April Pharmaceutical Care Services in NHS Fife 2015/16

Transcription

1 April 2015 Pharmaceutical Care Services in NHS Fife 2015/16

2 CONTENTS PAGE EXECUTIVE SUMMARY... page 1 1 Introduction to NHS Fife Health Board Area... page 3 2 Description of Current Pharmaceutical Services in NHS Fife... page 18 3 Description of Current General Medical Service Provision in NHS Fife... page 42 4 Analysis of Pharmaceutical Needs within NHS Fife with Recommendations to Meet Identified Under Provision... page 43 5 Appendices... page 45 Appendix 1 - NHS Fife Pharmaceutical List at April page 45 Appendix 2 - NHS Fife... page 46 2a - NHS Fife - Pharmacies, GP Practices and PCES 2b - NHS Fife - Population Density by InterZone 2c - NHS Fife - Scottish Indices of Multiple Deprivation Appendix 3 DWF CHP... page 48 3a - DWF CHP - Population Density by InterZone 3b - DWF CHP - Scottish Indices of Multiple Deprivation 3c Dunfermline - Scottish Indices of Multiple Deprivation Appendix 4 GNEF CHP... page 50 3a - GNEF CHP - Population Density by InterZone 3b - GNEF CHP - Scottish Indices of Multiple Deprivation 3c Glenrothes - Scottish Indices of Multiple Deprivation Appendix 5 K&L CHP... page 52 3a K&L CHP - Population Density by InterZone 3b K&L CHP - Scottish Indices of Multiple Deprivation 3c Kirkcaldy - Scottish Indices of Multiple Deprivation Appendix 6 - General Pharmacy Services Financial Report Summary (Financial year 14/15)... page 54 Appendix 7 - Methods of Approaches Used to Assess Needs and Consult with the Public... page 55 Appendix 8 - Glossary of Acronyms and Other Terms... page 56

3 EXECUTIVE SUMMARY The publication of NHS (Pharmaceutical Services) (Scotland) Amendment regulations 2011 requires NHS Boards to publish pharmaceutical care service (PCS) reports and annually update them. PCA (P) 7 (2011) advised NHS Boards of the amended regulations and the revised control of entry regulations. Agreement was made with Scottish Government Health Department (SGHD) at the March 2011 meeting between Directors of Pharmacy and SGHD that for 2011/12 Boards would be expected to publish extended Pharmaceutical Lists detailing the full range of services available from community pharmacies within the Board area. It was agreed with SGHD that Boards would develop fuller PCS reports for publication from April Pharmaceutical Care Services (PCS) 2015/16 in NHS Fife This report gives a brief overview of the population of NHS Fife and then provides a detailed description of the current pharmaceutical services that exists within NHS Fife. Data from a range of sources are utilised to establish the need for each of the core contract services and those additional services currently provided in NHS Fife. The extent to which that need is met is examined through assessment of any existing gaps. It is important to remember that provision of the current services may not represent the current capacity for delivery of the services included in the new contract. Proposed changes to legislation relating to pharmacist supervision will potentially allow different skill mix within community pharmacies and provision of services outwith the pharmacy premises. There are 85 contracted community pharmacies in Fife. These are well distributed across the region and meet the access needs of the vast majority of the population, with no large gaps being identified. In addition the report has not identified unmet need for new community pharmacies across Fife, although the need for the services delivered through existing pharmacies may require ongoing scrutiny. It would appear that overall there are no identified gaps in provision of pharmaceutical services in NHS Fife and it is important to continue to support development of community pharmacy services through staff training and ensuring a robust infrastructure for continued delivery of pharmaceutical services that meet the needs of the population. 1

4 Acknowledgement The NHS Fife Community Pharmacy Services Group has led the review & development of the Pharmaceutical Care Services report 15/16. The membership of the Community Pharmacy Services Group in 2014 is listed below; Evelyn McPhail, Director of Pharmacy (Chair) Dawn Balfour, IM&T Facilitator Nick Barber, Public Partnership Forum Representative Natalie Bate, Communications Officer, Pharmacy Services Dr Alex Collinson, GP Representative Kenny Craig, Chair - Area Pharmaceutical Committee Fiona Forsyth, Communications Officer, Pharmacy Services William John, Public Health Pharmacist Joyce Kelly, Primary Care Manager Alec Murray, Pharmacy Champion Alison Simpson, Public Partnership Forum Representative Andrea Smith, Lead Pharmacist, Pharmacy Services Jacqueline Watson, Management Accountant 2

5 INTRODUCTION The primary function of the Pharmaceutical Care Services (PCS) report is to describe the unmet need for pharmaceutical services within the Health Board population and the recommendation of the Health Board as to how these needs should be met. A secondary function of the report is to inform and engage members of the public, health professions and planners in the planning of pharmaceutical services. As a descriptor of needs within Boards for new or enhanced community pharmacy services this report is a data source that Pharmacy Practices Committees are directed to use in assessing need when considering applications to the Pharmaceutical List. 1 Introduction to NHS Fife Health Board Area The purpose of this section of the report is to describe the NHS Board area in terms of the population demographics, main health indices and urban/rural nature in order to gain an overall picture of the population and its health. This will outline the context within which pharmaceutical services are delivered. 1.1 Geographies to be Considered NHS Fife contains three Community Health Partnership (CHP) Areas; Dunfermline and West Fife (DWF), Glenrothes and North East Fife (GNEF) and Kirkcaldy and Levenmouth (K&L). The populations of these areas are indicated in the table below. Table 1 - Population of NHS Fife & its three CHPs (2011 Census) Location Population (2011 Census) NHS Fife 365,198 Dunfermline and West Fife 145,485 Glenrothes and North East Fife 122,351 Kirkcaldy and Levenmouth 97,362 The maps in appendices 2 to 5 outline the geography of NHS Fife & the three CHP areas. From April 2015 CHPs will be replaced by Health & Social Care Integration between NHS Fife & Fife Council. 1.2 NHS Fife and CHP Population Description Sex and Age The 2011 Census recorded the population of Fife to be 365,198 persons which rose to an estimated 366,910 in mid In the 10 years between the current Census and the last in 2001 the total population of Fife 3

6 increased by 4.5% (more than 15,700 persons) which was similar to the 4.6% growth reported nationally. There were more women than men in Fife, 51.5% to 48.5% of the total population at the 2011 Census with the ratio of women to men increasing with increasing age. The median age of Fife residents was 42 years Of the total 2011 Census day Fife population 17.6% were children (0-15), 64.8 % were of working age (16-64) and 17.5% were of pensionable age (65+). Within Fife Dunfermline and West Fife had the largest proportion of children (18.8%) and the smallest proportion of older people (15.9%). Kirkcaldy and Levenmouth had the greatest proportion of population aged 65 and over, 18.9%. Fife had slightly higher proportions of children and older people than Scotland but a lower proportion of working age adults (Table 2). Table 2: 2011 Census population by broad age group; Fife, Fife CHPs and Scotland Dunfermline and West Fife Kirkcaldy & Levenmouth Glenrothes and NE Fife Fife Scotland No. % No. % No. % No. % No. % , , , , , , , , , ,488, , , , , , Total 145,485 97, , ,198 5,295,403 Source: Census Data Explorer Chart 1 shows the number of persons in each of the five year age bands at both the 2001 and 2011 Census. Increases were observed in the number of children aged 0 to 4 and among young people aged 15 to 29. The years age group has seen the largest decrease of 4,816 persons (19%) between the two Census periods. Decreases were also seen in the number of children aged 5-9 and and adults aged years. 4

7 Chart 1: Population of Fife by five year age band; 2001 and 2011 Census Population (Number) Age group Source: Scroll and Census Data Explorer There has been in an increase in the number of persons in each of the age bands from years upwards. The age group has seen the largest increase of 7,035 persons (39%) between the two Census periods. There were also substantial increases in the number in the oldest age groups in Fife, an 18% increase in those aged and a 27% increase in persons aged 90 and over. The proportion of the Fife population who are aged 75 and over and 85 and over has also increased since the last Census rising from 7.5% to 7.9% and from 1.8% to 2.9% respectively. Fife, in common with Scotland, has an ageing population and the proportion of the Fife population aged 75 and over is projected to continue to rise and be 14.4% by 2037 according to projections recently published. The 2012-based population projections, based on the 2011 Census results, estimate that Fife s overall population will increase by 31,769 (9%), from 366,220 in 2012 to 397,898 in Increases however will not be seen across all age groups (Chart 2). In the next 25 years it is estimated that there will be an overall net reduction of 16,207 persons (9%) aged 30-64, the mid to older working age group, in Fife. Increases will be seen in the number of younger Fife residents aged both 0 to 15 (8%) and 16 to 29 (4%). The largest increases will be seen in persons 5

8 aged and those aged 75 and over. By 2037 the number of persons aged expected to be more than 12,000 more than in 2012, a rise of 33%. However the number of persons aged 75 and over is estimated to increase by 93% from 29,632 in 2012 to 57,327 in From 2027 the number of persons aged 75 and over in Fife is estimate to exceed the number of persons aged (Chart 2). Chart 2: 2012-based population projections; Fife by age group Population (thousands) All Ages Year Source: National Records for Scotland Ethnic Group In the 2011 Census, 97.6% of the population of Fife described their ethnicity as White, a decrease of approximately 1% on the 98.7% reported in 2001 (Table 3). Within this grouping the most commonly reported category was White Scottish stated by 85.7% of the Fife population followed by White Other British stated by 8.6%. A new category for the 2011 Census showed that there were just over 3,000 persons living in Fife who stated they were White Polish, 0.8% of the total population. A separate White Gypsy/Traveller response category was also added to the Census in people in Fife recorded their ethnic group within this category corresponding to 0.1% of the population of Fife (Table 3). This proportion was the same as that recorded nationally but compared to other council areas Fife had the fourth (of 32) largest number of people who identified themselves as White Gypsy/Traveller. 6

9 Table 3: Population of Fife by broad ethnic group; 2001 and 2011 Census White White: Scottish White: Gypsy/ Traveller White: Polish Asian African, Caribbean or Black 2001 number. 345, , , % % number 356, , ,058 5,748 1, % Source: Scroll and Census Data Explorer There have been increases in all of the minority ethnic groups in Fife in the last ten years with the largest increase seen in the proportion of people in Fife who stated they were Asian (a grouping which includes Indian, Pakistani, Bangladeshi and Chinese). In the 2011 Census this was 1.6%, double the 0.8% reported in 2001 (Table 3). There was also an increase from 0.1% to 0.3% in people classifying themselves as African, Caribbean or Black. There were differences in the proportions of ethnic groups within the age groups of the Fife population. Almost 98% of the population aged 65 and over in Fife described themselves as White Scottish or British compared to 88% of those aged % of the population aged was White Polish which was four times the proportion across the total population. This age group also had the highest proportion of people who identified themselves as Asian and African, Caribbean or Black, 3.4% and 0.5% respectively. There were also geographic differences in ethnic group populations living across Fife. 43% of the White Polish population in Fife lived in Kirkcaldy representing 2.7% of the total population in that settlement. St Andrews had the largest proportion of Asian residents, 8% of the population, which corresponded to almost a quarter (24%) of the Asian population in Fife. Approximately a quarter (24%) of African, Caribbean or Black Fife residents lived in Dunfermline and a further 21% in Kirkcaldy, representing 0.3% and 0.5% of the total populations of these settlements respectively Life Expectancy The latest figures available for life expectancy show that babies born during in Fife could expect to live 77.2 years for males and 81.2 years for females. Life expectancy has increased among both males and females in the last 10 years. Although male life expectancy is still significantly lower than female it has increased more in the last 10 years, 2.9 years compared to 1.7 years for females. This means the gap between male and female life 7

10 expectancy has reduced from 5.2 years in to 4.0 years in Fife has higher values for both male and female life expectancy than Scotland but Scotland has seen greater increases in the last 10 years, 3.3 years among males and 2.0 years among females (Chart 3). Chart 3: Male and female life expectancy; Fife and Scotland to Years Scotland Males Scotland Females Fife Males Fife Females Three year period Please note axis starts at 68 years Source: National Records of Scotland Deaths Number & rates During 2013 there were 3,845 deaths of Fife residents. This was 13 more deaths than recorded in Fife continues to have lower rates of death (all causes all ages) than Scotland with a rate of 1143 per 100,000 population in 2013 compared to 1152 per 100,000 population. Rates of death, for all ages and from all causes in Fife, decreased by 16% between 2001 and 2013 (Chart 4). 1,381 deaths were to Fife residents aged under 75 years which corresponded to 36% of the total number of deaths in This included 651 deaths to residents younger than 65 years. Rates of death among those both aged under 75 years and under 65 years have decreased by 8

11 22% since 2001 (Chart 4). Fife had lower premature mortality rates (under 75 years) than Scotland, 413 per 100,000 population compared to 438 per 100,000 population in Chart 4: All cause mortality rates by age; Fife ASR Mortality Rate All ages Under 75s Under 65s Year Source: Information Services NHS Fife Despite decreasing all age and premature mortality rates in Fife the relationship between increased deprivation and higher mortality rates persists. Rates of death for all causes and all ages have been between 1.7 and 1.8 times greater among the most deprived areas than the least deprived in the last five years. Chart 5 shows that the relative gap in premature mortality rates between the most and least deprived has fluctuated between 2.2 and 2.9 since

12 Chart 5: Premature mortality rates; Fife and Most/Least Deprived Areas Relative gap Most Deprived Fife Least Deprived ASR per 100,000 population Relative Gap Year Source: Information Services NHS Fife Causes In 2013, 1,813 deaths in Fife were due deaths from cancer, coronary heart disease (CHD) and cerebrovascular disease (stroke), often referred to as the big three causes of death. Since 2001 the number of deaths from these causes has reduced, falling from 56% of all deaths to currently 47% of all deaths. The proportion of deaths caused by CHD decreased from 22% to 13% between 2001 and 2013 and in the same time period the proportion of deaths caused by stroke has also decreased, from 8 to 5%. During this time the proportion of deaths attributed to cancer has increased from 26% to 30% resulting from an increase in the number of cancer deaths in Fife from 1,034 in 2001 to 1,126 in 2013 and a decrease in overall deaths. The differences between the big three causes are also reflected in age standardised mortality rates which have decreased almost annually for CHD and stroke to now be 48% and 53% lower than rates in Rates for cancer deaths have fluctuated more and decreased less being 6% lower in 2013 than in Increasing numbers of cancer deaths but decreasing age standardised rates are due to an increasing proportion of older people within 10

13 the population and the fact cancer is more common among older people; 50% of cancer deaths in Fife occur among those aged 75 and over. There were 1,126 cancer deaths in Fife in 2013 with half (567) of these deaths among persons aged under 75 years of age which included 236 deaths to persons aged under 65 years. In 2013, Fife had a very similar rate of all cancer mortality to Scotland, 332 per 100,000 population compared to 334. Other common causes of death among Fife residents included deaths from respiratory diseases which accounted for 13% (485 deaths) of the total number of deaths in This category includes deaths from pneumonia (151 deaths) and chronic lower respiratory diseases (226 deaths) such as chronic obstructive pulmonary disease (COPD). A further 8% (302) of all deaths were due to mental and behavioural disorders including dementia. Diseases of the digestive systems (e.g. chronic liver disease) were the cause of death among 200 Fife residents, 5% of all deaths in Healthy Weight Body Mass Index (BMI) calculated from the height and weight (kg/m 2 ) of adults is a widely accepted measure that allows for differences in weight due to height. This information is collected by the interviewer in the Scottish Health Survey and used to monitor progress towards the national long term outcome of having the majority of Scotland s adult population in normal weight throughout life. Being obese significantly increases the risk of developing a range of serious diseases, including type 2 diabetes, hypertension, heart disease and premature mortality. In the majority of adults (67%) in the Fife sample had a BMI which exceeded the normal weight range so were classed as either overweight or obese. Levels of obesity were recorded among 31% of Fife adults, a significantly higher proportion than the 27% in Scotland. A third of all adults in Dunfermline and West Fife were obese as were a third of all adults in the most deprived areas in Fife (Table 4). The least deprived areas had the greatest proportion of adults with a normal weight and the most deprived the greatest proportion underweight. Women were more likely to be obese and severely obese than men. 29% of men and 32% of women were obese in Fife but more than double the proportion of women to men were severely obese in Fife, 5.2% compared to 2%. Obesity levels were lowest among those in the youngest age group of (16%) with proportions less than half those reported for adults aged (40%) and aged 65 and over (35%). 11

14 Table 4: BMI Categories; Fife and Fife SIMDQuintiles Fife DWF K&L GNEF Most Deprived Least Deprived % of adults Underweight Normal Overweight (incl obese) Obese (incl severely) Severely obese Source: Fife Scottish Health Survey Results Deprivation Information from the 2011 Census collected for each household was used to classify households as being deprived on up to four dimensions: employment, education, health and housing. In Fife in 2011, 41% of households were not classified as deprived in any of the four dimensions. A third of households were deprived in one dimension, just over a fifth in two dimensions, 6% in three dimensions and 0.4% in all four dimensions. These proportions were very similar to those reported for Scotland. Chart 6 shows the differences in the proportion of households with none and multiple deprivation dimensions in the most and least deprived areas in Fife. In the most deprived areas 27% of households did not have any deprivation dimensions compared to 56% in the least deprived areas. The proportion of households with two or more deprivation dimensions increased with increasing deprivation with 0.8% of households in the most deprived areas having all four dimensions which was eight times the 0.1% in the least deprived areas. Chart 6 also shows that there are households in all areas in Fife living in deprived circumstances as each of the five quintiles has households with one or more deprivation dimension. Kirkcaldy and Levenmouth had the greatest proportion of households with four deprivation dimensions (0.5%) and Glenrothes and North East Fife the greatest proportion with none, 43%. 12

15 Chart 6: Households by deprivation dimensions; Fife and SIMD 12 Quintiles 100% Household is not deprived in any dimension Household is deprived in 2 dimensions Household is deprived in 4 dimensions Household is deprived in 1 dimension Household is deprived in 3 dimensions 90% 80% 70% % of households 60% 50% 40% 30% 20% 10% 0% Most Q2 Q3 Q4 Least Fife Source: 2011 Census Data Explorer The 2012 SIMD showed that 13.3% of the population in Fife were income deprived, adults and children living in households in receipt of one or more income related benefits, similar to the 13.4% reported nationally. In the most deprived areas this proportion rose to 27% which was more than six times greater than the proportion in the least deprived areas of 4%. 20% of people were income deprived in the Levenmouth area compared to 16% in Glenrothes area and 11% in Dunfermline area Smoking In , cigarette smoking prevalence among the Fife sample was 26.4%, slightly higher than the 25% reported nationally. Smoking prevalence was significantly higher among adults living in the most deprived areas than Fife and any of the other Fife SIMD deprivation quintiles with 41% of adults reporting being a current smoker. Chart 7 shows that this was more than twice the proportions reporting smoking in the least deprived area and that smoking prevalence increased in line with increasing deprivation. Cigarette smoking prevalence was 28.3% among men which was higher than the 24.7% among women. Smoking prevalence was highest among those aged (36%) followed by those aged (34 13

16 Chart 7: Smoking prevalence; Fife and Fife SIMD 2009 Quintile 50% 45% 40% 35% 30% % of adults 25% 20% Fife 15% 10% 5% 0% Most Deprived Q2 Q3 Q4 Leaset Deprived Decreasing Deprivation Source: Fife Scottish Health Survey Results Of the three CHPs, Kirkcaldy and Levenmouth had the highest smoking prevalence with 30% of adults reporting being a current smoker compared to 27% in Dunfermline and West Fife and 23% in Glenrothes and North East Fife. In Dunfermline and West Fife CHP smoking prevalence was slightly higher than among women than men but greater among men than women in the other two CHPs (Table 5). Approximately a quarter of adults in Fife stated they are ex-smokers (24%) with similar values reported across the CHPS. Table 5: Smoking prevalence by sex; CHPs Current smoker Ex regular smoker Never smoked DWF (%) GNEF (%) K&L (%) Total Male Female Total Male Female Total Male Female Source: Fife SHeS In Fife smoking prevalence was highest among those aged (36%) followed by those aged (34%) (Table 6) Smoking prevalence decreased with age from years and was lowest amongst those aged 14

17 65 and over but the proportion of those reporting they had never smoked in Fife was highest amongst those aged Table 6: Smoking status by age group; Fife % of respondents All Current smoker Never smoked Source: Fife SHeS Alcohol consumption Guidelines for sensible levels of alcohol consumption state that women should drink no more than 2-3 units per day and men no more than 3-4 units with a recommendation that everyone should have at least two alcohol free days per week. In addition weekly consumption should be not be greater than 14 units per week for women and 21 units per week for men. 43% of men and a third of women in Fife exceeded daily drinking guidelines which was similar to levels reported nationally. Dunfermline and West Fife had the largest proportion of men and women to report this with men in all age groups more likely than women to drink beyond daily limits. Drinking beyond daily limits was reported by more than half of men aged (58%) drank and 47% of women aged 35-44, the largest proportions across the age groups. Adults living in the least deprived areas were most likely to report this with 43% drinking beyond daily limits (Chart 8). The lowest proportions of adults doing so were in the more deprived areas (most deprived and quintile 2). Binge drinking, defined as consuming more than 6 (women) or 8 (men) units on any one occasion was reported by 26% of men and 15% of women in Fife. Proportions were the same among males in Scotland but slightly higher among female Scottish respondents at 17%. Reports of binge drinking were most common among men and among younger age groups. Among men aged 25-34, 46% drank more than 8 units on their heaviest drinking day (binge drinking) as did 28% of women aged Reports of binge drinking were highest among males and females in Dunfermline and West Fife (28% of men and 18% of women) and lowest in Kirkcaldy and Levenmouth (23% of men and 13% of women). Levels of binge drinking were similar across areas of differing levels of deprivation ranging from 19% (least deprived) to 21% (most deprived and quintile 3). Weekly drinking limits of 14 or more units for women and 21 or more units for men were exceeded by 23% of adults in Fife and Scotland, 28% of men and 18% of women in Fife. Kirkcaldy and Levenmouth CHP had the highest proportion of men to do this and Dunfermline and West Fife CHP the largest 15

18 proportion of women. The less deprived quintiles (quintile 4 and least deprived) reported the highest proportions of adults to exceed weekly limits with Quintile 2 having the lowest proportion of 19% (Chart 8). Among women in Fife consumption of alcohol beyond weekly sensible limits was most likely in those aged (29%) and among men those aged (36%). Chart 8: Excess alcohol consumption; Fife and Fife SIMD Quintiles Exceeds daily limits Binge drinking Exceeds weekly limits % of adults Fife Most Deprived Q2 Q3 Q4 Least Deprived Decreasing Deprivation Source: Fife Scottish Health Survey Results Sexual Health One of the most widely used indicators of sexual health is unplanned pregnancy and the measure commonly used is the number of abortions. However, this is an indicator of unwanted rather than unplanned pregnancy. There are many pregnancies that, although unplanned, are continued to the birth of a baby. It is, therefore, not possible to ascertain the true level of unplanned pregnancy. An additional measure of sexual health associated with unplanned pregnancy is teenage pregnancy. It must be accepted that many teenage pregnancies are not unplanned, unwanted or undesirable. However, a high level of teenage pregnancy is a cause for concern, and pregnancies in women under the age of sixteen are particularly undesirable in that they imply that sexual intercourse has taken place under the legal age of 16

19 consent. Teenage pregnancy refers to conceptions i.e. deliveries plus abortions. Generally there are more abortions than deliveries in the under 16 s. From 2012 data the Fife rates for teenage pregnancy in the under 16, under 18 & under 20 age groups were all higher than the Scottish average - see table 7 below Table 7 - Teenage pregnancy rates (as rates per 1,000 women) for calendar year 2012 under 16 s under 18 s under 20 s Fife average Scottish average Source: Information Services Division Scotland 17

20 2 Description of Current Pharmaceutical Services in NHS Fife 2.1 Community Pharmacy Services - General Description The following section provides a list of the NHS services provided by the 85 community pharmacies in NHS Fife at December Number of Community Pharmacies across NHS Fife and by CHP At December 2014, NHS Fife has 85 community pharmacies that are located across three Community Health Partnership Areas; Dunfermline and West Fife, Glenrothes and North East Fife and Kirkcaldy and Levenmouth. Table 8 below lists the number of community pharmacies in each CHP. Based on this information, each individual pharmacy can be estimated to be serving a population of just under 4300 people. This is in line with figures found previously in neighbouring areas of Lothian and Tayside. Table 8: Community Pharmacies in NHS Fife (December 2014) CHP Location Number of community Pharmacies Population (2011 Census) Population per community Pharmacy NHS Fife , Dunfermline and West , Fife Glenrothes and North , East Fife Kirkcaldy and Levenmouth 23 97, There is no standard as to the number of population that should be served by a pharmacy but Table 8 shows that there are small differences in the average population served by each pharmacy between the three CHP areas. The distribution of community pharmacies across Fife allows wide access to their many services. (See maps in appendices 2 to 5) Overall Annual Prescriptions Dispensed In terms of absolute activity relating to prescribing, 6,652,359 prescription items were dispensed in NHS Fife in 2013/14 (these are for all prescriptions dispensed in community pharmacies i.e. GP10s GP10Ns, CPUS, MAS scripts etc). See table 9 for the volume of prescription items dispensed in Fife over the last 6 financial years. 18

21 Table 9 - Volume of prescription items dispensed in Fife over period April 2008 to March 2014 Financial Year Number of prescription items dispensed ,652, ,521, ,398, ,159, ,987, ,759, Resources - Premises/Facilities Many community pharmacies have been developed to provide private areas which can be utilised for the provision of counseling and/or advice. These areas in the pharmacies enable patients to be spoken to with some privacy and to enable other private services such as emergency hormonal contraception to be provided in a confidential manner. The development of consultation or private areas in many pharmacies has been an enabling factor in the development of these services. These areas can either be fully enclosed providing complete audible and visual privacy or can provide a less degree of privacy. Under the Disability Discrimination Act 1995 (DDA), it is unlawful to treat a person less favourably for a reason related to that person s disability (unless it can be justified). Pharmacies that have fewer than 15 employees are exempt from the employment regulations of the Act but everyone providing services, regardless of size, must follow the provisions of the Act. Pharmacies are specifically included in this section because they provide health services. Pharmacies must take reasonable steps to provide auxiliary aids or services, which will enable disabled people to make use of their service. Where physical barriers make it impossible for disabled people to use a service, the pharmacy is expected to facilitate the provision of the service by an alternative method. This could involve directing the patient to a nearby alternative pharmacy with the appropriate facilities. In recent years there has been significant investment in improving pharmacy premises to ensure that they are fit for purpose. This has been supported by the Scottish Government, the Right Medicine and contractors themselves. The majority of pharmacies now have a private consulting room or a private area where more sensitive issues can be discussed. NHS Circular: PCA(P)(2007)28 Pharmaceutical Services Remuneration Arrangements For : Contract Preparation Payments Premises 19

22 Guidance and Assessment Tool provides guidance on the premises requirements under the new community pharmacy contract. It provides a tool for pharmacies to assess their ability to meet the requirements and produce an action plan for any rectification work that is required to meet those requirements. This guidance will aid the planning of any future pharmacy premises or potential relocations. In NHS Fife 99% of pharmacies currently have either a private area or consultation room. And the majority also has induction loop facility (83%) and wheelchair access (88%). The circular PCA(P)(2007)28 aims to ensure that those pharmacies with a deficit in these areas undertake corrective action Resources - Community Pharmacy workforce Each community pharmacy will have at least one pharmacist & all pharmacists have a minimum qualification of a degree in pharmacy & are registered with the General Pharmaceutical Council. The NHS Pharmaceutical List (see appendix 1) lists the pharmacy manager for each community pharmacy, although no other details of pharmacist numbers are listed e.g. part time staff. With change in legislation pharmacists now have the ability to be supplementary or independent prescribers. Supplementary prescribing is a voluntary prescribing partnership between an independent prescriber and a supplementary prescriber, to implement an agreed patient-specific clinical management plan with the patient's agreement. These supplementary and independent prescribers are involved in the provision of clinics within Fife across numerous specialty areas such as hypertension, stroke, warfarin, vascular, substance misuse, respiratory and pain. There are 14 pharmacist led clinics in Fife where patients are managed by the pharmacists working in coordination with other health care professionals to provide appropriate pharmaceutical care to the patients. Table 10: Pharmacist numbers training or trained with prescribing rights (December 2014) Prescribing status No. of pharmacists Independent prescribing training in progress 5 Qualified supplementary prescribers 10 Practicing supplementary/ independent prescribers 14 Qualified independent prescribers 30 20

23 Community pharmacy is supported by a trained and knowledgeable workforce. The workforce ranges from those who provide healthcare and medicines advice from their role as healthcare counter staff and those that work directly in the dispensary. The support staff work in direct contact with the public and are suitably trained to provide advice on numerous health related matters. The pharmacist provides an expert source of knowledge to the support staff although many staff have developed specialised areas of competence in which they work. As part of community pharmacy development to ensure continued ability to deliver NHS services, work has been ongoing to support development of support staff. One aspect of that work has mapped out the support staff and their qualifications in NHS Fife. The table below shows the number of staff in Fife and in the individual CHPs according to the role titles. There are 4 job categories for the pharmacy support staff and then there are those involved in training towards the categories. Table 11: Numbers of support staff in community pharmacies per CHP area. (December 2014) Support staff title Dunfermline and West Fife Glenrothes and North East Kirkcaldy and Levenmouth NHS Fife Medicine Counter Assistant (MCA) Pharmacy Assistant Pharmacy Checking Technician Pharmacy Technician Student MCA Student Pharmacy Assistant Student Pharmacy Technician Student Pharmacy Checking Technician Grand Total

24 2.2 Community Pharmacy Services - Core Services Minor Ailment Service This service was the first of 4 core services to be implemented, on 1st July This service is delivered by all 85 community pharmacies in Fife and is available to those patients who did not pay prescription charges and require treatment of minor ailments. Since the abolishment of prescription charges the service continues to be available to the same group of people, i.e. those who did not pay prescription charges. When a registered patient accesses this service they will receive a consultation and supply of an appropriate product if indicated, advice only or referral to their GP or other healthcare professional. Charts 9a & 9b highlight the use of this service in 2013/14 compared with figures for 2012/13 & 2011/12. The figures show a steady increase from 2012 which continues into 2013: Charts 9a NHS Fife MAS registrations - Dec 11-May 12 to Dec 13-May 14 22

25 Charts 9b NHS Fife MAS monthly dispensed prescriptions - Dec 11-May 12 to Dec 13-May 14 Community Pharmacists continue to offer the service to their patients, resulting in increased registrations and a steady rise in consultations (although this does fluctuate depending on time of year), which may result in the provision of health and medicines advice, referral to another healthcare professional e.g. GP where necessary and dispensing of medication if required to treat the patient. Table 12 below shows further recent MAS activity data between selected Health Boards. Table 12 - Number of patients registered for MAS within NHS Fife & selected neighbouring Health Boards (November 2014) Health Board Area Number of MAS registered patients Fife 60, Tayside 63, Forth Valley 45, Lothian 130, Scotland 892, MAS registered patients per 1,000 of population 23

26 Minor Ailment Service Patient Stories Mr GB He was treated for a sports injury via the Minor Ailment Service on a see and treat basis If all health professionals would see and treat, as opposed to referring you elsewhere, the NHS would be so much more efficient Mrs HK Child with severe earache Saturday morning, possible infection. Referred to PCES; Appointment within 2 hours. I was not expecting such rapid treatment on a Saturday Public Health Service The Public Health Service comprises of the following services: 1. The provision of advice to patients or members of the public on healthy living options and promotion of self care in circumstances where in the professional opinion of the pharmacist it is appropriate to do so or by request from a patient or member of the public; 2. Making available for use by patients and members of the public a range of NHS or NHS approved health promotion campaign materials and other health education information and support material; 3. Participating in health promotion campaigns, each campaign being on display and visible within a pharmacy for at least six weeks, agreed nationally by Scottish Ministers and a body deemed to be representative of community pharmacy contractors. Between these campaigns generic display material will be made available by the Scottish Ministers for use by PHS providers if they wish; and 4. Where agreed between a PHS provider and the Health Board, participation in locally agreed health promotion campaigns in the intervals between the national campaigns as described in the above paragraph above. There are two patient service elements of the public health service, which commenced in August Stop Smoking Services The service which began in August 2008 consisted of the provision of a stop smoking service comprising support & advice together with the supply of nicotine replacement therapy (NRT) over a period of up to 12 24

27 weeks, in order to help smokers successfully stop smoking. In July 2014 the national service specification of the Community Pharmacy Stop Smoking Service was revised; this now includes the option for the supply of varenicline via a Patient Group Direction by a community pharmacist. The submission of claims and minimum data set information on the quit attempt is now done electronically via the Pharmacy Care Record (PCR).The Community Pharmacy Stop Smoking Service is delivered by all 85 community pharmacies in Fife. The community pharmacy service contributes significantly to the NHS Fife smoking cessation HEAT 6 target, for example for calendar year % of all MDS quit attempts made in Fife came from the community pharmacy stop smoking service (with 34% via non-pharmacy services). The total number of MDS quit attempts in the pharmacy service has increased by 5% between calendar year 2012 to 2013 i.e. from 4,056 to 4,266. Table 13 below shows the MDS quit attempts made in community pharmacies over calendar year 2013 in Fife & selected neighbouring Health Boards. The divergence between the Fife figure compared with the Scottish average can be partly explained by the different stop smoking service model used by other Health Boards e.g. some Health Boards use mainly a pharmacy model whereas NHS Fife has a joint pharmacy/chp specialist service model. Table 13 - Number of MDS quit attempts in community pharmacies Jan- Dec 2013 Health Board Area MDS quit attempts made in community pharmacies Jan-Dec 2013 Number of MDS quit attempts per 1,000 population Fife 4, Tayside Forth Valley Lothian Scotland Source: Information Services Division Scotland 25

28 Table 14 below shows number of prescriptions (form type CPUS) issued for NRT during the last three financial years. Table 14 - Number of prescriptions (form type CPUS) issued for NRT Month 2011/ / /14 April May June July August September October November December January February March Monthly average Dave s Story I stopped smoking with the help of my local community pharmacist. What I really liked was the easy procedure. I saw a NO BUTTS notice in the window; I went in to ask for more information and was speaking to the pharmacist within 5 minutes, NO APPOINTMENT NEEDED. The pharmacist interviewed me and supplied me on the spot with the NRT substitutes that we agreed I needed, he also gave me some motivational support and a contact number for any problems. I returned on a regular basis and got a top up of NRT and motivation. The other thing I liked was the pharmacist had a non-judgmental attitude so any minor lapses I had were not treated like it was the end of the world. I would recommend that any smoker wishing to quit should go straight to their local pharmacist Sexual Health Services The introduction of a national PHS service for EHC has ensured equitable access to the population of Fife. The community pharmacy is an appropriate and accessible route to EHC, as demonstrated by the figures below which show steady numbers of consultations and ultimately supply of EHC. Community pharmacists continue to issue around 75% of the total 26

29 EHC prescribed/supplied in NHS Fife. This service comprises of the provision of advice on sexual health matters & the supply of emergency hormonal contraception (EHC) to women aged 13 years and above, where appropriate. This service is delivered by all 85 community pharmacies in Fife. The number of EHC consultations undertaken & prescriptions generated by the community pharmacy service for the last three financial years (prescription type CPUS) are listed below in Table 15 Table 15 - Number of prescriptions (form type CPUS) issued for EHC Month 2011/ / /2014 April May June July August September October November December January February March Monthly average Table 16 below shows the number of dispensed items via the community pharmacy EHC service over a recent 12 month period in Fife & selected neighbouring Health Boards Table 16 - Number of prescriptions (form type CPUS) issued for EHC amongst neighbouring Health Boards for calendar year 2013 Health Board Total number Monthly average Monthly Area of EHC CPUS of EHC CPUS average of EHC scripts scripts CPUS scripts dispensed dispensed over dispensed per Jan-Dec 2013 time period 1,000 (Jan-Dec 2012 population figs in brackets) Fife (422) 0.9 Tayside (414) 0.8 Forth Valley (332) 0.9 Lothian (1504) 1.4 Scotland (7070)

30 2.2.3 Acute Medication Service AMS is the provision of pharmaceutical care services for acute episodes of care and electronically supports the dispensing of acute prescriptions and any associated counseling and advice, and is provided by all 85 community pharmacies in Fife. All Fife pharmacies have been scanning prescriptions and claiming for them electronically through their clinical system (PMR) for some time now. Figures from August 2014 show that 89% of Fife pharmacies are scanning and claiming over 90% of their total prescriptions, a target set by the Scottish Government. The number of prescriptions automated through the epay facility at Practitioner Services Division (PSD) continues to increase month on month, and as of August 2014, 82% of claims were automated Chronic Medication Service CMS allows patients with long-term conditions to register with the community pharmacy of their choice for the provision of pharmaceutical care as part of a shared agreement between the patient, the GP and the pharmacist. CMS allows the GP to generate a patient s prescription for a 24 or 48 week period. In this period the patient will not require to visit the GP to pick up their repeat prescription they will only be required to visit the pharmacy to pick up their medication. This process sends electronic messages between the pharmacy system and GP practice system to update the GP record with the dispensing information. NHS Fife was chosen to be the national early adopter site within Scotland for the roll out of the CMS and this commenced in April A further phase commenced in spring 2011 with all Health Board areas participating. All Health Boards are now involved in the full roll-out of CMS, which includes serial prescribing, working towards the aim of having all of their GP practices and Community Pharmacies providing the service. Although uptake has been slow (and this is mirrored in other Health Board areas), NHS Fife currently has 30 GP practices generating serial prescriptions with 55 pharmacies involved in processing them. We continue to work with practices and pharmacies to encourage uptake, with an emphasis on supporting keen practices to increase the numbers of their patients receiving serial prescriptions. Community Pharmacists continue to register patients for the service, which incorporates completion of a Pharmaceutical Care Plan. A secure, username/password protected, on-line Pharmacy Care Record (PCR) is used to record information about the patient, including any care issues identified. Pharmacists can now carry out and record High Risk Medicine 28

31 (HRM) assessments for their Warfarin patients along with assessments for their Lithium and Methotrexate patients. They also continue to monitor and record New Medicine Interventions (NMI). For both HRM and NMI the patient does not need to be registered for CMS. The Pharmacist then works with the patient to support and help them to resolve any issues with their medicines and health conditions, using PCR to record their contact with the patient and the outcomes achieved. Although not part of CMS, support tools for the Gluten Free Food Service and Stop Smoking Service are now part of the Pharmacy Care Record. As of 10 November 2014, across Scotland there are 414,111 patients registered for CMS within 1,250 Community Pharmacies. Table 17 - Number of CMS registered patients as at November 2014 in Fife & selected neighbouring Health Boards Health Board Area Number of CMS registered patients Fife 28, Tayside 28, Forth Valley 24, Lothian 59, Scotland 417, No of CMS registered patients per 1,000 of population 2.3 Community Pharmacy Services - Additional Services There are several additional services agreed within NHS Fife. These are locally negotiated contracts and as such not all pharmacies participate in these services. It is responsibility of the NHS Board to ensure that these additional services meet the needs of the population however this does not mean that the population requires these services equally across geographical areas or that it is necessary to provide them from every community pharmacy. The services might also not entirely be provided by pharmacy alone and so provision must be looked at in the context of wider healthcare services. 29

32 Table 18 - Summary of the community pharmacy numbers providing Additional Services by CHP CHP DWF K&L GNEF NHS Fife Dispensing/supervision of methadone Dispensing/supervision of buprenorphine Injecting equipment provision Advice to Care Homes Community Pharmacy Palliative Care Network Just in Case Programme Anticoagulant monitoring Keep Well Counterweight Substance Misuse Supervised Self-Administration of Methadone Methadone is a well-established treatment for opiate dependant patients. It reduces harm to the individual and society by reducing the injecting of drugs which in turn helps to reduce the spread of potentially fatal blood borne viruses such as Hepatitis B, C and HIV. It can also help to stabilise and decriminalise the lives of drug misusers and integrate them back into society. Supervised self-administration of methadone has become a key component of any methadone programme. Supervision is undertaken at the request of the prescriber and is a clinical decision based on the patient s stability, home circumstances and progress through treatment. 30

33 Supervision ensures that adequate blood and tissue levels of methadone are maintained and helps to prevent diversion onto the black market. The use of community pharmacists for dispensing methadone allows patients to be treated in their own communities. Community pharmacists are the best placed healthcare professionals to carry out the supervision of methadone. A valuable supportive relationship can develop between the community pharmacist and the patient. Daily contact allows the pharmacist to monitor patient compliance (e.g. missed doses) and suspected misuse of illegal drugs and alcohol. It also allows the pharmacist to provide health promotion advice. 84 out of 85 pharmacies in Fife dispense and supervise methadone - the majority of pharmacies are able to provide supervision either in a consultation room or an area screened off from general view. The number of installments of methadone dispensed and the number of supervised doses given, for the last 3 financial years, are noted in table 19 below. Both parameters have decreased over this time period. Table 19 Methadone dispensing noted as number of installments & number of supervised doses over the last 3 financial years (% change noted in brackets) 2011/ / /14 Number of methadone 293,088 (-6.7%) 271,106 (-7.6%) 252,218 (-7%) installments Number of supervised methadone doses 186,178(-12.4%) 164,395 (-11.7%) 149,039 (-9.3%) Supervised Self-Administration of Buprenorphine There are 60 pharmacies in Fife which offer the supervised selfadministration of buprenorphine, although in practice those not registered are generally willing to do so if a request is forthcoming from a prescriber. The use of buprenorphine for opiate substitution has shown a steady increase over the last four years with the combination tablet of buprenorphine with naloxone being the most commonly prescribed form. The addition of naloxone makes the tablets less attractive to the illicit market and therefore less likely to be diverted. The amount of time the patient will require supervised self-administration should, therefore, be reduced. Supervision of self-administration of buprenorphine is a lengthier process than that for methadone as the sublingual tablet takes between 5 and 10 minutes to dissolve, however the patient only needs to be under close observation for 2-3 minutes whilst the ingredients becomes unrecoverable for diversion. 31

34 41,594 installments of buprenorphine were dispensed in financial year 2013/14. There has been an increase of 33% each year for the last 2 financial years. Community pharmacies supervised 14,748 installments of buprenorphine - an increase of 19% from last year Injecting equipment provision Injecting equipment is provided with the aim of reducing the transmission of blood borne viruses by the sharing of injecting equipment; to protect the public from discarded equipment; to make contact with drug users who are not in contact with drug treatment services; and to improve access to health and harm reduction advice. There are 19 community pharmacies in Fife who currently provide this service on behalf of the Alcohol and Drug Partnership. Injection equipment is provided in pre-packed packs standardised throughout Scotland via a national procurement. Injecting equipment providers are asked to encourage clients to use a new set of works for every injection. Five different packs are available, including one suitable for steroid users. Data is collected at each transaction and forwarded to Information Services Division for input to the annual report. The report Provision of Injecting Equipment in Scotland 2012/13 published by Information Services Division in May 2014 highlighted that, in comparison with Health Boards across Scotland, NHS Fife distributed the highest number of needles/syringes per head of population over 16, distributing 1.7 needles/syringes per person. Of the 16,133 attendances at injecting equipments outlets across Fife, 14,919 were at Community Pharmacies the remaining 1,214 were at outlets or by outreach services provided by the third sector agency Addaction Domiciliary Oxygen Therapy Services (DOTS) Following a Scottish Government review, the oxygen service transferred from community pharmacies to a national single supplier from September An integrated oxygen service has been identified as a positive development for patients, supports the delivery of the Quality Ambitions and it is hoped, will reduce costs. NHS Fife Pharmacy services engaged with pharmacy contractors regarding offering contingency arrangements for a period of 12 months following transition. Currently two community pharmacies hold contingency stock and will continue to do so until 31 March Pharmacy Services are working 32

35 with NHS Fife GPs to implement urgent in-hours access to oxygen concentrators for patients at the end of life. This new system will commence in January 2015 and will be managed by Pharmacy Services Supply of Stoma Appliances From 1 July 2011 suppliers of stoma appliances must be entered on the NHS Scotland list of approved suppliers. Stoma service providers are expected to comply with the agreed standards for service provision. All NHS Fife community pharmacies have registered to provide this service currently. In addition other appliance suppliers also provide this service giving NHS Fife adequate coverage for this service. At the start of 2015 a review of Stoma Care Services began to assess the quality & cost effectiveness of the current arrangements Pharmaceutical Advice to Care Homes Community pharmacies provide a service to Care Homes to provide advice on safe keeping and correct administration of drugs and medicines to residential and nursing homes. There is work ongoing nationally to review the current service available, with a view to introducing a version of CMS for care home patients (currently excluded from CMS) Palliative Care Network The aim of this service is to provide a network of community pharmacists throughout Fife, who are able to meet the pharmaceutical care needs of palliative care patients. The key services provided are: Dispensing of specialist palliative care medicines Providing advice and information on the use of these medicines to patients/carers and healthcare professionals Liaising with the patients usual community pharmacist and primary healthcare team to ensure continuity of supply of the specialist medicine(s). Additional funding secured from Scottish Government has enabled an extension to the network, from 15 to 20 pharmacies. This funding also enables a community pharmacist to join the network group to inform future education and training requirements Services Commissioned By NHS Fife Just in Case Programme 33

36 A Just in Case - JIC programme is delivered from community pharmacies. Such a programme has been advocated by the Scottish Government through Living and Dying Well - a national action plan for palliative and end of life care in Scotland. The NHS Fife Action Plan contains as part of action 6: To identify if there are areas or circumstances within NHS Fife where the use of 'Just in Case' boxes would improve the accessibility of medicines likely to prevent hospital admissions. JIC relies on appropriate anticipatory prescribing which forms part of wider anticipatory care planning processes. The programme was developed with the NHS Fife Palliative Care Guidelines Group and the Network of Palliative Care Community Pharmacy Development Group. The programme uses the already established Fife Network of Palliative Care Community Pharmacies to work closely with the patient s Primary Care team to monitor the supply of boxes and the medicines contained therein. The programme is now operational across all three CHP areas. Avoidable hospital admissions and GP out of hours calls are being prevented. Where a JIC box is issued and subsequently used, 99% of patients were found to be able to remain in their preferred place of care i.e. home. Feedback from both health professionals and patients and their families are that having the JIC at home is greatly reassuring. This successful scheme has now been extended to make it available to all patients at the end of life e.g. heart failure and chronic obstructive pulmonary disease Pharmacist Led Warfarin Clinics (Anticoagulant Monitoring) Pharmacist led warfarin clinics have been available in Dunfermline in Fife following a successful pilot and evaluation in The service was created to improve the management of the increased number of warfarin patients and the corresponding increase in the number of International Normalised Ration (INR) monitoring episodes. Four Pharmacies are now involved in this service which involves managing patient appointments, extracting bloods, measuring and interpreting INR results, modifying warfarin dose if required, discussion of the result and the factors affecting the result. Scheduling of next appointments are then made and if necessary referral or discussion with GP or secondary care. The service is sub-contracted by certain GP practices to these community pharmacies Keep Well Currently, there are two community pharmacies taking part in the Keep Well initiative across Fife, offering health checks to year olds living in Scotland s most deprived households and communities. All pharmacy staff have been fully trained to undertake these health checks which have 34

37 previously taken place within GP surgeries and other community venues. Funding has been confirmed for the Keep Well initiative until The benefits of providing these health checks within the pharmacy means that those eligible can benefit from the longer and weekend opening hours, as well as being able to discuss their medicines with the pharmacist. The Keep Well health check may also provide a referral pathway to other services such as the stop smoking service and Counterweight management programme. Ben s Story Ben, aged 54, received a call from the Keep Well Team asking whether he would be interested in a free health check. Ben said: I feel healthy at the moment and haven t seen my doctor for years. I do feel a little breathless at times which is probably due to me not being as fit as I used to be but the fact my brother had a heart attack 4 weeks ago, makes me feel I should attend. During the health check the importance of good cholesterol, glucose, blood pressure (BP) and weight control in relation to lifestyle factors such as diet, physical activity, alcohol & smoking became apparent. Ben s cholesterol and BP measurements were high. Also having a family history and being a big smoker put him at high risk of cardiovascular disease himself. Ben didn t realise the effects of a high salt intake on BP and promised he would look at his diet more closely to help and reduce his risks of heart disease. Ben declined our in-house Stop Smoking Service but armed with relevant reading material said: I have a lot to think about. Ben was referred to his GP for further investigations Weight Management Pilot Scheme (Counterweight) The Counterweight Programme has been funded by the Scottish Government in NHS Fife since Counterweight is a clinically and cost effective UK Primary Care weight management programme. The role of community pharmacy in providing health improvements and reducing health equalities is recognised in several key documents, including the Public Health Service Directions 2007 of the Community Pharmacy Contract. Ongoing research demonstrates community pharmacy delivery of weight management is as effective as general practice. 35

38 Referral into the programme occurs following a Keep Well health check either in a GP practice, a pharmacy or another community venue. Specialist dieticians provide training, support and resources to pharmacy support staff. In Fife, six community pharmacies & three GP practices are currently delivering the programme. Claire s Story "I have found the service very helpful and the advice made me think of how I could lose weight along with more exercise. I have succeeded (12 lbs) over 4 months with the help of my local community pharmacist Community Pharmacy Pain Network In order to address waiting times, the Pain Specialist Pharmacy team developed a proposal to form a community pharmacist pain network. This proposal was supported by the Local Medical Committee (LMC). Around the same time, a short-life working group (SLWG) was established to consider what the clinical priorities for pharmacist prescribing in community pharmacy might be. The SLWG agreed that a pilot community pharmacy pain network had the potential to both address waiting times for patients and to support those pharmacists yet to become active prescribers. A training package was developed supported by specialist pain pharmacists. Each community pharmacist was also allocated a buddy specialist pharmacist. A service specification outlining the roles and responsibilities for individuals within the service has been developed together with a competency framework to support the community pharmacists. Six community pharmacists participated in an initial pilot and have subsequently been supported to deliver pain clinics. An evaluation found that patients were highly satisfied with the service and that the service also had the potential to reduce medicine costs. Further data collection and analysis is currently underway in order to inform service improvement Healthy Start Vitamins Service In May 2013 in a 12 month pilot started within community pharmacies which aims to improve the uptake by beneficiaries in Scotland of Healthy Start Vitamins (HSV). At October 2013 the majority of pharmacies (93%) in NHS Fife were signed up to provide this service. This HSV distribution 36

39 supports the healthier nutrition of pregnant women & young children who meet the eligibility criteria. This pilot will now be continued until May Gluten Free Foods Service A Community Pharmacy Service was introduced in April 2014 enabling patients to obtain gluten free foods directly from a local pharmacy. The service will run as a pilot until 30 September NHS Fife has developed a Gluten Free Food Formulary and a patient leaflet is available. Only diagnosed patients with coeliac disease and/or dermatitis herpetiformis will be allowed to access this service, and will be given an agreed allocation of Gluten Free units. Patients will be able to choose which staple foods they require from the Fife Gluten Free Formulary. Pharmacists are required to register patients, complete a Pharmacy Care Record (PCR) and carry out an initial and thereafter an annual check on patients using this service. All 85 NHS Fife community pharmacies have signed up to this service. Alternatively patients can choose to remain with their GP practice to collect their prescription for gluten free foods. 2.4 Community Pharmacy Services - Unscheduled Care Unscheduled care can be described as: NHS care which cannot reasonably be foreseen or planned in advance of contact with the relevant healthcare professional, or is care which, unavoidably, is out with the core working period of NHS Scotland. It follows that such demand can occur at any time and that services to meet this demand must be available 24 hours a day. In the past the largest group of patients requiring unscheduled care tended to use one of the following routes: an urgent appointment with their GP advice from NHS 24 referral to the Out of Hours service via NHS 24 More recently service developments in community pharmacy have led to pharmacies becoming 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. This service was initiated nationally in December Community Pharmacies can also use Direct Referral to local Out of Hours services where the pharmacist feels that the patient does not have a medicines supply issue. 37

40 Table 20 lists the number of prescriptions (CPUS) issued for urgent supply of repeat medicines via this PGD over the last 6 financial years Table 20 - Number of prescriptions (form type CPUS) issued for urgent supply over last 6 financial years Financial year Number of urgent supply prescriptions , , , , , ,948 Urgent Supply Patient Stories Mrs HS When I ran out of my salbutamol inhaler at the weekend, I was relieved when my local community pharmacy could provide a replacement. It saved me a trip to A+E Ms MC I found this service convenient and easy 2.5 Community Pharmacy Services - Accessibility of Pharmaceutical Services Travel times to community pharmacies Previous national research has indicated that 86% of the population are within 20 minutes travelling time of their pharmacy and 44% are within 10 minutes. This data also showed that 47% of respondents travelled by car and 42% walked. The majority (83%) started and ended their journey at home with only 8% travelling from their place of work. Another UK wide survey showed that 56% of respondents were a short walk away from a pharmacy with an additional 22% further than a short walk but less than one mile. The respondents in this survey reported a mean distance of travel of 0.8 miles to a pharmacy. The distance the population live from a pharmacy has been calculated for Fife. The information shows similar results to the research findings above. 38

41 The distance from the pharmacy and the percentage of the population living within this distance are shown in the table below. Table 21: Percentages of the Fife population living within various distances of their nearest pharmacy Distance population live from Percentage of population their nearest pharmacy living within the distance Quarter of a mile of Pharmacy 25% Half a mile of pharmacy 60% Within one mile of pharmacy 84% Within 2 miles of pharmacy 92% Within 4 miles of pharmacy 98% Within 6 miles of pharmacy 100% The information above shows that 84% of the Fife population live within 1 mile of their nearest pharmacy and based on this information it has been calculated the average distance that Fife residents live from a pharmacy is 0.65 miles. (NHS Fife is the third most densely populated of all Scottish Health Boards) It cannot be assumed that the population will necessarily use the nearest pharmacy but location has been shown to be critical in the access to pharmaceutical services. Survey results as part of the Office of Fair Trade review of the control of entry regulation and retail pharmacy services in the UK demonstrated that 89% of people found the location of their pharmacy easy to get to from home. Convenience of the pharmacy location is related to the distance required to travel to the pharmacy by the population that they serve Hours of service Pharmacies provide opening hours that must cover 9.00am to 5.30pm on 5 days of the week in which they can be closed for 1 hour during the middle of the day and offer one day per week of an 9am to 1pm opening (NHS Fife General Pharmaceutical Services: Hours of Service Scheme). In summary this shows that each contracted pharmacy must be open five and a half days per week. There are some local variations on these hours that have been agreed by the NHS Board based on local circumstances to suit the requirements at individual locations. Several pharmacies have extended hours to 6pm and many offer a service on Saturday and some on Sundays. See table 22 below for a summary of the hours of service of community pharmacies in Fife. 39

42 Table 22: Summary of the hours of service of community pharmacies in Fife (December 2014) CHP Open Open Open Open up Open 7 Number of less only 5 only 5 1 / 2 to 6 full days per community than 5 full days days per days per week pharmacies full days per week per week week week DWF 1 7 (3*) K&L 2 (1*) GNEF 1 (1*) Total 1 10 (5*) *The numbers in brackets indicate the pharmacies that are open 4 1 / 2 days during Monday to Friday & half day Saturday In September 2010 a NHS Fife Pharmaceutical Needs Assessment of Out of Hours Community Pharmacy Provision on Sundays included a benchmarking exercise which showed the NHS Fife provision of pharmaceutical services on a Sunday to be at least in line with, if not more generous than other similar NHS Board areas i.e. most health board areas have fewer Sunday opening pharmacies per head of the population than Fife. It should also be noted that the 8 community pharmacies that do open on a Sunday are located in the same areas/towns as the NHS Fife Primary Care Emergency Service (PCES) where prescriptions on a Sunday will be generated from. 2.6 Community Pharmacy - General Services Financial Report Summary A summary of the budgets in financial year 2014/15 for the general services within community pharmacies is listed in appendix Future developments of Pharmaceutical Care Services The Scottish Government publication - Prescription for Excellence - A Vision & Action Plan for the right pharmaceutical care through integrated partnerships and innovation September 2013 ( ) states that Pharmaceutical Care Services Plans will be central to how NHS Scotland plans, provides & delivers pharmaceutical care & medicines to its 40

43 communities. Prescription for Excellence places a clear emphasis on delivery of pharmaceutical care in the community from both pharmacy premises & away from those premises. This change in emphasis needs to be reflected in PCS Plans with appropriate assessment of pharmaceutical care needs. National development work is currently underway which will improve methodologies to allow future PCS Plans to be delivered in the context of Prescription for Excellence, Health & Social Care Integration and the amendments to the Control of Entry Regulations. 41

44 3 Description of General Medical Service Provision in NHS Fife See web link below for details of the 58 GP practices in NHS Fife at April 2015 that provide General Medical Services (additional services & enhanced services are also noted) A31C-50E0-CD260D2371D607C2 Appendix 2 shows a map of NHS Fife with all the GP practices & community pharmacies denoted. The relationship between pharmaceutical and medical services is strong in NHS Fife and the location of GP practices has historically played a significant influence over the geographical location of community pharmacies. At December 2014 there is one GP practice that currently provides dispensing services. This is the Auchtermuchty/Strathmiglo practice - dispensing services are provided from the Strathmiglo surgery each morning (Monday to Friday; 8.30am pm) plus from 4.00pm to 5.30pm on Thursdays. 42

45 4 Analysis of Pharmaceutical Needs within NHS Fife with Recommendations to Meet Identified Under Provision Information on both the health of the population of Fife and the services currently provided by community pharmacies has been detailed in the previous sections of the report. This has allowed adequate information to be considered to contemplate what the implications of this are for the future of the community pharmacy service within NHS Fife. It would appear that overall there are no identified gaps in provision of pharmaceutical services in NHS Fife. These services are well distributed across the region and meet the access needs of the vast majority of the population, with no large gaps being identified. In addition the report has not identified unmet need for new community pharmacies across Fife, although the need for the services delivered through existing pharmacies may require ongoing scrutiny. 4.1 Number of community pharmacies There are 85 contracted community pharmacies in NHS Fife. These are well distributed across the region & appear to meet the access needs of the vast majority of the population. Since 2009, there have been seven new community pharmacy contracts awarded in NHS Fife (three in DWF & two each in GNEF and K&L). 4.2 Hours of service There would appear to be no under provision in terms of opening hours for NHS Fife. For example there are eight community pharmacies that open seven days a week; three in Kirkcaldy, two each in Dunfermline & St Andrews & one in Glenrothes. Opening hours out with core hours are likely to remain fluid and a local process for agreement of any opening hour changes should be retained. 4.3 Pharmacy workforce The formation of the Community Pharmacy Pain Network has provided an opportunity for pharmacists who are independent prescribers to utilize this qualification in order to provide pharmaceutical care, reduce waiting times & reduce medicine costs. 4.4 Community Pharmacy services - core services The Minor Ailment Service The number of patients registering for MAS is comparable with neighbouring Health Boards & the national picture. The number of MAS dispensed items across NHS Fife has increased over a 3 year period when three six month periods in 2012, 2013 & 2014 were examined. 43

46 4.4.2 The Public Health Services The Community Pharmacy Stop Smoking Service - The introduction of the revised service specification for the CPSSS has provided an opportunity for support to be developed & delivered to underpin this service, so that the new NHS Fife HEAT target (from April 2014) can be successfully achieved. The NHS Fife CPSSS Action Plan 2014 will aim to provide the support & direction to facilitate this Sexual Health (EHC) Service During 2014 work has been undertaken to maximize the links & referral pathways between the recently re-vamped NHS Fife Sexual Health Service & the community pharmacy service in order that issues such as teenage pregnancy rates can be reduced. A national review of the Sexual Health Service is underway & its recommendations are expected in Chronic Medication Service Work to complete implementation of CMS is progressing in line with Scottish Government timescales. The number of CMS registered patients within NHS Fife is also in line with neighbouring Health Boards. 4.5 Community Pharmacy services - additional services The Additional Services developed under the Community Pharmacy Contract have developed robustly and make a fundamental contribution to the health of the population. Locally agreed services have been developed across the region according to the priorities of NHS Fife and the assessed needs of local communities. Several community pharmacy services are negotiated at a local level and there is potential to review each of those on an ongoing basis to ensure that the services delivered still meet the needs of the local population Substance misuse There would appear to be no current evidence of unmet need for the supervised methadone & buprenorphine services. The services provided by pharmacies relating to substance misuse are part of an overall strategy led by the Drug and Alcohol Action Team and services require to be addressed within that wider context and appropriate funding identified to support any increase in demand. The level of injecting equipment provision by community pharmacies & other services was reviewed in 2014 & an additional community pharmacy (in K&L CHP) was added to list of community pharmacies undertaking IEP. 44

47 Appendix 1 NHS Fife Pharmaceutical List at April 2015 See web link below for details of the 85 community pharmacies in NHS Fife at April 2015 and the NHS services that they provide. 45

48 Appendix 2 - NHS Fife Pharmaceutical Care Services in NHS Fife 2015/16 (April 2015) Appendix 2a NHS Fife Community Pharmacies, GP Practices & Primary Care Emergency Services (PCES) November

49 Appendix 2b - Population Density by InterZone - November 2014 (NHS Fife) Appendix 2c - Scottish Indices of Multiple Deprivation (SIMD) 2012 Quintiles - Nov 2014 (NHS Fife) 47

50 Appendix 3a - Population Density by InterZone - November 2014 DWF CHP 48

51 Appendix 3b - Scottish Indices of Multiple Deprivation (SIMD) 2012 Quintiles - Nov 2014 (DWF CHP) Appendix 3c - Scottish Indices of Multiple Deprivation (SIMD) 2012 Quintiles - Nov 2014 (Dunfermline) 49

52 Appendix 4 a - Population Density by InterZone - November GNEF CHP 50

53 Appendix 4b - Scottish Indices of Multiple Deprivation (SIMD) 2012 Quintiles - Nov 2014 (GNEF CHP) Appendix 4c - Scottish Indices of Multiple Deprivation (SIMD) 2012 Quintiles - Nov 2014 (Glenrothes) 51

54 Appendix 5a - Population Density by InterZone - November K&L CHP 52

55 Appendix 5b - Scottish Indices of Multiple Deprivation (SIMD) 2012 Quintiles Nov 2014 (K&L CHP) Appendix 5c - Scottish Indices of Multiple Deprivation (SIMD) 2012 Quintiles - Nov 2014 (Kirkcaldy) 53