Pharmaceutical Needs Assessment (PNA) by NHS Medway

Pharmaceutical Needs Assessment Made in accordance with the National Health Service (Pharmaceutical Services and Local Pharmaceutical Services) (Amendments) Regulation 2010

www.medwaypct.nhs.uk1

1. ABBREVIATIONS AND GLOSSARY .................................................................................................... 7 2. EXECUTIVE SUMMARY ..................................................................................................................... 10 2.1.

Context ...........................................................................................................................................................10

2.2.

The Pharmaceutical Needs Assessment ..........................................................................................................11

2.3.

Our assessment ...............................................................................................................................................11

2.4.

Consultation....................................................................................................................................................12

2.5.

Access to dispensing services ..........................................................................................................................12

2.6.

Advanced Services ..........................................................................................................................................12

2.7.

Minor ailments service ....................................................................................................................................12

2.8.

Emergency Hormonal Contraception Service ..................................................................................................13

2.9.

Smoking Cessation Service ..............................................................................................................................13

2.10.

Chlamydia screen and treatment ....................................................................................................................14

2.11.

Needle Exchange Service and Supervised Consumption Service ......................................................................14

2.12.

Palliative Care Access Service ..........................................................................................................................14

2.13.

Other services and future commissioning .......................................................................................................15

2.14.

Conclusions .....................................................................................................................................................15

2.15.

Next steps .......................................................................................................................................................15

3. INTRODUCTION .................................................................................................................................. 16 3.1.

Background .....................................................................................................................................................16

3.2.

Context for the PNA ........................................................................................................................................17

3.3.

The duty on the PCT ........................................................................................................................................17

3.4.

The scope of the pharmaceutical needs assessment .......................................................................................18

3.5.

What is excluded from scope of the assessment .............................................................................................21

4. PROCESS FOLLOWED IN THE DEVELOPMENT OF THE PNA ................................................ 23 4.1.

Development process and methods ................................................................................................................23

4.2.

Governance and steering group ......................................................................................................................24

4.3.

How the PCT areas has been divided into localities for the purposes of the PNA ............................................25

4.4.

Controlled and non-controlled localities .........................................................................................................26

4.5.

Consultation during the development of the PNA ...........................................................................................27

4.6.

Equality impact assessment ............................................................................................................................27

4.7.

Regulatory consultation process and outcomes ..............................................................................................28

4.8.

Presentation of data in the PNA document .....................................................................................................28

5. NHS MEDWAY ...................................................................................................................................... 30 5.1.

NHS Medwayâ&#x20AC;&#x2122;s strategic plans ........................................................................................................................31

6. HEALTH NEED IN NHS MEDWAY ................................................................................................... 33 6.1.

Population ......................................................................................................................................................33

6.2.

Age profile ......................................................................................................................................................34

6.3.

Population structure by locality ......................................................................................................................35

6.4.

Population projection .....................................................................................................................................37

6.5.

Ethnicity ..........................................................................................................................................................38

6.6.

Access .............................................................................................................................................................41

6.7.

Deprivation .....................................................................................................................................................41

6.8.

Life expectancy ...............................................................................................................................................45

6.1.

Infant mortality ...............................................................................................................................................47

6.2.

Burden of disease and ill health ......................................................................................................................47

6.3.

Disease prevalence .........................................................................................................................................49

6.1.

Hospital admissions ........................................................................................................................................50

6.2.

Adult care homes ............................................................................................................................................52

6.3.

Smoking ..........................................................................................................................................................53

6.4.

Alcohol ............................................................................................................................................................54

6.1.

Exercise and obesity ........................................................................................................................................55

6.2.

Teenage pregnancy .........................................................................................................................................56

6.3.

Sexual health ..................................................................................................................................................57

7. INSIGHTS FROM PATIENTS AND THE PUBLIC .......................................................................... 58

7.1.

Background to the questionnaire ....................................................................................................................59

7.2.

Results ............................................................................................................................................................59

7.3.

General Demographics ....................................................................................................................................62

7.4.

Use of Pharmacies ...........................................................................................................................................62

7.5.

Most Recent Visit to a Pharmacy.....................................................................................................................63

7.6.

Access to Pharmacy Services ...........................................................................................................................63

7.7.

Consultations with Pharmacists ......................................................................................................................65

7.8.

Experiences of Getting a Prescription ..............................................................................................................66

7.9.

Advice-giving by Pharmacists on Public Health Issues .....................................................................................69

7.10.

The Range of Pharmacy Services .....................................................................................................................70

7.11.

General Comments about Pharmacies ............................................................................................................73

7.12.

Rating of Pharmacy Service Elements .............................................................................................................75

7.13.

Conclusions .....................................................................................................................................................76

7.14.

Further work ...................................................................................................................................................77

8. THE ASSESSMENT .............................................................................................................................. 78 8.1.

Essential services ............................................................................................................................................78

8.2.

Distribution of pharmacies and dispensing practices by locality .....................................................................78

8.3.

Analysis of distribution of pharmacies ............................................................................................................82

8.4.

Opening hours ................................................................................................................................................83

8.5.

Dispensing services .........................................................................................................................................85

8.6.

Advanced services ...........................................................................................................................................88

8.7.

Enhanced Services ...........................................................................................................................................94

8.8.

Minor ailments service ....................................................................................................................................94

8.9.

Emergency Hormonal Contraception Service ..................................................................................................98

8.10.

Stop smoking service ....................................................................................................................................102

8.11.

Chlamydia screen and treatment .................................................................................................................. 105

8.12.

Needle exchange & Supervised Consumption Service ................................................................................... 108

8.13.

Palliative Care Access Service ........................................................................................................................ 112

8.1.

Other enhanced services ............................................................................................................................... 114

APPENDIX 1: PHARMACEUTICAL SERVICES PROVIDERS ........................................................... 117 APPENDIX 2: OPENING HOURS OF PHARMACIES.......................................................................... 121 APPENDIX 3: SERVICES AVAILABLE FROM COMMUNITY PHARMACIES ............................... 128 APPENDIX 4: THE ROLE OF THE PHARMACIST IN ADVISING CARE HOMES ........................ 131 APPENDIX 5: POLICY CONTEXT AND BACKGROUND PAPERS .................................................. 133 APPENDIX 6: MEMBERSHIP OF THE STEERING GROUP ............................................................. 138 APPENDIX 7: LIST OF ADULT CARE HOMES IN MEDWAY........................................................... 139 APPENDIX 8: REPORT OF THE CONSULTATION ON THE DRAFT PNA ................................... 143 APPENDIX 9: REPORTS OF FOCUS GROUPS .................................................................................... 148

Version control

Version

Date

Author

V01

26/1/2011

Gian Celino, Webstar Health

Supplementary statements

Statement number

Date of publication

Comments

Author

1. Abbreviations and Glossary BMI

Body Mass Index

LPC

Local Pharmaceutical Committee

Blood Pressure

LPS

Local Pharmaceutical Services

CHD

Coronary Heart Disease

LTC

Long Term Condition

CKD

Chronic Kidney Disease

LTLI

Long Term Limiting Illness

MDS

Monitored Dosage System

Chronic COPD

Obstructive

Pulmonary

Disease Community

Pharmacy

Patient

CPPQ

Questionnaire

MUR

Medicines Use Review

CSP

Commissioning Strategy Plan

NHSIC

NHS Information Centre

CVD

Cardio Vascular Disease

NRT

Nicotine Replacement Therapy

DDA

Disability Discrimination Act

ONS

Office of National Statistics

EHC

Emergency Hormonal Contraception

PCT

Primary Care Trust

EPS

Electronic Prescription Service

PMR

Patient Medication Record

General Practitioner

PNA

Pharmaceutical Needs Assessment

HbA1c

Glycosylated haemoglobin

PWP

Pharmacy White Paper

Heart Failure

QOF

Quality and Outcomes Framework

JSNA

Joint strategic needs assessment

Repeat Dispensing

LES

Local Enhanced Service

SHA

Strategic Health Authority

LINk

Local Involvement Network

LMC

Local Medical Committee

Community pharmacy contract

The community pharmacy contract is made up of three service levels:

Essential

Services,

Advanced

Services

and

Enhanced Services. A definition can be found on page20 Consultation facilities / area

Most community pharmacies now have an area in the pharmacy where the patient and pharmacist can have a private consultation. The design and specification of these facilities varies from pharmacy to pharmacy.

Medicines Use Review

See page 88 for a definition

ONS Cluster

PCTs which are grouped according to local social and economic factors.

Pharmacist

A registered pharmacist has typically completed five years of training which includes a degree and post graduate training.

Pharmaceutical Services

These are services available from pharmacies (including LPS providers), dispensing appliance contractors and dispensing GPs. Pharmaceutical services are defined on page 18

Pharmacy

A registered pharmacy premises that is regulated by the Royal Pharmaceutical Society and appears on the PCTâ&#x20AC;&#x;s list.

Prescription item(s)

Each medicine on a prescription is counted as one item. A prescription may have many items.

Quartile

One of four divisions which divide a series of data into four equal parts

Quintile

One of five divisions which divide a series of data into five equal parts

Repeat Dispensing

Repeat dispensing is a mechanism by which the patientâ&#x20AC;&#x;s GP may issue the pharmacist with a prescription to dispense at agreed intervals for on-going treatment. The benefits of repeat dispensing are that it removes the need for the patient to return to the practice for a repeat prescription between reviews. It allows patients to be treated for periods up to one year without

returning to the GP. Repeat dispensing also has benefits for pharmacists; it allows the workflow in the pharmacy to be shaped to match the resources in the pharmacy and smoothes out peaks and troughs in demand. Around 80% of prescriptions are repeat prescriptions.

Secondary Care

Hospital based care

Tertiary Care

Specialist residential care

2. Executive Summary This document describes NHS Medway‟s pharmaceutical needs assessment (PNA). NHS Medway commissioned Webstar Health to assist in the production of the PNA. This document has been prepared to meet the requirements of the National Health Service (Pharmaceutical Services and Local Pharmaceutical Services) (Amendments) Regulation 2010 These regulations require PCTs to prepare and publish a PNA by 1st February 2011. The purpose of the PNA is: To inform and support the PCT‟s commissioning plans for pharmaceutical services To inform and support the PCT‟s decision making process in relation to market entry, this function requires further enabling regulation which is expected in the autumn of 2010. We have developed this PNA through a process of engagement and collaboration with patients and the public, pharmacists and dispensing doctors and local stakeholders. 2.1. Context Pharmaceutical services in Medway are provided by pharmacy contractors (including Local Pharmaceutical Services (LPS) providers), dispensing practices and dispensing appliance contractors. Through this network of providers we ensure that our population has good access to safe, effective and reliable pharmaceutical services. The PNA has been prepared at a time of significant change in the NHS, the recent White Paper, Liberating the NHS, has set in motion a significant programme of change which will have an impact on how we plan and use pharmaceutical services. It is too early to say how this change will affect the PNA or pharmaceutical services. We expect that some aspects of pharmaceutical services will be managed by the NHS commissioning board, it is also likely that many of the enhanced services commissioned by the PCT today will be commissioned through public health departments within local authorities. It is not clear how pharmaceutical services commissioning will fit with the proposed commissioning consortia set out in the White Paper. At the same time the NHS is being asked to reduce costs and find savings, following a period of sustained growth in spending. As a result all areas of NHS spending, including pharmaceutical services will be scrutinised to ensure that money is best spent to deliver the outcomes expected by patients and the public. The task at hand for the PCT is to ensure that it has in place a robust PNA by 1 st February 2011, this document is intended to meet that requirement.

2.2. The Pharmaceutical Needs Assessment The pharmaceutical regulations governing PNA require the PCT to define pharmaceutical services in terms of: Services currently commissioned that are necessary to meet a current need Services not currently commissioned that will be necessary in specified future circumstances Services not currently commissioned that would secure improvements or better access to pharmaceutical services Services that are currently commissioned which are relevant but do not constitute necessary services. In making this assessment we have tried to balance the need for a high quality, accessible network of pharmacies that are able to invest and develop to deliver services with the needs of our patients for services when and where they are needed. In the last five years the number of pharmacies in Medway has grown in response to relaxation of the rules governing the opening of pharmacies. We have three new 100 hour pharmacies which did not exist in 2005. We also have five dispensing GP practices who ensure that people can get access to dispensing services where the population is not sufficient to support a pharmacy. This network is an essential element of ensuring our population has good access to dispensing and other services. In the last five years the services available from our pharmacies have developed both through the national contract and through local commissioning. As a result our patients can access a wider range of services from our pharmacies than ever, and our plans include building on these services to develop pharmacies as a source of health and wellbeing services in our communities. 2.3. Our assessment We have reviewed the health needs of our population from the perspective of pharmaceutical services, using the JSNA and supporting data, we have consulted with patients and our pharmacy and GP providers, we have looked at our current commissioning of pharmaceutical services and our plans as an organisation for the future as expressed in our strategic plan. Finally when assessing adequacy of the provision of services we have also looked at where other providers are helping to meet the need for services in our area for example stop smoking services provided in GP surgeries. 2.3.1. Localities We have divided the PCT area into three localities, for the purposes of the PNA. Our localities are:

Chatham Rainham Rochester However when making this assessment we have, where possible, looked at needs and provision at ward level. 2.4. Consultation The PCT conducted a consultation on a draft of the PNA with a broad cross section of stakeholders. The consultation built on the PCTâ&#x20AC;&#x;s significant engagement activity with patients and the public during the development of the PNA. A report of the consultation is provided at appendix 8. 2.5. Access to dispensing services The core function of our pharmacies and the dispensing service our dispensing GP practices provide is to provide a safe and accessible dispensing service to our population. In the pharmacy contract, dispensing services are a sub set of essential services. Our PNA has found that our population has good access to dispensing services. The distribution of pharmacies in Medway is as good or better when compared to our peers. In our rural areas, a mixture of pharmacies and dispensing GP practices ensure that there is access in all communities to dispensing services. Access in Medway has improved recently as three new 100 hour pharmacies have opened in the last 5 years. We have decided that dispensing services are a necessary service. Dispensing is a core service that we need to ensure our population can obtain with reasonable ease. Based on the information we have gathered we have concluded that our population has good access to dispensing services. We have concluded that there are no current gaps in this service. 2.6. Advanced Services Since 2005 community pharmacies have been able to provide medicines use reviews / prescription interventions (MUR/PI) under the advanced services within the community pharmacy contract. The MUR/PI service is intended to improve patients' understanding of their medicines; highlight problematic side effects & propose solutions where appropriate; improve adherence; and reduce medicines wastage, usually by encouraging the patient only to order the medicines they require. The stated purpose of advanced services fits well with the PCTâ&#x20AC;&#x;s strategic aims, particularly improving outcomes for patients with long term conditions (LTCs). Evidence for the effectiveness of MUR/PI is not yet well developed although some early studies show that the service can improve self-reported rates of adherence among patients. We have concluded that the MUR/PI service is a necessary service and that there are no gaps in provision. 2.7. Minor ailments service

NHS Medway commissions a minor ailments service from pharmacy contractors. Patients can choose to have a consultation with the pharmacist for a range of minor conditions which can be treated by the pharmacist with no charge to the patient. The service provides an alternative to a consultation with a GP for patients that do not pay prescription charges. We consider the Minor Ailments Service is a necessary service which provides additional primary care capacity, particularly in deprived communities. The current provision and future willingness to provide means that there are no gaps in provision. 2.8. Emergency Hormonal Contraception Service NHS Medway commissions an Emergency Contraception Service from community pharmacies. This service addresses the need to provide easy and convenient access to emergency contraception to women. The impact that the service seeks to make is to address the rates of teenage pregnancy in Medway. The EHC service through pharmacies provides important access to EHC for women in Medway. Without this service access would only be available via a GP appointment or sexual health service clinic, this would limit access considerably. We consider the EHC service is a necessary service, we do not believe that there are any current gaps in provision. 2.9. Smoking Cessation Service NHS Medway commissions a Stop Smoking Service from community pharmacies. The service includes the provision of advice on stopping smoking and supply of nicotine replacement therapy (NRT) a key differentiator of pharmacy stop smoking services from other providers of stop smoking services is the ability to supply medicines at the point of care. Pharmacies are seen as key providers of stop smoking services due to their opening hours, accessibility and ability to advise and supply NRT. The stop smoking service directly addresses a key outcome measure for the PCT. Stopping smoking is the single most effective health care intervention that can be made. The stop smoking service through pharmacies is an important strand of the PCTâ&#x20AC;&#x;s efforts to reduce smoking rates among the population. Pharmacy is a unique provider with the ability to provide access to NRT at the point of care. The current network of providers together with providers that are willing to provide this service are sufficient to meet the needs of our population at this time. Given this and the priority placed on reducing smoking rates in Medway we consider the smoking cessation service to be a necessary service, we have concluded that there are no gaps in provision... We will review commissioning of this service within a year to confirm that the pattern of commissioning continues to meet the needs of our population.

2.10.

Chlamydia screen and treatment

NHS Medway commissions a Chlamydia Screening and Treatment service from pharmacies. The service allows pharmacies to offer the option of a Chlamydia test to the target population and to then offer treatment if the test is positive. Increasing screening, education and treatment are key priorities for the PCT, the target age group is young people aged 16 â&#x20AC;&#x201C; 24 years, however there is also evidence that STI rates are rising in our older population. The Chlamydia screen and treat service has yet to fully develop, our experience is mirrored in other PCTs where uptake, generally has been low, however in areas where pharmacy is a destination for young people the service works well. We want to increase the involvement of pharmacy contractors in sexual health services in the future. We have concluded that the Chlamydia screening and treatment service is a relevant service for our population. We will review the uptake and commissioning of this service to ensure the best fit with our objectives and to fit with other screening programmes. 2.11.

Needle Exchange Service and Supervised Consumption Service

Pharmacies in NHS Medway provide two services to support drug treatment services: a needle exchange service which is focused on ensuring that injecting drug users have access to clean injecting equipment, are able to safely dispose of used equipment and have access to advice from pharmacists. A supervised consumption service which is focused on ensuring that clients in drug treatment programmes take and use their treatment as prescribed and to provide an opportunity for the pharmacist to make relevant interventions Drug treatment and harm minimisation services directly address an important strand in the PCTâ&#x20AC;&#x;s strategic plan. Although the numbers of people affected are small the impact on the wider community can be significant if not properly managed. With consequences for blood borne disease, health and safety and drug related crime. The provision of needle exchange and supervised consumption from pharmacies is a necessary service, through pharmacy we secure good access across the PCT area. The pattern of provision is consistent with the needs of our population and we do not believe that there are any gaps in provision. 2.12.

Palliative Care Access Service

The PCT commissions an important service for patients and healthcare professionals which ensures that there is ready access to advice and supply of palliative care drugs for end of life care. Making

these drugs available, and having a network of pharmacies that undertake to hold stock of these unusual, but urgently needed drugs, facilitates the choice of patients to die at home. This service is a service that we consider is necessary for our population. The service should be extended so that there is provision in Rochester, we will do this by working with our existing contractors to meet this need. 2.13.

Other services and future commissioning

NHS Directions include a list of Enhanced Services which PCTs may commission under local arrangements from community pharmacists. Some of these are currently commissioned in Medway and have been described previously in this document. Where these services will sit in the future is not yet clear, the White Paper, Liberating the NHS suggests that these services would naturally sit with new consortia envisaged under the White Paper. The mechanism for taking forward these ideas will emerge as the details of the programme of change are confirmed. We will revisit these services at that time to identify how these could be taken forward in the future. 2.14.

Conclusions

This is our first PNA under the new regulations. We have reviewed the services available from our pharmacies and our plans for future services, looking at the needs of our population and the current provision from our pharmacies and dispensing GP practices. Our assessment has found that there is good access to pharmaceutical services for our population, which has been improved in recent years by the opening of new pharmacies. The services we commission have each been assessed, many of these services we now consider necessary for our population We intended to continue to work with our pharmacies and dispensing GPs to develop and improve pharmaceutical services in Medway for our population 2.15.

Next steps

We expect new regulations to be published in 2011 telling us how PNAs will be used to manage market entry. These regulations will then shape how our PNA is used and develops.

3. Introduction NHS Medway is the local NHS organisation responsible for health services in the local authority area of Medway which is located within the South East of England. The PCTâ&#x20AC;&#x;s area takes in the towns of Chatham, Gillingham, Rainham, Rochester and Strood. We are responsible for commissioning and planning services for the people who live in our area. This includes responsibility for ensuring that our population can obtain safe, effective and personal pharmaceutical services from a local community pharmacy or dispensing GP. This document sets out our first pharmaceutical needs assessment (PNA) to meet the legal and regulatory requirements set out in the Health Act 2009 and the subsequent pharmaceutical regulations1. 3.1. Background The pharmaceutical needs assessment (PNA) is a document that records our assessment of the need for pharmaceutical services in our area. This assessment is then used to help us to plan pharmacy services for our population by identifying where we should focus our efforts to commission services for our population. At this time PCTs are under a duty to prepare a pharmaceutical needs assessment which must be published by 1st February 2011. Further legislation is expected to require PCTs to make commissioning decisions using the PNA, in particular in relation to market entry. The PNA will also help us to shape the future of pharmaceutical services for our population by providing a single point of reference for all of our information about pharmaceutical services in Medway. The PNA differs from other needs assessments in that the contents and manner of preparation are all set out in regulations. In some ways this is similar to the requirement on PCTs to prepare JSNAs, however the PNA differs in that there is a PNA specific consultation process. The PNA is asked to consider the need for a specific type of service (e.g. pharmaceutical services) and the PNA is being prepared in order to support market entry decisions in the future.

SI 2010 No.914. The National Health Service (Pharmaceutical Services and Local Pharmaceutical Services) (Amendment) Regulations 2010. Available at: http://www.opsi.gov.uk/si/si2010/uksi_20100914_en_1

3.2. Context for the PNA PNAs were first developed in 2005 to assist PCTs in preparing for changes to market entry. Since that time PNAs have been used to support market entry decisions but are not required. The White Paper Pharmacy in England: Building on strengths â&#x20AC;&#x201C; delivering the future2 was published by the Department of Health in April 2008.

It highlighted the variation in the structure and data

requirements of PCT PNAs and confirmed that they required further review and strengthening to ensure they are an effective and robust commissioning tool which supports PCT decisions. The Health Act 2009 amended the National Health Service Act 2006 to include provisions for regulations to set out the minimum standards for PNAs. The regulations3 were consulted on in late 2009 and early 2010 and were laid before Parliament on 26 March 2010 and came into force on 24 May 2010. Appendix 5 has a detailed description of the policy background and references to further reading on PNAs. 3.3. The duty on the PCT The regulations4 place a statutory duty on each PCT to develop and publish their first PNA by 1 February 2011. The regulations set out the minimum requirements for the first PNA produced under the regulations, and these include such things as data on the health needs of the PCTâ&#x20AC;&#x;s population, current provision of pharmaceutical services, gaps in current provision and how the PCT proposes to close these gaps. The PNA should also consider the future needs for services. The regulations require PCTs to undertake a consultation on their first PNA for a minimum of sixty days, and list those persons and organisations that must be consulted e.g. the Local Pharmaceutical Committee, Local Medical Committee, LINks and other patient and public groups. The regulations also require the PCT to define localities around which the PNA will be structured so that the comparative needs of different populations can be taken into account.

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_083815

http://www.opsi.gov.uk/si/si2010/uksi_20100914_en_1

3.4. The scope of the pharmaceutical needs assessment A pharmaceutical needs assessment is defined in the regulations5 as: “The statement of the needs for pharmaceutical services [in its area] which each Primary Care Trust is required to publish” It follows, therefore, that we must understand what is meant by the term “pharmaceutical services” in order to assess the need for such services in the PCT‟s area. Pharmaceutical services are defined by reference to the regulations and directions governing pharmaceutical services provided by community pharmacies (which may be LPS providers), dispensing doctors and appliance contractors. Whether a service falls within the scope of pharmaceutical services for the purposes of PNA depends on who the provider is and what is provided. For the purposes of this PNA we have adopted the following scope:

For dispensing practices the scope of the service to be assessed in the PNA is the dispensing service. This means that, for the purposes of the PNA, we are concerned with whether patients have adequate access to dispensing services, including where those services are provided by dispensing GPs but not concerned with assessing the need for other services dispensing GPs may provide as part of their national or local contractual arrangements. There are 5 dispensing practices in NHS Medway which are shown on the map on page 26. Dispensing doctors may dispense from premises that have been registered with the PCT. For appliance contractors the scope of the service to be assessed in the PNA is the dispensing of appliances and the provision of the recently introduced Appliance Use Review (AUR) service and Stoma Appliance Customisation Service (SAC). This means that, for the purposes of the PNA, we are concerned with whether patients have adequate access to dispensing services, including dispensing of appliances, AURs and SACs where these are undertaken by an appliance contractor but not concerned with other services appliance contractors may provide. There is one dispensing appliance contractor in Medway. Our population also accesses specialist appliance dispensing providers outside Medway in

SI 2010 No.914. The National Health Service (Pharmaceutical Services and Local Pharmaceutical Services) (Amendment) Regulations 2010. Available at: http://www.opsi.gov.uk/si/si2010/uksi_20100914_en_1

significant numbers so we will need to take this into account when thinking about the needs of our population. For community pharmacy contractors the scope the services to be assessed in the PNA is broad and comprehensive. It includes the essential, advanced and enhanced services elements of the pharmacy contract whether provided under the terms of services6 for pharmaceutical contractors or under Local Pharmaceutical Services (LPS) contracts. There are 48 pharmacy contractors in Medway. Pharmaceutical services in relation to community pharmacy contractors are defined as: Essential Services – which are set out in the 2005 NHS Regulations, these include: o

Dispensing and actions associated with dispensing (e.g keeping records)

Repeatable dispensing

Disposal of waste medicines

Promotion of healthy lifestyles

Prescription linked interventions

Public health campaigns

Signposting

Support for self care

All pharmacy contractors must provide the full range of essential services. Advanced and Enhanced Services – which are set out in the Directions made subsequent to the 2005 Regulations, these include: o

Advanced Services, specifically: 

Medicines Use Review and Prescription Interventions (MURs)



Appliance Use Reviews (AUR)



Stoma Appliance Customisation Service (SAC)

Any contractor may choose to provide Advanced Services, there are requirements which need to be met in relation to premises, training or notification to the PCT. At this time a pharmacy may undertake up to 400 MURs per annum, a limited number of AURs linked to the dispensing of appliances and as many SACs as required. o

Enhanced Services, specifically: 

Anticoagulant monitoring service



Care home service

Pharmacy contractors do not have a contract in the legal sense with primary care trusts, they operate under terms of service set out in regulations. These are often referred to as the “community pharmacy contract”.



Disease specific medicines management service



Gluten free food supply service



Home delivery service



Language access service



Medication review service



Medicines assessment and compliance support service



Minor ailments service



Needle syringe exchange service



On demand availability of specialist drugs service



Out of hours service



Patient group directions service



Prescriber support service



Schools service



Screening service



Stop smoking service



Supervised administration service



Supplementary prescribing service

The regulations are intended to be permissive and allow PCTs to interpret how any of the above Enhanced Services should be commissioned, its scope and method of delivery. Each PCT must make arrangements for the provision of these services in its area. In the case of Medway PCT arrangements are in place for the provision of the services shown in the table below.

Local name

Description in NHS Directions Minor ailments service

Description

Needle exchange scheme

Needle syringe exchange service

Pharmacies provide clean injecting equipment to drug users and take in used injecting equipment for safe disposal

Palliative care service

On demand availability of specialist drugs service Patient group directions service

Pharmacies maintain a stock of medicines used in end of life care (palliative care) and make these medicines available during their hours of operation. Pharmacies provide access to emergency contraception under patient group directions

Patient group directions service

Pharmacies provide access to treatment to patients who test positive for Chlamydia through the local screening service

Minor ailments service

EHC Service

Chlamydia treatment service

Pharmacies may provide treatment or advice, without charge to patients with a minor ailment

Chlamydia screening service

Screening service

Diabetic sharps collection service

Pharmacies provide access to screening for Chlamydia infection Pharmacies provide a safe disposal service for needles and other used injecting or testing equipment used by diabetics

Smoking cessation service

Stop smoking service

The PCT commissions a service for the supply of nicotine replacement therapy (NRT e.g. patches, gums, inhalers) and advice and counselling to support smokers to give up.

Supervised methadone services

Supervised administration service

The PCT commissions a service whereby patients prescribed drug treatments for addiction can obtain their treatment on a frequent basis, often daily and that this treatment is taken in the presence of the pharmacist.

Figure 1: Enhanced services commissioned in Medway

Community pharmacy contractors also provide services directly to patients which are not commissioned by the primary care trust, for example some pharmacies provide a home delivery service but this is not commissioned or paid for by the PCT but may be provided for a payment by the patient or other users. In making its assessment the PCT needs to take account of any services provided to its population which may affect the need for pharmaceutical services in its area. This could include services provided across a border to the population of NHS Medway: We have identified dispensing appliance contractors and pharmacies outside Medway which play a significant role in providing a service to our patients. Our GP practices also provide services which, although not part of the assessment, may affect our assessment of the need for services. For example many practices offer smoking cessation services to their patients. In developing this PNA the PCT has considered the need in its area for the â&#x20AC;&#x153;pharmaceutical servicesâ&#x20AC;? described above and specifically from: o

Community pharmacy contractors

Dispensing practices (dispensing only), and

Appliance contractors

3.5. What is excluded from scope of the assessment The PNA has a regulatory purpose which sets the scope of the assessment. However pharmaceutical services and pharmacists are evident in other areas of work in which the PCT has an interest but are excluded from this assessment. These include prison pharmacy and secondary

care services where patients may be obtaining a type of pharmaceutical service that is not covered by this assessment. 3.5.1. Prison pharmacy Pharmaceutical services are provided in prisons by providers contracting directly with the PCT or prison authorities. NHS Medway has two prison facilities: HMP/YOI Cookham Wood which has a capacity of 157 places and takes remanded and sentenced young men aged 15-17 and HMP Rochester which has a capacity of 620 and takes sentenced young men aged 18 â&#x20AC;&#x201C; 21 serving up to 6 years Primary care services, including pharmaceutical services are commissioned by the primary care trust for provision in the prison setting. There is a prison health needs assessment and commissioning process for ensuring that prisoners have access to the health services that they need. 3.5.2. Secondary care pharmacy Patients in Medway have a choice of provider for their elective hospital services. Most of our hospital services are provided by the following trusts:

Medway NHS Foundation Trust Kent and Medway NHS and Social Care Partnership Trust Maidstone and Tunbridge Wells NHS Trust) Patients may exercise choice in where they are treated for elective treatment which means that in practice NHS Medway patients may choose any hospital in England. The PNA makes no assessment of the need for pharmaceutical services in secondary care, however we are concerned to ensure that patients moving in and out of hospital have an integrated pharmaceutical service which ensures the continuity of support around medicines. To this end the PNA makes some assessment of the needs of patients moving into and out of hospital who may have received, or may be receiving pharmaceutical services from a secondary care trust.

4. Process followed in the development of the PNA NHS Medwayâ&#x20AC;&#x;s PNA has been developed using a mixture of methods drawing on a range of information source and reinforced through consultation with patients and providers. This has included: A questionnaire sent to a broad cross section of Medway residents about pharmacy services A questionnaire of community pharmacy contractors A review of PCT held commissioning data The table below lists the main data sources used to develop and inform the PNA. The process was divided into five steps which are illustrated using Figure 1, below. 4.1. Development process and methods

PNA development process Step 1

Step 1: PCT priorities, health needs

Step 2

Step 2: Pharmacy profile and audit

Step 3

Step 3: Patient experience

Step 4

Step 4: Synthesis and assessment

Step 5

Step 5: Consultation and consensus

Pharmaceutical Needs Assessment

Pharmacy commissioning strategy

The development process combines the PCTâ&#x20AC;&#x;s strategic plans, draws on the JSNA which describe the health needs of our population and links this to the commissioning of pharmacy services.

The PNA provides a foundation for further work to develop a pharmacy commissioning strategy for the PCT.

Figure 2: Medway PNA development process

Each step has a specific function and / or source of data which is described in Figure 3, below. These data have been combined to provide a picture of our population, their current and future health needs and how our pharmacy network can be used to support the PCT to improve the health and wellbeing of our population.

Step

Data source(s)

Step 1

Activity

Strategic Plan 2010-2015

Analysis and synthesis of relevant data for the

JSNA 2008 and Public Health Report 2010

PNA.

Routine contracting and activity data which is held by the PCT Step 2

A postal survey of pharmacy contractors in Medway National benchmarking using NHS Information Centre data

Step 3

A postal survey of Medway residents, to which 673 people responded (16%)

Drawing together and synthesis of emerging themes and ideas

Step 4

Drafting of the PNA and synthesis of the assessment and recommendations A web-based questionnaire of health and social care stakeholders. Step 5

PCTs are required to consult on their PNA before publication.

Figure 3: Medway PNA development data sources and activity

4.2. Governance and steering group The development of the PNA was overseen by a steering group whose membership was drawn from the PCTâ&#x20AC;&#x;s commissioning, primary care and public health departments, together with Practice Based Commissioners, GPs, the Local Pharmaceutical Committee, the Local Medical Committee and community pharmacy contractors. The membership of the steering group is described in Appendix 6.

4.3. How the PCT areas has been divided into localities for the purposes of the PNA The PNA regulations require that the PCT divide its area into localities which are then used a basis for structuring the assessment. For the purposes of the PNA the steering group agreed that the PCT should adopt the three localities used within NHS Medway as a basis for planning services. Following the consultation process the steering group was asked to consider whether these localities were likely to be relevant in the future and in particular whether these localities would fit with the new control of entry regulations which the Department of Health will publish for consultation in 2011. The steering group was mindful that there were a number of uncertainties, however there was a firm timetable in regulations for the publication of the PNA and consequently the proposed three locality structure was the “best fit” approach at the time of preparation of the PNA. The steering group noted that it may be necessary to revisit the locality structure in the future, and that the regulations permitted the PCT to revise the PNA where required. The localities adopted for the PNA are: Chatham Rainham and Gillingham Rochester and Strood Throughout this report we abbreviate these localities to Chatham, Rainham and Rochester. The localities are defined by GP practice location and registered populations, however information about health need is predominantly held at a geographical level, typically in relation to electoral wards. Translating these localities to local geography is not a precise process. The following table shows the “best fit” association between the three localities and the wards which make up each one. This relationship has been used throughout this report to present and analyse data in relation to the population and pharmaceutical services in each locality. Code 00LCNN 00LCNT 00LCNU 00LCNX 00LCPB 00LCPD 00LCPK 00LCNQ 00LCNR 00LCNS 00LCNY 00LCNZ 00LCPA 00LCPJ

Ward name Chatham Central Lordswood and Capstone Luton and Wayfield Princes Park River Rochester South and Horsted Walderslade Gillingham North Gillingham South Hempstead and Wigmore Rainham Central Rainham North Rainham South Twydall

Locality Chatham Chatham Chatham Chatham Chatham Chatham Chatham Rainham Rainham Rainham Rainham Rainham Rainham Rainham

00LCPL 00LCNP 00LCNW 00LCPC 00LCPE 00LCPF 00LCPG 00LCPH

Watling Cuxton and Halling Peninsula Rochester East Rochester West Strood North Strood Rural Strood South

Rainham Rochester Rochester Rochester Rochester Rochester Rochester Rochester

Figure 4: Division of Medway into Localities

4.4. Controlled and non-controlled localities For most of the population of Medway the provision of pharmaceutical services is by community pharmacies, however in some areas the main provider of pharmaceutical services are dispensing GPs. Dispensing GPs and community pharmacies provide pharmaceutical services in different ways and the two are not equivalent in all respects. The arrangements for dispensing in rural areas require the co-operation and collaboration of GPs and pharmacists, and there are historical rights and regulatory requirements which seek to ensure that patients have the best possible provision of pharmaceutical services. GP dispensing may be required where a pharmacy service would not be viable due to the nature or size of the population. GPs may dispense for their patients who have requested them to do so, if permission has been granted by their PCT. Generally, the patients who ask their GPs to dispense must be resident in a „controlled locality‟ (i.e. an area which is rural in character) and live more than 1.6km from a pharmacy. The PCT may determine whether an area is a controlled locality on the request of its LPC or LMC, or because it believes that a determination should be undertaken, for example if an application is made in or near the area. If the PCT decides that an area is rural in character, it will publish a map showing the precise boundaries of this „controlled locality‟, and this will generally be valid for five years unless there is a substantial change in circumstances in relation to the area. If a new pharmacy wishes to open in a controlled locality then there are additional tests that the applicant must satisfy, so as not to prejudice any dispensing by doctors being undertaken for patients in that area. If a GP is asked to dispense by his patients resident in a controlled locality, the PCT must undertake a test to ensure that there is no prejudice to any pharmacies. Controlled localities in Medway NHS Medway has prepared the map overleaf which shows the areas which have been determined in the past to be controlled localities, and these will remain controlled localities unless and until a new determination finds that they no longer satisfy the requirements of being rural in character.

Figure 5: Map showing controlled and non-controlled localities (at December 2010)

The PCT will be using the PNA to encourage the LMC and LPC to work together to ensure that the arrangements in rural areas reflect the needs of our population. 4.5. Consultation during the development of the PNA The PCT has engaged in a process of consultation throughout the development of the PNA, this has included: A questionnaire sent to 4,200 Medway residents about pharmaceutical services in Medway A questionnaire of community pharmacy contractors in NHS Medway An online questionnaire sent to health and social care stakeholders Focus groups with stakeholder groups identified by the steering group

4.6. Equality impact assessment

The PCT has a responsibility to consider the impact of any policy on its population, in particular to ensure that no group is subject to an inequality (e.g. excluded, disadvantaged or discriminated against) as a result. The PNA regulations also ask PCTs to consider their PNA in terms which assess whether the needs of specified groups within the population are considered. The PCT undertook an Equality Impact Assessment using the preparation of the draft PNA which concluded that the PNA did not introduce or exacerbate any inequality. The PCT has processes for assessing and monitoring policies which the PNA will be part of in the future. 4.7. Regulatory consultation process and outcomes The PCT conducted a consultation on a draft of the PNA with a broad cross section of stakeholders. The consultation built on the PCTs significant engagement activity with patients and the public during the development of the PNA. Responses were received from a variety of health care professionals, many pharmacy contractors, the LPC and LMC and our local authority partners. A report of the consultation is provided at appendix 8.

4.8. Presentation of data in the PNA document Throughout this document, where data is available, we refer to these localities in describing services or assessing the need for services. These localities can be subdivided into electoral wards or into Super Output Areas (SOAs). Electoral wards are political units of geography whose boundaries are managed by the electoral commission, ward boundaries change over time. SOAs are administrative units of geography which have been established by the ONS. SOA boundaries do not change and provide a consistent basis for tracking changes in the population over time. These areas can be aggregated up to ward level, however, ward boundaries do change occasionally as electoral boundaries are redrawn so links between any one SOA and a particular ward can be lost. SOAs exist at three levels: Lower Layer SOAs – have a population of approximately 1,500 persons Middle Layer SOAs – have a population of approximately 7,200 persons Upper Layer SOAs – are not yet developed but are expected to have a population of approx 25,000 persons. Where data is available then the PNA describes the health needs and current provision of pharmaceutical services at all three levels: Medway, Locality and Ward or SOA level. We have also used data from the latest NHS Information Centre statistical bulletin on pharmacy services to provide comparators for NHS Medway where this is available. The PCT is grouped with nine other PCTs with similar characteristics by the Office of National Statistics (ONS):

Comment [GC1]: Barbara – I wanted to get this in as it is something that has come up elsewhere and is mentioned in the regulations. You may need to review how I have described the Medway process.

Bexley Care Trust East and North Hertfordshire Havering Medway Teaching Milton Keynes Peterborough South West Essex Teaching Swindon West Essex This group is described by the ONS as the â&#x20AC;&#x153;New and growing townsâ&#x20AC;? cluster group. More information

about

clusters

and

their

construction

can

found

here:

http://www.statistics.gov.uk/about/methodology_by_theme/area_classification/ha/cluster_summaries .asp).

5. NHS Medway Medway is located around the mouth of the river Medway to the east of London in the South East of England, the borough covers an area of approximately 192 sq km which is most densely populated around the riverside and more rural in nature to the north and south. The area covered by Medway has a resident population of approximately 253,5337 and a registered population of [TBC] it is for the registered population that the PCT is responsible for commissioning services. NHS Medway has a population due to rise from approximately 274,000 to over 320,000 over the next 20 years. Medway includes the towns of Strood, Rochester, Chatham, Gillingham & Rainham, and the more rural population living on the Hoo Peninsula. Medway has seen gradual economic recovery and diversification over the last 20 years, after the collapse of heavy industries and the closure of the Chatham Royal naval dockyard in the early 1980s. Overall Medway is not a deprived area and does not attract deprivation based funding. Yet at ward level there are some of the most deprived as well as some of the most affluent areas in the country. Deprivation is particularly driven by low income and employment levels. NHS Medway is seeking to close this gap and to address the multiple causes of deprivation where people in some areas experience the combined effect of unemployment, poor educational attainment, and crime, anti social behaviour and health problems. Regeneration in Medway, known as „Medway Renaissance‟8 focuses on brown field sites along the waterfront, the redevelopment of Chatham as Medway‟s city centre, as well as improvements to existing town centres. While 88 per cent of Medway‟s population lives in the urban areas, half of the land is rural. This includes eight internationally or nationally designated areas of nature conservation. The PCT shares a border with: West Kent Eastern and Coastal Kent Teaching South West Essex Teaching South East Essex

ONS mid-2008 Ward Population Projections (2009)

http://www.medwayrenaissance.com/site.html

Figure 6: Map of Medway pharmacies and GP practices

5.1. NHS Medwayâ&#x20AC;&#x;s strategic plans NHS Medwayâ&#x20AC;&#x;s Strategic Commissioning Plan sets out its vision and aims for the health of the people of Medway and the health services commissioned on their behalf. The plan sets out an ambitious strategy to deliver significant improvements in the health status of local people. The challenges facing NHS Medway are significant. In recent years, NHS Medway has received considerable increases in funding. However, over the next five years, in common with the wider NHS, we are planning for a real terms reduction in expenditure. In 2010 health outcomes in Medway are worse than the England and South East Coast average. Medway has high levels of smoking, obesity and teenage pregnancy. On average, people in Medway die two years before people in the rest of England. Indicators of deprivation, such as poverty, unemployment, poor physical health or poor housing, all of which are present in Medway, are strongly correlated with mental ill health. And our challenges will only increase as the population of Medway ages. By 2015, working with other NHS and non-NHS partners, NHS Medway will have delivered a step change in the life chances of people in Medway. By achieving our six strategic goals, we will reduce

health inequalities, add life to years and years to life. At the same time, we and our partners will deliver substantial efficiency gains through the health system, and we will be relentless in our drive for quality. The strategic plan sets out a number of goals: Improving health and well being: Reducing the high levels of smoking, obesity and teenage pregnancy Target killer diseases: Reducing premature deaths in cancer and cardiovascular disease and in doing so improve the end of life experience for patients Care pathways â&#x20AC;&#x201C; closer to home: Developing the capacity and capability of local services whilst offering more choice and greater responsiveness to local need Supporting future generations: Securing better outcomes and access to services for children and young people in Medway Promoting independence and improved quality of life: Meeting the challenge of the growing number of older people and people with long term conditions, maximising their independence and well being Improving mental health: Improving access to a wide range of preventative and treatment services to improve the mental well being of people in Medway The focus for 2010 â&#x20AC;&#x201C; 2015 will be on a number of programme areas to deliver these goals: Primary prevention, including support to children and young people, and early diagnosis; Urgent Care, to include the development of a single point of access, keeping people at home where possible and discharging smoothly where admission is required; Clinical protocols for decision making thresholds at all interfaces of care (eg referrals, new to follow ups, intermediate care, 19 ambulatory care conditions,); Long Term Conditions - especially COPD, CHD, diabetes, stroke; Dementia â&#x20AC;&#x201C; ensure services are able to identify need at an early stage and provide support for people in the community, including support for carers; Adult mental health - complete pathway redesign; End of Life Care - considering the totality of redesign (not just cancer and palliative care). In the context of the PNA the current and future commissioning of pharmaceutical services will demonstrate how they contribute to achieving these goals and fit with the programme areas set out in the strategic plan.

6. Health need in NHS Medway This section explores a summary of the evidence for heath need in NHS Medway which has been informed by the PCTâ&#x20AC;&#x;s JSNA and other sources of data relevant to pharmaceutical services 6.1. Population The resident population according to ONS projections is approximately 255,000, this population is distributed across our three localities as shown in the table below. With approximately 80,000 population in each locality but some variation in populations from 96,000 in Rainham to 79,000 in Chatham. Name Chatham Rainham Rochester

Ward

Medway Council

Population 7 8 7

78,887 95,883 78,763

253,533

Figure 7: Population by locality (2008) Source: ONS mid-2008 Population Projections

Individual wards vary considerably in size with the smallest (Cuxton and Halling) having a population of 5,430 and the largest (Gillingham South) having a population of 16,031. Locality Name

Code

Ward Name

Chatham Chatham Chatham Chatham Chatham Chatham Chatham Chatham Rainham Rainham Rainham Rainham Rainham Rainham Rainham Rainham Rainham Rochester Rochester Rochester Rochester Rochester Rochester Rochester Rochester Medway

00LCNN 00LCNT 00LCNU 00LCNX 00LCPB 00LCPD 00LCPK

Chatham Central Lordswood and Capstone Luton and Wayfield Princes Park River Rochester South and Horsted Walderslade

00LCNQ 00LCNR 00LCNS 00LCNY 00LCNZ 00LCPA 00LCPJ 00LCPL

Gillingham North Gillingham South Hempstead and Wigmore Rainham Central Rainham North Rainham South Twydall Watling

00LCNP 00LCNW 00LCPC 00LCPE 00LCPF 00LCPG 00LCPH

Cuxton and Halling Peninsula Rochester East Rochester West Strood North Strood Rural Strood South

Population 15,475 9,201 13,624 10,260 8,537 12,429 9,361 78,887 15,363 16,031 8,125 12,549 8,533 13,275 12,921 9,086 95,883 5,430 12,934 9,643 10,291 13,036 13,578 13,851 78,763 253,533

Figure 8: Population by ward (2008) Source: ONS mid-2008 Population Projections

6.2. Age profile Medwayâ&#x20AC;&#x;s population has a younger profile that that of England, relative to England we have more people aged under 20, particularly children and young adults and fewer people aged over 60. The population pyramid below shows how our population compares to England.

Male

Female

Figure 9: Medway population pyramid (Medway: Columns / England: Line) Figure 10: Population pyramid (England = line, Medway = columns) Data Source: Office for National Statistics mid-2008 estimates

What this means for our PNA Older people and families with young children are higher uses of pharmacy services and are more likely to need regular access to pharmacies. A nationally representative survey of the population in England9 showed that people aged over 40, female and those with long term conditions were more likely to visit pharmacies once a month or more. Men, younger adults and those in employment were less likely to visit pharmacies regularly.

COI research published with Pharmacy White Paper, 2008

6.3. Population structure by locality The age profile varies across the PCT, the wards with the highest proportion of younger people are Chatham Central, Princes Park and Luton and Wayfield, all of which are in the Chatham locality and Gillingham North and Gillingham South both of which are in the Rainham locality. Locality Name

Code

Name

Chatham Chatham Rainham Chatham Rainham

00LCNN 00LCNX 00LCNQ 00LCNU 00LCNR

Chatham Central Princes Park Gillingham North Luton and Wayfield Gillingham South

% Under 16 24.0% 23.7% 23.7% 22.6% 21.7%

Figure 11: Population under 16 years, upper quintile Source: ONS-mid 2008 population projections

The wards with the highest proportion of older people live in Rainham where Rainham Central, Rainham North, Tydall and Hemstead and Wigmoreare all appear in the upper quintile while one ward in Chatham locality, Rochester South and Horsted also falls within the upper quintile.

Locality Name Rainham Rainham Chatham Rainham Rainham

Code 00LCNY 00LCNZ 00LCPD 00LCPJ 00LCNS

Name Rainham Central Rainham North Rochester South and Horsted Twydall Hempstead and Wigmore

% Males over 65 and Females over 60 23.3% 22.7% 21.7% 21.4% 21.2%

Figure 12: Population over 60 (f) and 65 (m) years, upper quintile Source: ONS-mid 2008 population projections

The variation in population age structure can be seen when the wards are aggregated up to locality level. Chatham has a very significant young population when compared to Medway, which is turn has a younger population than England and SE Coast SHA.

Figure 13: Population structure by locality (over 60/65s) Source: ONS-mid 2008 population projections

Medway has a smaller older population which is concentrated in Rainham and Rochester, but still well below the England figure.

Figure 14: Population structure by locality (over 60/65s) Source: ONS-mid 2008 population projections

What this means for our PNA Caution is needed when using the locality level population profiles as these mask variation at ward level, however the general picture for pharmacy services is that there is likely to be proportionally

greater demand from families and younger people in Chatham and from older people in Rainham and Rochester. 6.4. Population projection Population forecasts by the ONS predict that the population of Medway will grow by 4.90% by 2020 and by 9.48% by 2030. This growth is more moderate than that predicted for other comparators.

2015 2020 2025 2030

Medway (% Growth from 2010)

ONS (% Growth from 2010)

SEC SHA (% Growth from 2010)

England (% Growth from 2010)

2.27% 4.90% 7.29% 9.48%

3.92% 7.95% 11.73% 15.24%

3.79% 7.67% 11.51% 15.02%

3.87% 7.76% 11.50% 14.91%

Figure 15: Population growth 2010 â&#x20AC;&#x201C; 2030 Source: ONS based on ONS mid-2006 estimates

This moderate growth however will include some quite dramatic changes in the profile of our population. The proportion of our population aged under 16 years is expected to decrease slightly to 20.9% but still greater than that of England as whole. Year 2010 % U16 2015 % U16 2020 % U16 2025 % U16 2030 % U16

Medway

ONS Cluster

SEC SHA

England

21.6% 21.3% 21.7% 21.5% 20.9%

20.0% 19.8% 20.1% 19.9% 19.4%

21.1% 21.0% 21.3% 21.1% 20.5%

19.8% 19.8% 20.1% 20.0% 19.4%

Figure 16: Population structure forecast Source: ONS based on ONS mid-2006 estimates

However the most dramatic change is expected in our older population where Medwayâ&#x20AC;&#x;s population structure is projected to change from 14.1% aged over 60/65 to 20.3% aged over 60/65. Year 2010 % O65 2015 % O65 2020 % O65 2025 % O65 2030 % O65

Medway

ONS Cluster

SEC SHA

England

14.1% 16.2% 17.3% 18.6% 20.3%

17.2% 18.9% 19.9% 21.1% 22.8%

14.9% 16.3% 17.1% 18.3% 19.9%

16.4% 17.9% 18.7% 19.9% 21.4%

Figure 17: Population structure forecast Source: ONS based on ONS mid-2006 estimates

What this means for our PNA The forecast periods described exceed the scope of the PNA which is expected to be updated regularly and completely refreshed every 3 years. However, based on these projections the number of older people in our population will increase by 56% from 36,000 in 2010 to 56,000 in 2030. The

combined effect of these changes will be to decrease the proportion of our population of working age while increasing the population more likely to require care.

6.5. Ethnicity The 2001 census recorded Medway as having a less diverse population than England with only 5.4% of the population being non-white (England 9.1%).

Figure 18: Ethnicity in Medway and comparators Source: Census 2001

Analysis at locality level shows that Chatham has the most diverse population in Medway with three wards being closer to the England average than the Medway average. Locality Chatham Rainham Chatham Chatham Rochester Rochester Rainham Rochester Rainham Chatham Medway

Ward Chatham Central Gillingham South River Rochester Sth and Horsted Rochester East Strood North Watling Rochester West Hempstead and Wigmore Luton and Wayfield

% nonwhite 10.6% 8.4% 8.4% 8.1% 7.3% 7.3% 6.8% 6.2% 6.1% 5.6% 5.4%

% asian 7.4% 4.8% 2.8% 5.7% 4.5% 4.9% 4.3% 2.3% 3.6% 2.7% 2.9%

% black 1.1% 1.1% 1.6% 0.5% 0.8% 0.7% 0.8% 1.6% 0.5% 1.0% 0.7%

% chinese or other 0.7% 0.9% 2.6% 0.7% 0.8% 0.7% 0.8% 1.0% 1.0% 0.6% 0.7%

% mixed 1.4% 1.6% 1.3% 1.1% 1.3% 1.0% 1.0% 1.3% 1.0% 1.3% 1.1%

Figure 19: Top 10 wards by ethnicity Source: Census 2001

Estimates for current ethnicity show that Medway‟s population has grown more diverse, estimates suggest that by 2007 7.8% of Medway‟s population was classed as not white, an increase of 2.4% from the time of the census in 2001.

Figure 20: Changes in ethnicity 2001 – 2007 Source ONS 2007 estimate

Migration is also a factor in population changes between the census, national insurance number registrations show that since 2002 around 14,000 adult migrants coming into Medway have requested an NI number. The rate of registrations has moderated slightly with number peaking in 2007 at 2,500.

Figure 21: Adult national insurance NI number registrations (2002 – 2009) Source: DWP, 2009

The origin of these migrants shows that the majority settling in Medway are from the EU accession states and Asia and the Middle East.

Figure 22: Adult NI registrations, area of origin Source: DWP, 2009

These figures only report adults registering a National Insurance number, they do not include migrants that are self employed, unemployed or dependents. The statistics do not take account of emigration, crude estimates suggest that for every migrant with a registered NINO in the South-East there are 2 more migrants in the self-employed/unemployed categories.

What this means for our PNA There is correlation between health inequalities and the levels of diversity in the population. Ethnic minority communities are exposed to a range of health challenges, from low birth weight and infant mortality through to higher incidence of limiting illnesses like diabetes and cardio vascular disease. Economic migration brings younger more mobile populations and their families. The demands for pharmaceutical services from this group are focused on public health and minor illness management.

6.6. Access Car ownership is also recorded at the census, at that time of the last census 23% of Medway households did not have access to a car (England 26.8%). This is more marked in Chatham where 25.5% of households do not have access to a car. Locality Name

Code

Name

Chatham Chatham Rainham Chatham Rochester

00LCPB 00LCNN 00LCNQ 00LCNU 00LCPC

River Chatham Central Gillingham North Luton and Wayfield Rochester East

No car 38.9% 36.3% 33.6% 32.5% 31.8%

Figure 23: Car ownership in households, wards in top quintile ONS 2001

6.7.

Deprivation

Over all Medway has lower concentration of deprivation than England as a whole, however there are extreme variation where the most and least deprived in our population live within a few miles of each other. The national index of multiple deprivation (IMD) provides a comparative measure of the deprivation experienced by a population based on their circumstances which can then be applied to a geography. The index provides a score for each output area and ranks areas relative to each other. The relative level of deprivation experienced by a population has a direct correlation with outcomes for that population. The map below shows the relative levels of deprivation by ward for the population of NHS Medway. This is concentrated around our urban centres but is also evident on the Hoo Peninsula.

Figure 24: Deprivation by ward Source: NHS Medway SCP 2010 - 2015

Analysis of the IMD for the lower level super output areas in Medway shows that each of the localities, has some levels of deprivation. The highest concentration of LSOAs in the most deprived quintile is in Chatham which has similar levels of deprivation to England, this is in contrast to Rainham where there are fewer areas of high deprivation.

Figure 25: Distribution of LSOAs by quintile of deprivation in Medway. Source IMD 2007

What this means for our PNA There is correlation between deprivation and health outcomes, with higher incidence of long term condition, earlier onset of disease and lifestyle related health inequalities. Pharmacy services are often as accessible source of health services and the promotion of positive health messages in these localities.

We can also draw on other measures of inequalities that are available including: Under 18 conception rates Children in low income families Rates of economic activity Qualifications

The table below highlights some of the wards with indicators that are consistent with health inequalities and reduced socioeconomic opportunity. Highlighted cells are values in the top quintile in Medway for the indicator. The first five wards in this table have consistently poor indicators across these indicators, three of these are located within Chatham. Locality Name Rainham Chatham Chatham Rochester Chatham Rainham Rochester Rainham Rochester Rochester Chatham Rochester Chatham Rochester Chatham Rainham Chatham Rainham Rainham Rochester Rainham Rainham

Name Gillingham North Chatham Central Luton and Wayfield Strood South River Gillingham South Rochester East Twydall Peninsula Strood North Princes Park Rochester West Walderslade Strood Rural Lordswood and Capstone Rainham North Rochester South and Horsted Rainham South Watling Cuxton and Halling Rainham Central Hempstead and Wigmore

Average IMD Score 32.99 31.96 31.28 27.58 25.97 24.02 22.74 20.67 18.92 18.71 17.99 17.30 16.16 15.67 15.49 13.72 12.60 12.50 12.13 11.72 7.91 5.49

% under 18 conceptions

% children in low income families 7.3% 6.1% 7.6% 7.6% 2.8% 6.9% 7.1% 9.8% 7.5% 6.0% 4.1% 4.6% 4.1% 4.6% 4.4% 3.9% 4.6% 3.5% 3.8% 3.2% 4.8% 4.3%

56.4% 56.4% 52.0% 46.7% 34.3% 46.9% 45.5% 43.0% 32.4% 36.0% 33.6% 36.9% 35.1% 27.4% 32.0% 31.1% 25.3% 34.0% 24.6% 23.4% 23.4% 16.1%

% economically active 67.7% 66.7% 67.5% 68.1% 72.4% 71.6% 68.1% 65.8% 67.9% 71.6% 77.2% 66.6% 68.8% 71.3% 75.8% 69.0% 69.2% 76.1% 73.4% 73.6% 70.0% 73.2%

Figure 26: Socio economic factors Data Source: ONS, NOMIS and End Child Poverty. Employment and Qualifications, 2001. Child Poverty, Aug 2005. Teenage Conceptions, 2005-2007. Child Poverty figures were rounded to the nearest 5 at ward level, this will have affected aggregations. Teenage Conception figures were suppressed to preserve confidentiality at ward level, this will have affected aggregations where a ward has a zero percentage. Qualifications data aggregated from MSOA level.

6.8. Life expectancy Life expectancy is a measure of how long a person born in an area would be expected to live by reference to current observed rates of mortality. The gap in life expectancy between the best and worst helps us to understand how inequalities affect our population differently. Life expectancy in England is 81.3 years for women and 76.4 years for men. In Medway the equivalent figures are 80.1 years and 75.2 years, living in Medway reduces life expectancy by almost 1.3 years for women and 1.2 years for men. However the gap across Medway, which is a key measure of the challenge facing the PCT is stark with men born in Hempstead and Wigmore living 8.7 years longer than men born in River ward.

Locality Name

Code

Name

Rainham Rainham Rainham Rochester Chatham Rochester Rochester Chatham Rochester Rainham Chatham Rainham Rainham Rochester Chatham Chatham Chatham Rochester Rochester Rainham Rainham Chatham

00LCNS 00LCNY 00LCPA 00LCNP 00LCNX 00LCPE 00LCPF 00LCPK 00LCPG 00LCPL 00LCNT 00LCPJ 00LCNZ 00LCNW 00LCPD 00LCNU 00LCNN 00LCPH 00LCPC 00LCNR 00LCNQ 00LCPB

Hempstead and Wigmore Rainham Central Rainham South Cuxton and Halling Princes Park Rochester West Strood North Walderslade Strood Rural Watling Lordswood and Capstone Twydall Rainham North Peninsula Rochester South and Horsted Luton and Wayfield Chatham Central Strood South Rochester East Gillingham South Gillingham North River

Male Life Expectancy at Birth (years) 78.9 77.4 77.3 77.0 76.9 76.7 76.3 76.2 76.1 75.7 75.6 75.2 75.1 75.1 74.9 74.7 73.8 73.5 73.0 72.8 72.4 70.2

Figure 27: Life expectancy at birth Source: ONS. Life expectancies have been averaged to give higher level summaries

For women the gap is smaller but nonetheless significant with women born in Cuxton and Halling living 6.1 years longer than women born in Gillingham South.

Locality Name

Code

Name

Rochester Rainham Rainham Chatham Rainham Rainham Rochester Chatham Rainham Chatham Rochester Chatham Chatham Rochester Rochester Rochester Rochester Chatham Chatham Rainham Rainham Rainham

00LCNP 00LCNZ 00LCNY 00LCPK 00LCNS 00LCPA 00LCPH 00LCNT 00LCPJ 00LCNX 00LCNW 00LCNU 00LCPD 00LCPG 00LCPC 00LCPE 00LCPF 00LCNN 00LCPB 00LCNQ 00LCPL 00LCNR

Cuxton and Halling Rainham North Rainham Central Walderslade Hempstead and Wigmore Rainham South Strood South Lordswood and Capstone Twydall Princes Park Peninsula Luton and Wayfield Rochester South and Horsted Strood Rural Rochester East Rochester West Strood North Chatham Central River Gillingham North Watling Gillingham South

Female Life Expectancy at Birth 83.9 83.7 82.0 81.4 81.4 80.7 80.5 80.3 80.3 79.8 79.7 79.6 79.6 79.5 79.3 79.3 79.2 79.1 79.0 78.5 78.2 77.8

Figure 28: Life expectancy at birth Source: ONS. Life expectancies have been averaged to give higher level summaries

What this means for our PNA Closing the gap in life expectancy is a key outcome for the PCT, this requires targeted effort focusing on communities that have the worst outcomes. Efforts on public health measures are the most likely to have an impact on these Examples of pharmacy services which can impact life expectancy include: Smoking cessation, Vascular risk assessment, Alcohol interventions Healthy living advice, Medicines use review.

6.1. Infant mortality Infant mortality in Medway is better than England and in line with the levels in the South East Coast. Perinatal Mortality Rate

Neonatal Mortality Rate

Infant Mortality Rate

(1 week)

(4 weeks)

(1 year)

Name England

2.62

3.41

4.94

ONS Cluster

2.14

2.80

4.21

South East

2.08

2.73

3.98

Medway Council

2.16

2.77

3.90

Figure 29: Infant mortality Source: ONS

What this means for our PNA Infant mortality is linked to maternal health. Improving maternal health and providing appropriate antenatal care contribute to reducing infant mortality. Early access to antenatal care can also be secured through pharmacy pregnancy testing services linked to antenatal referral for women who are pregnant. Pharmacies in East London provide an early pregnancy testing service in order to encourage women who are pregnant into the antenatal care system as early as possible in the pregnancy.

6.2. Burden of disease and ill health Medwayâ&#x20AC;&#x;s population enjoys better health than the rest of England, our younger population profile and location in the South East of England means that fewer of our population reported suffering a Long Term Limiting Illness (LTLI) at the last census. Medway residents reporting living with poor health was also lower than for England. Area England ONS Cluster South East Medway Council Chatham Rainham Rochester

% reporting LTLI 17.9% 15.8% 15.5% 15.6% 15.2% 15.7% 15.9%

% reporting poor health 9.0% 7.7% 7.1% 7.6% 7.6% 7.4% 7.7%

Figure 30: Population reporting LTLI and poor health by locality Source: ONS based on 2001 census data

However some wards in Medway have reported rates of LTLI or poor health significantly above the rate for England. Twydall ward, which also has one of the largest proportion of older people, has rates of 19.0% and 9.3% respectively. Locality Name Rainham Rochester Chatham Chatham Rochester Rainham Rainham Rainham Rochester Chatham Rochester Chatham Rainham Rochester Rainham Rochester Chatham Rochester Rainham Chatham Rainham Chatham

Ward Twydall Peninsula Chatham Central Luton and Wayfield Rochester East Rainham North Gillingham North Gillingham South Rochester West Rochester South and Horsted Strood South Walderslade Watling Strood North Rainham Central Strood Rural River Cuxton and Halling Hempstead and Wigmore Lordswood and Capstone Rainham South Princes Park

% reporting LTLI 19.0% 17.7% 17.6% 17.5% 17.2% 16.7% 16.5% 16.4% 16.4% 16.1% 16.0% 15.7% 15.5% 15.0% 15.0% 14.7% 13.7% 13.5% 13.0% 12.8% 12.7% 10.8%

% reporting poor health 9.3% 8.5% 8.9% 9.1% 8.9% 7.5% 8.7% 7.9% 7.9% 7.3% 7.6% 8.0% 7.0% 7.3% 6.5% 6.8% 6.8% 6.0% 5.4% 6.2% 6.1% 5.6%

Figure 31: Population reporting LTLI and poor health by locality Source: ONS based on 2001 census data

What this means for our PNA The two measures of LTLI and reported poor health are inter-related. The NHS spends the majority of its resources managing long term conditions, a consequence of better interventions and lifestyles means that more people will be living with a LTC at some point in their lives. The quality of our management of LTC to provide quality of life is reflected in the reports of living with poor health from the census. Pharmaceutical services have a role to play in optimising the management of long term conditions through the provision of advice with prescribed medication and medicines use review. Also through the provision of more specialist disease management services in addition to those already provided by GP surgeries.

6.3. Disease prevalence Disease prevalence can be measured using data recorded for the Quality and Outcomes Framework (QoF) used by GPs. These data are helpful but have their limitations. There can be under recording which is not apparent meaning that prevalence looks lower than in practice. However as a comparative tool it can help to demonstrate variation across the localities. NHS Medway has higher prevalence in Hypertension and Diabetes when compared to England and the South East Coast SHA area.

Figure 32: Disease prevalence comparing Medway with SHA and England Data source: QMAS 2008/09

Figure 33: Disease prevalence comparing localities within Medway Data source: QMAS 2008/09

6.1. Hospital admissions Hospital admissions help us to understand what are the causes of admissions and where patients that are admitted live in Medway. Admission rates in Medway are lower than that in England with 144.8 admissions per 1,000 population compared to 200.6 in England. Within Medway the Rochester locality has the highest rate of admissions. Area

England ONS Cluster South East Medway Council Chatham Rainham Rochester

Admissions per 1,000 population 200.6 180.8 172.4 144.8 139.9 145.4 148.9

Figure 34: Admissions per 1,000 population Source HES 2007/08

Looking at the individual causes of admissions we can see that some wards in particular have consistently high rates of admissions across disease areas. The table on the next page highlights those admissions rates in the top 20% for the IDC-10 code area within Medway. What this means for our PNA Pharmacy services are an important, but often overlooked part of the long term conditions pathway. One in three people have a long term condition and most long term conditions are treated or managed using medicines. Ensuring that medicines are used safely and effectively improves outcomes and reduces the risk of hospital admission. It is estimated that around 20% of all admissions to hospital are medicines related, so while the above admissions categories may be disease specific one in five is likely to be related to a failure or unintended consequence of using prescribe medicines. Non-adherence is a silent but significant challenge in managing long term conditions and medicines waste, the WHO estimates that between one third and one half of all dispensed medication is not taken as intended. This has the double negative impact of denying the patient of the benefit of the treatment while costing the health system to drugs that are essential wasted as a result. Pharmacy has a role in ensuring patients, clinicians and carers can obtain the maximum benefit from medicines while reducing risks associated with treatment.

7.3 9.8 7.0 12.0 6.2 9.8 10.1 6.8 7.4 8.4 8.1 4.4 6.4 4.3 7.1 7.1 7.9 6.9 6.6 7.3 4.8 5.7

19.9 21.7 22.7 19.0 21.2 22.3 17.9 16.1 15.0 20.9 17.0 18.1 17.0 14.3 15.9 19.5 17.0 15.2 18.0 16.1 12.2 12.4

19.3 18.5 16.3 14.6 17.8 15.2 12.5 15.5 15.2 16.9 20.3 21.9 21.2 16.0 17.1 15.7 13.8 15.1 12.9 10.3 13.3 16.3

31.4 30.2 30.4 27.8 26.3 27.8 24.4 28.2 24.7 28.6 29.9 26.9 25.7 27.8 23.6 22.3 26.8 27.6 26.7 19.8 24.5 23.0

Skin and subcutaneous tissue (L00 to L99)

Ear and mastoid process (H60 to H95) 2.4 1.5 1.6 1.5 1.6 1.9 1.3 2.0 1.0 1.0 2.0 2.0 1.8 2.6 2.2 0.8 1.7 1.7 1.5 1.0 1.3 1.3

4.5 3.6 4.2 3.9 6.1 5.1 6.6 4.5 4.6 4.8 6.5 4.9 4.8 6.2 3.5 4.6 7.3 4.1 4.8 3.4 4.4 6.4

Genitourinary (N00 to N08)

3.8 5.6 4.4 6.2 6.1 5.1 3.0 5.9 4.0 7.3 3.9 4.9 4.8 6.2 4.5 3.5 3.7 5.3 6.3 3.1 3.8 3.3

Eye and adnexa (H00 to H59)

Nervous system (G00 to G99)

Endocrine, nutritional and metabolic diseases (E00 to E90) 3.1 4.0 3.7 1.6 3.8 3.3 1.7 2.5 3.5 2.6 1.6 3.3 2.7 3.0 3.5 2.4 2.3 4.4 1.5 1.6 2.4 3.9

Musculoskeletal (M00 to M99)

3.3 2.0 3.0 4.7 2.0 2.6 2.5 2.1 2.2 2.6 1.8 2.2 3.7 1.9 1.4 2.3 2.9 1.6 3.1 1.2 0.6 1.2

Digestive (K00 to K93)

21.0 29.4 26.9 27.1 24.0 20.3 34.1 23.1 20.2 19.6 14.5 14.1 18.1 15.8 21.7 20.0 17.6 17.9 17.1 21.2 13.9 9.7

Blood and blood-forming organs (D50 to D89)

Neoplasms (C00 to D48)

Infectious and parasitic diseases (A00 to B99) 2.6 2.2 2.6 3.3 3.0 2.6 2.2 3.3 3.6 3.1 5.1 3.8 3.9 3.9 3.8 3.7 1.9 2.0 3.7 2.1 3.0 3.3

Respiratory (J00 to J99)

173.1 169.6 161.5 160.4 160.4 151.3 150.5 150.5 148.6 148.0 145.6 141.7 139.5 139.3 138.4 137.8 136.0 135.2 134.3 115.4 113.2 113.2

Circulatory (I00 to I99)

Walderslade Twydall Peninsula Rainham North Strood South Rochester South and Horsted Rainham Central Strood Rural Rochester West Watling Luton and Wayfield Gillingham North Chatham Central Gillingham South Strood North Lordswood and Capstone Rochester East Rainham South Cuxton and Halling Hempstead and Wigmore Princes Park River

All Chapters

Ward

17.2 20.8 19.2 17.7 17.8 15.2 15.9 16.1 14.4 15.1 16.2 15.0 13.3 17.0 16.2 19.0 14.7 16.8 18.2 13.5 14.1 14.2

37.3 20.2 19.5 21.1 24.5 20.4 18.2 24.4 32.9 17.1 18.9 20.1 15.9 20.3 17.9 17.2 18.5 16.5 13.8 14.8 14.9 12.5

Figure 35: Admissions per 1,000 population by chapter, wards in upper quintile highlighted Source HES 2007/08

6.2. Adult care homes NHS Medway has 12 nursing homes with 615 places providing nursing care in a residential setting. Name Grace Manor Bryon Lodge Heatherdale Fort Horsted Friston House Winchester House10 Copper Beeches Fontenay Valley View Frindsbury Hall Berengrove Park Pembroke House Total beds

Postcode ME7 2UD ME7 5PX ME7 3QG ME4 6HZ ME1 2BQ ME1 3TR ME1 3LL ME1 1RX ME1 3LT ME2 4JS ME7 4AH ME7 4BS

Beds 60 28 37 30 80 118 42 27 33 74 36 50 615

Ward Gillingham North Gillingham South Hempstead and Wigmore Rochester South and Horsted Rochester South and Horsted

Locality Rainham Rainham Rainham Chatham Chatham

Rochester South and Horsted Rochester West Rochester West Rochester West Strood Rural Watling Watling

Chatham Rochester Rochester Rochester Rochester Rainham Rainham

Figure 36: Nursing homes in Medway

Nursing homes are located in each of the PCTâ&#x20AC;&#x;s localities, however Rochester South and Horsted and Rochester West both have three care homes in each ward.

Row Labels Chatham Rochester South and Horsted Rainham Gillingham North Gillingham South Hempstead and Wigmore Watling Rochester Rochester West Strood Rural Grand Total

Sum of Beds 228 228 211 60 28 37 86 176 102 74 615

A list of all adult care homes in Medway is set out in Appendix 7.

Winchester house is funded by NHS West Kent and is located just across the border. For illustrative purposes this care home has been allocated to the Rochester South and Horsted ward which is closest to the homeâ&#x20AC;&#x;s location.

What this means for our PNA Recent research has highlighted the challenge of providing integrated primary care services to patient in care homes. This work highlighted the risks and issues associated with the current way in which GPs, pharmacists, care home staff and hospitals work together to manage the care of residents. A summary of this research is provided at Appendix 4.

6.3. Smoking The single biggest determinant of health is whether a person smokes. Rates of smoking have fallen in recent years, however it remains a focus for health services to reduce rates further, especially among harder to reach groups. Smoking prevalence is estimated from a small scale survey which is then used to develop estimates at MSOA level. The table below shows the estimates for smoking prevalence in the MSOA with the lowest estimate, the MSOA with the highest estimate and the average of all MSOAs in Medway. This shows that Medway has higher levels of smoking, even in areas with the lowest rates, the rates are above England, SEC and ONS cluster averages. Name England ONS Cluster South East Medway Council

Minimum Smoking Estimate 7.30 12.10 9.10 16.20

Maximum Smoking Estimate 54.20 44.10 43.70 39.80

Average Smoking Estimate 24.23 26.16 21.85 28.92

Figure 37: Smoking estimate (percentage of population) Data source: ONS 2003-05

What this means for our PNA Pharmacies already play an active role in providing support for smoking cessation. The role of community pharmacy is two-fold; providing access to nicotine replacement therapy and providing advice from pharmacists and staff trained as level 2 counsellors. Whilst this service is also provided under alternative in other healthcare settings harmacy is a unique provider, in that pharmacies have access to NRT at the point of care, they also provide a â&#x20AC;&#x153;walk inâ&#x20AC;? service across extended hours of service.

6.4. Alcohol The methodology for estimating binge drinking behaviour in the population is similar to that used in smoking. NHS Medway has a higher binge drinking estimate than comparator PCTs with high levels even in areas with the lowest rates. Name England ONS Cluster South East Medway Council

Minimum Binge Drinking Estimate 5.20 10.00 9.90 12.20

Maximum Binge Drinking Estimate 63.90 36.40 40.60 21.10

Average Binge Drinking Estimate 17.93 16.61 16.18 16.69

Figure 38: Binge drinking estimate (percentage of population) Data source: ONS 2003-05

What this means for our PNA Pharmacies have a small but evolving role in providing brief interventions in alcohol use. Pharmacies in Merseyside provide a brief intervention service designed to identify, support and refer patients into alcohol services.

6.1. Exercise and obesity Estimates of the levels of physical activity among in NHS Medway show that fewer adults in Medway report undertaking exercise, the reported rates for Medway are well below all comparators. Name

% adults 3 hours exercise per week

England ONS Cluster South East Medway Council

21.8% 19.7% 22.9% 14.1%

Figure 39: Adults reporting greater than 3 hours exercise per week (percentage of population) Data source: Sport England N18 2007/08

The reported rates of exercise link to the observed rates of obesity in Medway which are higher than in SEC SHA and England. Minimum Obesity Estimate 5.40 15.60 8.50 18.00

Name England ONS Cluster South East Medway Council

Maximum Obesity Estimate 35.70 32.80 33.40 28.40

Average Obesity Estimate 23.45 25.15 22.03 24.41

Figure 40: Obesity estimate (percentage of population) Data source: ONS 2003-05

Among our children, who are measured during reception year and at Year 6 the rates of obesity are also high.

89.1% 88.0% 88.3% 89.6%

1.3% 1.1% 1.2% 0.7%

Y6 obese

9.6% 9.8% 8.6% 11.7%

Y6 overweight

13.2% 13.4% 13.3% 13.4%

Y6 Healthy

% Y6 measured

76.2% 76.0% 77.4% 74.0%

Y6 Underweight

R Obese

1.0% 0.8% 0.8% 0.9%

R overweight

R underweight

91.2% 90.4% 89.9% 88.2%

R Healthy

% Reception measured England ONS Cluster South East Coast SHA Medway PCT

66.1% 66.4% 68.4% 65.3%

14.3% 14.6% 14.4% 14.6%

18.3% 17.8% 16.0% 19.4%

Figure 41: Reception and Year 6 BMI measurement Source: NHSIC 2008/09

What this means for our PNA Pharmacies provide advice and support for healthy lifestyles as part of their core contract. Pharmacies in Coventry have offered a comprehensive weight management service since 2006 which includes a risk assessment and motivational interviewing to support people to lose weight. The service is successful in attracting men who are often more difficult to reach through traditional weight management services.

6.2. Teenage pregnancy Teenage pregnancy rates in Medway are higher than in England (5.8% vs 4.8%) with significantly higher rates in Rainham and Rochester. Rate conceptions per population 4.8% 4.7% 4.2% 5.8% 5.2% 6.1% 6.1%

Area England ONS Cluster (New and Growing Towns) South East GOR Medway Council Chatham Rainham Rochester Figure 42: Under 18 conception rates Source: ONS 2005-2007

The wards with the highest rates are shown in the table below

Name

% under 18 conceptions

Twydall Luton and Wayfield Strood South Peninsula Gillingham North Rochester East Gillingham South Chatham Central Strood North Rainham Central

9.8% 7.6% 7.6% 7.5% 7.3% 7.1% 6.9% 6.1% 6.0% 4.8%

Figure 43: Teenage Conceptions - 2005-2007 Source: ONS

What this means for our PNA Pharmacies in NHS Medway provide access to Emergency Hormonal Contraception through a Patient Group Direction (PGD). The service is free of charge to women using the service. Pharmacies are seen as a safe, accessible and non-judgemental provider of EHC services, some women, particularly younger women prefer to use town centre pharmacies as these offer a sense of anonymity when compared to “local” pharmacies

6.3. Sexual health Medway has lower rates of sexually transmitted infections (STIs) among the population when compared to England and SEC SHA. Name England South East Medway PCT

STIs - 15 to 19 13.46 10.72 9.56

STIs - 20 to 24 24.56 21.97 20.91

STIs - 25 to 34 9.92 8.30 8.16

STIs - 35 to 44 2.96 2.44 2.32

STIs - 45 to 64 0.79 0.73 0.84

Figure 44: Sexually transmitted infection rates

This is also reflected in the rates of Chlamydia infections reported in the population. Name England South East Medway PCT

Chlamydia Infections 15 to 19 8.17 5.97 4.83

Chlamydia Infections - 20 to 24 12.80 10.75 10.66

Chlamydia Infections 25 to 34 4.30 3.38 2.97

Chlamydia Infections - 35 to 44 0.95 0.71 0.55

Chlamydia Infections 45 to 64 0.19 0.17 0.21

Figure 45: Chlamydia infection rates

What this means for our PNA Pharmacies in NHS Medway provide a Chlamydia screen and treat service. Uptake has been good in areas that are a destination for young people. More could be done to raise pharmacy‟s profile as a source of this type of screening, particularly with this age group.

7. Insights from patients and the public An important element of any needs assessment is to capture the view of current and potential services uses to understand their perspective and to identify actions which will ensure the successful implementation of services arising from the needs assessment. NHS Medway undertook a postal questionnaire in December 2009 which achieved a response from 673 people (16%) out of a sample of 4,200 people registered with Medway GPs. The questionnaire covered the current use of pharmacy services, preferences for, and satisfaction with services, prescription medicines use and access to pharmacies. The responses to the questionnaire provide a very valuable insight into the views of patients that can be used immediately to inform the PCT‟s plans for pharmacy services. The highlights from the questionnaire include: High levels of satisfaction with pharmacy services which extends across Medway. The results showed that ensuring adequate privacy in pharmacies remains a challenge even though most pharmacies have consultation areas. This suggests that there is work that needs to be done to change the way in which pharmacies use their private areas. Low levels of knowledge of extended pharmacy services but a strong willingness to use pharmacies for these kinds of services in the future. This suggests there is more that can be done to match patients‟ perceptions with their willingness to use pharmacies in new ways. People responding to the questionnaire were more likely to report problems accessing pharmacy services during “normal” opening hours than during the out of hours period (6pm – 8am). This suggests that lunchtime closures or pharmacist absence over lunchtime can be a barrier to access in some areas. There is a significant group of people in Medway that are not getting the best from their medicines. This suggests that there are opportunities to explore how pharmacists could help patients with the practical problems that they experience. The results have provided a unique and valuable insight into the views of patients which will be useful in developing the PNA and planning pharmacy services in the future.

7.1. Background to the questionnaire The development of NHS Medway‟s Pharmaceutical Needs Assessment (PNA) has been informed through a process of purposive research with patients and residents in Medway in order to develop insights into the views of this important stakeholder group on the current and potential future role of community pharmacy. Little is known about the views of patients in Medway about pharmacy services. Current and future commissioning needs to be informed by, and sensitive to the views of patients. However there is very little systematic collection of patient experience feedback or views about pharmacy services that is available to the PCT. To provide some context for the PNA an in-depth postal survey was conducted with a sample of 4,200 (2%) of patients aged over 15 years of age registered with Medway GPs. The survey was complemented by two focus groups one with young people (Medway Youth Parliament) and one with Medway Cyrenians which is a Registered Social Landlord and Registered Charity, that house and support vulnerable, single, homeless people aged sixteen year's plus. The reports of these focus groups are included at Appendix 9. 7.2. Results 673 (16.0%) people responded to a survey exploring the frequency and nature of their visits to local pharmacies, and their wider experiences and opinions of pharmacy services. Most of the data are presented as percentages of the total number of respondents answering a particular question: some questions have also been subject to comparisons of groups (e.g. by gender). Findings deemed „significant‟ are all measured at the level p<0.05. Respondents were asked to provide their postcode, this was used to determine the electoral ward and locality where they live. Of the 673 respondents 550 (81.2%) gave a valid Medway postcode. Respondents by locality Chatham Rainham Rochester Other local authority areas Gravesham Maidstone Swale Tonbridge and Malling

26.9% 42.0% 31.1%

Resident population by locality11 31.1% 37.8% 31.1%

0.9% 1.8% 1.6% 2.1%

Figure 46: Respondent by locality

Source: ONS mid-2008 estimates

The results show that the respondents were well distributed across the PCT with Chatham under represented and Rainham over represented. There were respondents from every ward in Medway with over/under-representation at locality level reflected at ward level.

Figure 47: Respondents by ward and locality

The sampling of the survey was intended to be randomly distributed across an age stratified sample, this stratification was administered by the PCT using the registered population in Medway. The results showed that the respondents were skewed towards older people, who are also higher responders to this type of questionnaire.

Figure 48: Respondents by age group

In order to obtain a representative sample, the respondents were weighted by age to achieve an age structure which reflects the population of Medway. Of the 673 respondents, 33 (4.4%) did not provide their age, the remaining 644 were subject to weighting to achieve an age balanced sample for analysis. The ethnicity of respondents fits well with the ethnicity of the population at the last census in 2001. The proportion of respondents that reported their ethnicity as non-white was similar to the census levels. However respondents from the Asian ethnicity census groups were under represented while those from the Black groups were over represented. Ethnicity in Medway has changed over the 9 years since the last census and while our results are in line with ethnicity at that time they are likely to under-represent non-white groups in todayâ&#x20AC;&#x;s population and to under-represent white ethnic minority groups that have moved in to the area since the last census. Ethnicity

Respondents

Medway PCT Census 2001

White

94.7%

94.6%

Mixed

0.8%

1.1%

Asian or Asian British

1.9%

2.9%

Black or Black British

1.7%

0.7%

Chinese and Other

1.0%

0.7%

Figure 49: Respondents by ethnicity

Men were under represented in the respondents, making up 39% of respondents versus making up 49% of the Medway‟s population. (ONS 2008-mid year). With the exception of the general demographics section, which reports unweighted data, all other results are weighted for age. 7.3. General Demographics In terms of general demographics, 39% of the respondents were male and 61% female. Forty per cent of respondents were under 39 years of age, and just over a half (52%) did not pay for prescriptions. Overall, the respondents rated their health as „good‟ or „fairly good‟ (55% and 38% respectively). A significant minority of the sample classed themselves as „carers‟ of someone in their or another household (22%), and 6% as „cared for‟ by someone which was not part of their job. Almost all the respondents were white (93%). 7.4. Use of Pharmacies Almost half of respondents stated that they used the same pharmacy all the time (49%). In later analysis, this group will be referred to as „one-pharmacy users‟. Only 7% of the sample indicated that they used different pharmacies, and none more frequently than any others. Eighteen percent of respondents believed that the pharmacist knew a great deal about them and their care, just over a third (31%) indicated this to some extent, and over another third felt that the pharmacist was not engaged in their care (many of whom said that they did not usually see the same pharmacist). „One-pharmacy users‟ were significantly more likely to report that the pharmacist knew „a great deal‟ about them and their care (31% vs 5%). When asked about location factors that influenced pharmacy choice, most respondents used a pharmacy close to their GP practice (40%) or close to their home (37%) (Figure 48). Location factor important to respondent It is close to my doctor‟s surgery It is close to my home It is close to other shops I use It is close to my children‟s school or nursery It is easy to park nearby Other

% (n=537) 40.2 36.6 12.1 8.0 0.7 2.4

Figure 50 – Location factors influencing choice of pharmacy

When asked about service factors that influenced pharmacy choice, most respondents indicated that a quick service (39%) or the pharmacy stocking their medication (26%) were the most important to them (Figure 49). „One-pharmacy users‟ were more likely than others to cite the pharmacist/staff

knowing them (18% vs 5%) as an important factor: other users were more likely than „one-pharmacy users‟ to cite evening and weekend opening hours as a reason for use (5% vs 17%). Service factor important to respondent The service is quick The pharmacy usually has my medicines in stock The pharmacist or staff knows about me and my medicines The pharmacy is open late or at weekends The pharmacy offers a prescription collection and delivery service There is some privacy when I want to speak to the pharmacist Other

% (n=527) 38.8 25.5 11.5 11.1 6.0 5.9 1.2

Figure 51: Service factors influencing choice of pharmacy

7.5. Most Recent Visit to a Pharmacy Almost 67% of respondents had visited a pharmacy within the last month for a health-related service, with 26% having visited in the last week: only 16% had not visited a pharmacy in the last six months. Sixty-eight percent of respondents had visited the pharmacy for themselves. The most frequent reason given for this visit was to obtain medicine/s on prescription (80% - Figure 50), and this was more likely to be the reason for „one-pharmacy users‟ than other users (85% vs 75%). Reason for using the pharmacy To get medicine(s) on a prescription To buy medicine(s) from the pharmacy To get advice at the pharmacy Can't remember Other

% (n=542) 79.7 14.3 4.4 0.5 1.1

Figure 52: Reasons for which respondents most recently visited a pharmacy

Most of the respondents had visited a pharmacy that they used regularly (84%). Most accessed the pharmacy by car (39%) or by walking there (32%). 7.6. Access to Pharmacy Services In the last twelve months, only 7% of respondents reported problems finding a pharmacy to get a medicine dispensed, to get advice or buy medicines. „One-pharmacy users‟ were significantly less likely than other users to have a problem. The majority of respondents (84%) were satisfied with the opening hours of their pharmacy. When asked, however, whether they had experienced problems accessing their usual pharmacy, or the pharmacy closest to them, 25% responded that they had, and for 8% of people it had happened on several occasions (Figure 51).

Number of times unable to use regular or closest pharmacy Not at all Once or twice Three or four times Five or more times Can't remember

% (n=628) 64.4 25.1 6.1 1.9 2.6

Figure 53: Access problems with local pharmacies

Most respondents (46%) indicated that the problem was on a normal weekday, and 32% had a problem over the weekend (Figure 52). Half of access problems (54%) were cited during normal opening hours 8am to 6pm, with fewer during the evening, and very few overnight.

Time 8am – noon Noon – 2pm 2pm – 6pm Total “Daytime” 6pm – midnight Midnight – 8am Total “Night time”

Weekday n= 107 14 24 15 53 38 5 43

% of respondents who answered the question Saturday Sunday & Bank Holidays n=47 n=41 15 20 40 15 23 29 79 63 15 12 0 0 15 12

Figure 54: Access problems during „normal‟ hours and out of hours

Written

comments

associated

with

these

questions

revealed

that

people

wanted

weekend/evening opening hours, that lunch time cover could be a problem, there was a mismatch with practice opening times, and that there were problems finding a pharmacy in the out-of-hours period:

I work 9-5, there should be better evening opening hours for people like myself. Lunch hours are a problem there is no cover. Nothing open locally after 7pm (in cases where you run out of medicines for children it can be a problem). They need to be open when the doctors is open, otherwise what‟s the point. More need to be opened later and at weekends especially Sunday.

Sixty-two percent of the sample needed the pharmacy visit for themselves, and just over two-thirds needed a medicine on prescription (67%). Under half (46%) considered the situation urgent. As a result, half (50%) waited until the pharmacy was open again and 41% went to another pharmacy. 64

In terms of how they found the alternative pharmacy, 58% said they already knew which one would be open; almost 13% drove around to find a pharmacy; 10% looked on the internet, and a smaller minority called NHS Direct, or found out by either telephoning, or receiving information from a friend or family member. 7.7. Consultations with Pharmacists

In the last twelve months, a minority of respondents (15%) had had a consultation with a pharmacist: Some of these had been medicine-related (6%). There was no difference in incidence between „onepharmacy users‟ and other users. Most were initiated by the patient (78%), rather than the pharmacist (19%). The varying subjects discussed were reflected in the associated written comments: Advice re: skin problems for grandson Cholesterol check Confirm my having shingles

Over half of consultations (58%) were carried out at the pharmacy counter, 19% in a quiet part of the pharmacy shop, and 16% in a separate room. Respondents rated the pharmacist highly in the consultation in terms of listening, time spent, confidence and trust, and being treated with dignity and respect – although a significant minority felt this „to some extent‟ (Figure 53).

Question (n=) Did the pharmacist listen carefully to you? (n=121) Were you given enough time with the pharmacist? (n=120) Did you have confidence and trust in the pharmacist? (n=122) Did the pharmacist treat you with dignity and respect? (n=123)

85.6

% Yes, to some extent 13.4

1.0

74.2

24.8

1.0

75.8

21.6

2.6

85.4

13.2

1.3

Yes, definitely

Figure 55: Perceptions of the consultation

Most respondents (72%) said the pharmacist definitely provided useful information, 25% said it was useful to some extent and 3% considered the advice or information not to be useful. Ninety percent of respondents believed that they felt able to ask as many questions as they wanted. Seventy-seven percent said the pharmacist answered all of the questions they asked, but 18% indicated the pharmacist had answered only some of their questions. 7.8. Experiences of Getting a Prescription As stated earlier, most respondents had made their most recent visit to a pharmacy to get medicine/s on prescription. The majority (65%) said that a member of staff had explained how long their prescription would take: 22% said that they were not told, and did not mind, but 12% were not told how long their prescription would take, and they would have liked to have been informed. Two thirds of respondents (68%) waited in the pharmacy for their prescription. Of those who waited, 68% waited up to ten minutes: ten per cent had to wait more than twenty minutes. The majority of respondents (87%) got all the medicines they needed on their last visit to the pharmacy. Of those who did not, 72% said the main reason for incomplete prescriptions was stock shortage at the pharmacy. Half of respondents had received their owing medicine within a day of the visit (55%), but a significant minority of 8% waited more than a week for their prescription to be completed. The â&#x20AC;&#x17E;otherâ&#x20AC;&#x; reasons given for not getting all the medicines needed included the following written explanatory comments â&#x20AC;&#x201C; stock issues (short and long-term), and dispensing errors: Aveeno cream - not always stocked. Medication needed, needs to be reordered I was told one drug was permanently unobtainable They gave me lorazepam but my prescription is for loprazolam. Second time they got it wrong

7.8.1. Repeat Prescriptions Over half of the respondents (59%) had a repeat prescription. Most people (60%, n=231) ordered it themselves by visiting the surgery, but there was a range of ordering methods (Figure 54).

Ordering Method I visit my doctor‟s surgery to order the repeat prescription I call or visit the pharmacy to ask then to order the repeat prescription from my doctor I post an order for the repeat prescription to my doctor‟s surgery The pharmacy automatically orders my repeat prescription from my doctor I telephone my doctor‟s surgery to order the repeat prescription I e-mail my doctor‟s surgery to order the repeat prescription

% (n=382) 60.3 14.6 13.1 4.3 3.1 2.1

Figure 56: Repeat prescription ordering methods

Most respondents collected their prescription from the surgery and took it to the pharmacy (56%), but over a third had it collected by the pharmacy (33%), and almost 6% had it posted to them by the surgery. When asked for ideas for improvements to their repeat prescription service, there were many comments. Most reflected a feeling that the system was good as it currently exists. Others wanted longer repeat supplies, a system to avoid visits to the surgery unless needed, and more ways of ordering their repeat.

Cannot see how anything could be improved, very happy as it is. As it is basically automatic for both my wife and me, why can‟t it be automatic for 6 months and doctors not in loop? (If problems, doctor must be involved) Be easier if someone could send to pharmacist and I could pick up from there or they deliver. Do it online. I am happy with the present system of doctor‟s surgery and then pharmacy, but of course I am fit and mobile.

At their last dispensing, 94% of respondents said that they got exactly what they needed on their repeat. A minority of 4% did not get all the medicines needed, and four people (1%) said that they got some medicines that they did not need at the time. 7.8.2. Problems Experienced with Long-term Medicines Many of the respondents (59%) had been taking prescribed medicines for three months or more. Almost half (44%) stated that they had had no problems with their medicines, and 84% did not report any problems, but a minority of 31 people (5%) reported two or more problems. The most common 67

medication problems were remembering to take medicines, changes to colour or shape of the medicine, and getting medicines out of the packaging (Figure 55). Problem experienced with a medicine Remembering to take my medicines Changes to colour or shape of the tablet Getting my medicine out of the package Swallowing or using my medicines Reading the information leaflet Confused by medicines that look similar Reading the label

% (n=645) 7.4 4.7 4.3 2.9 1.3 0.8 0.7

Figure 57: Types of problems experienced with long-term medicines

The most common adherence problems were forgetting to take medicines sometimes, and discontinuing medicines if they made them feel worse (Figure 56). â&#x20AC;&#x17E;One-pharmacy usersâ&#x20AC;&#x; were significantly less likely than other users to stop the medicine if feeling better (10% vs 23%), but there were no significant differences for the other adherence problems. Adherence problem reported Forgetting to take medicines sometimes Stopping the medicine if it made them feel worse Stopping the medicine when they feel better

% (n=645) 20.3 20.1 15.2

Figure 58: Types of adherence problems reported with long-term medicines

7.8.3. Getting help with medicines from pharmacies Respondents were asked whether they were getting different types of help with medicines from pharmacies, and whether they would like these types of help from pharmacies (Figure 57).

% (n=645) Type of Help Collecting my prescription from the doctor Put a label on my medicines that is easy to read Order my prescription from the doctor Deliver the prescription to my home Put my medicines in a container that is easy to open Put my medicines in an organiser to help me remember to take them Give me a chart to help me remember when to take medicines Someone at the pharmacy to explain medicines to me

Already get 13.8

Would like to get 9.3

10.6

2.6

7.6

10.7

2.3 1.8

6.6 2.2

0.4

2.1

0.4

0.6

Not asked

2.7

Figure 59: Help with medicines both received and desired from pharmacies

The most frequently reported and desired help related to the mechanics of the medicine supply process (ordering through to delivery), but some respondents reported actual and desired help with enhanced labelling and adherence aids. There was modest demand for explanations of medicines from someone at the pharmacy (2.7%). 7.8.4. Getting New Medicines Over a third of the respondents (37%) stated that they had had a new medicine on prescription in the last 12 months. The extent to which respondents felt that the pharmacist had explained different aspects of use of the new medication is reported in Figure 58.

Did the pharmacist explain.............? (n=) How to use this medication (n=242) When to use this medication (n=241) What the medication was for (n=242) What other medicines, drinks or foods you should avoid (n=240) Possible side-effects of the medication (n=242)

Yes, completely 32.2 31.1 21.8 19.2

Yes, to some extent 9.7 7.0 12.1 9.1

Did not need it

28.6 27.0 29.8 42.3

29.5 35.0 36.1 29.0

16.3

8.2

46.9

28.5

Figure 60: Perception of explanations about new medicines

The table shows that, in each case, around 30% of respondents felt that they did not need an explanation of this aspect of use. Of those who did, many felt that the pharmacist gave a complete explanation about how to use the medication, and when to use it. Respondents felt more strongly that the pharmacist had not given a clear explanation of what the medication was for, other medicines, drinks or foods to avoid, and side-effects. Most respondents (69%) felt able to ask as many questions as they wanted about the new medication. On this occasion, one-quarter (25%) of respondents felt the pharmacist answered all of their questions, but 64% had stated that they had not asked any questions. 7.9. Advice-giving by Pharmacists on Public Health Issues The survey asked respondents whether the pharmacist had ever discussed four important public health issues with them: stopping smoking; weight control; alcohol consumption; and risk of heart disease (Table 59).

Has the pharmacist ever talked to you about..................? (n=) Stopping smoking (n=520) Drinking alcohol (n=529) Weight control (n=530) Your risk of heart disease (n=536)

Yes 1.7 1.7 2.2 5.1

No, and I would like advice 5.0 2.2 12.9 28.3

No, and I donâ&#x20AC;&#x;t need advice 92.4 95.2 84.0 64.9

Figure 61: Reports of the pharmacist discussing public health issues

The table shows that most respondents did not perceive a need to get advice from the pharmacist about these health issues, and a very low level of such discussions taking place. Comparison of groups showed that pharmacists had spoken to more men than women about and heart disease and how much alcohol they drink. There was some interest in getting advice about weight control (12.9%) and risk of heart disease (28.3%) from the pharmacist. More men than women wanted heart health advice, and respondents over 60 years of age were more likely to want advice on heart disease. This will be explored further in the next section about pharmacy services.

7.10.

The Range of Pharmacy Services

Respondents were asked if they knew of, and had used, several NHS pharmacy services (Figure 60). % (n=645) Had heard of service Had used service 27.6 1.3 16.8 11.5 9.4 3.7 6.9 2.5 3.8 0.7

Service Stop smoking help Treatment on the NHS for a minor illness Medicine reviews The morning after pill without prescription Chlamydia testing and treatment

Figure 62: Knowledge and use of existing NHS pharmacy services in Medway pharmacies

Respondents were also asked whether they would use a wider range of services from local pharmacies, if these were to be commissioned by the PCT. (Figure 61). Service Healthy heart check ups Treatment on the NHS for a minor illness Flu vaccination Help watching your weight Monitoring how your medicines are working Diabetes check ups Advice about diet and/ or exercise Advice about leading a healthy life Medicine reviews Contraception medicines without a prescription

% (n=645) 37.7 31.4 25.5 21.6 20.7 20.0 19.0 18.4 16.2

Service Treatment on the NHS for head lice Condoms on the NHS Pregnancy testing Anticoagulation checks The morning after pill without a prescription Stop smoking help Disposal of injecting equipment Gluten free foods Chlamydia testing and treatment

% (n=645) 11.9 10.6 8.4 7.4 7.3 6.3 5.6 4.9 4.0

13.9

Figure 63: Predisposition to use services, if available, from local pharmacies

A NHS minor ailment service and healthy heart check-ups were the two most popular services. Further analysis of responses regarding the healthy heart check-up showed that this service could be targeted to a particularly receptive group of men and women aged 40-74 years (Figure 62). Age (years) 16 - 39

Male

Female

26 (10.3%)

45 (11.5%)

All (n=645) 71 (11.0%)

40 - 74

63 (25%)

93 (23.7%)

156 (24.2%)

75+

6 (2.4%)

10 (2.6%)

16 (2.5%)

Total

95 (37.7%)

148 (37.8%)

243 (37.7%)

Figure 64: Further analysis of groups wanting healthy heart advice

When data were analysed to explore women‟s awareness of, and intention to use, EHC services, the results also showed how the service could be targeted (Figure 63). The youngest women (aged 16-19) showed good knowledge and intention to use: further marketing to women aged 20-29 and 40-44 might be needed.

Age (years) 16-19

% of respondents (n=211 – women only) who: Know service is Have used service in Would use it in the available past future 30 7 30

20-24

25-29

30-34

35-39

40-44

Total

Figure 65: Further analysis of women‟s knowledge and intention regarding an EHC service

Further analysis of respondents‟ awareness of, and intention to use, Chlamydia testing services also showed marked group responses that might aid targeting (Figure 64 and 65).

Age (years) 16-19

% of respondents (n=211 – women only) who: Know service is Have used service in Would use it in the available past future 15% 0% 0%

20-24

18%

25-29

30-34

35-39

40-44

Total

Figure 66: Further analysis of women‟s knowledge and intention regarding a Chlamydia testing service

Age (years) 16-19

% of respondents (n=118 â&#x20AC;&#x201C; men only) who: Know service is Have used service in Would use it in the available past future 10% 0% 0%

20-24

21%

25-29

30-34

10%

35-39

40-44

Total

Figure 67: Further analysis of menâ&#x20AC;&#x;s knowledge and intention regarding a Chlamydia testing service

These tables show very low levels of awareness, past use and intention to use. High percentages in specific age bands are likely to be caused by low numbers of respondents in this range leading to high weighted percentages. Responses to a question that explored what factors might cause people concern about accessing new services from pharmacies revealed a range of issues that should be addressed when promoting new enhanced services. These issues included: the training of the pharmacists and staff; the space/privacy available to provide the service; the danger of fragmentation of care, and whether such services were really the pharmacistâ&#x20AC;&#x;s role. There were other comments that people would have no concerns. Are they qualified as doctor or nurse? Surgery do mass vaccinations quicker and easier. GP needs to keep oversight of medical conditions, but the pharmacy could help me to have some contribution to monitoring my own health. How does the pharmacy provide private space for these? Let the pharmacists concentrate on dispensing medicines and simple advice on colds/sore throats etc. They are not doctors, the types of services you list might be better provided by special themed nurses. Yes it seems as though the services you suggest are bypassing our local doctor. Only when we find the waiting time to visit the doctor is excessive will we think of using those facilities which is not the case at the moment. No concerns.

In a final question regarding respondents‟ perception of the range of pharmacy services, 21% of respondents stated that they wished pharmacies could provide more services, and 67% were satisfied with current service provision (n=533). „One-pharmacy users‟ were significantly more likely to report satisfaction with the range than multi-pharmacy users (74% vs 61%).

7.11.

General Comments about Pharmacies

Respondents were asked what was good about pharmacies and what could be improved. Good points included many comments about good pharmacists and staff. Other good points reflected themes in the wider survey: convenient location; efficient repeat prescription systems; good stock; good access, and short waiting time.

Above all it is very friendly, informative and they know you by name. You feel you are not just a 'number'. [Pharmacist] is the most helpful, caring pharmacist I have ever met. He is such a kind and friendly man, if only he was a GP. His staff are all happy, friendly people. One of the two pharmacies I use is open for extremely long hours, late evenings, weekends etc, which is excellent and has proved invaluable, they were also able to collect my prescription once when I was unable to myself but I have not have to sign up to a collection service. The pharmacist at the other one is extremely helpful, understanding, attentive and confidently knowledgeable - wonderful man. The staff are always polite, the service is quick and you can always ask about the medicine. They have got seats while you‟re waiting for prescriptions. They provide a very comprehensive service with a good stock of medicines and even other goods. Very friendly, helpful staff. They provide a quick service and are well trained. Treat my husband and I like an individual, very caring and knowledgeable. Very convenient, near to my home and GP. Yes, they are open from 7-11pm 7 days a week.

Suggestions for improvement were mainly the negative reflection of the good points, although the most frequent response was that no improvement was necessary. Those who did suggest improvements asked for shorter waiting times; longer opening hours; better stock control, and better access/space/privacy. A notable minority sought more information and support with medicines, and services closer to home through pharmacy such as diabetes monitoring services. The cost of prescriptions was also raised as an issue.

Area surrounding the Pharmacy is restricted. Not enough seating for the elderly. At the pharmacy I use repeat prescriptions take up to five days to get because of a doctor having to sign the prescription. Ways of speeding this up would help. Do not dispense 1/2 a script and ask the patient to call back later/another day for the rest. Give the pt the option to go elsewhere. People like people, why keep changing pharmacists who do not have a clue of history. Could improve by staying open at lunch time. Give pharmacists more responsibilities like monitoring diabetics. Free prescriptions in line with Scotland and Wales. More privacy when speaking to the assistant. There's usually a queue and some health matters are sensitive. More staff to deal with prescriptions. You couldn't improve my local pharmacy.

7.12.

Rating of Pharmacy Service Elements

Respondents were asked for rating of different aspects of pharmacy services within the survey. Figure 66 combines the answers to these questions to explore and compare results across these elements of the pharmacy service.

Figure 68: Respondent rating of pharmacy service elements (% of respondents who answered the question)

When this analysis was run with „one-pharmacy users‟ only, ratings of „excellent‟ increased for each aspect. 75

Friendliness of staff: Consistent with the written comments, respondents rated staff friendliness highly, with 73% rating them „excellent‟ or „very good‟. Only 2% rated them „poor‟ or „very poor‟. Using a Pharmacy: Overall, 73% of the sample rated their most recent experience of using a pharmacy as „excellent‟ or „very good‟. Only 2% rated their last experience of using a pharmacy as „very poor‟ or „poor‟. Getting a Prescription: Overall, 60% of the respondents rated their experience of getting their prescription as either „excellent‟ or „very good‟ on their last visit. Only 8% rated their experience as „poor‟ or „very poor‟. Privacy in the Pharmacy: Thirty-eight per cent of the sample rated the level of privacy as „excellent‟ or „very good‟, but just over a quarter (26%) rated the privacy of the consultation as „fair‟ or worse. A third (33%) of respondents were offered the choice of having the consultation somewhere where they could speak privately. Written comments from respondents reflect their feelings about this issue: It's nice to see a smiling face in the pharmacy, but embarrassing when you ask advice and can be heard by others. Provide more stock and an area where more personal/private matters can be discussed. More privacy when asking for advice across the counter, usually at least the next two customers are listening in.

Access to a pharmacy: When people had found their normal pharmacy closed and had to find an alternative, they were still fairly positive in their rating of the experience. 14% rated it „excellent‟, 56% rated it „very good‟ or „good‟, but 30% rated it „fair‟ or worse. 7.13.

Conclusions

The results show that there is generally good satisfaction with pharmacy services among respondents. This positive view extends across the factors assessed in the questionnaire, however respondents that had had a consultation with the pharmacist rated privacy lower than other service factors. This presents a challenge to how pharmacists and pharmacies deliver services that require a consultation to ensure that patients have the privacy that they require. While access to pharmacies was generally considered good there was a significant group of respondents that had experienced problems accessing pharmacy services in “normal” daytime hours. This suggests that there is a need to ensure that lunchtime closures are co-ordinated within localities to ensure that patients always have a choice of an alternative pharmacy. Patients‟ knowledge of the extended services available from pharmacy was poor, but they demonstrated a propensity to use services from pharmacy which are not traditionally associated 76

with dispensing in the future. Particularly services focused on disease prevention like weight management and heart health. The poor knowledge of existing services strongly suggests that any new services need to marketed to patients to ensure that the willingness of patients to use these services is capitalised upon. A significant minority of patients taking prescribed medicines reported problems in using or taking medicines. This suggests that there is a silent, but significant group that is not fully realizing the benefits of their prescribed medication. The WHO estimates that between 35 and 50% of all prescribed medication is not taken as intended. The challenge of non-adherence is evident in Medway and merits active consideration. 7.14.

Further work

A postal questionnaire has limitations, generally the response to unsolicited, anonymous (i.e. where no follow up is possible) is generally poor. The method used to select respondents omits persons that are not registered with GPs and a written questionnaire, by its nature, excludes those with low literacy levels. The PNA questionnaire has succeeded in securing a good response rate from a broad cross section of respondents across Medway. It has provided valuable insight into how patients use pharmacies, their views on current and future pharmacy services and their experience of using medicines. Further work with patients will be undertaken as part of the PCT‟s consultation process and will focus on patients and groups of patients that have been under-represented through the process used so far. Work using qualitative methods can be used to both close these gaps and to explore important themes in greater depth. The results suggest that the following groups should be focused on: Children and young people who were excluded from the questionnaire method for ethical reasons Carers and older people – who rely a great deal on pharmacies for essential services Seldom heard and hard to reach groups – including ethnic minorities, communities with high levels of deprivation, travellers and asylum seekers, and Men – who were under represented in the sample The working population

8. The assessment The pharmaceutical regulations governing PNA require the PCT to define pharmaceutical services in terms of: Services currently commissioned that are necessary to meet a current need Services not currently commissioned that will be necessary in specified future circumstance Services not currently commissioned that would secure improvements or better access to pharmaceutical services Services that are currently commissioned which are relevant but do not constitute “necessary services”. In reaching these conclusions the PCT is expected to explain where it has taken account of other services which have influenced its assessment. This section describes each of the services currently commissioned in Medway and describes the PCT‟s assessment of the need for each one. 8.1. Essential services In order to assess the provision of essential services against the needs of our population we have looked at the distribution of pharmacies, their opening hours and the provision of dispensing services. We consider these to be the key factors in determining the extent to which the current provision of essential services meets the needs of our population. NHS Medway has 5012 pharmacy contractors who together with five dispensing GP practices provide pharmaceutical services to our population. 8.2. Distribution of pharmacies and dispensing practices by locality The pharmacy contractors include three “100 hour” pharmacies. This type of pharmacy contractor must open for at least 100 hours each week and may be required to provide certain specified local services by the PCT. The distribution of the pharmacies and dispensing contractors is shown in the table below.

One pharmacy was previously associated with Medway but following relocation now falls outside Medway‟s boundaries and has been allocated to West Kent.

Locality

Ward

Chatham

Chatham Central Lordswood and Capstone Luton and Wayfield Princes Park River Rochester South and Horsted Walderslade Gillingham North Gillingham South Hempstead and Wigmore Rainham Central Rainham North Rainham South Twydall Watling Cuxton and Halling Peninsula Rochester East Rochester West Strood North Strood Rural Strood South

Rainham

Rochester

Totals

All pharmacies

100 hour pharmacies

Dispensing practices

2 1 2 4 5 3 2 6 3

1 1

3 2 1 2 2 2 2 2 2 4 50

1 2

1 4

Figure 69: Distribution of community pharmacies by locality

Distribution of GP practices Locality Chatham

Ward Chatham Central Lordswood and Capstone Luton and Wayfield Princes Park River Rochester South and Horsted Walderslade Chatham Total Rainham Gillingham North Gillingham South Hempstead and Wigmore Rainham Central Rainham North Rainham South Twydall Watling Rainham Total Rochester Cuxton and Halling Peninsula Rochester East Rochester West Strood North Strood Rural Strood South Rochester Total Grand Total

Total 6 2 5 3 2 3 3 24 3 8 1 3 3 4 4 1 27 1 2 4 2 5 2 2 18 69

Figure 70: Distribution of GP practices by locality

Figure 71: Location of pharmacies and dispensing practices

8.3. Analysis of distribution of pharmacies We can set the provision of pharmacy services in Medway into context by comparing the provision using national benchmarks which are available. This chart shows that Medway is in line with the SEC average of 19.2 pharmacies per 100,000 resident population.

Figure 72 Pharmacies per 100,000 population in SEC SHA Source: NHSIC 2009

Within the ONS peer group the average is 20 pharmacies per 100,000 population, Medway (19.3) is slightly below the average suggesting that the number of pharmacies at Medway PCT level is in line with those in other similar areas. Medway is not an outlier in the group.

Figure 73: Pharmacies per 100,000 population in ONS cluster Source: NHSIC 2009

These data suggest that at a Medway PCT level pharmacy provision is consistent that found in our ONS peer group and when compared to neighbouring PCTs. 8.3.1.1.

Patients views

Patients prefer pharmacies located close to their GP (40.2%) and close to their home (36.6%). Most important in choosing a pharmacy was the service (38.8%) and having the medicines in stock (25.5%). Only 7% of respondents to the questionnaire had reported a problem finding a pharmacy when they needed one in the last 12 months. Most of these problems related to opening hours which are discussed in the next section. 8.3.1.2.

Conclusions on distribution

NHS Medway has a level of pharmacy provision which is in line with comparable peer PCTs and appropriate for the size of our population. Our population is able to access pharmacy services and has a reasonable choice of provider. 8.4. Opening hours Pharmacies are required to open between specific times by their terms of service. A visual representation of pharmacy opening hours by ward and locality is provided in Appendix 2. GP dispensing practices determine their opening hours according to local need and do not have contracted dispensing hours. 8.4.1. 100 hour pharmacies and extended hour pharmacies. 100 hour pharmacies are contracted to open for at least 100 hours each week, thereby guaranteeing access for around 14 or 15 hours each day. Opening 100 hours each week is a condition of their license to provide NHS services. There are four 100 hour pharmacies, two in Chatham and two in Rainham. In addition some pharmacies choose to open extended hours, these pharmacies may vary their hours by giving the PCT 3 months notice. There are three pharmacies that routinely open until 8pm each day, one in Chatham, one in Rainham and one in Rochester. 8.4.2. Weekday opening hours During the day some pharmacies close for between one and one and a half hours at lunchtime. Patients responding to the questionnaire noted that sometimes pharmacies in the same areas close at the same time when their closure could be staggered. Wards where there are clusters of pharmacies that close at the same time during the date are: Chatham Central, Strood Rural and Watling. 8.4.3. Saturday opening hours Of the 50 pharmacies in Medway 44 open on Saturday, most open for half the day closing between noon and 1pm. After 1pm 18 pharmacies remain open, five in Chatham, nine in

Rainham and four in Rochester. This reduces to five, eight and three respectively at 3pm and then two, four and one at 5pm. 8.4.4. Sunday opening hours Chatham and Rainham have five pharmacies each open for six hours on Sunday, Rochester has one pharmacy open for six hours on Sunday. 8.4.5. Out of hours services The Carson Review (2004) of out of hours provision made recommendations relating to medicines supply in the out of hours setting. The review placed the responsibility for ensuring that patients receive medicines, if required, out of hours on the out of hours provider and not on the patient. Out of hours provision in Medway is provided by MedOCC which provides a telephone, clinic and home visiting service. Patients seen in the clinic setting are seen at one of three sites: Quayside House, Chatham Maritime, Chatham, Kent ME4 4UH Medway Maritime Hospital (Windmill Road, Gillingham, Kent ME7 5NY (Co-located with the A&E department) Rochester Healthy Living Centre, Delce Road, Rochester, Kent ME1 2EL These sites are located in Chatham Central, Gillingham South and Rochester East wards. None of these wards has one of our late opening pharmacies located in the ward, in fact only one site is within one mile of a late opening pharmacy (Rochester Health Living Centre is located around 0.5 miles from Karsons). However arrangements are in place to ensure patients using the clinics are also able to obtain medicines from MedOCC where these are required urgently and / or a prescription to be dispensed during the

in hours period where the clinician is satisfied that this is

appropriate. 8.4.6. Patientâ&#x20AC;&#x;s views Most patients (84%) reported that they were happy with the opening hours of their pharmacies, this did not vary significantly by locality. Only 7% of respondents reported a problem in accessing pharmacy services, most of these being during daytime hours on Saturday, Sunday and Weekdays. 8.4.6.1.

Conclusions on opening hours

The opening of four 100 hour pharmacies in the last five years together with four extended hours pharmacies means that our population has improved access to pharmacies across an extended period of the day. There are some areas where we would like to work with our existing contractors to build on this to ensure that patients are either able to access a 84

pharmaceutical service when it is needed or are given sufficient information to find a pharmacy that is open. We do not believe that any further extended hours pharmacies are required to meet the needs of our patients.

8.5. Dispensing services Dispensing services are provided by community pharmacies and dispensing GP practices in Medway West. This mixed model compliments the geography of Medway. Pharmacies in Medway dispense an average of 6,049 prescription items per month (NHS IC: 2008/09), this compares with an average of 6,129 in England and 6,301 in South East Coast SHA.

Figure 74: Prescription activity in SEC SHA Source: NHSIC 2009

Within the ONS cluster group Medway is in line with the average of 5,966 items per month.

Figure 75: Prescription activity in ONS group Source: NHSIC 2009

8.5.1. Patient views Very few patients reported problems in finding a pharmacy to get a pharmaceutical service (7.0%). In relation to dispensing the most commonly reported problem was being unable to get the full amount of the medicines prescribed by their GP. Of the respondents that had taken a prescription to the pharmacy to be dispensed on their last visit 13% did not get their complete prescription on that visit for the majority of these (72%) this was due to a stock shortage at the pharmacy, most of these 55% received the remaining medicine the next day, however 8% waited more than a week. 8.5.1.1.

Cross border services

Some of our patients choose to use pharmacies located outside Medway for their dispensing needs. However, not in significant numbers as our border is predominantly rural. There is an historical relationship with Medipharmacy in Higham, which was previously located in NHS Medway but which is now located in West Kent PCT. Consequently this remains a popular pharmacy with patients in that area. Analysis of EPACT data for a recent 12 month period shows that less than 0.5% of prescriptions written by NHS Medway GPs are dispensed outside NHS Medway (excluding NHS Medway). We have concluded, therefore, that with the exception of Medipharmacy there are no other significant providers of pharmaceutical services to our population based outside NHS Medway.

Our patients rely upon a mixture of pharmacies in our urban areas and pharmacies and GP practices in rural areas to get prescriptions dispensed. This service works well with an appropriate balance between the needs of our population and the infrastructure to meet those needs. There is a current and known issue with the supply of common medicines which is related to supply chain changes taking place nationally. This is the subject of a national focus involving the Department of Health, pharmaceutical manufacturers, wholesalers and pharmacy owners. We will monitor the outcome of these discussions to understand if there is any local action that could be taken to improve the supply of medicines to our patients. 8.5.2. Essential services â&#x20AC;&#x201C; conclusions We consider that access to essential services, specifically dispensing services, is a necessary service the need for which is secured through our pharmacy contractors in urban areas and a combination of pharmacies and dispensing GP practices in rural areas. The opening hours of pharmacies provide our population with goods access to services across the week. We have not found any evidence of a gap in this service. 8.5.3. Essential services â&#x20AC;&#x201C; future improvements We have identified areas where, working with our existing contractors, we could improve access to essential services these include: Working with contractors to plan lunchtime closures to minimise overlap where possible Improve signposting for patients to pharmacies that are open when their usual pharmacy is closed

8.6. Advanced services Since 2005 community pharmacies have been able to provide medicines use reviews / prescription interventions (MUR/PI) under the Advanced Services within the community pharmacy contract. Contractors may choose to provide MURs and must make a declaration to the PCT of conformity with the requirements to provide. The MUR/PI service is intended to improve patients' understanding of their medicines; highlight problematic side effects & propose solutions where appropriate; improve adherence; and reduce medicines wastage, usually by encouraging the patient only to order the medicines they require. The provision of Advanced Services is linked to the provision of consultation areas within pharmacies, this was explored in some depth in the pharmacy contractor questionnaire. 8.6.1. Premises and consultation areas Of the 45 pharmacies responding to our questionnaire, 40 have a consultation area providing good access generally to pharmacies with the facilities to undertake confidential consultations with patients. Locality / Ward Chatham Chatham Central Lordswood and Capstone Luton and Wayfield River Rochester South and Horsted Walderslade Rainham Gillingham North Gillingham South Hempstead and Wigmore Rainham North Rainham South Twydall Watling Rochester Peninsula Rochester East Rochester West Strood North Strood Rural Strood South Medway

Consult area 14 1 1 2 4 4 2 14 1 4 2 3 2 2 12 1 2 2 1 2 4 40

All pharmacies 17 2 1 2 4 5 3 18 2 6 3 3 2 1 2 13 2 2 2 2 2 4 50

Figure 76: Pharmacies with consultation areas in Medway

Figure 77: Map of pharmacies providing MUR service

8.6.1. Patients views Most of the consultations that patients had in the pharmacy took place at the pharmacy counter with only 16% taking place in a consultation area. A third (33%) of respondents were offered the choice of having the consultation somewhere where they could speak privately. Thirty-eight per cent of the respondent to the survey rated the level of privacy as „excellent‟ or „very good‟, but just over a quarter (26%) rated the privacy of the consultation as „fair‟ or worse. Privacy was an area of concern that was raised consistently in the written comments to the questionnaire. 8.6.2. Future work The presence of consultation areas in so many pharmacies presents an opportunity to the PCT to use pharmacies in new and different ways to deliver services. In many respects the PCT is already doing this through commissioning of local enhanced services. The change in the last five years in the physical premises of pharmacies has been dramatic, this now needs to be accompanied by a cultural change in how and when consultation areas are used by pharmacists and their staff. 8.6.3. Benchmarking Most pharmacies in Medway have informed the PCT that they propose to provide MUR/PI as part of Advanced Services. There are two new Advanced Services which were introduced in 89

April 2010, these are not yet well established and it is too early to determine how these will develop in Medway. Looking specifically at MUR/PI which has been provided since 2005 we find that median for provision of MUR among pharmacy contractors in our ONS cluster group was 83.7% (2008/0913) of pharmacies, Medway (95.1%) exceeded this level of participation.

Figure 78: MUR uptake in ONS peer group (Source NHSIC 2008/09)

The maximum number of MURs that a pharmacy may provide is 400 in any one financial year. Pharmacies in Medway provided 146 MURs in 2008/09 on average; this is below the median of 166 MURs for our cluster group.

This is the latest data which is available from the NHSIC. 90

Figure 79: MUR in ONS peer group (Source: NHSIC 2008/09)

8.6.4. Current provision According to PCT records 42 of the 50 pharmacies in Medway have informed the PCT of their intention to provide MUR. The discrepancy between these data and the data reported by the NHSIC may be due to pharmacies providing MUR that have not yet informed the PCT of their intention to provide the service. A questionnaire sent to all pharmacy contractors as part of the PNA sought to confirm the current status of the provision of MUR. Of the 45 pharmacies that responded 40 reported that they currently provide this service. Of the three that did not respond PCT records show that two of these pharmacies provide this service but these data may be out of date. The analysis shows that there is good correlation between MUR provision by contractors and the presence of older populations and those reporting LTLI at the last census.

All Pharmacies Locality Chatham Chatham Central Lordswood and Capstone

17 2 1

Provide MUR (PCT Survey) 13 1

Provide MUR (PSNC Survey)

Combined PCT and PSNC data

15 1 1

Did not respond 2 1

Luton and Wayfield River Rochester South and Horsted Walderslade Rainham Gillingham North Gillingham South Hempstead and Wigmore Rainham North 14 Rainham South Twydall Watling Rochester Peninsula Rochester East Rochester West Strood North Strood Rural Strood South Grand Total

2 4 5 3 18 2 6 3 3 2 1 2 13 2 2 2 2 2 4 50

2 4 4 2 9 1 4 2 1 1 1 12 1 2 2 2 2 3 35

1 3

1 1

1 6

2 4 5 2 12 1 4 2 3 1 0 2 13 1 2 2 2 2 4 41

1 1

Figure 80: MUR provision by ward

8.6.5. Patient views Few patients knew that the pharmacy could offer a medication review service (9.4%) and fewer reported having used the service (3.7%). A larger proportion would use this service (16.2%) if it were available from a local pharmacy. Patients taking long term medication reported problems using their medicines, particularly remembering when to take (7.4%), dealing with changes to the presentation (4.7%) and getting medicines out of the packaging (4.3%). These percentages are low. However a far higher proportion reported adherence problems including stopping their medicine when they felt worse (20.1%) or better (15.2%). These patients also reported wanting more information from the pharmacist about their medicines, particularly about possible side effects (46.9%) and what other medicines or foods to avoid (42.3%). 8.6.1. Advanced services â&#x20AC;&#x201C; conclusions The stated purpose of advanced services fits well with the PCTâ&#x20AC;&#x;s strategic aims, particularly improving outcomes for patients with long term conditions (LTCs). Evidence for the effectiveness of MUR is not yet well developed although some early studies show that the service can improve self-reported rates of adherence among patients. We have concluded

Rainham Central ward is in the top quintile for older population but no pharmacies are physically located in the ward. Pharmacies on the border of Rainham South serve the population of Rainham Central so this ward has been highlighted instead. 92

that MUR is a necessary service and that there are no current gaps in the provision of this service. 8.6.1. Advanced services â&#x20AC;&#x201C; future improvements While there are no gaps in provision our data show that there more that could be done to meet patientâ&#x20AC;&#x;s needs for support with their medicines. More could be done to link MUR with local priorities, using, for example an MUR+ service model where contractors are incentivised to seek out and provide MUR to target patient groups. Looking at provision at a ward level, there is only one pharmacy in Twydall ward, this pharmacy does not provide the MUR service as the pharmacy has no consultation area on the premises, the pharmacy contractor plans to introduce a consultation area by early 2011 which would allow this pharmacy to provide this service. Twydall ward is the ward with the highest reported LTLI, the second highest admissions rate and the fourth highest proportion of older people in the PCT.

8.7. Enhanced Services We commission the following local enhanced services from our pharmacy contractors: Minor ailments Emergency hormonal contraception (via PGD) Chlamydia screen and treat Needle exchange Supervised administration Smoking cessation Palliative care Sharps disposal

8.8. Minor ailments service NHS Medway commissions a minor ailments service from pharmacy contractors. Patients can choose to have a consultation with the pharmacist for a range of minor conditions which can be treated by the pharmacist with no charge to the patient. The service provides an alternative to a consultation with a GP for patients that do not pay prescription charges. 8.8.1. Current commissioning Thirty-three of the 50 contractors in NHS Medway are commissioned to provide this service. In a recent 12 month period (April 2009 â&#x20AC;&#x201C; March 2010) 26 pharmacy contractors reported one or more consultations. Commissioning in areas with a high proportion of young people and high levels of deprivation is good with most pharmacies in these wards commissioned and actively providing. 8.8.1. Patient views The minor ailments service was the second most recognised and most used service among patients in Medway, 16.8% had used the service and 11.5% reported having used the service. It was also the second most popular service among patients for use in the future (31.4%).

Locality / Ward Chatham Chatham Central Lordswood and Capstone Luton and Wayfield River Rochester South and Horsted Walderslade Rainham Gillingham North Gillingham South Hempstead and Wigmore Rainham North Rainham South Twydall Watling Rochester Peninsula Rochester East Rochester West Strood North Strood Rural Strood South Medway

All pharmacies 17 2 1 2 4 5 3 19 2 6 3 3 2 1 2 14 2 2 2 2 2 4 50

Currently commissioned

Willing to provide

15 2

1 1

2 4 4 3 11 1 4 1 1 2 1 1 7

1 1 2 3 33

5 1 1 2

Figure 81: Minor ailments commissioning and willingness to provide.

Figure 82: Map showing pharmacies providing or willing to provide Minor Ailment Scheme

Consultation activity Locality / Ward Chatham Chatham Central Luton and Wayfield River Rochester South and Horsted Walderslade Rainham Gillingham North Gillingham South Hempstead and Wigmore Rainham North Rainham South Twydall Watling Rochester Rochester West Strood North Strood Rural Strood South Medway

<1 3

1 1 1 2 2

1 1

1-250 8 1 2 2 2 1 8 2 1 1 2 1 1 4

251-500 3 1

501-750

> 750 1

1 1 1 1 1

2 2 20

1 1

Total 15 2 2 4 4 3 11 1 4 1 1 2 1 1 7 1 1 2 3 33

Figure 83: Minor ailments service â&#x20AC;&#x201C; activity Apr 2009 â&#x20AC;&#x201C; Mar 2010

8.8.2. Enhanced Service â&#x20AC;&#x201C; Minor Ailments Service Conclusions The Minor Ailment Service is an important service, it makes good use of pharmacies as an accessible and flexible resource. We consider the Minor Ailments Service is a necessary service which provides additional primary care capacity, particularly in deprived communities. The current provision and future willingness to provide mean that there are no gaps in provision.

Emergency Hormonal Contraception Service NHS Medway commissions an Emergency Contraception Service from community pharmacies. To provide this service the pharmacy must be commissioned by the PCT to provide the service. Each pharmacy must have at least one pharmacist trained and accredited to provide the service. This enhanced service addresses the need to provide easy and convenient access to emergency contraception to women. The impact that the service seeks to make is to address the rates of teenage pregnancy in Medway. Our strategic plan includes the aim of reducing teenage pregnancy and improving the lives of children and young people. There is good evidence for pharmacyâ&#x20AC;&#x;s role as an effective, acceptable and accessible outlet for emergency contraception. The service is commissioned by over 70% of PCTs in England. 8.8.3. Current commissioning The service is actively provided in 28 pharmacies across Medway, a further seven are willing to provide this service. Provision is focused in areas where young women are more likely to access the service, like town centre pharmacies. Locality / Ward Chatham Chatham Central Lordswood and Capstone Luton and Wayfield River Rochester South and Horsted Walderslade Rainham Gillingham North Gillingham South Hempstead and Wigmore Rainham North Rainham South Twydall Watling Rochester Peninsula Rochester East Rochester West Strood North Strood Rural Strood South Medway

All pharmacies 17 2 1 2 4 5 3 19 2 6 3 3 2 1 2 14 2 2 2 2 2 4 50

Currently commissioned 9 1

Willing to provide 1 1

1 3 3 1 14 1 5 2 2 2 2 5 1 1 1 1 1 28

2 1

1 1 2 7

Figure 84: Emergency contraception service commissioning and willingness to provide.

The table above shows the provision by ward in Medway with wards with high teenage conception rates highlighted.

Figure 85: Map showing pharmacies providing EHC service

Consultation activity Provision of this service is dependent on demand; the service is marketed to women who can request the service from pharmacies that provide the service. Of the 28 pharmacies commissioned to provide the service, 14 have been active in the last 12 months. Activity is concentrated in wards with high street settings. Locality / Ward Chatham Chatham Central Luton and Wayfield River Rochester South and Horsted Walderslade Rainham Gillingham North Gillingham South Hempstead and Wigmore

<1 3

1 2 9 4 1

1-100 4 1 1 1 1 4 1 1

101-200 1

201-300 1

301-400

Total 9 1 1 3 3 1 14 1 5 2

1 99

Rainham North Rainham South Watling Rochester Peninsula Rochester East Rochester West Strood Rural Strood South Grand Total

1 1 2 2

1 1 14

1 1

2 2 2 5 1 1 1 1 1 28

3 1 1 1

Figure 86: Emergency contraception service activity Apr 2009 â&#x20AC;&#x201C; Mar 2010.

100

8.8.4. Patient views When data were analysed to explore women‟s awareness of, and intention to use the EHC service, the results showed how the service could be targeted in future. The youngest women (aged 16-19) showed good knowledge and intention to use: further marketing to women aged 20-29 and 40-44 might be needed.

Age (years) 16-19 20-24 25-29 30-34 35-39 40-44 Total

% of respondents (n=211 – women only) who: Know service is Have used service in Would use it in the available past future 30 7 30 18 0 32 16 16 24 6 0 0 10 10 5 4 0 18 14 6 17

Figure 87: Further analysis of women‟s knowledge and intention regarding an EHC service

8.8.5. Enhanced Service – EHC Service Conclusions The EHC service through pharmacies provides important access to EHC for women in Medway. Without this service access would only be available via a GP appointment or sexual health service clinic, this would limit access considerably. We consider the EHC service is a necessary service, we do not believe that there are any current gaps in provision.

101

8.9. Stop smoking service NHS Medway commissions a Stop Smoking Service from community pharmacies. The service includes the provision of advice on stopping smoking and supply of nicotine replacement therapy (NRT) a key differentiator of pharmacy stop smoking services from other providers of stop smoking services is the ability to supply medicines at the point of care. Pharmacies are seen as key providers of stop smoking services due to their opening hours, accessibility and ability to advise and supply NRT. The stop smoking service directly addresses a key outcome measure for the PCT. Stopping smoking is the single most effective health care intervention that can be made. Rates of smoking are highest in areas of deprivation. 8.9.1. Current commissioning The service is actively provided in 25 pharmacies across Medway, a further 11 are willing to provide this service. The table below shows the provision by ward in Medway with wards with areas with high estimated smoking rates highlighted.

All pharmacies 17 2 1 2 4 5 3 19 2 6 3 3 2 1 2 14 2 2 2 2 2 4 50

Currently commissioned 12 1

Willing to provide 1 1

2 3 4 2 7 1 2 1 2 1 6 1 1 1

7 1 3 2

1 3

2 1 2 25

1 11

Figure 88: Smoking cessation service commissioning and willingness to provide. Wards with high smoking rates, ONS synthetic estimates, highlighted

102

Figure 89: Map showing pharmacies providing smoking cessation services

Activity â&#x20AC;&#x201C; smoking quitters The outcome measure which matters in smoking cessation services is the number of smokers who give up smoking. Pharmacy has one of the highest quit rates among the different smoking cessation services nationally, however provision is patchy with some pharmacies that we commission achieving higher numbers of quitters than others. Locality / Ward Chatham Chatham Central Luton and Wayfield River Rochester South and Horsted Walderslade Rainham Gillingham North Hempstead and Wigmore Rainham North Rainham South Watling Rochester Peninsula Rochester East Rochester West

<1 6 1 3 1 1 4

1-10 3 1

31-40

1 2 1

1 1 2 1 5 1 1 1

11-20 3

1 1 2 1 1

Total 12 1 2 3 4 2 7 1 2 1 2 1 6 1 1 1 103

Strood Rural Strood South Grand Total

1 1 15

1 5

1 2 25

Figure 90: Smoking cessation service activity (Quits) 2009 - 2010

8.9.2. Patient views The stop smoking service was the most recognised enhanced service among patients, this reflects local and national efforts to market pharmacies as a source of advice and support to smokers wanting to give up nicotine. Around 6% of respondents said they would use a pharmacy as a source of advice to stop smoking, with average prevalence rates of 28% this suggests that as many as one in five smokers would be willing to give up using pharmacy.

8.9.1. Enhanced Service â&#x20AC;&#x201C; Stop smoking service conclusion The commissioning matrix shows that with the exception of one ward the commissioning of pharmacy stop smoking services correlates well to the need for the service, using synthetic smoking estimates as a proxy for need. There is one ward where smoking rates are estimated to be high (Gilingham South) where none of the five pharmacies in the ward are commissioned to provide this service but three are willing to provide. We will work with our smoking cessation services and these local community pharmacies to ensure that there is adequate provision in Gillingham South. The stop smoking service through pharmacies is an important strand of the PCTâ&#x20AC;&#x;s efforts to reduce smoking rates among the population. Pharmacy is a unique provider with the ability to provide access to NRT at the point of care. The current network or providers together with providers that are willing to provide this service are sufficient to meet the needs of our population at this time. Given this and the priority placed on reducing smoking rates in Medway we consider the smoking cessation service to be a necessary service, we have concluded that there are no current gaps in provision... We will review commissioning of this service within a year to confirm that the pattern of commissioning continues to meet the needs of our population.

104

8.10.

Chlamydia screen and treatment

NHS Medway commissions a Chlamydia Screening and Treatment service from pharmacies. The service allows pharmacies to offer the option of a Chlamydia test to the target population and to then offer treatment if the test is positive. Increasing screening, education and treatment are key priorities for the PCT, the target age group is young people aged 16 â&#x20AC;&#x201C; 24 years, however there is also evidence that STI rates are rising in our older population. 8.10.1. Current commissioning The service is commissioned in 19 pharmacies across Medway, a further 11 are willing to provide this service. The table below shows the provision by ward in Medway with wards with above average younger populations highlighted. Locality / Ward Chatham Chatham Central Lordswood and Capstone Luton and Wayfield River Rochester South and Horsted Walderslade Rainham Gillingham North Gillingham South Hempstead and Wigmore Rainham North Rainham South Twydall Watling Rochester Peninsula Rochester East Rochester West Strood North Strood Rural Strood South Medway

All pharmacies 17 2 1 2 4 5 3 19 2 6 3 3 2 1 2 14 2 2 2 2 2 4 50

Currently commissioned 7 1

Willing to provide 1 1

1 2 3 8 1 2 2

5 1 1 2

2 1 4 1

1 5

1 1 1 19

2 1 2 11

Figure 91: Chlamydia screen and treat commissioning and willingness to provide.

105

Figure 92: Map showing pharmacies providing Chlamydia screening service

Screening rates through pharmacy are low, with most pharmacies not yet completing a screen, this perhaps reflects the low use of pharmacies by young people generally which we saw in the responses to the patient questionnaire. Pharmacies that have been active are generally in areas where young people go to shop and socialise.

<1 5 1

1-5 1

11-15 1

1 1 3 6 1 1 1

1 1

2 1 2

Total 7 1 1 2 3 8 1 2 2 2

1 4 106

Peninsula Rochester East Rochester West Strood North Strood Rural Strood South Grand Total

1 1 4

1 1 19

Figure 93: Chlamydia screen and treat activity (screens 2009 – 2010).

8.10.2. Patient views Analysis of respondents‟ awareness of, and intention to use, Chlamydia testing services also showed marked group responses that might aid targeting (Figure 87 and 88).

Age (years) 16-19

% of respondents (n=211 – women only) who: Know service is Have used service in Would use it in the available past future 15% 0% 0%

20-24

18%

25-29

30-34

35-39

40-44

Total

Figure 94: Further analysis of women‟s knowledge and intention regarding a Chlamydia testing service

Age (years) 16-19

% of respondents (n=118 – men only) who: Know service is Have used service in Would use it in the available past future 10% 0% 0%

20-24

25-29

30-34

10%

35-39

40-44

Total

21%

Figure 95: Further analysis of men‟s knowledge and intention regarding a Chlamydia testing service

These analysis are based on small numbers of respondents, however they illustrate that there is more we could do to establish pharmacies as a source of Chlamydia screening and treatment in the minds of the target population.

107

8.10.1. Enhanced Service â&#x20AC;&#x201C; Chlamydia Screen and Treat Service The Chlamydia screen and treat service has yet to fully develop, our experience is mirrored in other PCTs where uptake, generally has been low, however in areas where pharmacy is a destination for young people the service works well. We want to increase the involvement of pharmacy contractors in sexual health services in the future. We have concluded that the Chlamydia screening and treatment service is a relevant service for our population. We will review the uptake and commissioning of this service to ensure the best fit with our objectives and to fit with other screening programmes.

8.11.

Needle exchange & Supervised Consumption Service

Pharmacies in NHS Medway provide two services to support drug treatment services: a needle exchange service which is focused on ensuring that injecting drug users have access to clean injecting equipment, are able to safely dispose of used equipment and have access to advice from pharmacists. A supervised consumption service which is focused on ensuring that clients in drug treatment programmes take and use their treatment as prescribed and to provide an opportunity for the pharmacist to make relevant interventions The local authority has a DAAT team which co-ordinates the local strategy for drug and alcohol treatment. Drug treatment and harm minimisation services directly address an important strand in the PCTâ&#x20AC;&#x;s strategic plan. Although the numbers of people affected are small the impact on the wider community can be significant if not properly managed. With consequences for blood borne disease, health and safety and drug related crime. 8.11.1. Current commissioning The aim of commissioning these services is to ensure that there are strategically located needle exchange sites across the PCT area and to ensure that there is a comprehensive network of supervised consumption sites across the PCT to ensure that clients in drug treatment are able to use a service close to where they live or work. As the two tables overleaf show we have good provision of both services commensurate with these commissioning intentions. Six of our 50 pharmacies currently provide the needle exchange service and a further eight would be willing to do so.

108

Twenty nine of our pharmacies provide the supervised consumption service and a further three would be willing to do so. The net provision for a PCT of our size is good with the option to extend the needle exchange service if demand required.

Figure 96: Map showing pharmacies providing needle exchange service

109

Figure 97: Map showing pharmacies providing supervised consumption services

110

All pharmacies 17 2 1 2 4 5 3 19 2 6 3 3 2 1 2 14 2 2 2 2 2 4 50

Currently commissioned 3

Willing to provide 3 1

2 1 2

1 1 4 1 1

1 1

1 1 6

Figure 98: Needle exchange commissioning and willingness to provide.

All pharmacies 17 2 1 2 4 5 3 19 2 6 3 3 2 1 2 14 2 2 2 2 2 4 50

Currently commissioned 10 2 1 1 2 2 2 11 2 3

Willing to provide 1

1 1

1 3 1 2 8 1 2 1

1 4 29

Figure 99: Supervised consumption commissioning and willingness to provide.

111

8.11.2. Conclusion â&#x20AC;&#x201C; Needle Exchange and Supervised Consumption Service Assessing the need for services from community pharmacies is difficult using the available data, we will continue to review the provision and needs with DAAT stakeholders to ensure that commissioning and provision are aligned with needs. The provision of needle exchange and supervised consumption from pharmacies is a service that is necessary to secure good access across the PCT area. The pattern of provision is consistent with the needs of our population and we do not believe that there are any gaps in provision.

8.12.

Palliative Care Access Service

Finally the PCT commissions an important service for patients and healthcare professionals which ensures that there is ready access to advice and supply of palliative care drugs for end of life care. Making these drugs available, and having a network of pharmacies that undertake to hold stock of these unusual, but urgently needed drugs, facilitates the choice of patients to die at home. 8.12.1. Current commissioning The PCT currently commissions eight pharmacies to provide this service We have identified a need to extend provision into Rochester and to look at how access to advice and medicines could be improved out of hours, the current service provides an in hours service only, albeit from pharmacies that are open extended hours.

Figure 100 Map showing pharmacies providing palliative care access services

112

8.12.1. Conclusion â&#x20AC;&#x201C; Palliative Care Access Service This service is a service that we consider is necessary for our population. The service should be extended so that there is provision in Rochester, we will do this by working with our existing contractors to meet this need. We believe that access to this service could be improved by providing access out of hours, however this will be complex and something that we will look at with our contractors and palliative care teams to understand what exactly is needed and what the best way to meet this need would be.

Locality / ward Chatham Chatham Central Lordswood and Capstone Luton and Wayfield River Rochester South and Horsted Walderslade Rainham Gillingham North Gillingham South Hempstead and Wigmore Rainham North Rainham South Twydall Watling Rochester Peninsula Rochester East Rochester West Strood North Strood Rural Strood South Medway

All pharmacies 17 2 1 2 4 5 3 19 2 6 3 3 2 1 2 14 2 2 2 2 2 4 50

Palliative care Service 4 1

2 1 4 1 2 1

Figure 101: Palliative care access service provision.

113

8.1. Other enhanced services NHS Directions include a list of Enhanced Services which PCTs may commission under local arrangements from community pharmacists. Some of these are currently commissioned in Medway and have been described previously in this document. The table below lists each of these enhanced services and considers how these fit with the PCTâ&#x20AC;&#x;s strategic plan. The scoring shown in the table is taken from an exercise undertaken by the steering group to prioritise services for investigation and development. The table shows that the focus for pharmaceutical services is likely to move from the well established role pharmacy has in delivering public health type services, like smoking cessation, drug misuse services and emergency contraception towards services linked to long term conditions.

Services Medication Review Language Access Service Medicines assessment and compliance Support Service Anticoagulation Service Care Home Service Obesity Management (Adults & Children) Vascular Risk Assessment (NHS Healthchecks) Disease Specific Meds Management Service Gluten Free Food Supply Service Home Delivery Services Independent Prescribing Service Prescriber support service Screening Service (currently commissioned only for Chlamydia) Supplementary Prescribing Service Vaccination Service

Improving Health and Well Being

Target Killer Diseases

Y Y Y

Y Y

Y Y Y Y Y

Y Y

Care Pathways - Closer to Home Y Y Y Y Y

Supporting Future Generations Y

Promoting Independence and improved quality of life Y Y Y Y Y

Y Y Y Y Y

Y Y Y Y

Y Y

Improving Mental Health Y Y

Score 6 4 4 3 3 3 3 2 2 2 2 2 2 2 1 0

Figure 102 Mapping potential enhanced pharmaceutical services to the strategic plan

114

Where these services will sit in the future is not yet clear, the White Paper, Liberating the NHS suggests that these services would naturally sit with new consortia envisaged under the White Paper. The mechanism for taking forward these ideas will emerge as the details of the programme of change are confirmed. We will revisit these services at that time to identify how these could be taken forward.

115

APPENDICIES

116

Appendix 1: Pharmaceutical Services Providers Community pharmacies in Chatham locality Pharmacy Name

Address 1

National Co-operative Chemists

22 Magpie Hall Road

Palmers Chemist

98 Palmerston Road

Lloyds Pharmacy

17-18 Kestral Road

Delmergate Limited Delmergate Limited Boots UK Ltd

30 - 34 Wilmot Square

Brompton Pharmacy

Address 2

Address 3

Postcode

Ward

Locality

Chatham

ME4 5JY

Chatham Central

Chatham

Centurian Park

Chatham

ME4 5SJ

Chatham Central

Chatham

Lordswood

Chatham

ME5 8TH

Lordswood and Capstone

Chatham

163 Wayfield Road

Chatham

ME5 0HD

Luton and Wayfield

Chatham

23 Street End Road

Chatham

ME5 0AA

Luton and Wayfield

Chatham

Pentagon Centre

Chatham

ME4 4BB

River

Chatham

3 High Street

Brompton

Gillingham

ME7 5AA

River

Chatham

Island Pharmacy

Aster Drive

St Mary's Island

Chatham

ME4 3EB

River

Chatham

Paydens Limited

139 New Road

Chatham

ME4 4PT

River

Chatham

Asda Pharmacy

387 Maidstone Road

Chatham

ME5 9SD

Rochester South and Horsted

Chatham

Delmergate Limited

21 Shirley Avenue

Chatham

ME5 9UR

Rochester South and Horsted

Chatham

Karsons Pharmacy

69/71 City Way

Rochester

ME1 2BA

Rochester South and Horsted

Chatham

Karsons Pharmacy

33 Pattens Lane

Chatham

ME4 6JR

Rochester South and Horsted

Chatham

Merlin Pharmacy

364 City Way

Rochester

ME1 2BQ

Rochester South and Horsted

Chatham

ME5 9LR

Walderslade

Chatham

Fenns Chemist

9-10 Walderslade Centre

Walderslade Road

Merlin Pharmacy

54 Silverweed Road

Weedswood

Chatham

ME5 0QX

Walderslade

Chatham

Morrisons Pharmacy

Neighbourhood Centre

Princes Park

Walderslade

ME5 8BA

Walderslade

Chatham

100 hour

117

Community pharmacies in Rainham locality Pharmacy Name

Address 1

Address 2 Richmond Road

Address 3

Postcode

Ward

Locality

Delmergate Limited

Sunlight Centre

Gillingham

ME7 1LX

Gillingham North

Rainham

Osbon Pharmacy

1 Railway Street

Gillingham

ME7 1XF

Gillingham North

Rainham

212 Pharmacy

212 Canterbury Street

Gillingham

ME7 5XL

Gillingham South

Rainham

Boots UK Ltd National Co-Operative Chemists

125-127 High Street

Gillingham

ME7 1BS

Gillingham South

Rainham

135 High Street

Gillingham

ME7 1AQ

Gillingham South

Rainham

Smiths Pharmacy

318-320 Canterbury Street

Gillingham

ME7 5JP

Gillingham South

Rainham

Osbon Pharmacy

17 Duncan Road

Gillingham South

Rainham

Gillingham

ME7 4LA

The Healthy Living Centre

Balmoral Gardens

Gillingham

ME7 4PN

Gillingham South

Rainham

Boots UK Ltd

5 Hempstead Valley Centre

Hempstead

Gillingham

ME7 3PB

Hempstead and Wigmore

Rainham

Hempstead Chemist

Hempstead

Gillingham

ME7 3QE

Hempstead and Wigmore

Rainham

Hempstead

Gillingham

ME7 3PB

Hempstead and Wigmore

Rainham

Boots UK Ltd

148 Hempstead Road Hempstead Valley Shopping Centre 21-22 Rainham Shopping Centre

Rainham

ME8 7HW

Rainham North

Rainham

Lloyds Pharmacy

8 Rainham Shopping Centre

Rainham

ME8 7HW

Rainham North

Rainham

Lloyds Pharmacy

Units 1-2 Stanford House

2-3 Station Road

Rainham

ME8 7PH

Rainham North

Rainham

Fenns Chemist

33-35 Parkwood Green

Parkwood

Gillingham

ME8 9PW

Rainham South

Rainham

Phoenix Pharmacy

373 Maidstone Road

Wigmore

Gillingham

ME8 0HX

Rainham South

Rainham

J Spensley Ltd

1 Twydall Green

Twydall

Gillingham

ME8 6JY

Twydall

Rainham

Lloyds Pharmacy

76 Watling Street

Gillingham

ME7 2YW

Watling

Rainham

Sturdee Avenue Pharmacy

48 Sturdee Avenue

Gillingham

ME7 2HN

Watling

Rainham

Paydens Limited

Sainsburys

100 hour

118

Community pharmacies in Rochester locality

Pharmacy Name

Address 1

Address 2

Address 3

Postcode

Ward

Locality

Knights Pharmacy

39 Knights Road

Hoo

ME3 9DT

Peninsula

Rochester

Kentpharm

5 Main Road

Hoo

Rochester

ME3 9AA

Peninsula

Rochester

Boots UK Ltd

The Thorndike Centre

Longley Road

Rochester

ME1 2TH

Rochester East

Rochester

Paydens Limited

134-136 Delce Road

Rochester

ME1 2DT

Rochester East

Rochester

Focus Chemist

126 Borstal Street

Rochester

ME1 3JU

Rochester West

Rochester

Ryders Chemist

130 High Street

Rochester

ME1 1JT

Rochester West

Rochester

Bryant Road Pharmacy

61 Bryant Road

Strood

Rochester

ME2 3EP

Strood North

Rochester

Williams Chemist

86-88 Frindsbury Road

Frindsbury

Rochester

ME2 4HY

Strood North

Rochester

Marshlands Pharmacy

7 Parkside Parade

Cliffe Woods

Rochester

ME3 8HX

Strood Rural

Rochester

Marshlands Pharmacy

Wainscott Surgery

Miller Way

Wainscott

ME2 4LP

Strood Rural

Rochester

Medipharmacy

4 School Lane

Higham

Rochester

ME3 7AT

Strood Rural

Rochester

Boots UK Ltd

83 High Street

Strood

Rochester

ME2 4AH

Strood South

Rochester

Coles Pharmacy

29 Darnley Road

Strood

Rochester

ME2 2EU

Strood South

Rochester

Hobbs Pharmacy

41-43 Wells Road, Marlow Park Tesco Superstore, 3 Cuxton Road

Strood

Rochester

ME2 2PW

Strood South

Rochester

Strood

Rochester

ME2 2BT

Strood South

Rochester

Tesco Pharmacy

Borstal

100 hour

119

Dispensing GP practice sites in NHS Medway Practice

Site type

The Surgery

Address 1

Address 2

Address 3

Postcode

Ward

Locality

Branch

56 Oak Lane,

Upchurch

Kent

ME9 7AU

Rainham North

Rainham

St. Werburgh Medical Practice

Main

98 Bells Lane

Hoo

Kent

ME3 9HU

Peninsula

Rochester

St. Werburgh Medical Practice

Branch

Mallard Way

Lower Stoke

Rochester

ME3 9ST

Peninsula

Rochester

The Halling Medical Centre

Main

Ferry Road

Halling

Kent

ME2 1NP

Cuxton and Halling

Rochester

The Halling Medical Centre

Branch

19a Wood Street

Cuxton, Rochester

ME2 1LT

Cuxton and Halling

Rochester

Cliffe Surgery

Main

Millcroft Road

Cliffe

Kent

ME3 7QN

Strood Rural

Rochester

The Elms Medical Practice

Main

Tilley Close, Main Road

Hoo

Kent

ME3 9AE

Peninsula

Rochester

Dispensing appliance contractors in NHS Medway Name Amcare Ltd

Address 1 Unit 69

Address 2 Riverside Estate

Address 3 Sir Thomas Longley Rd

Address 4 Rochester

Postcode ME24BH

Ward Strood Rural

Locality Rochester

This practice is a branch practice site. The premises from which dispensing takes place are located in Eastern and Coastal Kent PCT area, for the purposes of the PNA the site has been associated with Rainham North ward and the Rainham locality. 120

Appendix 2: Opening hours of pharmacies Monday MONDAY FCS Code

FGR89 FTC25 FCR68 FF328 FNE17 FM682 FEP94 FL840 FKE87 FKK59 FQ410 FJF12 FGL46 FL693 FEL36 FFM54 FR909 FRM80 FMJ43 FJ887 FXP56 FE677 FKJ56 FNH68 FD032 FNL61 FX206 FEY67 FAV64 FGK03 FJF87 FC050 FX909 FHT25 FL383 FEM57 FYN18 FGF64 FH750 FHY79 FM600 FYC97 FRO48 FTT51 FV186 FR400 FTM63 FMH56

06:00 Pharmacy name

National Co-operative Chemists Palmers Chemist Lloydspharmacy Delmergate Limited Delmergate Limited Boots UK Ltd Brompton Pharmacy Ltd Island Pharmacy Paydens Limited Asda Pharmacy Delmergate Limited Karsons Pharmacy Karsons Pharmacy Merlin Pharmacy Fenns Chemist Merlin Pharmacy (Consultants Morrisons Pharmacy Delmergate Limited Osbon Pharmacy 212 Pharmacy Boots UK Ltd National Co-Operative Smiths Pharmacy Osbon Pharmacy Paydens Limited Boots UK Ltd Hempstead Chemist Sainsburys Boots UK Ltd Lloydspharmacy Lloydspharmacy Fenns Chemist Phoenix Pharmacy J Spensley Ltd Lloydspharmacy Sturdee Avenue Pharmacy Knights Pharmacy Kentpharm Boots UK Ltd Paydens Limited Focus Chemist Ryders Chemist Bryant Road Pharmacy Williams Chemist Marshlands Pharmacy Marshlands Pharmacy Boots UK Ltd Coles Pharmacy Hobbs Pharmacy Tesco Pharmacy

Postcode

ME4 5JY ME4 5SJ ME5 8TH ME5 0HD ME5 0AA ME4 4BB ME7 5AA ME4 3EB ME4 4PT ME5 9SD ME5 9UR ME1 2BA ME4 6JR ME1 2BQ ME5 9LR ME5 0QX ME5 8BA ME7 1LX ME7 1XF ME7 5XL ME7 1BS ME7 1AQ ME7 5JP ME7 4LA ME7 4PN ME7 3PB ME7 3QE ME7 3PB ME8 7HW ME8 7HW ME8 7PH ME8 9PW ME8 0HX ME8 6JY ME7 2YW ME7 2HN ME3 9DT ME3 9AA ME1 2TH ME1 2DT ME1 3JU ME1 1JT ME2 3EP ME2 4HY ME3 8HX ME2 4LP ME2 4AH ME2 2EU ME2 2PW ME2 2BT

Open

09:00 09:00 09:00 09:00 08:30 08:00 08:30 08:30 09:00 08:00 09:00 07:00 09:00 09:00 09:00 09:00 09:00 09:00 09:00 09:00 09:30 09:00 09:00 09:00 07:00 08:30 09:00 07:00 08:45 09:00 09:00 09:00 09:00 08:30 09:00 09:00 09:00 09:00 08:30 09:00 08:30 09:00 09:00 09:00 08:45 08:30 09:00 08:45 09:00 08:00

18:00 18:00 18:00 18:00 18:00 19:00 18:30 18:00 19:00 23:00 17:30 23:00 18:00 18:00 18:00 18:00 20:00 18:00 19:00 18:00 17:30 17:30 18:00 19:00 22:00 20:00 18:00 23:00 18:30 17:30 19:00 17:30 18:00 17:30 17:30 18:30 18:30 18:30 18:00 18:00 17:30 17:30 18:30 18:00 18:30 18:00 17:30 19:00 18:00 20:00

Lunch Close

Lunch Open

13:00 13:00 13:00 13:00 12:30

14:00 14:00 14:00 14:00 13:30

13:00

14:15

13:00

14:00

13:00 13:00

14:00 14:00

13:00

14:00

13:00

14:00

13:00

14:00

13:00

14:00

12:00 13:00 13:00 13:00 13:00

13:00 14:00 14:00 14:00 14:00

13:00

14:00

13:00 13:00 13:00 14:00

14:15 15:00 14:30 15:00

13:00

14:00

09:00

Noon

15:00

18:00

21:00

05:30 06:00 06:30 07:00 07:30 08:00 08:30 09:00 09:30 10:00 10:30 11:00 11:30 12:00 12:30 13:00 13:30 14:00 14:30 15:00 15:30 16:00 16:30 17:00 17:30 18:00 18:30 19:00 19:30 20:00 20:30 21:00 21:30 22:00 22:30 23:00 23:30 00:00

Ward

Chatham Central Chatham Central Lordswood and Capstone Luton and Wayfield Luton and Wayfield River River River River Rochester South and Horsted Rochester South and Horsted Rochester South and Horsted Rochester South and Horsted Rochester South and Horsted Walderslade Walderslade Walderslade Gillingham North Gillingham North Gillingham South Gillingham South Gillingham South Gillingham South Gillingham South Gillingham South Hempstead and Wigmore Hempstead and Wigmore Hempstead and Wigmore Rainham North Rainham North Rainham North Rainham South Rainham South Twydall Watling Watling Peninsula Peninsula Rochester East Rochester East Rochester West Rochester West Strood North Strood North Strood Rural Strood Rural Strood South Strood South Strood South Strood South

Locality

Chatham Chatham Chatham Chatham Chatham Chatham Chatham Chatham Chatham Chatham Chatham Chatham Chatham Chatham Chatham Chatham Chatham Rainham Rainham Rainham Rainham Rainham Rainham Rainham Rainham Rainham Rainham Rainham Rainham Rainham Rainham Rainham Rainham Rainham Rainham Rainham Rochester Rochester Rochester Rochester Rochester Rochester Rochester Rochester Rochester Rochester Rochester Rochester Rochester Rochester

121

Tuesday TUESDAY FCS Code

06:00 Pharmacy name

National Co-operative Palmers Chemist Lloydspharmacy Delmergate Limited Delmergate Limited Boots UK Ltd Brompton Pharmacy Island Pharmacy Paydens Limited Asda Pharmacy Delmergate Limited Karsons Pharmacy Karsons Pharmacy Merlin Pharmacy Fenns Chemist Merlin Pharmacy Morrisons Pharmacy Delmergate Limited Osbon Pharmacy 212 Pharmacy Boots UK Ltd National Co-Operative Smiths Pharmacy Osbon Pharmacy Paydens Limited Boots UK Ltd Hempstead Chemist Sainsburys Boots UK Ltd Lloydspharmacy Lloydspharmacy Fenns Chemist Phoenix Pharmacy J Spensley Ltd Lloydspharmacy Sturdee Avenue Knights Pharmacy Kentpharm Boots UK Ltd Paydens Limited Focus Chemist Ryders Chemist Bryant Road Pharmacy Williams Chemist Marshlands Pharmacy Marshlands Pharmacy Boots UK Ltd Coles Pharmacy Hobbs Pharmacy Tesco Pharmacy

Postcode

Open

Lunch Close

Lunch Open

09:00 09:00 09:00 09:00 08:30 08:00 08:30 08:30 09:00 07:00 09:00 07:00 09:00 09:00 09:00 09:00 09:00 09:00 09:00 09:00 09:30 09:00 09:00 09:00 07:00 08:30 09:00 07:00 08:45 09:00 09:00 09:00 09:00 08:30 09:00 09:00 09:00 09:00 08:30 09:00 08:30 09:00 09:00 09:00 08:45 08:30 09:00 08:45 09:00 08:00

18:00 18:00 18:00 18:00 18:00 19:00 18:30 18:00 19:00 23:00 17:30 23:00 18:00 18:00 18:00 18:00 20:00 18:00 19:00 18:00 17:30 17:30 18:00 19:00 22:00 20:00 18:00 23:00 18:30 17:30 19:00 17:30 18:00 17:30 17:30 18:30 18:30 18:30 18:00 18:00 13:00 17:30 18:30 18:00 18:30 18:00 17:30 19:00 18:00 20:00

13:00 13:00 13:00 13:00 12:30

14:00 14:00 14:00 14:00 13:30

13:00

14:15

13:00

14:00

13:00

14:00

13:00

14:00

13:00

14:00

13:00

14:00

13:00

14:00

12:00 13:00 13:00 13:00 13:00

13:00 14:00 14:00 14:00 14:00

13:00

14:00

13:00 13:00 13:00 14:00

14:15 15:00 14:30 15:00

13:00

14:00

09:00

Noon

15:00

18:00

21:00

Ward

Locality

122

Wednesday WEDNESDAY FCS Code

06:00 Pharmacy name

National Co-operative Palmers Chemist Lloydspharmacy Delmergate Limited Delmergate Limited Boots UK Ltd Brompton Pharmacy Ltd Island Pharmacy Paydens Limited Asda Pharmacy Delmergate Limited Karsons Pharmacy Karsons Pharmacy Merlin Pharmacy Fenns Chemist Merlin Pharmacy Morrisons Pharmacy Delmergate Limited Osbon Pharmacy 212 Pharmacy Boots UK Ltd National Co-Operative Smiths Pharmacy Osbon Pharmacy Paydens Limited Boots UK Ltd Hempstead Chemist Sainsburys Boots UK Ltd Lloydspharmacy Lloydspharmacy Fenns Chemist Phoenix Pharmacy J Spensley Ltd Lloydspharmacy Sturdee Avenue Knights Pharmacy Kentpharm Boots UK Ltd Paydens Limited Focus Chemist Ryders Chemist Bryant Road Pharmacy Williams Chemist Marshlands Pharmacy Marshlands Pharmacy Boots UK Ltd Coles Pharmacy Hobbs Pharmacy Tesco Pharmacy

Postcode

Open

18:00 18:00 18:00 18:00 18:00 19:00 18:30 18:00 19:00 23:00 17:30 23:00 18:00 18:00 18:00 18:00 20:00 18:00 19:00 18:00 17:30 17:30 18:00 19:00 22:00 20:00 18:00 23:00 18:30 17:30 19:00 17:30 18:00 13:00 17:30 18:30 18:30 18:30 18:00 18:00 17:30 17:30 18:30 18:00 18:30 18:00 17:30 19:00 18:00 20:00

Lunch Close

Lunch Open

13:00 13:00 13:00 13:00 12:30

14:00 14:00 14:00 14:00 13:30

13:00

14:15

13:00

14:00

13:00 13:00

14:00 14:00

13:00

14:00

13:00

14:00

13:00

14:00

13:00

14:00

12:00 13:00 (open again19:00 at 6:00 pm 13:00 14:00 13:00 14:00 13:00 14:00

13:00

14:00

13:00 13:00 13:00 14:00

14:15 15:00 14:30 15:00

13:00

14:00

09:00

Noon

15:00

18:00

21:00

Ward

Locality

123

Thursday THURSDAY FCS Code

06:00 Pharmacy name

Postcode

Open

09:00 09:00 09:00 09:00 08:30 08:00 08:30 08:30 09:00 07:00 09:00 07:00 09:00 09:00 09:00 09:00 09:00 09:00 09:00 09:00 09:30 09:00 09:00 09:00 07:00 08:30 09:00 07:00 08:45 09:00 09:00 09:00 09:00 08:30 09:00 09:00 09:00 09:00 08:30 09:00 09:00 09:00 09:00 09:00 08:45 08:30 09:00 08:45 09:00 08:00

Lunch Close

Lunch Open

13:00 13:00 13:00 13:00 12:30

14:00 14:00 14:00 14:00 13:30

13:00

14:15

13:00

14:00

13:00

14:00

13:00

14:00

13:00

14:00

13:00

14:00

13:00

14:00

12:00 13:00 13:00 13:00 13:00

13:00 14:00 14:00 14:00 14:00

13:00

14:00

13:00 13:00 13:00 14:00

14:15 15:00 14:00 15:00

13:00

14:00

09:00

Noon

15:00

18:00

21:00

Ward

Locality

124

Friday FRIDAY FCS Code

06:00 Pharmacy name

Postcode

Open

18:00 18:00 18:00 18:00 18:00 19:00 18:30 18:00 19:00 23:00 17:30 23:00 18:00 18:00 18:00 18:00 20:00 18:00 19:00 18:00 17:30 17:30 18:00 19:00 22:00 20:00 18:00 23:00 18:30 17:30 19:00 18:00 18:00 17:30 17:30 18:30 18:30 18:30 18:00 18:00 17:30 17:30 18:30 18:00 18:30 18:00 17:30 19:00 18:00 20:00

Lunch Close

Lunch Open

13:00 13:00 13:00 13:00 12:30

14:00 14:00 14:00 14:00 13:30

13:00

14:15

13:00

14:00

13:00

14:00

13:00

14:00

13:00

14:00

13:00

14:00

13:00

14:00

12:00 13:00 13:00 13:00 13:00

13:00 14:00 14:00 14:00 14:00

13:00

14:00

13:00 13:00 13:00 14:00

14:15 15:00 14:30 15:00

13:00

14:00

09:00

Noon

15:00

18:00

21:00

Ward

Locality

125

Saturday SATURDAY FCS Code

06:00 Pharmacy name

Postcode

Open

09:00 09:00 09:00 09:00

13:00 12:30 17:00 12:30

08:00

18:00

16:00 09:30 07:00 09:00 08:00 09:00 09:00 09:00 09:00 09:00

22:00 13:00 22:00 13:00 13:00 13:00 17:00 16:00 12:30 20:00

09:00 09:00 09:30 09:00 09:00 09:00 07:00 08:30 09:00 07:00 09:00 09:00 09:00 09:00 09:00 08:30 09:00 09:00 09:00 09:00 09:00 09:00

19:00 13:00 15:30 17:30 13:00 17:00 22:00 19:00 13:00 22:00 17:30 13:00 12:30 16:30 17:30 13:00 13:00 13:00 13:00 17:30 12:00 13:00

09:00 09:00 09:00 09:00

17:30 13:00 14:00 12:00

09:00 08:45 08:00

Lunch Close

Lunch Open

13:00

14:00

13:00

14:00

12:00

13:00

17:30 13:00

14:00

15:00

20:00

13:00

14:00

09:00

Noon

15:00

18:00

21:00

Ward

Locality

126

Sunday SUNDAY FCS Code

06:00 Pharmacy name

National Co-operative ChemistsChemist Palmers Lloydspharmacy Delmergate Limited Delmergate Limited Boots UK Ltd Brompton Pharmacy Ltd Island Pharmacy Paydens Limited Asda Pharmacy Delmergate Limited Karsons Pharmacy Karsons Pharmacy Merlin Pharmacy Fenns Chemist Merlin Pharmacy (Consultants Ltd) Morrisons Pharmacy Delmergate Limited Osbon Pharmacy 212 Pharmacy Boots UK Ltd National Co-Operative Chemists Smiths Pharmacy Osbon Pharmacy Paydens Limited Boots UK Ltd Hempstead Chemist Sainsburys Boots UK Ltd Lloydspharmacy Lloydspharmacy Fenns Chemist Phoenix Pharmacy J Spensley Ltd Lloydspharmacy Sturdee Avenue Pharmacy Knights Pharmacy Kentpharm Boots UK Ltd Paydens Limited Focus Chemist Ryders Chemist Bryant Road Pharmacy Williams Chemist Marshlands Pharmacy Marshlands Pharmacy Boots UK Ltd Coles Pharmacy Hobbs Pharmacy Tesco Pharmacy

Postcode

Open

Lunch Close

Lunch Open

09:00

Noon

15:00

18:00

21:00

Ward

Chatham Central Chatham Central Lordswood and Capstone Luton and Wayfield Luton and Wayfield

10:00

16:00

22:00

10:00

16:00

08:00

13:00

River River River River Rochester South and Horsted Rochester South and Horsted Rochester South and Horsted Rochester South and Horsted Rochester South and Horsted Walderslade Walderslade

10:00

16:00

Walderslade Gillingham North Gillingham North Gillingham South Gillingham South Gillingham South

10:00 08:00 10:00

18:00 18:00 16:00

10:00

16:00

10:00

16:00

Gillingham South Gillingham South Gillingham South Hempstead and Wigmore Hempstead and Wigmore Hempstead and Wigmore Rainham North Rainham North Rainham North Rainham South Rainham South Twydall Watling Watling

ME3 9DT ME3 9AA ME1 2TH ME1 2DT ME1 3JU ME1 1JT ME2 3EP ME2 4HY

Peninsula Peninsula

ME3 8HX ME2 4LP ME2 4AH ME2 2EU ME2 2PW ME2 2BT

Strood Rural

Rochester East Rochester East Rochester West Rochester West Strood North Strood North Strood Rural Strood South Strood South Strood South

10:00

16:00

Strood South

Locality

127

Appendix 3: Services available from community pharmacies Chatham locality FCS

Pharmacy Name

Postcode

FGR89 FTC25 FCR68 FF328 FNE17 FM682 FEP94 FL840 FKE87 FKK59 FQ410 FJF12 FGL46 FL693 FEL36 FFM54 FR909

National Co-operative Chemists Palmers Chemist Lloydspharmacy Delmergate Limited Delmergate Limited Boots UK Ltd Brompton Pharmacy Island Pharmacy Paydens Limited Asda Pharmacy Delmergate Limited Karsons Pharmacy Karsons Pharmacy Merlin Pharmacy Fenns Chemist Merlin Pharmacy (Consultants Ltd) Morrisons Pharmacy

ME4 5JY ME4 5SJ ME5 8TH ME5 0HD ME5 0AA ME4 4BB ME7 5AA ME4 3EB ME4 4PT ME5 9SD ME5 9UR ME1 2BA ME4 6JR ME1 2BQ ME5 9LR ME5 0QX ME5 8BA

Column headings EHC CLY MAS PCS SSS SCS NEX SRP MUR 100 hr / ext

100 hr / ext

Yes Yes

Yes

Description Emergency hormonal contraception service Chlamydia screening and treatment service Minor ailments service Palliative care service Stop smoking service Supervised consumption service Needle exchange service Sharps disposal service Medicines use review service 100 hour pharmacies / extended hour pharmacies

EHC

CLY

MAS

PCS

SSS

SCS

NEX

SRP

MUR

Ward

Locality

Yes No WTP Yes No Yes No Yes Yes Yes No Yes Yes No No Yes No

Yes No WTP Yes No Yes No No Yes Yes No Yes Yes No No No No

Yes Yes WTP Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes Yes Yes Yes

Yes No No No No No Yes No Yes No No Yes No No No Yes No

Yes No WTP Yes Yes Yes No Yes Yes Yes Yes Yes Yes No No Yes Yes

Yes Yes Yes Yes No Yes No No Yes WTP No Yes Yes No No Yes Yes

No No WTP No No WTP No No No WTP No Yes Yes No Yes No No

Yes No No Yes Yes No No No Yes No Yes Yes Yes Yes Yes Yes Yes

Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes

Chatham Chatham Chatham Chatham Chatham Chatham Chatham Chatham Chatham Chatham Chatham Chatham Chatham Chatham Chatham Chatham Chatham

Key Yes No WTP

Description The service is commissioned from this pharmacy The service is not commissioned from this pharmacy This pharmacy is willing to provide this service

128

Rainham locality FCS

Pharmacy Name

Postcode

FRM80 FMJ43 FJ887 FXP56 FE677 FKJ56 FNH68

Delmergate Limited Osbon Pharmacy 212 Pharmacy Boots UK Ltd National Co-Operative Chemists Smiths Pharmacy Osbon Pharmacy Paydens Limited Boots UK Ltd Hempstead Chemist Sainsburys Boots UK Ltd Lloydspharmacy Lloydspharmacy Fenns Chemist Phoenix Pharmacy J Spensley Ltd Lloydspharmacy Sturdee Avenue Pharmacy

ME7 1LX ME7 1XF ME7 5XL ME7 1BS ME7 1AQ ME7 5JP ME7 4LA ME7 4PN ME7 3PB ME7 3QE ME7 3PB ME8 7HW ME8 7HW ME8 7PH ME8 9PW ME8 0HX ME8 6JY ME7 2YW ME7 2HN

FD032 FNL61 FX206 FEY67 FAV64 FGK03 FJF87 FC050 FX909 FHT25 FL383

Column headings EHC CLY MAS PCS SSS SCS NEX SRP MUR 100 hr / ext

100 hr / ext

Yes Yes Yes

EHC

CLY

MAS

PCS

SSS

SCS

NEX

SRP

MUR

Ward

Locality

Yes WTP Yes Yes Yes Yes Yes No Yes No Yes Yes WTP Yes Yes Yes No Yes Yes

Yes WTP Yes No Yes WTP No No Yes No Yes No WTP WTP Yes Yes No WTP Yes

Yes WTP Yes Yes Yes Yes No No Yes No WTP WTP WTP Yes Yes Yes Yes WTP Yes

No No No No No No Yes No Yes No Yes Yes No No No No No No No

Yes WTP WTP WTP No WTP No No Yes Yes No Yes WTP WTP Yes Yes No Yes WTP

Yes Yes Yes Yes No No Yes No WTP No No Yes Yes Yes Yes No No Yes Yes

WTP No WTP No No No No No No No No No WTP Yes No No No Yes WTP

No No No No Yes No No No No No Yes No No No No Yes No No No

Yes No Yes Yes Yes No No Yes Yes No Yes Yes Yes Yes Yes No No Yes Yes

Gillingham North Gillingham North Gillingham South Gillingham South Gillingham South Gillingham South Gillingham South Gillingham South Hempstead and Wigmore Hempstead and Wigmore Hempstead and Wigmore Rainham North Rainham North Rainham North Rainham South Rainham South Twydall Watling Watling

Rainham Rainham Rainham Rainham Rainham Rainham Rainham Rainham Rainham Rainham Rainham Rainham Rainham Rainham Rainham Rainham Rainham Rainham Rainham

Key Yes No WTP

Description The service is commissioned from this pharmacy The service is not commissioned from this pharmacy This pharmacy is willing to provide this service

129

Rochester locality FCS

Pharmacy Name

Postcode

FEM57

Knights Pharmacy Kentpharm Boots UK Ltd Paydens Limited Focus Chemist Ryders Chemist Bryant Road Pharmacy Williams Chemist Marshlands Pharmacy Marshlands Pharmacy Boots UK Ltd Coles Pharmacy Hobbs Pharmacy Tesco Pharmacy

ME3 9DT ME3 9AA ME1 2TH ME1 2DT ME1 3JU ME1 1JT ME2 3EP ME2 4HY ME3 8HX ME2 4LP ME2 4AH ME2 2EU ME2 2PW ME2 2BT

FYN18 FGF64 FH750 FHY79 FM600 FYC97 FR048 FTT51 FV186 FR400 FTM63 FMH56

Column headings EHC CLY MAS PCS SSS SCS NEX SRP MUR 100 hr / ext

100 hr / ext

Yes

EHC

CLY

MAS

PCS

PCA

SSS

SCS

NEX

SRP

MUR

Ward

Locality

Yes No No Yes No Yes WTP No Yes WTP Yes WTP No WTP

Yes No No No No Yes WTP WTP Yes WTP Yes WTP No WTP

No No No No No Yes Yes No Yes Yes No Yes Yes Yes

No No No No No No No No No Yes No No No No

No No No No No No No No No No No No No No

Yes No No Yes No Yes WTP WTP No Yes Yes WTP No Yes

Yes No Yes Yes Yes No No No No WTP Yes Yes Yes Yes

No No No No No No No No No WTP No No Yes No

Yes No No Yes No No Yes No No No No Yes Yes No

Yes No Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes

Peninsula Rochester East Rochester East Rochester East Rochester West Rochester West Strood North Strood North Strood Rural Strood Rural Strood South Strood South Strood South Strood South

Rochester Rochester Rochester Rochester Rochester Rochester Rochester Rochester Rochester Rochester Rochester Rochester Rochester Rochester

Key Yes No WTP

Description The service is commissioned from this pharmacy The service is not commissioned from this pharmacy This pharmacy is willing to provide this service

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Appendix 4: The Role of the Pharmacist in Advising Care Homes The Care Homes Use of Medicines (CHUMS) study, published in 200916, took a whole-system view of the medicines use processes in 55 care homes in Cambridgeshire, London and West Yorkshire. The authors used Reason and Vincent‟s understanding of human error and patient safety to inform and structure their investigation of the medication-related errors that they found. The CHUMs team identified a mean of 1.9 errors per resident (from 256 residents in 55 diverse homes where the mean number of medicines being taken was 8). The study was very interesting as the team looked at system factors within GP practices, community pharmacies and care homes, and interviewed a number of people across the system who had been in some way involved with an error. The results of the study included the following: “Contributing factors from the 89 interviews included doctors who were not accessible, did not know the residents and lacked information in homes when prescribing; home staff‟s high workload, lack of medicines training and drug round interruptions; lack of team work among home, practice and pharmacy; inefficient ordering systems; inaccurate medicine records and prevalence of verbal communication; and difficult to fill (and check) medication administration systems.” The authors also noted a lack of overall responsibility for the integrity of the system. These findings indicate a number of points at which pharmacists could make a difference. Prescribing and monitoring errors: Many „errors‟ were actually an absence of dosing information that could lead to problems. Pharmacists could complete this information through accurate historytaking. Similarly, a number of common drugs were not being monitored and Administration errors: Most medicines were supposed to be given in the morning, but this was the time at which care home staff were most likely to be distracted by other tasks. Administration charts in the home were often incorrect or incomplete, yet should be the primary channel for communication between doctor, pharmacist and home staff. Dispensing errors: Sources of error found in pharmacies included the following: Re-packing tablets had the potential for error; There was a small but significant difference in errors found in cassette and blister monitored dosage systems, with the cassette system being associated with more labelling challenges; Differences between the prescription and the medication administration record, leading to confusion about which was correct; Poor checking process in the pharmacy, and challenges of locum use; In-pharmacy factors – being busy, lots of distractions, poor working conditions;

ND Barber, DP Alldred, DK Raynor, et al. Care homes‟ use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people. Qual Saf Health Care 2009; 18: 341-346. 131

Lack of knowledge among pharmacists and staff of the care home processes, and poor relationships with care home staff. Communication and management issues within and between the centres involved (GP practice, community pharmacy and care home) needed improvement.

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Appendix 5: Policy context and background papers This Appendix provides some context for the development of the policy influencing the development of pharmacy and PNAs. At the time of writing we do not know how the trajectory set by this policy will change as the new government sets out its policy proposal for the NHS. A Vision for Pharmacy in the New NHS (July 2003) The pace of change for NHS community pharmaceutical services over the last 10 years has been more rapid than at any other time in the last 60 years. Community pharmacy has featured more prominently in the NHSâ&#x20AC;&#x;s efforts to improve services and is increasingly recognised by the NHS and by other health professionals, and how its ability to respond innovatively and creatively can be better utilised. That is what was intended when the Department of Health launched A Vision for Pharmacy in the New NHS in July 2003. That identified and aligned the ambitions for pharmacy alongside the wider ambitions for the NHS as a whole. The current policy context shaping the direction of pharmacy services has its roots in the publication of a strategy for pharmacy Choosing Health published by the Government in 2004. In this White Paper, the Government set out a programme of action to provide more of the opportunities, support and information people want to enable them to improve their health. Choosing health through pharmacy As part of this programme, the Government made a commitment to publish a strategy for pharmaceutical public health (Choosing Health Through Pharmacy) which expanded the contribution that pharmacists, their staff and the premises in which they work can make to improving health and reducing health inequalities. This strategy recognised that pharmacists work at the heart of the communities they serve and they enjoy the confidence of the public. Every day, they support self care and provide health messages, advice and services in areas such as diet, physical activity, stop smoking and sexual health. A new contractual framework for community pharmacy As part of the Vision for Pharmacy a new community pharmacy contractual framework was put in place in April 2005. It comprises three tiers of services â&#x20AC;&#x201C; essential, advanced and local enhanced services. Essential services are those which every pharmacy must provide, including dispensing. Advanced services are those which, subject to accreditation requirements, a pharmacy contractor can choose to provide. At present, there is one advanced service - the Medicines Use Review (MUR) - where a pharmacist discusses with a patient their use of

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the medicines they are taking and whether there are any problems which the pharmacist can help resolve. Essential and advanced services are determined nationally. Local enhanced services, such as help for substance misusers, are commissioned locally by PCTs direct with contractors. „Our health, our care, our say‟ The White Paper Our health, our care, our say launched in January 2006 set out a new strategic direction for improving the health and well-being of the population. It focused on a strategic shift to locate more services in local communities closer to people‟s homes. This recognised the vital role that community pharmacies provide in providing services which support patients with long term conditions and make treatment for minor illnesses accessible and convenient. NHS Next Stage Review The NHS Next Stage Review final report set out a vision of an NHS that gives patients and the public more information and choice, works in partnership and has quality of care at its heart – quality defined as clinically effective, personal and safe. The changes that are now being taken forward, locally and nationally, will see the NHS deliver high quality care for all users of services in all aspects, not just some. It will see services delivered closer to home, a much greater focus on helping people stay healthy and a stronger emphasis on the NHS working with local partners. Pharmacy has a key role to play in delivering this vision, particularly as a provider of services which prevent ill-health, promote better health for all and improve access to services within communities. The pharmacy White Paper, Pharmacy in England - Building on strengths delivering the future In April 2008 the government set out its plans for pharmacy in the Pharmacy White Paper Pharmacy in England: Building on strengths - delivering the future (PWP) subsequently a regulatory consultation was undertaken to consult on the proposed changes to the regulations for pharmacy. This White Paper sets out a vision for improved quality and effectiveness of pharmaceutical services, and a wider contribution to public health. Whilst acknowledging good overall provision and much good practice amongst providers, it revealed several areas of real concern about medicines usage across the country which it seeks to address through a work programme which will challenge and engage PCTs, pharmacists and the NHS. It identifies practical, achievable ways in which pharmacists and their teams can improve patient care in the coming years. It sets out a reinvigorated vision of pharmacy‟s potential to contribute further to a fair, personalised, safe and effective NHS. This vision demonstrates how pharmacy can continue, and expand further, its role in an NHS that focuses as much on prevention as it does on treating sick people, helping to reduce health inequalities, supporting healthy choices, improving quality and promoting well-being for patients and public alike. 134

This White Paper has put forward a broad range of proposals to build on progress over the last three years which has succeeded in embedding community pharmacy‟s role in improving health and well-being and reducing health inequalities. These include proposals for how pharmacies will, over time: become „healthy living‟ centres – promoting health and helping more people to take care of themselves; offer NHS treatment for many minor ailments (e.g. coughs, colds, stomach problems) for people who do not need to go to their local GP; provide specific support for people who are starting out on a new course of treatment for long term conditions such as high blood pressure or high cholesterol; offer screening for those at risk of vascular disease – an area where there are significant variations in access to services and life expectancy around the country; use new technologies to expand choice and improve care in hospitals and the community, with a greater focus on research; and be commissioned based on the range and quality of services they deliver.

For PCTs the PWP presents a timely opportunity to take stock of progress with the development and integration of pharmacy services and to prepare a strategy to deliver the PWP vision over the next 3-5 year period. High quality commissioning is a recurring theme throughout these documents. A robust Pharmaceutical Needs Assessment (PNA) is key to world class commissioning of services from community pharmacy. The following documents provide some background to the PNA development process, the relevant policy and guidance available to PCTs. Pharmacy in England: building on strengths - delivering the future This White Paper sets out a vision for building on the strengths of pharmacy, using that capacity and capability to deliver further improvements in pharmaceutical services over the coming years as part of an overall strategy to ensure safe, effective, fairer and more personalised patient care. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_ 083815 PNAs as a part of world class commissioning guidance.

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This guidance sets out why Pharmaceutical Needs Assessments (PNAs) are important, how they fit into the primary care trust (PCTs) planning cycle and how it can be used to drive intelligent, world class commissioning of pharmaceutical services. http://www.nhsemployers.org/PayAndContracts/CommunityPharmacyContract/Pages/PNAsasapart ofworldclasscommissioning.aspx Developing pharmaceutical needs assessments guidance This guidance and individual supporting guides explain why Pharmaceutical Needs Assessments (PNAs) are important and how they fit into PCTs' planning cycles. It outlines how to produce a new PNA or revise an existing one. http://www.nhsemployers.org/PayAndContracts/CommunityPharmacyContract/Pages/PNA_Guidanc e.aspx Pharmacy-based stop smoking services guidance This guidance covers the key areas for primary care trusts (PCTs) when commissioning 'world class' pharmacy-based stop smoking services. http://www.nhsemployers.org/PayAndContracts/CommunityPharmacyContract/Pages/Pharmacybasedsmokingservices.aspx The NHS (Pharmaceutical Services) Regulations: information for primary care trusts - revised September 2009 This guidance has been produced to assist primary care trusts in the assessment and determination of applications to provide NHS pharmaceutical services. It incorporates reforms effective from 1 April 2005 to the regulatory system and amendments to the Regulations since. This includes the amendments which came into force on 17 September â&#x20AC;&#x201C; SI 2009/2205. It also incorporates supplementary information for primary care trusts on the NHS Pharmaceutical Services (Fees for Applications) Directions 2008 which give primary care trusts the ability to charge for certain applications for inclusion on their NHS pharmaceutical services lists. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_ 105361 World class commissioning: Improving Pharmaceutical Services This is a practical guide to support PCTs in commissioning pharmaceutical services. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/DH_097408 Local pharmaceutical services (LPS)

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LPS is a tool available to PCTs by which they may contract locally for provision of pharmaceutical and other services, including services not traditionally associated with pharmacy, within a single contract. http://www.dh.gov.uk/en/Healthcare/Medicinespharmacyandindustry/Communitypharmacy/Localpha rmaceuticalservices/LPSPermanenceguidance/index.htm Advisory Group on the NHS (Pharmaceutical Services) Regulations Following the publication of the White Paper Pharmacy in England: Building on strengths delivering the future, a consultation was held in the autumn 2008 on proposals for legislative change. http://www.dh.gov.uk/en/Healthcare/Medicinespharmacyandindustry/PharmacyWhitePaper/Regulati onsAdvisoryGroup/index.htm The DH has now published the revised guidance and regulations. The regulations were laid in parliament on 23rd March 2010 and will come into force on 24th May 2010. The updated guidance and regulations can be accessed at: http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@ps/documents/digitala sset/dh_114952.pdf

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Appendix 6: Membership of the steering group Name

Role

Organisation

Aeilish Geldenhuys

Senior Public Health Manager

Medway Council

Alan Dixon

Asst Director Community Commissioning

Medway PCT

Anne Child

Community Pharmacy Advisor

Medway PCT

Barbara Parkinson

Community Pharmacy Dev. Mgr

Medway PCT

David Selling

Head of Quality

Medway PCT

Dawn Hollis

PBC

Medway PCT

Dean Givens

Finance

Medway PCT

Chris Styles

Di Tyas

Local Medical Council (LMC)

Dr Maggie Bruce

Public Health

Medway PCT

Dr P Green

Medical Director

Medway PCT

Dr T Gill

Kent Local Pharmaceutical Committee (LPC)

Dr V Shaunak

GP Medway

Emma Burns

Media Manager

Medway PCT

Fiona Gaylor

Engagement Co-ordinator

Medway PCT

Gertrude Spensley

Community Pharmacist

Medway PCT

Janice Moorekite

Snr MM Advisor

Medway PCT

Jo Ringer

Chief Pharmacist

Medway NHS Trust

Mary Kirk

PAC Member

Medway PCT

Mike Keen

Kent Local Pharmaceutical Committee (LPC) Kent and Medway Public Health Observatory

Natasha Roberts

Head of Health Intelligence

Richard Woolterton

Assistant Director

Medway PCT

Rita Oâ&#x20AC;&#x;Brien

Community Health Services Pharmacist

Medway Community Healthcare KPA Prescribing Service

Robert Lawrence Roger Pargeter

Community Pharmacist

Teresa McEvoy

Community Pharmacy Dev Officer

Medway PCT

Verity Williams

Community Pharmacy Dev Officer

Medway PCT

Zara Johnson

Commissioning Manager - GPs

Medway PCT 138

Appendix 7: List of adult care homes in Medway Name / Address

Town

Postcode

Type

Platters Farm Lodge

Gillingham

ME8 0EQ

Residential & day services for older people

Robert Bean Lodge

Rochester

ME1 2QT

Residential & day services for older people

Nelson Court

Chatham

ME5 7JZ

Residential & day services for older people with mental health needs

Izzat Day Centres

Chatham

ME4 4DT

Day care for older people from ethnic minority communities

Enhanced Care Unit

Rochester

ME1 2RB

Day services for adults with learning disabilities

Birling Avenue

Rainham

ME8 7EY

Short break service for adults with a learning disability

Napier Unit

Rochester

ME1 2QT

Short break service for adults with profound & complex learning disability

Berengrove Park

Gillingham

ME7 4AH

Residential Nursing Home

Byron Lodge Residential Nursing Home

Gillingham

ME7 5PX

Residential Nursing Home

Copper Beeches Nursing Home

Borstal

ME1 3LL

Residential Nursing Home

Fontenay Nursing Home

Rochester

ME1 1RZ

Residential Nursing Home

Fort Horsted Nursing Home

Chatham

ME4 6HZ

Residential Nursing Home

Frindsbury Hall Nursing Home

Rochester

ME2 4JS

Residential Nursing Home

Friston House Nursing Home

Rochester

ME1 2BQ

Residential Nursing Home

Grace Manor Nursing Home

Gillingham

ME7 2UD

Residential Nursing Home

Heather Dale Nursing Home

Gillingham

ME7 3QG

Residential Nursing Home

Pembroke House

Gillingham

ME7 4BS

Residential Nursing Home

Valley View Residential Nursing Home

Rochester

ME1 3LT

Residential Nursing Home

Winchester House

Rochester

ME1 3TR

Residential Nursing Home

Abbeyfield Rogers House

Gillingham

ME8 0NX

Private & Voluntary Residential Home

Acorn House

Chatham

ME4 6DP

Private & Voluntary Residential Home

Agape House

Chatham

ME4 6DG

Private & Voluntary Residential Home

Amicus

Strood

ME2 3DB

Private & Voluntary Residential Home

Ampersand House Residential Care Home

Strood

ME2 4HP

Private & Voluntary Residential Home 139

Aquarius

Chatham

ME5 9SH

Private & Voluntary Residential Home

Cherry Acre Residential Home

Gillingham

ME8 7LS

Private & Voluntary Residential Home

Chimnies Residential Care Home

Rochester

ME3 9PD

Private & Voluntary Residential Home

Clairmont Residential Home

Gillingham

ME8 0PN

Private & Voluntary Residential Home

Durland House

Gillingham

ME8 8AT

Private & Voluntary Residential Home

Grafton Lodge

Rochester

ME2 3DE

Private & Voluntary Residential Home

Greenford

Gillingham

ME7 4NA

Private & Voluntary Residential Home

Hawthorn Manor

Gillingham

ME8 0HX

Private & Voluntary Residential Home

Hempstead Home

Gillingham

ME7 3QG

Private & Voluntary Residential Home

Holly Lodge Residential Home

Chatham

ME4 6HS

Private & Voluntary Residential Home

Jeanette Lodge

Gillingham

ME7 4AS

Private & Voluntary Residential Home

Lennox Wood

Gillingham

ME8 6SY

Private & Voluntary Residential Home

Northmore Residential Care Ltd

Gillingham

ME7 4AE

Private & Voluntary Residential Home

Sherwood House Care Centre

Rochester

ME1 3BU

Private & Voluntary Residential Home

Sherwood Lodge

Gillingham

The Grange

Rochester

ME3 8RJ

Private & Voluntary Residential Home

The White House

Chatham

ME4 6HY

Private & Voluntary Residential Home

Yew Tree Lodge

Rochester

ME3 9BJ

Private & Voluntary Residential Home

1-2 Downer Court

Rochester

ME1 2SA