acute Medication Service (AMS) The Acute Medication Service is the provision of pharmaceutical services for acute prescriptions. 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 Chronic Medication Service (CMS) The Chronic Medication Service is the continuity of pharmaceutical care of patients with long term medical conditions. CMS provides personalised pharmaceutical care by a pharmacist to patients with long term conditions. It is underpinned by a systematic approach to pharmaceutical care in order 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 in Aberdeenshire are currently involved in registering patients with variable activity in Stage 1 and 2 that aims to formalise the pharmaceutical care given to patients. There is no simple measure to compare activity as community pharmacists do not have a definitive patient lists, unlike GP practices. Only one GP practice in Huntly and 2 associated pharmacies are involved with serial prescriptions (Stage 3) as part of the Early Adopter scheme. Pharmaceutical Care Services Plan Review Date: 2014 Version

54 Scottish Government has recently announced plans to ensure that GP practices and Community Pharmacists are able to produce/dispense serial prescriptions by the end of The CHP will require to plan for this in conjunction with Information Technology (IT) support services Additional Services Additional services are those negotiated at individual Board level. They include a range of services and may not necessarily be available from all community pharmacies. Information on pharmacies providing these services and the geographical access to these services is provided in the Technical Document Substance Misuse The provision of methadone dispensing is widespread across Aberdeenshire although not all community pharmacies provide this service, at least one in each community does, with the exception of Alford. Patients from Alford may be required to travel for daily dispense methadone, and in this area public transport links are limited. Insch has access to dispensed methadone, but not the consume on premises service, methadone is only supplied for patients to take home. These gaps in service are acknowledged, but the substance misuse populations in these areas are low. The doctors at Peterhead Medical Practice do not prescribe methadone, but an independent pharmacist prescriber in one of the community pharmacies does and this service has been well received. This service was developed in conjunction with the NHS Grampian Substance Misuse Service to address an identified gap in service. In order to improve the sustainability of this project, a second pharmacist is undergoing an independent prescribing qualification. In other areas where GP practices do not prescribe methadone, service users are able to access services in other locations, such as the Kessock Clinic in Fraserburgh or the Fulton Clinic in Aberdeen. Proposed changes to the community pharmacy methadone contract will see a move away from a mechanical dispensing process and aims to integrate community pharmacists into the multidisciplinary substance misuse team. The regular contact that community pharmacy has with patients will aid their clinical role and ultimately improve patient services and has the potential to increase recovery roads, as per the The Road to Recovery: A New Approach to Tackling Scotland's Drug Problem (Scottish Government, May 2008) Injecting Equipment Provision The use of such services is high in north, less in central and low in south Aberdeenshire, reflecting the relative populations of injecting substance misusers. Some service users within rural areas can be reluctant to use community pharmacies as they perceive a lack of anonymity in these small towns and villages. Needle exchange facilities have been reviewed and a new site identified for Ellon. There is an only one needle exchange service available in Banchory to cover the Pharmaceutical Care Services Plan Review Date: 2014 Version

55 whole Lower Marr area. This has recently been relocated to coincide with the community pharmacy that dispenses methadone with the aim of increasing awareness and uptake of the service Naloxone Kits 7 community pharmacies across Aberdeenshire provide naloxone kits under PGD and are able to provide advice about using the naloxone, Basic Life Support skills and signposting to other organisations for support. These are some of the same pharmacies that provide injecting equipment and are geographically spread across Aberdeenshire Blood Borne Virus Services The Hepatitis C Nurse provides a testing, vaccination and treatment service from within a community pharmacy in Peterhead. This mirrors the service provided in other NHS Grampian premises such as the Kessock Clinic in Fraserburgh. There are 31/131 pharmacies across Grampian registered as current condom distributors, 17 of which are in Aberdeenshire. Following an exercise to identify community pharmacies that fall into either an area of high deprivation or an area which has a high teenage pregnancy rate and where there is no existing provision, one further pharmacy Ballater will be approached to ask if they are willing to provide this service Chlamydia & Gonorrhoea Testing 16 community pharmacies across Aberdeenshire provide kits for Chlamydia and gonorrhoea testing and are also able to supply treatment as necessary. There is generally one pharmacy in each of the larger towns providing a good geographical coverage of the service across the CHP. Information suggests that there may be a national roll out of this service and local changes may be necessary to meet the recommendations Participation in Out of Hours Rota There are limited out of hour s rota services that had been provided and some of these are not well used. The two Banchory community pharmacies rotate week about to open until on weekdays except Thursdays to allow the local GP practice to offer later appointment times for the convenience of the significant number of commuting workers. The Peterhead and Huntly pharmacies have been advised that the rota service will cease as of 31st March The rota service in Fraserburgh remains in place, but will be reviewed in conjunction with the Chemist Contractors Committee, GP Sub-Committee and local general practices and currently operates between 4 community pharmacies (Sundays ). N.B. In addition one Pharmacy in Inverurie opens on a Sunday between and 13.00, and one in Portlethen is open but these are not part of an organised rota. Pharmaceutical Care Services Plan Review Date: 2014 Version

56 Palliative Care Network There are pharmacies in selected geographical areas across Aberdeenshire CHP that are contracted to keep an agreed list of medicines that may be required promptly for palliative care patients. The medicines include a range of oral and injectable therapies that facilitate continuation of treatment when there are dosage changes and/or deterioration of a patient s condition e.g. the patient is no longer able to take oral therapy. There is work ongoing within Aberdeenshire to promote the use of Just In Case Boxes to provide anticipatory care to those patients whose condition may deteriorate, but this does not diminish the need for a network of community pharmacies able to provide palliative care medicines when required Travel Clinics Anti-malarials can be supplied under PGD (patient group direction) by pharmacists in 5 locations in Aberdeenshire: Fraserburgh, Peterhead, Mintlaw, Inverurie and Portlethen. In addition travel immunisations can also be provided, again under PGD, by one community pharmacy in Inverurie Influenza Vaccination Service Flu vaccinations can be administered by pharmacists after appropriate training and authourised under PGD. 13 pharmacies across Aberdeenshire provide this service to eligible patients and staff groups (Banff, Portsoy, Aberchirder, Fraserburgh, Peterhead, New Deer, Tarves, Turriff, Banchory, Portlethen, Newtonhill, Stonehaven, Laurencekirk, and Inverbervie) Medicines Management by Care at Home Workers There are gaps in provision of Homecare Medicines Management across Deeside and Kincardine & Mearns that are being addressed, and changes to the service provision are being progressed in Buchan and Ellon. Monitored Dosage Systems (MDS) support appropriate patients in managing their own medicines. Most community pharmacists provide these. However, increasingly there are difficulties in accessing these for patients as the MDS are time-consuming to fill and some community pharmacies are capping the number they are willing to provide. The provision of MDS devices should be reviewed, in conjunction with Homecare Medicines Management programme Domiciliary Oxygen It was noted in the Phase 1 Plan that domiciliary oxygen provision from community pharmacy is not available in the Alford area, and was identified as a gap in service that warranted investigation. However, the new national contract was introduced during November/December 2012 whereby domiciliary oxygen is delivered to the patient s home via Dolby Vivisol with community pharmacies ceasing to provide the service. A short term resilience plan is likely to be put in place to ensure oxygen cylinder provision via a very limited number of community pharmacies in the unlikely event that Dolby Vivisol cannot meet required timescales for providing a service, e.g. Pharmaceutical Care Services Plan Review Date: 2014 Version

57 due to adverse weather or where there are prolonged power outages. This service will be withdrawn once it has been shown that it is no longer required. Additionally it is proposed a small number of portable oxygen concentrators are held by a limited number of strategically located community pharmacies who are part of the palliative Care Network for those limited number of patients who are acutely unwell and are hypoxemic but for whom hospital admission to would be unwise e.g. end of life care, frail elderly care home residents etc Unscheduled Care Community pharmacy is an important access route for people requiring unscheduled care particularly over weekends and public holidays. One of the tools available to pharmacists is the National Patient Group Direction for the Urgent Supply of Repeat Medicines and Appliances. Community Pharmacies can also use Direct Referral to local Out of Hours services where the pharmacist feels that the patient requires a more specialist consultation with a different healthcare professional Outwith the core working hours of 0900 to 1700 hours Monday to Friday (commonly referred to as out of hours); there is wide variation of the availability of Pharmaceutical Services Most of the pharmacies in the towns of Aberdeenshire will provide pharmaceutical services on Saturdays for all or part of the day. Pharmaceutical services are not available in Cruden Bay, Fyvie or Braemar on Saturdays. Community pharmacies in Aberchirder, Crimond, New Pitsligo, Portsoy, Strichen, Kemnay, Kintore, Newmachar, Old Meldrum, Tarland, Torphins and Newtonhill close early (generally around lunchtime) on Saturdays. On Sundays patients would generally have to travel into Aberdeen as very few community pharmacies open, and those that do are often only open for short periods of time (30 mins or an hour is typical). Dispensing doctors are closed at weekends. A small number of pharmacies are open into the early evening on weekdays, to correspond to the local GP practice consulting times. At times or on days (including public holidays) where pharmaceutical services are not accessible, advice can be sought from NHS 24, a range of treatments can be provided by nurses in the Minor Injury Units in some of the Community Hospitals and emergency medical care is provided via the out-of-hours GP services (G-MED). GMED 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 the pharmacy is open. Pharmacist Prescriber Clinics There are currently 7 pharmacist independent prescribers and 5 supplementary prescribers working within Aberdeenshire. 9 of them are not currently involved in prescribing clinics. There are two substance misuse clinics (Peterhead and Inverurie) and one asthma/copd clinic (MacDuff). A further pharmacist independent prescriber has undergone training to provide resilience to the substance misuse service and potentially increase the capacity of the service in Peterhead. The NHS Grampian substance misuse service values the contribution community pharmacist Pharmaceutical Care Services Plan Review Date: 2014 Version

58 prescribers offer and would be keen to develop this service further where appropriate. A further two pharmacsts have completed their independent prescriber training and discussion is underway to identify potential options for prescribing clinics to be started. The funding for the pharmacist prescriber clinics is agreed annually, and therefore at this time funding is only guaranteed up until the end of March Keep Well Project (Fraserburgh only) The Keep Well programme aims to reduce health inequalities in cardiovascular disease by increasing the rate of health improvement among high risk groups, aged 45-64, living in the most deprived communities. A number of models have been used to deliver health checks and offer appropriate interventions and/or referral/signposting to NHS and non-nhs Services e.g. Third Sector. Community pharmacy staff in Fraserburgh have been trained through the Keep Well Programme to deliver health checks. They work with the GP practices in Fraserburgh to identify eligible patients then carry out health checks to patients that respond to the Health Check invitation. They provide appropriate Health Promotion advice and support and refer patients to a variety of local groups, including back to the GP practice, for interventions to improve health. They have also developed links with the Aberdeenshire Public Health team to maximise opportunity for delivery of health promoting initiatives and prevent duplication of effort. Over the next three years much of this activity will directed at defined vulnerable groups e.g. substance misuse clients, homeless people, members of the travelling community and carers. Prison HMP Peterhead currently has medicines and pharmaceutical products supplied via Community Pharmacy through a national prison contract. Health Services to prisons are now the responsibility of the NHS and the contract for the provision of medicines to the current prisons and the future Grampian Community Prison will be reviewed by NHS Grampian in conjunction with other Health Boards Accessibility of Pharmaceutical Services It is recognised that patients often access pharmaceutical services close to their place of work or on a public transport route, with easier access than their place of residence. The majority of Aberdeenshire residents can access Core Pharmaceutical Services within a 20 minute travelling time (see map at ). Those residents who are outwith a 20 minute travelling time may have access to dispensing services provided by dispensing doctors, not the wider pharmaceutical services provided via community pharmacies. Dispensing doctors can provide access to prescribed medicines in areas of low population density where it would be unlikely for a community pharmacy to be financially viable. There are also individuals who live in isolated rural areas who would be required to travel for more than 20 minutes to access services. Pharmaceutical Care Services Plan Review Date: 2014 Version

59 Some community pharmacies also have arranged collection points remote from their own premises. They will deliver dispensed prescriptions on specific days of the week. These are currently operating in Hatton, Maud, Boddam, Cumineston, Echt and Johnshaven. Two of the dispensing doctor services also use delivery points at Lumsden (remote from Rhynie Practice) and Strathdon (extended opening hours). The Essential Small Pharmacy Scheme is intended for contractors who have a steady state of dispensing low volumes of prescriptions and is a minimum of 2 miles from the next nearest community pharmacy. It provides an allowance to those pharmacies that are providing essential services to communities in areas where access to the nearest alternative pharmacy would present patients with considerable difficulties. There are 7 Essential Small Pharmacies in Aberdeenshire located in, Tarves, Fyvie, Kintore, Torphins, Tarland, Braemar and Newtonhill. Core opening times Most pharmacies are open Monday to Friday between 9am and The exceptions are community pharmacies in small rural towns who continue the tradition of half day closing one afternoon each week, and the two pharmacies in Huntly that close at hours. A small number open earlier and close slightly later. Only one pharmacy, situated within a supermarket in Portlethen is open until Three small rural community pharmacies are closed on Saturdays and one community pharmacy in a larger community pharmacy is also closed, but pharmaceutical services can be accessed at other premises in the town. Just over a quarter of pharmacies close around lunchtime on Saturdays. Generally other community pharmacies within the same town or a community pharmacy in the next closest town are open on Saturday afternoons. Community pharmacies are generally closed all day on Sunday, with the notable exceptions being Inverurie having one pharmacy with restricted opening ( ) and another supermarket pharmacy in Portlethen open Pharmaceutical Care Services Plan Review Date: 2014 Version

60 Pharmaceutical Care Services Plan Review Date: 2014 Version

61 14.3 Description of General Medical Service Provision in Aberdeenshire CHP General Medical Services In addition to community pharmacy services in specified areas where there is a serious difficulty in accessing dispensed medicines from a pharmacist, NHS Grampian has contracted General Practitioners (GPs) to provide a medicine dispensing service to some, or all, of their registered patients. Aberdeenshire has 7 dispensing doctors, 5 of which are in rural areas with no community pharmacy provision to serve the local area Relationship with Community Pharmacy Community pharmacy services are mostly provided to smaller communities by an unopposed pharmacy that has close links with the local GP practice, the larger towns having two or more community pharmacies linked to one or two GP practices. Because of the closely defined communities there are generally good relationships between the two. Of note are the many commuters who will access community pharmacies close to their place of work, or close to their travel route and inevitably the links between the GP practice and these more distant community pharmacies are generally weaker. The redesign of community pharmacy services to bring them under the management of the CHP teams will, in time, serve to strengthen the links between pharmacy and GP practice and ultimately with other community pharmacies within the CHP Areas Dispensing practices NHS Grampians Primary Care Integrated Management Group agreed that a review of dispensing doctor service should be undertaken. In areas of where there is difficulty in patients accessing dispensing services, the review should be undertaken in the understanding of the wider primary care services. The process should seek to understand the benefits and risks to the holistic service to patients from any change or variation of the service provision and should involve Aberdeenshire CHP. The context of the locality and communities should be central to this Analysis of Pharmaceutical Needs Within Aberdeenshire CHP Area Phase One of the plan assessed basic geographical access to services. There are a number of major housing and infrastructure developments to come in Grampian and these will impact on the need for pharmaceutical services The Need for Additional Pharmaceutical Services from existing providers Opening Hours The opening hours of community pharmacies generally seem to provide reasonable access to pharmaceutical services, but there is no evidence to support this. The Pharmaceutical Care Services Plan Review Date: 2014 Version

62 CHP should investigate options for assessing patient satisfaction with access to pharmaceutical services. Serial Dispensing Two pharmacies in Huntly are involved with the Early Adopter Phase of serial dispensing, which is part of the Chronic Medication Service. During 2013 this should be rolled out across the CHP, so that all GP practices are able to prescribe using serial prescriptions and all community pharmacists are able to receive electronic messages for the serial prescriptions allowing them to be dispensed. This should be carefully planned within the CHP to make most use of local knowledge and area networks. Primary Care Organisation Redesign As part of the wider PCO redesign General Medical, Optometry and Dental Services independent contractors moved from an NHS Grampian centrally managed service to one where the management was devolved to the CHP. Pharmacy remains the only independent contractor that remains under a central management arrangement. In order to provide a cohesive approach to healthcare provision it is planned to move pharmacy into a similar CHP managed service. Clearly some aspects, such as certain contractual arrangements for example, will require to be consistent and therefore require co-operation and agreement from all 3 CHP s. Pharmacy Clinical Lead Roles In line with the other General Medical, Optometry and Dental independent contractors there is a desire to have Pharmacy Clinical Leads. These posts will require to be created and individuals developed to perform these roles. Funding proposals have been created and the CHP s will be required to recruit suitable community pharmacists to fill these posts. Aberdeenshire CHP plans to have 4 such posts, 2 to cover Buchan, Banff & Buchan and Formartine and 2 for Garioch, Marr and Kincardine &Mearns. A job description and appropriate advertisement and recruitment processes required. The funding of these posts will initially be supported by the Pharmacy Champions monies, but may require to be additionally supported by Aberdeenshire CHP. Future services The Pharmacy Directors 2020 vision suggest there will be a significant increase in the numbers of independent prescribers who will prescribe for patients with stable chronic diseases in partnership with their general practitioner (GP). To achieve this greater numbers of community pharmacists will require to undertaken appropriate training courses and funding arrangements put in place. In order to undertake such clinical roles there would be a requirement to share medical information currently held by the GP practice. Electronic data sharing, perhaps in the form of a single shared record could be required. Pharmaceutical Care Services Plan Review Date: 2014 Version

63 To facilitate this process, patients could be required to register with a community pharmacy, similar to the way patients are currently registered with general practice. This is likely to involve changes to the national community pharmacy contract and would require changes to IT systems. Many community pharmacies already have consultation areas, but potentially in the future more of these areas may be required. This could require redesign of the pharmacy interior or even relocation to more appropriate premises. Clearly these developments will require organisational change within each community pharmacy to free pharmacist time to develop these roles. Some of the pressures of dispensing could be managed by Accuracy Checking Technicians (ACT s). Again, thought needs to be given to meet their educational requirements taking cognisance of the form this accreditation will take. There would also be cost implications to providing this training that will require to be addressed. Community pharmacies will eventually be subject to a contract review process similar to the one GP practices currently undergo. Discussions are ongoing as to what performance measures might be used during this process. All of these changes will require a major reorientation for patients, who will increasingly use their pharmacy as first point of contact. Pharmaceutical Care Services Plan Review Date: 2014 Version

64 14.5 Planning and Action Plan Topic Actions Timescale CMS - serial dispensing Implementation plan to be developed Information Services Division to enable all GP systems Community Pharmacy Clinical Lead Develop a role profile Phased roll-out across Aberdeenshire to allow prescribing/serial dispensing in collaboration with NHSG IT Facilitators Recruitment process to be agreed Additional financial support to be considered as required and contingency plan developed to provide ongoing funding should pharmacy champions funding be withdrawn Development of individuals to meet the requirement of the post(s). Mid Jan 2013 End of Jan 2013 End of Dec 2013 Jan 2013 End of March 2013 End of March 2013 Long term Interpretation services for ethnic minority groups Investigate the potential for installing Language Line in Fraserburgh and Peterhead June 2013 Investigate options to assess patient satisfaction with accessibility to community pharmacy services Discuss with Clinical Effectiveness team May 2013 Pharmaceutical Care Services Plan Review Date: 2014 Version

65 Topic Actions Timescale Medicines Management for Care at Home Workers Roll out service to areas that do not currently provide the service Change to MAR charts in areas not currently using December 2013 December 2013 Care Homes Investigate the options for providing a service to care homes using Community Pharmacies Varenicline Supply under PGD Roll out of service to other community pharmacies June 2013 March 2014 Dispensing doctor review PCIMG to lead review in conjunction with CHP March 2014 Pharmaceutical Care Services Plan Review Date: 2014 Version

66 15 Community Health partnership section Moray 15.1 Introduction to Moray Community Health & Social Care Partnership (CHSCP) Area Geography and Demographic profile of Moray One of the key components to the NHSG 2020 Vision is the development of a population based approach to health and health care supported by the creation of 11 cluster-areas across Grampian. The clusters are built around Grampian citizens and will allow services and resources to be integrated for the delivery of care as close to the service user as possible; at home, a homely setting or in the local community. Furthermore the 2020 Vision describes a significantly higher degree of integration (than currently) between service users, providers, health & care agencies, 3rd and private sectors locality clusters will facilitate this integration and become the route through which transformation of services will occur. Since late 2011 Grampian, as a region, consists of 11 cluster-areas; 4 in Aberdeen City, 6 in Aberdeenshire and Moray. Locality populations range from 40,000 to 90,000 (Moray) with a similarly wide geographical range; relatively compact geography in Aberdeen City to a significantly greater spread in Aberdeenshire, Each cluster-area has dedicated GP Leadership supported by aligned CHP management and functional areas (pharmacy, public health, nursing, AHP, etc). Formal structures exist within all eleven localities, for regular cluster-area meetings (all locality stakeholders NHS/Council), clinical leadership meetings (GP Leads/local senior management) and Grampian-wide senior clinical and executive leadership meetings. It is envisaged that a dedicated pharmacy lead post will be appointed in the near future in order for community pharmacy issues to be included within the cluster discussions mentioned above. The Moray cluster is the biggest in Grampian with a population of 90,000. Further details of the citizens within the Moray cluster are given in the table below: Age Group Population % 0-4 years 4, % 5-14 years 9, % years 10, % years 21, % years 26, % years 9, % years 5, % 85 up 1, % Pharmaceutical Care Services Plan Review Date: 2014 Version

67 As Moray CHSCP is one of the biggest clusters in Grampian it is useful to break it down to smaller localities. These will be useful for planning purposes. The current localities are Locality Population % Elgin / Lossiemouth 40, % Buckie / Fochabers 18, % Forres 15, % Keith and Speysdie 15, % Pharmaceutical Care Services Plan Review Date: 2014 Version

68 Through the Health and Care Framework, NHS Grampian has already started a process of assessing the needs of localities across Grampian. Forres was one of the pilots and the process there is nearing completion. A similar process in Keith and Speyside is about to be launched and other localities will follow in due course. In terms of landmass, Moray is the 8 th largest Council area in Scotland, covering an area of 2238 square kilometres, from the Cairngorm Mountains in the south to the coast of the Moray Firth in the north. The area is mostly rural comprising 70% of open countryside and a further 25% of woodland. The estimated population of Moray in 2010 was 87,660 just 1.7% of the Scottish population. The average population density is low at just 39 people per square kilometre compared to a Scottish average of 66 per square kilometre. However, approximately 57% of the population live in the 5 main towns of Elgin, Forres, Buckie, Lossiemouth and Keith, where the population density is approximately 2500 people per square kilometre. The area has a 0.9% ethnic minority population, which is significantly lower than the Scotland average of 2.0%. Overall, Moray is one of the least deprived areas in Scotland, as defined by the Scottish Index of Multiple Deprivation (SIMD), having no data zones in the 15% most deprived in Scotland and just 2 in the 20% most deprived areas, both of which are in Elgin. This represents just 1.7% of Moray s data zones, the lowest in Scotland with the exception of the three island groups. By comparison, Aberdeenshire has 8 data zones in the 20% most deprived and Angus has 9, representing 2.7% and 6.3% of their data zones respectively. However, the rural nature of Moray means that 27.6% of its data zones are within the 15% most access deprived in Scotland, due to the financial cost, time and inconvenience of travelling to basic services. This compares with 42.5% of data zones in Aberdeenshire and 26.1% in Angus. Trends Major demographic change is underway in Scotland and the population is projected to rise over the next 25 years before declining slowly. Some of the significant challenges are summarised below and will impact Moray: Scotland s population is aging; between 2004 and 2031 the number of people aged 50 plus is projected to rise by 28 % and the number of people aged 75 and over is projected to increase by 75 % Between 2005 and 2010 there is an expected 29.5% increase in people aged 85 years plus in Moray, (national average 17%) Fewer children aged 0-15 years and people aged years; the numbers are projected to decrease by 15% and 11% respectively by 2031 The number of births in Moray has declined by 2.79% between 2007 and People living longer; life expectancy at birth is projected to increase from 74.3 years for males and 79.4 years for females for those born around 2004 to 79.2 years and 83.7 years respectively by 2031 (Ref: All Our Futures 2007) Scotland s carers population is increasing; Scotland has an estimated 660,000 unpaid carers but this is expected to increase by more than 50% by (Ref: Carers Scotland 2009) Pharmaceutical Care Services Plan Review Date: 2014 Version

69 The impact of the elderly population in Moray is important to note: Projected Over 65s Population Breakdown - Scotland 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Table 1 Projected over 65s population breakdown Scotland Projected Over 65s Population Breakdown - Moray 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Table 2 Projected over 65s population breakdown Moray Comparison of data in tables 1 and 2 shows that the percentage of over the 75+ cohort is at an increasing rate in Moray the over 75s become predominant in Moray from 2023, whilst this takes place for the Scotland five years later in Current Health and Care Service Provision in Moray: Moray has a fully integrated Community Health and Social Care Partnership led by a joint management team. It has a common set of aims and objectives, which are set out in the Moray Community Health and Social Care Partnership Performance Management Plan Pharmaceutical Care Services Plan Review Date: 2014 Version

70 Dr Gray s, a 145 bedded District General Hospital provides acute services to the greatest density of the Moray population. There are five Community Hospitals in the towns of Aberlour, Buckie, Dufftown, Forres and Keith providing 89 in-patient beds in total and deliver a range of acute and intermediate care services for the aforementioned local areas. There are 14 General Practices, 17 dentists, 26 community pharmacies and 9 opticians. Primary and community care services are built around the Community Hospitals with community based health and social care teams where possible. Health and social care teams in Elgin are aligned to GP practices and co-located where possible. The Linkwood (Elgin) and Lossiemouth general practices have co-located health and social care service provision. Health The Moray population s perception of their general health is the same as Angus and Aberdeenshire, with 93% of the population reporting good or fairly good health and just 7% reporting not good health. The percentage of the population that has a limiting long-term illness is also very similar to both Angus and Aberdeenshire, representing around 1/6 of the total population in all 3 authorities. However, prevalence data from general practices indicates that Moray has some of the highest disease prevalence in Scotland, particularly with respect to diabetes, obesity, chronic kidney disease and hypothyroidism. The relationship between health and tenure indicates that 88% of occupants of social rented accommodation report good or fairly good health compared with 94% of occupants of owned or privately rented/rent free accommodation. This is reflected in the incidence of limiting long-term illness, which is 10% higher is for occupants of social rented accommodation, at 24%, than for occupants of owned or privately rented/rent free accommodation. The spread across age groups is comparable, with 65-84yr olds representing the largest proportion of each tenure type having a longterm illness. Deprivation Health Deprivation Moray has fewer areas in the 40% most deprived in Scotland for health compared with income, employment and education. The areas of Moray with the most multiple health deprivation are predominantly in Elgin (north and east and New Elgin). There are areas of multiple health deprivation in Buckie (east), Forres (central, north and south) and Lossiemouth (south west). Fochabers, Rothes and other rural areas (Dufftown, Aberlour, Cullen, Garmouth, Keith, Mosstodloch, Portknockie and Tomintoul) have slightly higher figures for anxiety/depression/psychosis medication prescribing than the majority of Moray s areas. Pharmaceutical Care Services Plan Review Date: 2014 Version

71 Lhanbryde (east) has among the highest incidence of both alcohol and drug-related hospital admissions in Moray. Rothes, Fife Keith and Keith (Balloch Road area) have among the highest incidences of alcohol-related hospital admissions in Moray. Dufftown and Fochabers (south) have among the highest incidences of drug-related hospital admissions in Moray. Burghead and Cullen, Findochty (east), Lhanbryde, Mosstodloch and multiple areas of Keith have among the highest figures for low birth weight babies in Moray. Income Deprivation The areas of Moray with the most significant concentrated income deprivation are Elgin (eastern side of the town and New Elgin), Buckie (town), Lossiemouth (central and west of town), Lhanbryde (eastern side of town) and Forres (north and west). There are also concentrated areas of income deprivation in Keith (Balloch Road/Den Crescent area) and Rothes (Provost Christie Drive area). Employment Deprivation The most significant concentrated employment deprivation is in Forres (central and north, including Applegrove Primary School area, Burdshaugh and Waterford), Elgin (Cathedral and Lesmurdie areas) and Buckie (Millbank Primary School area, Milton Drive, Douglas Crescent to Linn Crescent). There are also concentrations of employment deprivation in Lossiemouth (Boyd Anderson Drive) and Rothes (Provost Christie Drive). Areas in the 40% most employment deprived in Scotland almost all have high proportion of social rented housing. Areas of Moray in the 40% most employment deprived in Scotland all have a high concentration of Incapacity Benefit/Severe Disablement Allowance claimants. Education, Skills And Training Deprivation The most significant deprivation in Moray is in Buckie (predominantly in the east), Elgin (east and New Elgin) and Forres (central and south-west) There is also a significant education deprivation in Lossiemouth, Lhanbryde (east of primary school), Keith (Fife Keith and Balloch Road), Portknockie and Rothes (Provost Christie Drive). Buckie: Education deprivation in Buckie is largely due to high percentages of the working age population with no qualifications, although directly school-related results (particularly absences and percentage not in education, employment or training) play an important part. Pharmaceutical Care Services Plan Review Date: 2014 Version

72 Elgin: Education deprivation in Elgin is a combined result of directly school-related and high percentage of working age population with no qualifications, dependant on the area. Forres: Education deprivation in Forres is largely due to high pupil absences and percentage not in education, employment or training. Lossiemouth: Education deprivation in Lossiemouth is largely due to directly schoolrelated results, namely pupil performances and absences. Lhanbryde: Education deprivation in Lhanbryde is a combined result of directly school-related and high percentages of the working age population with no qualifications. Keith: Education deprivation in Keith is largely due to high percentages of the working age population with no qualifications. Portknockie: Education deprivation in Portknockie is a combined result of directly school-related (particularly absences and percentage not in education, employment or training) and high percentages of the working age population with no qualifications. Rothes: Education deprivation in Rothes is largely due to a high percentage of the working age population with no qualifications, with high pupil absences contributing. Areas in the north east and south east of Elgin (Kingsmills, South Lesmurdie, Manitoba) and Lhanbryde (east) are in the 20% or 40% most education, skills and training deprived in Scotland and also in the 30% most public transport deprived in Moray. Areas in the north east of Elgin and Lhanbryde (east), and a variety of large rural areas around Craigellachie, Cullen (east), Dufftown (north-east), Spey Bay and rural Rothes are among the 30% most public transport deprived as well as having the 30% highest proportions of year olds not in education, employment or training in Moray. Public Transport Areas in the north east of Elgin (Kingsmills, South Lesmurdie) and the east of Lhanbryde (east of primary school) are in the 20% or 40% most income and/or employment deprived in Scotland and also in the 30% most public transport deprived in Moray. Some rural areas with among the highest public transport deprivation also show high figures for certain income and employment related benefits; these include Portgordon (south west), Dufftown (north east), Elgin (south-west) and Forres (south -west). Lone parents: Areas with high concentrations of lone parents claiming income support include multiple areas of Elgin, Buckie (central and east), Fochabers (south), Pharmaceutical Care Services Plan Review Date: 2014 Version

73 Forres (central and south), Keith (Balloch Road and Fife Keith), Burghead, Lhanbryde (east), Lossiemouth (south-west) Portknockie and Rothes. Pension Credit: Areas with high concentrations of older people claiming the guaranteed component of pension credit include multiple areas of Buckie, Elgin, Forres, Burghead, Findochty, Hopeman (east), Keith (central and east), Lossiemouth (south-west), Portgordon, Portknockie, Rothes (west) and the Tomintoul/Glenlivet surrounding area. 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 and the vision for future service delivery in the Health and Care Framework. The Health Plan gives details of what the Board is trying to do to improve health and the way in which people are treated. 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 in NHS Grampian. Getting the most benefit from these medicines, and reducing the harm associated with medicines, is a core function of the Grampian Pharmacy Service. Pharmacy in 2020: Directors View outlines the vision for pharmacy that would see patients registering with community pharmacies, akin to the way they are currently registered with GP practices 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 independent prescribers. 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 Description of Primary Care Pharmaceutical Service Provision in Moray CHSCP Overview of Pharmacy Services Community pharmacies are independent contractors who provide a service to the NHS in accordance with national regulation and locally-negotiated contracts. Community pharmacies are very accessible to individual patients. They see patients regularly when they come in to collect prescriptions, and provide a no appointment necessary service for giving advice on managing illness and improving health. Pharmaceutical Care Services Plan Review Date: 2014 Version

74 Premises registered with the General Pharmaceutical Council, and supervised by a pharmacist, can advise about and sell Pharmacy Only (P) medicines, General Sales List (GSL) medicines, and health care products. This activity is an important and increasing aspect of self care. Pharmacies have been identified by the Scottish Government as the future walk-in healthy living centres for Scotland. Premises Standards The General Pharmaceutical Council (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: 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. Community Pharmacies within NHS Moray CHSCP Historically the central role of NHS Pharmaceutical Care Services has focused on the supply function i.e. supplying patient medication in response to prescriptions and supplying advice on taking these medicines to the patient. The shift from this historical supply function to a more comprehensive Pharmaceutical Care Service has been occurring for a number of years. In Scotland, it was cemented in health policy with the publication of The Right Medicine: a strategy for pharmaceutical care in Scotland, in The strategy emphasised the role of pharmacists in delivering pharmaceutical care for patients with chronic conditions, improving access to Pharmaceutical Care Services in general, and prescribed and over-the-counter medicines in particular, and the pharmacist s role in health improvement. There are 26 Community Pharmacies ( Chemist shops ) in Moray providing a network of NHS Pharmaceutical Care Services across the CHSCP area. All provide NHS dispensing services under agreement with NHS Grampian. These contractors may be individuals with one outlet, individuals or partnerships with more than one outlet or national multiples that generally have many outlets. The profile of providers differs from area to area as can be seen in the table below: Community Pharmacies within Contractor Categories at CH(SC)P level. CHP area Single Outlet Contractor Category Independent Multiple Outlet National Multiple Outlet Aberdeen City CHP Pharmacies Aberdeenshire CHP Pharmacies Moray CHSCP Pharmacies Total Pharmaceutical Care Services Plan Review Date: 2014 Version

75 Of the 26 community pharmacies, 4 provide pharmaceutical services for only part of the day, serving small local communities in Burghead, Hopeman, Portknockie and Findochty In addition, two rural GP practices provide dispensing services to their patients Glenlivet and the Tomintoul branch of the Rinnes practice. Community Pharmacy Dispensing The number of items dispensed in NHS Grampian in the last full year available at time of printing was 8,396,767 items at a Gross Ingredient Cost (GIC) of 90,942,573. These data have been broken down into the volumes in each of the three Community Health Partnership areas. CHP - Dispensing October 2010 to September 2011 Patient items/1000 No of Items Dispenser CHP Name GIC (Paid) Population patients (Dispensed) Size CHP ABERDEEN CITY CHP 3,199,949 36,314, ,205 13,104 ABERDEENSHIRE CHP 3,671,570 38,936, ,440 15,334 MORAY CHSCP 1,525,248 15,691,648 88,495 17,235 TOTAL 8,396,767 90,942,573 Dispensing in NHSG by CH(SC)P October 2010 to September 2011 ABERDEEN CITY COMMUNITY HEALTH PARTNERSHIP ABERDEENSHIRE COMMUNITY HEALTH PARTNERSHIP MORAY COMMUNITY HEALTH & SOCIAL CARE PARTNERSHIP Pharmaceutical Care Services Plan Review Date: 2014 Version

76 Interface with other providers Acute Sector (Secondary Care principally Dr Gray s Hospital) The interface between community pharmacy and secondary care is an area of increasing focus as Scotland pursues its policy of shifting the balance of care. A Grampian initiative whereby community pharmacies supply medicines that were previously only supplied from hospital pharmacy is being developed. The first medicine, Imatinib (used to treat multiple cancers), is now being supplied by community pharmacies and the initiative will be further developed. Communication between community pharmacists and their hospital colleagues in Moray is improving. Dr Gray s pharmacy staff inform community pharmacies when a patient with a compliance aid is being discharged from Dr Gray s and updates on any medicine changes. A patient who requires a new compliance aid will also be discussed with community pharmacy staff prior to discharge. Where there is uncertainty over the medication being taken by a patient admitted to Dr Gray s Hospital, hospital pharmacy staff are likely to confirm with the patient s community pharmacy their current medication. Health and Social Care Services Community pharmacies support the Home Carers Medicine Management scheme by providing medicine administration record sheets along with the dispensed medicines to enable council contracted home carers to administer medicines to their service users. Residential Care establishments ( Care Homes ) Pharmaceutical services provided by community pharmacies to residential care homes are defined by good practice guidance from both the Royal Pharmaceutical Society and Care Commission Scotland. Care Homes generally have an arrangement with a single community pharmacy to provide dispensed medicines for all their residents in patient specific metered dose systems. The Moray CHSCP Care Homes Pharmacy Technician supports community pharmacies, care homes and medical practices to provide safe, appropriate, cost effective medicine management processes. Community Hospitals Patients being discharged from Moray community hospitals have their medication reviewed prior to discharge by a GP who will organise a prescription for continuing medication. This prescription will be dispensed by the community pharmacy who will ensure the medicines are sent to the hospital prior to discharge, or will make arrangements to have the medicines available at the patient s home. Pharmaceutical Care Services Plan Review Date: 2014 Version

77 GMED / NHS24 Community pharmacists have direct access to GMED/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 be generally 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 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 with over-the-counter medicines, free of charge. The pharmacists 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 current exemption category to be eligible for the service. Pharmaceutical Care Services Plan Review Date: 2014 Version

78 CHP Level - Minor Ailment Service Items Dispensed Items Dispensed ABERDEEN CITY COMMUNITY HEALTH PARTNERSHIP ABERDEENSHIRE COMMUNITY HEALTH PARTNERSHIP MORAY COMMUNITY HEALTH & SOCIAL CARE PARTNERSHIP 2009/10 Q4 2010/11 Q1 2010/11 Q2 2010/11 Q3 2010/11 Q4 Pharmaceutical Care Services Plan Review Date: 2014 Version

79 Public Health Service (PHS) There are two patient service elements of the public health service Smoking Cessation Services This service 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. All community pharmacies are contracted to provide this service. A further development of this service is the supply of varenicline (a drug used to treat smoking addiction) under a Patient Group Direction. This is still in the early stages of roll-out but there are early adopter community pharmacies in Elgin (Bishopmill Pharmacy), Aberlour, Keith (Clarks Pharmacy) and Dufftown. Pharmaceutical Care Services Plan Review Date: 2014 Version

80 There is good geographical availability of this service from community pharmacies in Moray. However, as can be seen from the table below, there is a significant variance in the number of customers utilising the pharmacy smoking cessation service. It is not known if this is due to low demand for the service in some areas, customers accessing this service from alternative providers, or if there is no promotion of the service by the community pharmacies. Pharmaceutical Care Services Plan Review Date: 2014 Version

81 Moray NRT Items dispensed NRT Items Contractor Pharmaceutical Care Services Plan Review Date: 2014 Version

82 Sexual Health Services This service comprises of the provision of a sexual health service comprising the supply of emergency hormonal contraception (EHC) to women 13 years and above. Where a contractor decides not to supply emergency hormonal contraception (EHC), they should give notice in writing to the Health Board and advise the Agency of their decision and ensure prompt referral of patients to another provider who they have reason to believe provides that service. In addition, a pharmacist who chooses not to supply EHC on the grounds of religious, moral or ethical reasons must treat the matter sensitively and advise the client on an alternative local source of supply (such as another pharmacy, GP or sexual health service). 80 Moray EHC Activity per Pharmacy No. EHC patients treated Contractor Pharmaceutical Care Services Plan Review Date: 2014 Version

83 Acute Medication Service (AMS) The Acute Medication Service is the provision of pharmaceutical services for acute prescriptions. 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. Prescribing and dispensing data is available to NHS Boards in the form of the national database (PRISMs) Chronic Medication Service (CMS) The Chronic Medication Service is the continuity of pharmaceutical care of patients with long term medical conditions. CMS provides personalised pharmaceutical care by a pharmacist to patients with long term conditions. It is underpinned by a systematic approach to pharmaceutical care in order 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 in Moray are now contractually committed to stages 1 and 2. A number of community pharmacies are also now dispensing serial prescriptions, principally from Linkwood Medical, Elgin and Keith Medical Group who are early adopter practices. Other GP practices have now indicated an interest in developing this service and this will be facilitated by the IT Facilitators, the Pharmacy and Medicines Directorate and the Moray CHSCP Pharmacy team Additional Pharmaceutical Care Services Additional Services are those locally negotiated with community pharmacy contractors at individual NHS Board level, but with reference to nationally agreed indicative benchmarks for both service specification and payment. NHS Grampian is currently reviewing the contract process for these Additional Services. The Pharmacy and Medicines Directorate Team, Primary Care Contracts Team, and Primary Care Redesign Team are working together to prepare a more standard method of defining, implementing, monitoring and paying for additional services. In view of this all of the services mentioned in the following paragraphs will be reviewed over the coming year. The services available currently within NHS Grampian are: Pharmaceutical Care Services Plan Review Date: 2014 Version

84 Domiciliary Oxygen Service With the transition of the supply arrangements for Domiciliary Oxygen to a single integrated national route, community pharmacies will no longer stock 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. Community pharmacies providing this contingency service will be 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. Pharmaceutical Care Services Plan Review Date: 2014 Version

85 Methadone Supervision and Provision The pharmacist supervises the consumption of methadone (a heroin substitute) on the pharmacy premises, or supplies methadone in set quantities defined by the GP or Substance Misuse Service for a patient to take home. This service is widely available within Moray with no major geographical gaps. Generally there is availability for new service users when required. Service users in the Glenlivet / Tomintoul areas will to travel to avail themselves of this service. Pharmaceutical Care Services Plan Review Date: 2014 Version

86 Buprenorphine Supervision The pharmacist supervises the consumption of buprenorphine tablets (a heroin substitute) on the pharmacy premises. This service is widely available within Moray, with the major geographical gap being Forres and only limited provision in Speyside, at Dufftown. Service users in the Glenlivet / Tomintoul areas will have to travel to avail themselves of this service. Pharmaceutical Care Services Plan Review Date: 2014 Version

87 Syringe and Needle Exchange The pharmacist supplies packs of clean needles and paraphernalia on request to clients and collects used needles and syringes for safe disposal. There is limited availability of this service from community pharmacies in Moray. There is no pharmacy provision east of Elgin on the A96 corridor, and only limited availability in Speyside, in Dufftown. Service users in the Keith, Buckie/Cullen, Glenlivet / Tomintoul areas will need to travel to avail themselves of this service. Pharmaceutical Care Services Plan Review Date: 2014 Version

88 Palliative Care Network Pharmacists specifically trained in palliative care, provide service out of hours where required and maintain a set minimum stock of medicines used regularly to treat palliative patients. These pharmacies are known to the community nursing teams to ensure patients requiring urgent palliative medicines can be treated promptly. This service is widely available within Moray, with only minor geographical gap being in Fochabers, but there is availability from Elgin, Buckie and Keith. Pharmaceutical Care Services Plan Review Date: 2014 Version

89 Influenza Vaccination Service Specially trained pharmacists provide influenza vaccination to at risk patients and NHS Staff under a Patient Group Direction (PGD) and Occupational Health agreement and to non-at risk patients privately. There is limited availability of this service in Moray. Major gaps in provision are in Forres, Lossiemouth and Buckie, with limited availability in Speyside. However, it must be noted that all GP practices also provide influenza vaccination services. Pharmaceutical Care Services Plan Review Date: 2014 Version

90 Stoma Appliance Service All community pharmacies in Moray provide supply, customisation and delivery services on stoma products via a nationally agreed additional contract. Travel Medicine Clinics It is hoped this service will shortly be available from community pharmacies in Hopeman and Burghead. The pharmacist will provide holiday and travel medicine advice and treatment including vaccinations (with the exception of Yellow Fever) privately to patients requesting the service. Chlamydia Testing and Treat Services All community pharmacists in NHS Grampian can provide treatment for chlamydia for any person with a positive test result for chlamydia infection if the pharmacist is signed up to an azithromycin (an antibiotic) PGD. In addition, community pharmacies in Aberlour, Elgin, Keith and Lossiemouth provide a test and treat service as part of a national pilot. The outcome of a review of this service is awaited to inform the continuation of this service by community pharmacies. Collection and delivery service Lhanbryde community pharmacy collects prescriptions from an agreed, distant, collection point within a particular area. The dispensed medicines are then delivered back to this point for collection by the patient within an agreed timeframe. Pharmaceutical Care Services Plan Review Date: 2014 Version

91 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 (CPUS). Community pharmacies can directly refer to local Out of Hours services when the patient requires a more specialist consultation with another healthcare professional. CPUS Prescriptions Dispensed for Moray Patient Oct 11 - Sept 12 No. of Prescriptions Moray 1 Moray 2 Moray 3 Moray 4 Moray 5 Moray 6 Moray 7 Other Grampian Other Highland Other Scotland Contractor 363 CPUS prescriptions were dispensed for people registered with Moray GP s by seven Moray community pharmacies over the period October 2011 September A further 29 CPUS prescriptions were dispensed by community pharmacies elsewhere in Scotland. The three community pharmacies with the highest usage of this system are all located in Elgin. Pharmaceutical Care Services Plan Review Date: 2014 Version

92 Accessibility of Pharmaceutical Services Community pharmacy catchment areas and populations are not currently defined. Under current Pharmaceutical Care Services regulations for Scotland, services provision by contractors on the pharmaceutical list should be assessed within a defined neighbourhood. The NHS Board Pharmacy Practices Committee (PPC) determines the appropriate local area boundaries. However, there are no national standards for the number of community pharmacies required to meet the pharmaceutical care service needs of defined geographical populations, as this will vary depending on local factors including the size, structure and health-related characteristics of the population served and existing infrastructure such as transport networks. There is no target number of community pharmacies, either nationally or within NHS Grampian (or Moray). Other external influences on community pharmacy capacity to deliver services can include commercial and market factors, economies of scale or unavoidable costs, and cross-boundary flows. Importantly, an individual has the choice to access any community pharmacy for routine advice without appointment, and can register or transfer between contractors for specific care services. Previous Pharmaceutical Care Strategies for NHS Scotland 1, 2 suggest that an average community pharmacy serves a diverse population of approximately 4,500 people including: 1,000 people with long-term conditions, such as asthma, diabetes and hypertension; 1,000 smokers; 750 elderly people and 600 carers; 200 people with physical or mental disability; 300 children under 5; 50 pregnant women; 20 people suffering from cancer, of whom four are receiving active treatment and care; 6 people who use drugs and 2 people with HIV/AIDS. 1. Scottish Executive Health Department. The Right Medicine: A Strategy for Pharmaceutical Care in Scotland. Edinburgh: Public Health Institute of Scotland. Pharmacy for Health: The Way Forward for Pharmaceutical Public Health in Scotland. Glasgow: 2002 Moray has 26 community pharmacies serving its population of approximately 90,000, approximately 3,500 population per pharmacy, well within the Scottish average. Taking account of the four part-time pharmacies in Burghead, Hopeman, Findochty and Portknockie, the 24 whole time equivalent community pharmacies serve approximately 3,750 people each. Pharmaceutical Care Services Plan Review Date: 2014 Version

93 Community pharmacies are geographically spread across all localities within Moray (see map below), focussing on the main centres of population. The only geographical gap in provision of pharmaceutical services is in South Speyside where the low density of population receives dispensing services from the Glenlivet Medical Practice and the Tomintoul branch surgery of Rinnes Medical Group. Community pharmacies are required to open at certain times by their terms of contract to provide NHS pharmaceutical services. Detail of individual community pharmacy opening hours is detailed within the NHS Grampian Pharmaceutical list Pharmaceutical Care Services Plan Review Date: 2014 Version

94 provided as a separate document. It should be recognised that the contracted hours may not necessarily be the actual hours of opening as the contracted hours represent the minimum service provision. Generally, community pharmacies in Moray provide services between 0900hrs and 1730/1800hrs Monday to Friday, many closing for an hour at lunchtime. Some community pharmacies close on a Wednesday afternoon. The four part-time pharmacies work as linked pairs Hopeman with Burghead, and Findochty with Portknockie. Each pair effectively provide a full-time service over the paired sites. All community pharmacies in Moray provide a pharmaceutical service on Saturdays, but many close at lunchtime due to the lack of need for the services in their location on Saturday afternoons. Evening and Sunday pharmaceutical services in Moray are provided by a single contractor situated in an Elgin retail park. From the map below, it is apparent that the majority of the main population centres in Moray are within 30 minutes travelling time of this contractor. Outwith community pharmacy opening times, GMED, the out of hour s medical service, are able to provide medicines required to treat urgent acute conditions or a prescription which can be dispensed from a community pharmacy the following day. Pharmaceutical Care Services Plan Review Date: 2014 Version