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16 August 2013
1 Trevelyan Square REF: SHA/17205
APPEAL AGAINST NHS CB DECISION TO REFUSE AN
APPLICATION BY MR IAN FRASER FOR INCLUSION IN
OFFERING
UNFORESEEN BENEFITS AT UNIT 3 RIBBLE SQUARE,
RIBBLE DRIVE, WHITEFIELD, BURY, M45 8NA

The Application
By application dated 20 October 2012, Mr Ian Fraser ("the Applicant") applied to Bury Primary Care Trust ("the PCT") for inclusion in the pharmaceutical list offering unforeseen benefits at Unit 3 Ribble Square, Ribble Drive, Whitefield, Bury, M45 8NA . In support of the application it was stated: Within the PNA page 58 states that Besses is a ward with nearly 11,000 population but no pharmacy within it. This is clearly a future health problem in the making. It then states that there are no pharmacy hours provided within the ward. Page 66 of the PNA states that patients living in Besses can travel to another ward. Obviously, an unforeseen benefit of having a pharmacy within the ward would be better healthcare due to better access. Page 31 shows Besses as the most deprived of areas. Page 49 points to future needs of childhood obesity within Besses and respiratory disease. It then suggests tackling these issues by use of Medicine Use Reviews and Health Trainers/Education in Pharmacies. However, since the area currently has no pharmacy within it, an obvious unforeseen benefit of opening one within the Besses area would be that these proposed PCT solutions to problems highlighted within the PNA would be tackled. Page 66 lists coronary hear disease and smoking care areas that need treating within Besses but if left without signposting and pharmacy based education will only worsen. Besses is a health care time bomb that need planning for with pharmacy provision. The childhood obesity poor respiratory levels, high smoking levels and high levels of coronary heart disease are not coincidental but directly linked to the lack of pharmacy provision and as such greater access would have the unforeseen benefit of health education resulting in the community having a better understanding of these diseases and a better understanding of both how to avoid their occurrence as well as providing better compliance and better outcomes where such conditions pre-exist. Page 48 of the PNA recommends that a pharmacy goal should be to improve future outcome of cardiovascular disease by use of Medicine Use Reviews within community pharmacy. As with the respiratory outcomes and obesity outcomes it will be impossible to provide such series in a community which the PNA clearly states has "no pharmacy within its boundaries". Therefore the clear unforeseen benefit of opening a pharmacy within Besses is that the community will have a future focal point capable of addresses its needs and its likely increase in healthcare problems unless such a service is provided. In summary a growing community suffering with childhood obesity, coronary heart disease and respiratory problems above acceptable levels will have the unforeseen benefit of having the resource that Bury's PNA states on pages 48 and 49 is to be used to remedy these problems. This resource currently is lacking and as community continues to grow with the new developments in the area this will increase the need which the current PNA has not planned for. The future is related to the need for health education and the future problems related to childhood obesity, respiratory problems which will produce a significant increase in the need for healthcare provision. The Decision
The PCT considered and decided to refuse the application. The decision letter dated 16 April 2013 states: NHS Greater Manchester Pharmacy Panel has considered the above application and I am writing to confirm that it has been refused. Please see enclosed copy of the Pharmacy Panel Report. The Pharmacy Panel Report stated: NHS Bury has received a routine application under Regulation 18 on the NHS Pharmaceutical Regulation 2012 ‘Offering Unforeseen Benefits' at Unit 3 Ribble Drive from Mr Ian Fraser. Site Visit
A site visit was not undertaken on this occasion as one was carried on in April 2012 (please see 2.17 - 2.27 below). Local Pharmacies
Days of opening
Barash Pharmacy
Rowland Pharmacy
Co-operative Pharmacy
09:00 – 18:15
09:00 – 18:15
Wednesday
09:00 – 18:00
Thursday
09:00 – 18:15
09:00 – 18:15
Saturday
Local GP Practices
Uplands Medical Practice Whitefield 8,603 08:30 -10:30 – 16:00 -18:00 (Mon 0.9 miles / Tues / Thur / Fri) 08:30 -10:30 Wed 5 GP Practice
Unsworth Medical Centre
08:45 -12:30 – 13:30 -18:00 (Mon 1.0 miles 08:00 -12:30 – 16:00 -18:00 (Wed 5 GP Practice
The Elms Medical Practice Green 6,346 09:00 – 18:00 (Mon / Tues /Fri) 08:30 – 18:00 (Wed / Thur) 5 GP Practice

Unsworth Medical Practice and Uplands Medical Practice have both deployed Electronic Prescription Service (EPS) Release 2, which means that these practices can send prescriptions to a patient's nominated pharmacy electronically; resulting in a reduction of the numbers of trips that a patient would have to make to their practice to collect prescriptions. Complaints
NHS Bury's Complaint Manager confirmed that no complaints have been received with regards [sic] to inadequacies of the pharmaceutical services from either patients or Healthcare Professionals in the area. Extract from the PNA
Health issues for this locality:
2.10.1 Premature mortality rates are higher than the Bury average. 2.10.2 Coronary heart disease mortality rates (both all age, and premature) are higher than the Bury average. 2.10.3 Chronic obstructive pulmonary disease mortality rates (both all age, and premature) are higher than the Bury average. 2.10.4 Cancer mortality rates (both all age, and premature) are higher than the Bury 2.10.5 Obesity rates in both reception and year 6 children are higher than the Bury 2.10.6 There are areas within Besses that smoking rates, as reported in the health survey, are higher than the Bury average. Community Pharmacy services provided:
Besses has no pharmacy within the ward boundary. However, when considered using a map showing the exact location of all the pharmacies both within Bury and within one mile of it border, it can be seen that Besses is bordered by other wards that have pharmacies located on the ward boundary, and patients living within Besses will only have a relatively short distance to travel to access their medicines. Besses ward is divided by the M66 motorway – the east of this division is entirely rural and residents have access to a pharmacy in neighbouring Heywood, Middleton and Rochdale. West of the M66 is more densely populated, but residents have access to 3 pharmacies (Barash, Rowlands and Co-op) on the ward boundary with neighbouring Pilkington Park and Unsworth. One of these pharmacies provides Stop Smoking services and all three pharmacies offer a prescription collection and delivery service. Other provision:
The Bury Stop Smoking Service at Elms Square Whitefield is close by There are no GP Practices within this locality. Action for the Panel
The Panel is to consider this application ‘unforeseen benefits' under the NHS 2012 Regulations Decision
The application was REFUSED under Reg 18 (1) (a) (2) (a) (b). 2.16.1 The panel determined that NHS Bury's PNA considered the services the applicant is proposing to offer and concluded that there was sufficient service provision available to the population of Whitefield Pharmacy Panel Site visit report - Friday 20th April 2012 Proposed Pharmacy Site The proposed Site for the pharmacy is in a block of retail units in the process of construction it is difficult to determine whether there will be sufficient car parking at the retail units and the location is a busy T Junction/mini roundabout as the units are still under construction it is undetermined what the access to the shops will be however as they will be subject to the most up to date building regulations Disabled Access should not be an issue Characteristics Of The Area The area around Ribble Drive and Mersey Drive is a densely populated area composing mainly of Local Authority and Housing Association properties. The dwellings are a mix of flats, terraced, semi detached and detached properties. The east or the area is mainly countryside with dispersed properties. Whitefield has a diverse community made up of people of all ages, and from different backgrounds, faiths and cultures. Along with Prestwich it has the second largest Jewish community in the country. The Besses ward is bounded on the north by Unsworth, on the east by the rural area of Besses, to the west by Pilkington Park and to the south by Holyrood. The main north-south road passing from Central Manchester to Bury, Bury New Road (A56) passes through the district. The proposed location of the new pharmacy premises is approximately 0.7 miles from Unsworth Pole and there are a number of shops/retail outlets at this junction, including: a Cooperative supermarket, dental surgery, GP Surgery, Post Office, newsagent, takeaway, and a sandwich shop. The pharmacy located in Whitefield is 0.8 miles from the proposed location where a large Morrison's situated, plus 2 GP surgeries, 2 Dental surgeries, a hairdresser, Estate Agents and a busy coffee/restaurant shop amongst other commercial enterprises. Travelling by car or public transport the nearest pharmacies to the proposed pharmacy location are: 2.23.1 Rowland's Pharmacy: approximately 0.7 miles from the proposed pharmacy. 2.23.2 Barash Pharmacy: approximately 0.8 miles from the proposed pharmacy. 2.23.3 Cooperative Pharmacy: approximately 1.2 miles from the proposed Bury GP practices nearest to the proposed pharmacy are: 2.24.1 Unsworth Medical Centre, Bury BL9 6JR (0.7 miles) 2.24.2 The Elms Medical Centre, Green Lane, Whitefield Manchester M45 7FD (1.2 2.24.3 Whitefield Health Centre, Bury New Road, Whitefield, Manchester M45 8GH 2.24.4 Blackford House Medical Centre, 137 Croft Lane, Hollons, Bury, BL9 8QA (1 Public Transport The Besses ward has good public transport links with Manchester and Bury. There are high frequency bus services along Bury New Road, Ribble Drive and Mersey Drive, mostly provided by the 'First Manchester' bus company. The area is also served by a tram station on the Metro link line from Manchester to Bury. The following bus services travel through the Mersey Drive/Ribble Drive neighbourhood; the 93, 137, 138 and 154, to Bury. There is no car park at the proposed pharmacy location however there is limited on street parking along this busy junction. The Appeal
In a letter to the Family Health Services Appeal Unit of the NHS Litigation Authority ("the Appeal Unit"), dated 1 May 2013, the applicant, Mr I Fraser, appealed against the PCT's decision. The grounds of appeal are: It is acknowledged that there is no pharmacy within the ward of Besses, which contains over 11,000 population and it has a higher prevalence of obesity. Coronary disease, smoking, chronic obstructive pulmonary disease than surrounding areas. The nearest pharmacy is located 1,100 metres away. A supermarket store has recently opened at the location. The local surgeries are now operating the ETP2 electronic transmission of prescriptions. This means that local residents would no longer have to leave their local area to obtain prescriptions if there was a pharmacy in the immediate location. This is in line with new government directives of equality throughout NHS services. Under such guidelines one community should not be reliant upon surrounding wards for its NHS services. Mr Fraser states that it is also his contention that this situation of reliance upon adjoining wards has contributed to the higher prevalence of the previously mentioned diseases. It is vital to remember that pharmacy services are about education and signposting and as such the applicant states that they would propose their own innovative scheme based upon a successful weight loss scheme already trial led in Birmingham to confront the obesity problem. This problem is particularly prevalent in children in Besses and the applicant states that they would be looking to actively work with local schools. Also, this will be a self funded initiative and therefore not dependant on CCG funding. When considering unforeseen benefits consideration must be given to what is being provided, how it is being provided and where it is being provided. Therefore as well as the unforeseen benefits such as education being available at the point of source, where it is most needed, future obesity related conditions such as diabetes and heart disease will be prevented through better patient self care as they will understand more about the potential obesity/diabetes risks and appropriate weight/diabetes management. The innovation lies in both a desire to provide specially devised weight management/education programmes and greater medicines management through MURs, which are not conducted to anywhere near capacity by surrounding pharmacies, as well as provision in of service at a place where it is needed. Location of services is a relevant point with regard to innovation; in that a service may not be new to the NHS as a whole but may be new to a specific area. If resources are provided where they are needed but were not previously available that in itself is both innovative and unforeseen benefit. Collection and delivery is a means of providing drugs to the patient is not a substitute for pharmaceutical access and care. It is due to these facts that the local M.P. Ivan Lewis has written to detail the overwhelming community support and desire for a pharmacy as such the applicant would hope that the panel views the application under the latest regulations and overturns the Pharmacy Panel decision to refuse the application. Summary of Representations
This is a summary of representations received on the appeal. A summary of those representations made to the PCT are only included in so far as they are relevant and add to those received on the appeal. An initial view of the maps provided show that there are three pharmacies within the defined area and that each is co-located next to a G.P. surgery. Opposing parties to the application state that these pharmacies will provide all the health service necessary but that is untrue as the geographic location of these pharmacies show that people must travel out of the desired new pharmacy location to access pharmacy services. Therefore, the applicant states that before they can even consider the cholesterol and diabetes testing services that they shall fund even without CCG funding it is vastly important to stress that there is a large degree of innovation to providing pharmaceutical/health advice and education at the point at which is required rather than relying on peripheral out posts. As well as re-iterating that all the local councillors and the local M.P. welcome a pharmacy as the greatest individual health resource currently lacking in this area, the applicant should like to point out that the NHS is now supposed to be patient focused – ‘no decision about me without me'. Thus if al the people local representatives are strongly stating this is what the local people want and need how can there possibly be a lack of future benefit. Before moving on to points from the PNA the applicant states that they should like to mention some points from the Public Health Report 2011 ‘Living Well in Bury' Page 2. ‘The fact that in England today people in different social circumstances experience differences in health well-being and length of life is, quite simply, unfair. Creating a fairer society is fundamental to improving the health of the whole population and ensuring a fairer distribution of good health.' It is hard to believe that a health authority can make such a statement and at the same time expect a large deprived population to subsist using the pharmaceutical facilities of surrounding neighbourhoods. In this paper key issues are –putting ‘families first' delivering early intervention and prevention for vulnerable children and families. 4.1.8.1 Better targeting 4.1.8.2 Locality working – concentrating on narrowing the gap in health In Besses average life expectancy is 75.7 and virtually the worst in Bury where wards such as Pilkington have a life expectancy of 84 years. 4.1.10 Introducing pharmacy based dieticians as the applicant would propose, who can liaise with the local community and local schools to provided intervention and solutions to Besses obesity/childhood obesity time bomb. 4.1.11 Page 11 – ‘In Bury almost 50% of the adult population is overweight or obese… and 32.8% of year 6 children were overweight or obese.' 4.1.12 This problem will not be solved by prescriptions dispensed by the extremely busy dispensing factories located outside the locality but require a pharmacy based within the community that can introduce programmes such as Mend (mind exercise nutrition do it) to its local community. 4.1.13 The applicant would also aim to take the innovative approach of employing their own nutritionist to lead such schemes as an additional unforeseen benefit to allowing a pharmacy to open at the desired location. 4.1.14 A sound starting point for analysis of future needs is the PNA. 4.1.15 However, there appears to be huge discrepancy between the PNA's conclusions and the points made within it. 4.1.16 Similarly, whilst a summation of pharmacy the report may consider pharmacy needs within Bury to be adequately met a current running online survey on Bury PCT'S home page shows that nearly 30% of Bury's population consider that they are not satisfied with access to pharmacy within their local area. 4.1.17 The area Ribble Drive is a location at the centre of a defined ward referred to in the PNA as Besses and stated as having a population of 10,905 patients and no pharmacy within its boundaries. 4.1.18 Page 3:‘NHS Bury's vision is to ensure better health and well-being by promoting a health society and developing services which are clinically led and responsive to patient choice.' 4.1.19 The PNA continues stating that community pharmacies are crucial partners in helping achieve this vision and effect real change. It also states that these services should deliver better value and care for all. 4.1.20 This is impossible to deliver unless all wards in the PNA actually have at least one pharmacy within them. 4.1.21 To take the viewpoint that population health education can be successfully achieved by utilising pharmacies on the edge of deprived neighbourhoods leads to a two tier system, whereby in this particular case the residents of Hillock would be under exposed to educational resources and clinical screening services as proposed and would have a resultantly higher incidence of all preventable diseases such as COPD, Cardiovascular disease and Diabetes linked to obesity. 4.1.22 Unsurprisingly, this is the current position within Hillock but with a view to future needs all these problems will grow disproportionately within Hillock as will the associated drug and hospitalisation costs. In fact the website diabetes.co.uk estimates annual inpatient care to treat diabetes complication at between £1,800 and £2,500 per annum. Thus if a new pharmacy contract were to identify more than 10 potential diabetics or were to prevent 10 people becoming obese and having late onset diabetes it would more than recoup the additional £25,000 per annum practice allowance it currently pays to pharmacies. 4.1.23 Page 7:‘Providers of pharmaceutical services have a crucial role to play in improving the health of local people. They are often the first point of contact, especial y for those who might otherwise struggle to access health services.' 4.1.24 This is most interesting because the statement is re-affirming that pharmacy services is about far more than dispensing NHS prescriptions and that whilst a patient may get their prescription dispensed at an alternative location as the prescription provider may be located outside of the local neighbourhood it is simply unfair and disproportionate to expect them to receive their pharmaceutical based clinical services and educational support from a location that they would have no need to access. 4.1.25 It is also difficult to see how the current pharmacies will provide these necessary services as they require additional time and the current statistics available would indicate that the nearest pharmacy Rowlands is not currently able to complete it's authorised quota of MUR's one of the PCT's main mechanisms for health improvement. 4.1.26 Also, given the fact that MUR's are capped at 400 per pharmacy per annum it is impossible to argue that other pharmacies can fully accommodate another neighbourhood's pharmacy needs as once the pharmacy has reached their quota from their own neighbourhood they will no longer be able to service the MUR/clinical requirements of the additional neighbourhood. 4.1.27 Between August 2012 and October 2012 Rowlands the nearest chemist completed only 17 MUR's averaging less than 6 MUR's per month. 4.1.28 Looking to the future CCGs desire pharmacies to be more service orientated such that whilst prescriptions may be dispensed at alternative locations an area lacking in a pharmacy will lack these clinical services and education. 4.1.29 A comparable situation would be denying one African village a well and health advisors simply because a neighbouring village has one – ultimately, the village without a well will have worse health in the long term and a greater need of clinical support services in the future. 4.1.30 The population of Besses is already suffering and the future demand will only 4.1.31 The associated statistics are as follows: 4.1.31.1 11.15% of residents describe their health as ‘not good' compared to 9.94% for Bury (2001 census) 4.1.31.2 21.61% of people have a limiting long term illness compared to18.97% for Bury (2001 census) 4.1.32 The population of Besses has risen 18% since 2001 and is continuing to rise. Assuming a similar rate of growth the population will be approximately 13,000 by 2020. This is an astronomical number of people not to be serviced by a pharmacy 4.1.33 The neighbourhood has excessively high teenage pregnancy rates at 7.1%; far above surrounding wards. A pharmacy in the location would give better access both to educational materials and Emergency Hormonal Contraception. Not only is this a future need of the location but the rapid birth rate in the area will add to the future health burden 4.1.34 The area has specifically identified needs within the PNA such as alcohol use, overweight adults and obese children. These will undoubtedly contribute to future needs. 4.1.35 The Joint Strategic Needs Assessment targets 7 areas of focussed improvement over the next five years of these seven, five are easily improved by accessible pharmacy services. 4.1.36 The five being Stroke, Coronary Heart Disease, Respiratory Disease, Alcohol 4.1.37 The mechanisms being blood pressure testing/screening, diabetes screening, cholesterol testing, smoking cessation, education in primary schools about healthy eating and MURs. 4.1.38 Some of these services are already funded. However, as a community focussed future orientated pharmacy the applicant states that would be happy to self fund those that are not PCT/CCG funded. 4.1.39 The unforeseen benefit if a pharmacy at the desired location is that it will control and combat the health problems currently within the area and provide protection against the potential health problems. Page 23- Multiple Deprivation:
‘There is a strong evidence-based association between deprivation and health outcomes and health inequalities. Quite simply, those in the most deprived areas are likely to have a shorter life expectancy and have worse health and health indicators than those in more affluent areas.' ‘The highest rate of DLA(Disability Living Allowance) claimants shows that as at November 2009, the highest rate of DLA claimants are in Moorside, Besses, and Sedgely.' 4.1.40 Page 24 contains a colour coded map illustrating that Besses is in the top 10% of most deprived Super Output Areas according to 2007 IMD rankings ‘Barriers to accessing services are a key driver behind health inequalities and should be a key consideration in commissioning services.' ‘There are deep-seated and intractable links between poverty and health which flow both ways;' 4.1.41 These are quotes from page 25 of the PNA. 4.1.42 Page 25 also goes on to state that Moss Lane/Ribble Drive is in the 5% most income-deprived Super Output Areas nationally. 4.1.43 Low income will lead to worsening health, which will lower the income achievable by the population and the downward health/income cycle will continue in the area. 4.1.44 A new pharmacy would at least address this problem to some degree. ‘In commissioning services to improve health, we need to tackle health inequalities and target and/or weight resources accordingly.' 4.1.45 In Besses it can clearly be identified that there is an inequality and that as we move forward in time the gap widens. 4.1.46 A pharmacy would be the best solution to help regress this imbalance. ‘It is important to ensure all services/interventions are accessible to al groups of the population but with an emphasis on those in the areas with higher multiple and health deprivation, lower life expectancy and higher premature death rates.' 4.1.47 There could not be a more precise statement of why Besses has a need of a pharmacy than this. ‘Concern also exists about trends in the light of rising levels of obesity and other CVD risk factors eg diabetes.' 4.1.48 Besses has far worse levels of both conditions than other wards and as such has a huge need for a point of educational access and clinical intervention through patient contact. Nothing fulfils this requirement in the same way a local health focussed community pharmacy can. 4.1.49 Besses had the highest premature CHD (Coronary Heart Disease) mortality rates at 66.8 far above the next wards – 61.5 Pilkington Park, 61.1 Radcliffe, and 53.5 Unsworth. ‘More than 90% of the risk of having a first heart attack is attributable to socio-economic deprivation and lifestyle risk factors.' 4.1.50 Whilst a pharmacy in a neighbourhood may not enhance the wealth of the population it can educate the local population with regard to risk factors and as such is ideally placed to deal with the need for education about cardiovascular risk factors. This would be an unforeseen benefit. ‘Meanwhile there is a clear role for pharmacists in supporting patients to make best use of their respiratory medicines and Bury has asked community pharmacists undertaking Medicine Use Reviews(MURs) to target respiratory patients.' 4.1.51 This is impossible to do in Besses as there is currently no physical location to provide the service from and Rowlands are clearly too busy dispensing two wards worth of prescriptions to accommodate this. 4.1.52 There is therefore a need for a premises within Besses to conduct these ‘There is a need to extend, promote and increase participation in cancer screening programmes in the more deprived and among high risk groups in order to reduce cancer mortality rate inequality.' ‘There is also a need for targeted awareness raising,…' 4.1.53 This is a clear statement that the signposting and health promotion functions of a pharmacy that are essential services will be needed in the Besses ward. 4.1.54 A similar point applies to the intended focus on alcohol awareness. ‘Obesity is a major public health issue and is a national, regional, and local priority. Childhood obesity is associated with early onset of preventable disease. Obesity is a major risk factor in a number of diseases including CHD, stroke, some cancers, and diabetes and can be a complicating factor in the on going management of a wide range of conditions.' ‘Bury obesity prevalence is around 16.3%. 4.1.55 Around half the residents are overweight or obese and one in six is obese.' 4.1.56 There couldn't be a much louder alarm bel for a need than this statement within the PNA. Combating obesity would be an unforeseen benefit. 4.1.57 Ironically, when Ivan Lewis the M.P. for the area wrote asking why there was no pharmacy within the area his reply from Bury Clinical Commissioning Group seemed to indicate that it was due to a cost issue. 4.1.58 However, given the cost of not tackling the obesity problem via education and locally available weight loss scheme, which the applicant states that they have an innovative model for, the costs will far outweigh and slight additional costs incurred by locating a pharmacy within the neighbourhood. 4.1.59 With regard to dealing with this situation the PNA recommends ‘a variety of 4.1.60 And states ‘there is a need for targeted services'…'Intervention can range from awareness raising, brief intervention, and signposting, through to weight management services.' 4.1.61 As signposting is an essential pharmacy service it would make sense to have a facility that could provide this in the neighbourhood. 4.1.62 the applicant states that they would also intend to employ, despite no funding for such, a dietician to visit the local schools to create awareness of poor diet, obesity and its consequences as part of their community orientated approach. ‘This means that there could be 2,000 people with diabetes who are undiagnosed and going untreated.' ‘Screening is therefore an important part of the care pathway as is the resultant follow-up management of the condition to limit the complications.' 4.1.63 The screening service that the applicant proposes to offer is exactly what would be required to deal with such a large number of undiagnosed diabetics. 4.1.64 This would be an unforeseen benefit. 4.1.65 Bury PCT claims to have been successful with regard to smoking cessation programmes yet in Hillock Estate in the middle of Besses 31.3% smoke compared to on 9.7% in Unsworth. This differential can surely only be attributable to a lack of a resource centre/focal point within Hillock Estate to offer such a programme. 4.1.66 If as the PNA suggests that it desires to rectify inequalities the a pharmacy offering Smoking Cessation would go some way to doing this and would also help diffuse another potential health time bomb. 4.1.67 This is a huge unforeseen benefit. 4.1.68 ‘The JSNA recommends high level investment in Stop Smoking Services as a priority.' (emphasis added) 4.1.69 Currently, these are unavailable in Besses. 4.1.70 A colour coded map on page 45 shows Besses as a dark green mass of smokers wholly enclosed by healthier non-smoking communities. Personally, the applicant states that they can only attribute this to the lack of a pharmacy within the neighbourhood and the resultant lack of access to smoking cessation programmes. ‘Minimising costs to the NHS through unplanned pregnancies, sexual y transmitted infections (STIs), and the late diagnosis of HIV is a key objective. The provision of contraception is an important health care service which contributes to better maternal and child health.' (emphasis added) ‘Key issues in Bury are increasing rates of teenage pregnancy, repeat abortion rates, sexually transmitted infections and low levels of sexual knowledge amongst young people.' 4.1.71 It is wholly discriminatory and foolhardy to believe that young people will travel over 1km outside of their neighbourhood just to buy condoms when they should need them. 4.1.72 It is also unreasonable to expect the local grocer to undertake Chlamydia testing or signposting and education. 4.1.73 However, these are exactly the services that the PNA views as ‘key objectives' and they are exactly the services that a pharmacy would provide thus helping to deal with a potential sexual health problem. (emphasis added) 4.1.74 ‘Improving sexual health is an important issue, in terms of health-gain and reducing inequalities.' 4.1.75 ‘Teenage pregnancy is more common in disadvantaged areas.' 4.1.76 Besses is one such are and this statement from the PNA holds true. 4.1.77 Being a point of advise and education with regard to sexual knowledge would be another huge unforeseen benefit. Page 49 –Identified Health Need – Strategic Plan
CANCER – target to reduce cancer deaths in all ages from 187.3 to 167.7 per 100,000 – target area all age: – Besses. Pharmaceutical services which could contribute to meeting goal – Specialist Stop Smoking advice including provision of bupropion and varenicline via independent prescribing pharmacist at PGD. CARDIOVASCULAR DISEASE- reduce CHD deaths in all ages from 113 to100 – target area: – Besses – method:- Medicine Use Reviews by Community Pharmacies to promote best use of long term medication. Mental Health – all wards –method: - signposting Obesity – target – to halt the increase in obese children under 11 by 2011-target area: year 6 child age – Besses – method:- Health Trainers in Pharmacies. Respiratory Disease – reduce under 75 COPD deaths from 13.7 to 9.8 per 100,000 – target area under 75 years- Besses – method:- Medicine Use Reviews by Community Pharmacies to promote best use of long term medication. 4.1.78 Given this data it is impossible to argue against the need for a pharmacy 4.1.79 Besses is identified as a key target area in almost all of Bury's Identified 4.1.80 The resolution and targeted approaches to the problems are almost entirely pharmacy focussed. 4.1.81 Besses does not have a pharmacy within its boundaries to do this. 4.1.82 The nearest pharmacy outside its boundaries struggles to provide these services even when permitted. 4.1.83 There is a clear need of a pharmacy within Besses if Bury PCT/CCG is serious about meeting its identified health needs. 4.1.84 Bury PCT should be congratulated on being one of only 4% of PCTs to actually manage to get electronic transmission of prescriptions level 2 running. 4.1.85 However, now that it is the need for patients to actually visit the G.P. practice to obtain their prescriptions is also eliminated. 4.1.86 Therefore it would create an inequality if residents in the vicinity of Ribble Drive were forced to venture outside of their neighbourhood purely because they lacked a pharmacy. As such the resident would be making a special trip outside of the neighbourhood, which they would not have needed to do had a pharmacy been located within Besses. 4.1.87 If health equality is a PCT/CCG goal then a pharmacy within Besses is a required at some point in the near future. 4.1.88 Similarly, it can hardly be considered equal when too obtain a simple cough medicine other neighbourhoods have immediate access whereas Besses residents must walk over 1km when feeling unwell. 4.1.89 It is worth noting that 34% of Besses have no car compared with 26 % for the 4.1.90 Bury has 21 pharmacies per 100,000 population and each dispenses on average 7231 items monthly. Northwest comparative figures are 24 pharmacies per 100,000 and 6685 items per month.(Page 58) 4.1.91 These statistics alone may suggest that Bury is in need of another pharmacy. 4.1.92 Page 68:
4.1.92.1 Premature mortality rates are higher than the Bury average 4.1.92.2 Coronary heart disease mortality rates(both all age , and premature) are higher than the Bury average 4.1.92.3 Cancer mortality rates(both all age, and premature) are higher than the Bury average 4.1.92.4 Obesity rates in both reception and year 6 children are higher than the Bury average 4.1.92.5 There are areas within Besses that smoking rates, as reported in the health survey, are higher than the Bury average. Page 101:
‘A further new Primary Care Centre is planned for the Whitefield area, to replace the existing GP practice buildings' 4.1.93 The likelihood is that this new development will ultimately resultant in at least one of the pharmacies that currently border the neighbourhood moving even further away and thus the area of Ribble Drive will be even more isolated in terms of pharmacy services. 4.1.94 There is currently not a suitable anti-viral collection point in the area. 4.1.95 Should a Flu Pandemic occur the last scenario that would be welcomed would be residents travelling sizeable distance and into a variety of other wards to collect the vaccines. 4.1.96 Page 103 states ‘the views from stakeholders suggests there are potential y some new enhanced services which could be commissioned from pharmacies. These are: 4.1.96.1 NHS health checks/screening services 4.1.96.2 Weight management services 4.1.96.3 Alcohol intervention/treatment services 4.1.97 Obviously, a need would be a pharmacy to provide these services where they are most needed. Page 106:
4.1.98 NHS health checks including specific cholesterol, hypertension, and diabetes 4.1.99 Weight management services 4.1.100 Contraception services such as supply of the oral contraceptive pill and specialist long-acting reversible contraception (LARC) 4.1.101 Immunisation services 4.1.102 Hepatitis B and C screening 4.1.103 Anticoagulation monitoring service 4.1.104 These are areas where Bury PCT/CCG see pharmacy having a role to play but services are of little use unless there is a pharmacy to commission them from. 4.1.105 The major unforeseen benefit of a pharmacy at this location is that there would be a physical location to commission necessary services from. 4.1.106 This section completes by stating that the priorities for pharmaceutical service development for the life of the PNA focus on the key strategic aims and public health challenges for NHS Bury and are aligned to tackling the disparity of health inequalities across the borough. 4.1.107 It continues to discuss making available access to smoking cessation, vascular screening programmes to be commissioned from pharmacies, and obesity prevention. 4.1.108 If Bury wishes to comply with the its aim of tackling the disparity of health care inequalities across the borough then it needs to make all these proposed services available in the wards/communities that need them most (i.e. Ribble Drive in Besses ward) 4.1.109 In fact many people would go as far as to argue that the current inequalities exist due to the lack of pharmacy services within the ward/location and as such there is clearly an identified future need to rectify this situation. THE CO-OPERATIVE PHARMACY This application is for inclusion in the pharmaceutical list within the Besses locality. The Co-operative Pharmacy believe that this application fails to satisfy Regulation 18 and 19 of the NHS (Pharmaceutical Services) Regulations 2012 as an application to secure an improvement or better access to the existing pharmacy network if the need had been identified with the PCTs pharmaceutical needs assessment. The PCT must have regard to reasonable choice, service innovation and a protected characteristic being able to access pharmaceutical services. This application does not meet an unforeseen benefit to the residents of the locality for the following reasons, it does not provide a greater choice, it does not seek to meet health needs through service innovation and the applicant has failed to identify a protected characteristic. The PCT were aware of the absence of a pharmacy within the Besses locality at the time of drafting the PNA and if they felt a pharmacy would have met a need or provided an improvement to the current pharmaceutical services available to the population of the locality they would have identified the need within the PNA. The PCT have considered all the information mentioned by the applicant in the PNA and concluded that an additional pharmacy is not needed. It is up to the PCT to set the standards of pharmaceutical services within its area and they are satisfied that the current standards and availability of pharmaceutical services within the Besses locality are meeting the needs of the local population. This application should not be granted on the basis that the applicant has drawn a different conclusion to that of the PCT as the applicant has not provided any further evidence than what is contained within the PNA. The PNA has concluded that the existing pharmaceutical network out with the defined locality is meeting the needs of the residents of the Besses locality. There is an existing pharmacy located within 1100 metres of the proposed location that is significantly closer to the population than the proposed premises. The journey to the existing pharmacy from the proposed location is possible by foot, private and public transport. There is a bus service operating approximately every 10-15 minutes passed the proposed site to the existing pharmacies for those residents who do not have access to private transport and as the applicant states in their application the journey is not arduous. The journey time by bus from the proposed site to the existing pharmacies is approximately 5 minutes. The ground is level, with adequate lighting and drop curbs as appropriate. On street and off street parking is also available at the existing pharmacies. 4.2.10 There are also no geographical or physical barriers to accessing the existing pharmaceutical services. 4.2.11 The area immediately surrounding the proposed pharmacy is primarily residential in nature, with a very small few retail outlets to serve immediate needs for papers, cigarettes, alcohol, and convenience foods. The shops close to the proposed location would not be large enough to carry out a weekly shop in, they are convenience focused. Neither is there a medical services, banking services, post office or a high school. All of these services are located out with the immediate area of residence, which resident's access in the course of normal living. Where these services and amenities are located, there are also pharmacies located to provide opportunistic healthcare. 4.2.12 The Co-operative Pharmacy state that they also offer a free and unconditional prescription collection and delivery service from their pharmacy to the surrounding area to improve access to medication when there is no requirement to attend the surgery for an appointment. 4.2.13 The enhanced services the applicant is proposing to offer are not innovative as they are all services which are commissioned by the PCT. The applicants are not intending to meet any need with a new service that is required under Regulation 18 and 19 of the 2012 Regulations. 4.2.14 The PCT can commission all of the services in the application form with the existing pharmacy network if they felt there was a need for these services. 4.2.15 The applicant has failed to identify a protected characteristic which is experiencing difficulties in accessing the services provided by the existing pharmacy network. The Besses ward is ranked 4th out of 6 Bury Townships in terms of deprivation and Bury PCT is ranked 84th out of 151 PCT in terms of overall deprivation. Bury PCT is not the most deprived area in England neither is it the least deprived. 4.2.16 In summary The Co-operative Pharmacy maintain that the existing pharmacies are meeting the needs of the local population within the Besses locality and suggest that this application is not meeting any unmet need of a protected characteristic within the locality for it to meet the regulatory requirements under regulation 18 and 19 and we respectfully request the Litigation Authority to dismiss the appeal and refuse the application. PHARMACY CARE PLUS LTD Please consider the arguments already put forward by Pharmacy Care Plus Ltd (Barash Pharmacy) in earlier correspondence on file because the arguments still stand and Pharmacy Care Plus Ltd wish them to be reconsidered in full at appeal. Pharmacy Care Plus Ltd state that in respect of both applications, the case for offering unforeseen benefits remains exceedingly weak in their opinion. They seem to be very thin arguments. Pharmacy Care Plus Ltd state that none of the statements and proposals can be seen as unforeseen in their opinion and they believe that they have already been considered. As statement of fact, Pharmacy Care Plus Ltd wish it simply to be known that Barash Pharmacy is active in both MUR and NMS provision, and is on target to reach its 400 maximum quota of MURs this financial year. Pharmacy Care Plus Ltd state that they also deliver free blood pressure and diabetes checks, weight management advice and a paid weight management service to patients. In addition to their own considerable innovations they are very open to implementing any new proposals and schemes for services proposed locally, which have frankly been rationed in scope and depth to pharmacies locally until now in a cash-strapped PCT environment. Pharmacy Care Plus Ltd state that their Pharmacist Manager is on the LPC committee and is eagerly following developments on service provision locally for them to carry out when commissioned. It would be perverse to allow yet another pharmacy to open, where it is clear that tax payers' money would be better spent on funding service provision at great value for money of the public purse and arrange for it to be delivered through the existing (service hungry) pharmacy base. Please note that it is always generally the case that individuals when asked would certainly like there to be a pharmacy on every street corner and on every secondary parade of shops, but this is not a practicable or sensible outcome in the context of the panel's overall and wider responsibilities for decision making against a balanced range of recognised factors pertaining to pharmacy provision. In this fashion, Pharmacy Care Plus Ltd believe that the PCT/successor body certainly correctly reached its conclusion to refuse the earlier applications. Pharmacy Care Plus Ltd have no doubt though that while the applicants' cases were made with much involvement of voluminous data, that the underlying proposals were very weak in impact and novelty. Pharmacy Care Plus Ltd contend that the choice of pharmacies on the border of Besses is adequate even good (and indeed it may have been established in the paperwork issued that one of the three pharmacies is in fact within the boundaries to be considered). Pharmacy Care Plus Ltd believe that the PCT/NHS panel correctly concluded that there is adequate pharmaceutical provision in this respect. It was established that 100 hour pharmacies are available in the wider area, and that all pharmacies offer good collection and delivery services to patients that require them. In a letter to the PCT dated 15 January 2013 Pharmacy Care Plus Ltd stated: Under paragraph 19, Schedule 2 of the NHS (Pharmaceutical Services) Regulation 2013 as invited, Pharmacy Care Plus Ltd wish to make representations to NHS Salford/NHS Bury on behalf of Barash Pharmacy, Pharmacy Care Plus Ltd state that that this application should be refused on the grounds that unforeseen benefits are not provided. Pharmacy Care Plus Ltd assertion is that this application is in effect a ‘copy-cat' of a recent application for a Pharmacy in the same vicinity of Ribble Drive and Mersey Drive by Rushport LLP which was refused under necessary and expedient criteria by Bury PCT and then was refused again by the NHS Litigation Authority as recently as the 15th October 2012. Pharmacy Care Plus Ltd contention is that there is nothing in the current application that can be seen as an unforeseen benefit, since there is no new, innovative or surprising benefit to emerge either from the range of services, their mode of
delivery, a different technical approach, nor unforeseen increase in choice or
adequacy of services provided. The applicant here has posed nothing more
to add to earlier, fully posed arguments for a pharmacy application at this
location. Earlier arguments were fully appraised by the NHSLA in their letter
Ref: SHA/16848 dated the 15th November 2012, particularly in their detailed
conclusions in Section 9 leading to the Panel's unanimous conclusions in
Section 10 of the letter that a new pharmacy was unwarranted. Pharmacy
Care Plus Ltd respectfully refer NHS Salford/Bury to these arguments.
It is worth noting that this application is also very similar to an earlier application also in the vicinity of Ribble Drive and Mersey Drive that was refused both by the PCT and subsequently at Appeal without need for Oral hearing in February 2008, which dealt thoroughly with the issues, including definition of the relevant pharmaceutical neighbourhood which is wider than that of the applicant, and which refers also to various still earlier refused applications. The 2008 application was deemed neither necessary nor desirable, and so again it is unreasonable to think that the decision should be overturned in this later copy-cat application. 4.3.10 In support of this assertion, Pharmacy Care Plus Ltd note from the published Pharmaceutical Needs Analysis (PNA) for Bury states in the Executive Summary that, "The location of pharmacies when combined with good public transport links provide a choice of pharmacy and opening hours for Bury residents; the opening of four ‘100 hour' pharmacies in the past four years has significantly improved access for patients and these now meet Bury's need for early morning, late evenings and weekend opening hours. In addition pharmacies in adjoining Primary Care Trusts close to our borders or located on commuter routes provide a pharmaceutical service for Bury patients." 4.3.11 Pharmacy Care Plus Ltd assert that in considering this application that no fewer than three pharmacies: Barash, Co-op and Rowlands pharmacies: situated just outside the boundaries of the Besses Ward should be viewed as providing very good provision of pharmaceutical services to the housing estate surrounding the applicant's proposed location. In support of this point, the PNA states that, "NHS Bury has concluded that Bury residents have adequate access to a choice of pharmacies within Bury and within one mile of Bury's borders for essential services. The existing 100 hour pharmacies play a significant part in this and as we would not wish to see any reduction in the hours provided from these current sites." 4.3.12 It is also noteworthy that the recent Appeals Panel decision re: SHA/16848 of 15th November 2012 stated that: "The Panel accepted the submission made on behalf of Rowlands that the [Rushport] applicant's definition of neighbourhood was illogical in so far as it cut through the parade of shops at the north east corner which included the Unsworth Rowlands pharmacy and the Unsworth surgery. Accordingly the Rowlands pharmacy formed part of the applicant's [and therefore, Pharmacy Care Plus Ltd assert, since the pharmacy is in the same position, this current applicant's] neighbourhood, although that fact in itself contributed little to the Panel's conclusion…" 4.3.13 In fact (even if NHS Salford/Bury do not accept here the inclusion of Rowlands pharmacy at Unsworth in the applicant's pharmaceutical neighbourhood by the NHSLA's argument above), the Besses area is served from just outside its borders by no fewer than three pharmacies. 4.3.14 First, Rowlands Pharmacy situated by Unsworth Medical Centre on Parr Lane just to the north (see comments above on its proper inclusion). This Rowlands Pharmacy is in fact almost equidistant from the junction of Mersey and Ribble Drives to the distance to Barash Pharmacy from the proposed location. 4.3.15 Second, our own pharmacy, Barash Pharmacy/Pharmacy Care Plus is just off the corner of Moss Lane with Bury New Road to the west. 4.3.16 Finally, there is the Co-op pharmacy on Elms Square situated close to the Elms Medical Practice. 4.3.17 When viewing PNA data, it must be remembered to consider pharmacy providers close to the borders of any council ward or other defined area, which certainly applies here in respect of Barash, Rowlands and the Co-op Pharmacies with respect to the Besses Ward. 4.3.18 The area is served by a number of pharmacies in Whitefield, and in neighbouring Unsworth and Prestwich to the south, and is provided with good bus routes, fairly level gradients, good roads and street lighting. By the usual measures, this housing estate sub-area does not constitute an area for pharmaceutical services. It is not a requirement to site a pharmacy in every new small shopping parade that is developed. The applicant repeatedly relies on the assertion that the arbitrary area of Besses Council Ward has no community pharmacies operating within it, but this is undermined by the NHS Litigation Authority Panel's conclusions above. 4.3.19 It can, therefore, be seen that with Barash Pharmacy, Rowlands Pharmacy, Co-operative Pharmacy at Elms Square and numerous other pharmacies to the south in Prestwich including provision of 100-hour pharmacies in the wider Bury area, adequate provision of services, adequate access and adequate choice (there being many different competitive offerings). 4.3.20 In terms of opening hours, it should please be noted that the Applicant's nineteen Supplementary Hours of 5 pm until 8 pm on Monday to Friday, and of 9 am to 1 pm on Saturday could be withdrawn on 90 days' notice to the PCT or its successor body and therefore cannot be regarded as guaranteed hours. 4.3.21 After asking, Bury NHS informed Pharmacy Care Plus Ltd that there currently are no customer complaints regarding local pharmacy provision, nor any shortfalls identified as a result of PCT inspections carried out. Certainly annual patient surveys at Barash Pharmacy conducted of 2012/13 indicate a very high level of patient satisfaction with services that the pharmacy provides. In addition to providing all Essential and Advanced pharmacy services, Barash Pharmacy and other nearby pharmacies provide all of the Enhanced services currently sanctioned and funded as required by Bury PCT. The Pharmacy provides MURs, NMSs, all the Enhanced Services that are possible to provide, Minor Ailments, free blood pressure monitoring and free diabetes screening. The pharmacy, in common with competitors in the area, also already provides a good collection and van delivery service for those patients locally who require it. It also operates the EPS2 prescription service where applicable. A sizeable proportion of the pharmacy's collection and delivery service is already dedicated to patients in the estate where the new pharmacy is proposed. 4.3.22 It should please be noted that Bury PCT is currently unable to fund all but a very few enhanced services of the list proposed by the applicant. It would not be sensible for the application to succeed on the basis of it potentially providing services outside the scope of those that Bury currently allow before those services had been prioritised and offered to existing willing providers of pharmaceutical services in the area. Indeed, in Pharmacy Care Plus Ltd opinion, the cost to the PCT of bearing another pharmacy contract (practice and establishment fees, monitoring and admin cost at the PCT etc. totalling many tens of thousands of pounds per annum) in poorly funded and cash strapped Bury NHS would be tantamount to the misallocation of public funds until such time as a full range of enhanced services can be provided to the Bury populace through existing providers from the lower existing pharmacy cost base. For reference, the long list of services that Bury NHS would ideally like to commission through the pharmacy base if there were sufficient funds available is detailed in the PNA in the section entitled, "Future Development of Pharmacy Services." 4.3.23 Pharmacy Care Plus Ltd note that the PNA indicates that no gaps exist in pharmaceutical provision in the area of application. Indeed the PNA specifically addresses the point in the conclusion, stating in its Conclusions section that, "This needs assessment indicates that there are sufficient pharmacies in Bury to meet current and anticipated need within the lifetime of this PNA. All localities, particularly those containing the most deprived populations are well served with pharmacies within their immediate locality or close by, and these pharmacies provide a good range of opening hours throughout the week and weekends. " 4.3.24 In summary, it is not possible to see how the public would benefit from public investment in an additional pharmacy where it is not possible to see what actually comprises the ‘unforeseen benefits.' Every aspect of the applicant's proposal would appear to have been considered fully by competent PCT and Panel authorities already. The application is for a conventional pharmacy with conventional operations providing nothing in the way of guaranteed Enhanced Services. In Pharmacy Care Plus Ltd opinion, it would be expedient instead for Bury NHS to spend any money from the public purse on the long list of potential future pharmacy services that are not yet commissioned or are only partly commissioned by offering them to existing pharmaceutical providers rather than spending additional tax payers' money on additional practice and establishment fees for the already well provided set of existing services in the area concerned. This alternative approach would yield much more benefit for the residents of the sub-area highlighted by the applicant, where there is already comprehensive service provision, choice, accessibility and adequacy, than the unjustified granting of this application. Pharmacy Care Plus Ltd respectfully request the NHS Litigation Authority rejects Mr Fraser's application. There were no observations received. The Pharmacy Appeals Committee appointed by the Family Health Services Appeal Unit of the NHS Litigation Authority, ("the Committee") had before it the papers considered by NHS England, together with a plan of the area showing existing pharmacies and doctors' surgeries and the site of the proposed pharmacy. It also had before it the responses to the Authority's own statutory consultations. On the basis of this information, the Committee considered it was not necessary to hold an Oral Hearing. The Committee noted that this was an application for "unforeseen benefits" and fel to be considered under the provisions of Regulation 18 which states: If a Primary Care Trust receives a routine application and is required to determine whether the Primary Care Trust is satisfied that granting it, or granting it in respect of some only of the services specified in it, would secure improvements, or better access— to pharmaceutical services, or pharmaceutical services of a specified type, in its area; but the improvements or better access that would be secured were or was not included in its pharmaceutical needs assessment in accordance with paragraph 4 of Schedule 1, in determining whether it is satisfied as mentioned in section 129(2B) of the 2006 Act (regulations as to pharmaceutical services), the Primary Care Trust must have regard to the matters set out in paragraph (2). Those matters are— whether it is satisfied that granting the application would cause significant detriment to— proper planning in respect of the provision of pharmaceutical services in its area, or the arrangements it has in place for the provision of pharmaceutical services in its area; whether, notwithstanding that the improvements or better access were not included in its pharmaceutical needs assessment, it is satisfied that, having regard to the desirability of— there being a reasonable choice with regard to obtaining pharmaceutical services in the area of the Primary Care Trust, people who share a protected characteristic having access to services that meet specific needs for pharmaceutical services that, in the area of the Primary Care Trust, are difficult for them to access, or there being innovative approaches taken with regard to the delivery of pharmaceutical services, granting the application would confer significant benefits on persons in its area which were not foreseen when it published its pharmaceutical needs assessment; whether it is satisfied that it would be desirable to consider, at the same time as the appel ant's application, applications from other persons offering to secure the improvements or better access that the appellant is offering to secure; whether it is satisfied that another application offering to secure the improvements or better access has been submitted to it, and it would be desirable to consider, at the same time as the appel ant's application, that other application; whether it is satisfied that an appeal relating to another application offering to secure the improvements or better access is pending, and it would be desirable to await the outcome of that appeal before considering the appellant's application; whether the application needs to be deferred or refused by virtue of any provision of Part 5 to 7. The Primary Care Trust need only consider whether it is satisfied in accordance with paragraphs (2)(c) to (e) if it has reached at least a preliminary view (although this may change) that it is satisfied in accordance with paragraph (2)(b)." The Committee considered the Pharmaceutical Needs Assessment ("the PNA"), conscious that the document provides an analysis of the situation as it was assessed at the date of publication. The Committee bears in mind that, under regulation 6(2) of the NHS (Pharmaceutical Services) Regulations ("the 2012 Regulations"), the body responsible for the PNA must make a revised assessment as soon as reasonably practicable (after identifying changes that have occurred that are relevant to the granting of applications) unless to do so appears to be a disproportionate response to those changes. Where it appears disproportionate, the responsible body may, but is not obliged to, issue a Supplementary Statement under regulation 6(3). Such a statement then forms part of the PNA. The Committee noted that the PNA was dated February 2011 and that a supplementary statement had been issued on 30 June 2011. The Committee noted that the ward of Besses is specifically referred to at pages 67 to 68 of the PNA. The Committee noted that the applicant seeks to provide pharmaceutical services to the Besses ward and that all of the information provided by the applicant refers to the Besses ward as a whole with particular reference to the Hillock Estate in the area of Ribble Drive. The applicant stated that the unforeseen benefit of a pharmacy within Besses is that it will be a focal point for the community and will be able to address the healthcare problems and needs of the community. In order to be satisfied in accordance with Regulation 18(1), regard is to be had to those matters set out at 18(2). The Committee's consideration of the issues is set out below. Regulation 18(2)(a)(i)
The Committee had regard to whether it is satisfied that granting the application would cause significant detriment to— proper planning in respect of the provision of pharmaceutical services in its area …" The Committee noted that NHS England had not addressed the issue of any detriment to proper planning in its decision. The Committee further noted that no party had produced any information which would support a finding that significant detriment would be caused. The Committee was therefore satisfied that significant detriment to the proper planning of pharmaceutical services would not result from a grant of the application. Regulation 18(2)(a)(ii)
The Committee had regard to whether it is satisfied that granting the application would cause significant detriment to— … the arrangements it has in place for the provision of pharmaceutical services in its area" The Committee noted that NHS England had not addressed the provisions of Regulation 18(2)(a)(ii). The Committee further noted that no party had produced any information which would support a finding that significant detriment would be caused. The Committee was therefore satisfied that significant detriment to the arrangements currently in place for the provision of pharmaceutical services would not result from a grant of the application In the absence of any significant detriment as described in Regulation 18(2)(a), the Committee was not obliged to refuse the application and went on to consider Regulation 18(2)(b). Regulation 18(2)(b)
The Committee had regard to whether, notwithstanding that the improvements or better access were not included in its pharmaceutical needs assessment, it is satisfied that, having regard to the desirability of— there being a reasonable choice with regard to obtaining pharmaceutical services in the area of the Primary Care Trust, people who share a protected characteristic having access to services that meet specific needs for pharmaceutical services that, in the area of the Primary Care Trust, are difficult for them to access, or there being innovative approaches taken with regard to the delivery of pharmaceutical services, granting the application would confer significant benefits on persons in its area which were not foreseen when it published its pharmaceutical needs assessment" Regulation 18(2)(b) generally
The Committee noted the information with regard to the existing pharmacies and GP Surgeries as provided in the PCT's maps and site visit report and the distance to these pharmacies from the proposed site. The Committee noted that the nearest pharmacies are located in the vicinity of the existing medical provision for the area and other amenities. The Committee noted the comments from the applicant that a pharmacy would give the residents of the ward better access to healthcare as there is currently no pharmacy within the Besses ward meaning that those wishing to access pharmaceutical services must travel. While the applicant had advised that those wishing to access services would have to travel over 1km, a distance which has not been disputed by parties, nothing further had been provided to show that the residents of the Besses ward were currently experiencing any difficulties in obtaining pharmaceutical services. The Committee was of the view that distance of itself did necessarily mean that access is difficult. The Committee noted the comments from parties that the terrain was level with dropped kerbs and lighting, which had not disputed by the applicant. For those unable to access services on foot, the Committee noted the comments from parties that there are good public transport links with both buses and trams serving the area. In addition, while the Committee noted the statistics from the applicant with regard to car ownership being lower in the Besses ward than the Bury average, there was nothing further provided to show that those who did have access to a private vehicle were having difficulties in accessing and obtaining pharmaceutical services. The Committee noted the conclusions in the PNA which had found that "all localities, particularly those containing the most deprived populations are well served with pharmacies within their immediate locality or close by and that these pharmacies provide a good range of opening hours". The Committee noted the comments from parties that there has been no change to the area since the PNA was published in February 2011. Further, the Committee noted that the PNA had taken account of the deprivation levels of the area as well as the number of pharmacies in the area, the distribution of those pharmacies and the services offered. Regulation 18(2)(b)(i) to (iii)
The Committee noted the comments from the applicant that as there is currently no pharmaceutical provision within Besses ward there is no choice of pharmaceutical services. The Committee noted that the 3 pharmacies located in the area are all operated by different contractors which provided both a choice of provider as well as a choice of pharmaceutical services for the area. The Committee was of the view that given the location of accessible pharmacies within the area there is already a reasonable choice with regard to obtaining pharmaceutical services, such that granting this application would not lead to significant benefits based on the issue of choice. The Committee noted the full range of services that the applicant is proposing to provide and that they would be offering these services in an area where there is not currently a pharmacy. The Committee further noted the comments from parties that they are providing all services as commissioned by the former PCT and that they were prepared to offer any additional services as and when commissioned by the now HWB if it was considered that there was a need for such services. The Committee noted the comments from the applicant with regard to the distance to existing pharmaceutical services, however this had not been expanded upon and the Committee was mindful that distance of itself does not necessarily mean that pharmaceutical services are not accessible. The Committee further noted the comments with regard to public transport as well as the comments that there is parking available at the existing pharmacies for those who do have the use of a car. In addition, the Committee noted that while the proposed site may be in a parade of shops the services in the area of the proposed site were limited as the area was mainly residential in nature and therefore the population accessed services and amenities in the area of the existing pharmacies on a regular basis as part of their daily lives. The Committee is not satisfied on the information provided that those with mobility issues (arising from age or disability) currently experience difficulty in accessing current pharmaceutical services and would derive significant benefits from the granting of this application. The Committee noted that no information or evidence has been provided by the applicant to demonstrate that persons sharing a protected characteristic have difficulty in accessing current pharmaceutical services and would derive significant benefits from the grant of the application. The Committee noted the many services that the applicant was proposing to provide with regard to essential, advanced and enhanced services including obesity, EHC and Chlamydia screening, which they would be willing to provide if successful, and the references to these services within the PNA and other public documents. The Committee noted the assertions from the applicant that these would be an unforeseen benefit for the Besses ward as they are not currently being provided in the ward. The Committee noted the applicant's comments that these services are needs that had been identified by the former PCT and were identified in the PNA. The Committee was mindful that the instant application before them was for "unforeseen benefits" and that any need identified in the PNA should be satisfied by the making of a "current needs application" under the provisions of the Regulations. The Committee noted the comments from the applicant with regard to innovation and that they would be providing an innovative scheme in respect of weight loss as well as education and signposting of services. The Committee noted the comments from parties that these services are not innovative but are services that were commissioned by the PCT. The Committee after considering the information provided by the applicant concluded that the granting of this application would not lead to significant benefits by virtue of innovation. The Committee was not satisfied that the information provided demonstrates that there is difficulty in accessing current pharmaceutical services or that a pharmacy at the proposed site would improve access. The Committee concluded that there was no significant detriment of a kind described in regulation 18(2)(a). The Committee was of the view that in accordance with Regulation 18(2)(b) the granting of this application would not confer significant benefits on persons in the PCT area which were not foreseen when it published its PNA. Having determined that Regulation 18(2)(b) had not been satisfied, the Committee did not need to have regard to Regulation 18(2)(c) to (e). No deferral or refusal under Regulation 18(2)(f) was required in this case. The Committee considered whether there were any further factors to be taken into account and concluded that there were not The Committee concluded that the granting of this application would not provide better access to pharmaceutical services. DECISION
The Committee quashes the decision of the PCT and redetermines the application. The Committee has redetermined the application and determined that it should be refused on the following basis: The Committee has considered whether the granting of the application would cause significant detriment to proper planning in respect of the provision of pharmaceutical services in the area covered by the PNA, or the arrangements in place for the provision of pharmaceutical services in that area and has concluded that it would not; The Committee has also considered whether the granting of the application would secure better access to pharmaceutical services and has had regard to the fact that – 7.2.2.1 there is already a reasonable choice with regard to obtaining pharmaceutical services, 7.2.2.2 there is no evidence of people sharing a protected characteristic having difficulty in accessing pharmaceutical services, and 7.2.2.3 there is no evidence that innovative approaches would be taken with regard to the delivery of pharmaceutical services; Having taken these matters into account, the Committee is not satisfied that granting the application would secure improvements or better access to pharmaceutical services. Jill Jackson
Appeal Officer

A copy of this decision is being sent to:
Mr Ian Fraser
Rushport LLP
The Co-operative Pharmacy
Pharmacy Care Plus Ltd
NHS England, Greater Manchester Area Team on behalf of Bury PCT

Source: http://www.nhsla.info/fhsau/Documents/17205%20-%20Pharmaceutical%20Decisions%20(2012).pdf

ecea.gov.et

By: Frehiwot Mulugeta Seyoum Tefera Table of Contents 1. Introduction As in most developing countries in Ethiopia agriculture is the dominant sector of the economy. It contributes the lion share of the Gross Domestic Product (GDP) and foreign currency earnings of the country from the sell of agricultural outputs abroad. According to

Bb feb 2010 -

The population biologyof Common Sandpipersin Britain T. W. Dougall, P. K. Holland and D. W. Yalden Abstract The population biology of Common Sandpipers Actitis hypoleucos hasbeen studied, especially by colour-ringing breeding adults, at two sites, in the PeakDistrict and in the Scottish Borders. Adults are usually site-faithful, males more sothan females, contributing to a good apparent survival rate (72% and 67%,respectively). Some, at least, return to breed at one year old, but usually not to thesite where they hatched. The population in Britain seems to be in slow decline,most obviously indicated by a contraction along the edges of its range, whichresults especially from poor recruitment of young birds. This does not seem to bedue to poorer breeding success, but it is uncertain whether it is caused by a subtleeffect of climate change, change in quality of stopover sites on migration, orchanges in wintering habitat. Since we don't know precisely where British birdsspend the winter, the last possibility is especially hard to evaluate.