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The purpose of this document is twofold;

  • To determine if there are sufficient community pharmacies to meet the needs of the population of Northumberland
  • To determine other services which could be delivered by community pharmacies to meet the identified health needs of the population.
The Health and Social Care Act 2012 transferred the responsibility for developing and updating Pharmacy Needs Assessments to Health and Wellbeing Boards. They must produce an updated PNA by 1 April 2015. A PNA describes the population’s health needs and the pharmaceutical services which exist, or could be commissioned to address these. It is also used to identify any gaps in pharmaceutical services which could be filled by new pharmacies. 

Through the Joint Strategic Health Needs Assessment (JSNA), the council and the Clinical Commissioning Group (CCG) will identify the population’s health needs. They will each commission services from pharmacies to address these needs. NHS England will use the PNA to decide if applications for new pharmacies are necessary to meet such needs or to provide commissioned services.

A pharmaceutical needs assessment (PNA) describes the health needs of the population, current pharmaceutical services provision and any gaps in that provision. It also identifies potential new services to meet health needs and help achieve the objectives of the strategic plan, while taking account of financial constraints. The PNA will be used to:
  • inform commissioning plans about pharmaceutical services that could be provided by community pharmacists and other providers to meet local need;
  • support commissioning of high quality pharmaceutical services;
  • ensure that pharmaceutical and medicines optimisation services are commissioned to reflect the health needs and ambitions outlined within the joint strategic needs assessment;
  • facilitate opportunity for pharmacists to make a significant contribution to the health of the population of Northumberland; and
  • ensure that decisions about applications for market entry for pharmaceutical services are based on robust and relevant information.
This is not a stand-alone document. It is aligned with the joint strategic needs assessment (JSNA) and Northumberland Clinical Commissioning Group’s Five Year Plan. It will be used as a tool to inform future service developments aimed at meeting the objectives of the strategic plan e.g., delivering care in the most
appropriate setting, reducing reliance on hospital care, supporting those with long term conditions, promoting wellbeing and preventing ill-health, and improving access to primary care.

Market entry

If a person (a pharmacist, dispenser of appliances, or in some rural areas, a GP) wants to provide NHS pharmaceutical services they are required to apply to the NHS to be included on a pharmaceutical list. Pharmaceutical lists are compiled and held by NHS England. This is commonly known as the NHS “market entry” system. Under the NHS (Pharmaceutical Services and Local Pharmaceutical Services) Regulations (the “2013 Regulations”) a person who wishes to provide NHS pharmaceutical services must generally apply to NHS England to be included on the relevant list by proving they are able to meet a pharmaceutical need as set out in the relevant PNA.

The regulations allow an automatic exemption to the regulatory test for distance sellers or internet based pharmacies on the condition they meet the following; the uninterrupted provision of essential services, during the opening hours of the premises, to persons anywhere in England who request those services, and the safe and effective provision of essential services without face to face contact between any person receiving the services, whether on their own or on someone else’s behalf, and the applicant or the applicant’s staff.

The Health Act 2009 replaced the “control of entry” test with a new test requiring Primary Care Organisations to have statements of pharmaceutical needs. The Health and Social Care Act 2012 transferred the responsibility for producing the PNA to Health and Well Being Boards of local councils. NHS England will use the PNA to
determine applications to open new pharmacies in that local council area. It is essential that local councils are keenly aware of pharmacy services needed in the community, together with any gaps or opportunities in service provision so that these can be commissioned to support more effective patient care.

It is essential that local councils are keenly aware of pharmacy services needed in the community, together with any gaps or opportunities in service provision so that these can be commissioned to support more effective patient care.

2.1 Identification of health need

Population health needs across the county were identified by the Public Health teams. These teams provided an understanding of health needs identified within the joint strategic needs assessment which could be addressed by community pharmacies. Health needs were then compared with the strategic goals of public health commissioners and the Clinical Commissioning Group for Northumberland. This included a number of initiatives where the potential of using community pharmacies had been explored.

2.2 Assessment of current pharmaceutical provision

Population health needs across the county were identified by the Public Health teams. These teams provided an understanding of health needs identified within the joint strategic needs assessment which could be addressed by community pharmacies. Health needs were then compared with the strategic goals of public
health commissioners and the Clinical Commissioning Group for Northumberland. This included a number of initiatives where the potential of using community pharmacies had been explored.

2.3 Public engagement

The formal consultation on the draft PNA for Northumberland ran from 14th November 2014 to 30th January 2015 in line with the guidance on developing PNAs and section 242 of the Health Service Act 2012, which stipulates the need to involve Health and Wellbeing Boards in scrutinising Health Services. In keeping with the NHS (Pharmaceutical Services and Local Pharmaceutical Services) Regulations (2013) the following stakeholders were consulted during this time:
  • North of Tyne Local Pharmaceutical Committee
  • Northumberland Local Medical Committee
  • All persons on the pharmaceutical lists and all dispensing doctors list in Northumberland
  • LPS chemists in Northumberland with whom NHS England has mad arrangements for the provision of any local pharmaceutical services;
  • Northumberland Clinical Commissioning Group
  • Northumberland Healthwatch
  • Northumbria Healthcare NHS Foundation Trust, Newcastle Upon TyneHospitals NHS Foundation Trust, and NTW Mental Health NHS FoundationTrusts
  •  NHS England
  • Neighbouring HWBs in Newcastle, Durham, Cumbria and North Tyneside.
In addition the following were also consulted
  • GP practices
  • Parish Councils
  • Groups representing the housebound, carers and people with disabilities
  • Young people
Letters were sent to all consultees informing them of the web site address which contains the draft PNA document.
“a person is to be treated as served with a draft if that person is notified by the HWB of the address of a website on which the draft is available and is to remain available (except due to accident or unforeseen circumstances) throughout the minimum 60 day period for making responses to the consultation”. The draft document has been updated to reflect significant comments received during the consultation period. The revised document will be considered by the HWB which includes a report of the consultation.

2.4 Identification of localities

The PNA has adopted the four Clinical Commissioning Group localities which are based on groupings of Middle Layer Super Output Areas (MSOAs)4 (see Map 1), as at May 2014.

Map 1: Northumberland CCG localities mapped over Northumberland LSOAs
This chapter provides a brief overview of the health needs of the residents of Northumberland, highlighting in particular those health needs which may be amenable to intervention by services delivered through community pharmacies and those needs which should be met in order to achieve the objectives in the five year Strategic Plan.

Local priorities include reducing alcohol related harm, tackling obesity through diet and exercise and promoting mental wellbeing. Further details are available in the Joint Strategic Needs Assessment5, and the Northumberland CCG Five Year Plan.

3.1 Geographical characteristics

The north of the county is very sparsely populated. The principal towns of Alnwick, Berwick and Morpeth serve geographically large catchments that are also partially influenced by both Edinburgh to the north and Tyneside to the south. Many of the communities in this area are characterised by extreme physical remoteness, lack of
services and rural disadvantage. This is one of the most sparsely populated areas of England.

The west of the county is distinctly rural, albeit split by major road and rail transport corridors running into Newcastle and Gateshead. The towns of Ponteland and Hexham are desirable places to live and visit, placing considerable demands on their services and infrastructure. Many of the communities in this area are characterised by an economic and cultural interdependence with the Tyneside conurbation. The far west of the County is also sparsely populated. 

The southeast corner of the county is compact coastal lowland intersected by several river estuaries. It is distinctly built up, with the county’s largest towns of Ashington, Blyth and Cramlington in the northern fringe of Tyneside. Many of the communities in this area are characterised by high levels of multiple deprivation following the decline of coal mining and other industries.

The county’ demographic profile – very distinct settlements in each locality – means that one size does not fit all. It is therefore vital that services are customised to local needs. The extreme remoteness of some parts of the county makes service delivery challenging and costly.

3.2 Population profile

The last official estimate of the Northumberland population was produced by the 2011 Census and this was confirmed by the Office for National Statistics in June 2014 as a mid-2013 population estimate of 315,8066. 

The mid-2013 age profile for Northumberland is considerably different to that of the North East and England in that Northumberland has much smaller populations for those aged 20 to 40, then much larger populations aged between 50 and 70. The population lessens for the older ages, with higher populations among females than the corresponding male age groups (see Figure 1). Northumberland has a high number of over 65s, accounting for 21.9% of its population, compared to 18.4% across the North East and 17.3% across England.

Figure 1: Population pyramid of Northumberland compared to England

The over 65 population is expected to account for over 30% of the total population in Northumberland by 20357. The rural areas of North Northumberland, West Northumberland and Morpeth already have a high proportion of their population over 65. These dramatic changes in the balance of the population are part of an historic shift which is being experienced across the developed world; but they are happening earlier in Northumberland (especially rural Northumberland) than in most of England. This high number of over 65s could be expected to increase demand on health services.

In contrast, the number of children and young people resident in Northumberland is expected to be fairly static over the same period. The number of persons under the age of 15 will decrease slightly from 50,025 in 20118 to around 49,000 in 20169. To accommodate the increase in household numbers and to attract economically active families into Northumberland, Northumberland County Council plans to meet national housing targets by encouraging limited development around the main towns of Hexham, Ponteland, Morpeth, Ashington, Blyth and Alnwick (see Table 1 and Table 2 ).

Table 1: Housing scale and distribution by area

It is unlikely that developments of this scale will significantly impact on health service delivery. More GP capacity may be needed in the Ashington, Blyth and Cramlington areas over the next 3 -5 years.

Ethnicity

Culture and ethnicity may influence health beliefs and behaviours, and may therefore impact on health and wellbeing. In the 2011 Census (the latest year for which data are available), 98.4% of the population of Northumberland classified themselves as White. People from BME groups now represent 1.6% of the Northumberland population, compared with 4.7% in the North East and 14.5% nationally.

Table 2: Housing Plan – proposed annual development by town (*plan period: 2011-2031)

3.3 Transport

Within Northumberland in particular, access to health services can be hampered by transport issues – this is partially because of the problems of rurality, with a very sparsely populated county of more than 2,000 square miles. The maps in Section 4 and some of the maps in the appendices show settlement types, which highlights the rurality of Northumberland. Public transport in these rural areas can be poor and infrequent.

3.4 Deprivation

The link between social and economic deprivation and poor health has long been recognised. People living in areas with higher levels of deprivation tend to have poorer health than those living in more affluent areas. Northumberland is characterised by areas of rural poverty hidden amidst relative affluence, with the postindustrial areas of Ashington and Blyth suffering from multiple deprivation. Berwick is a town isolated from the rest of the county but suffering from unemployment and social deprivation similar to the south east of the county (see Map 2).

3.5 Lifestyle risk factors
 

Smoking
Smoking remains the greatest contributor to premature death and disease across Northumberland. It is estimated that up to half the difference in life expectancy between the most and least affluent groups is associated with smoking. It is estimated that 87% of deaths from lung cancer are attributable to smoking, as are 73% of deaths from upper respiratory cancer and 86% of chronic obstructive lung disease. Smoking is also a major factor in deaths from many other forms of cancer and circulatory disease. Overall, smoking mortality is significantly higher in Northumberland than the England average, although smoking prevalence is now below the England average (17.6% compared to the England average of 19.5%). It is important to note, however, that there is much disparity within Northumberland and this is not a true reflection of every locality in Northumberland.

Alcohol

Alcohol is the second biggest lifestyle risk factor after tobacco use. Recent figures from the Local Authority Profile for England (LAPE) show Northumberland has the sixth highest rate in the UK for binge drinking with 29.8% of those surveyed reporting drinking more than twice the recommended amount of alcohol in a single session.

Alcohol misuse is a major problem within Northumberland in terms of health, social and economic consequences which affect a wide cross section of the county at a considerable cost. The pattern of drinking has a socio-economic gradient with a higher proportion of both men and women in managerial and professional
households exceeding the recommended maximum intake on at least one day per week(10).

Map 2: Distribution of Index of Multiple Deprivation 2010 in Northumberland
Source: Northumberland InfoNet research report – English Indices of Deprivation 2010


There are rising trends in the levels of hospital related admissions for both men and women in the county. Between 2010/11 and 2012/13 there were 27 under 18 admissions to hospital for alcohol specific conditions. In 2012/13 alone there were 20 2,556 adult admissions for alcohol related harm, the rate of which (788 per 100,000) is significantly above the England average (637 per 100,000).

Substance misuse

Drug addiction leads to significant crime, health and social costs. Evidence-based drug treatment reduces these and delivers real savings, particularly in crime-related costs, but also in savings to the NHS through health improvements, reduced drugrelated deaths and lower levels of blood-borne disease. Tables 3a and 3b show the estimated prevalence of drug misuse in Northumberland.

Table 3a: Estimated prevalence rates per 1,000 population aged 15 to 64 (2010/11)
.
When engaged in treatment, people use fewer illicit drugs, commit less crime, improve their health and manage their health better. Preventing early drop-out and keeping people in treatment long enough to benefit contributes to these improved outcomes. In 2013 there were 943 adults in drug treatment. During this time 242 adults started a new treatment journey, 85% of which were retained for at least 12 weeks11.

Table 3b: Estimated prevalence of opiate or crack use by age – rates per 1,000 population
(2010/11)
Data source: National Drug Treatment Monitoring System

Obesity

In Northumberland in 201212, 72% of adults were classed as overweight or obese13. This is nearly 10% more than national prevalence. The Health Survey for England (HSE) 2014 indicates that 25% of both men and women are obese (25%) but that men are more likely to be overweight (32% for women and 42% for men). This also shows that the adult prevalence of severe obesity is 2.4%.

Figure 2: Adjusted prevalence of excess weight among adults, 2012
Data source: Active People Survey 6

Table 4: Prevalence of obesity (adults) 2012/13
Source: Monitoring data on QOF 2012/13, HSCIC

Between 1993 and 2012, obesity has risen from about 15% to 25% and projections show no halt to the rise in adult obesity. Women living in lower income households are more likely to be obese: obesity prevalence falls from 31% in the lowest income quintile to 19% in the highest income quintile. There is no clear pattern for men.

The latest data from the NCMP identified that 10% of Reception aged children were obese and 23% recorded with excess weight. By Year 6, this figure was 18% obese and 33% with excess weight.

Figure 3: Excess weight prevalence by age
Data sources: NCMP 2010/11-2012/13; APS 6

The underlying causes of obesity are considered to be the ready availability of high calorie food, and a more sedentary lifestyle caused by a reduction in activity and manual labour, and greater use of the car as a means of transport. Obesity is associated with a range of health problems including Type 2 Diabetes, cardiovascular disease and cancer. The resulting NHS costs attributable to overweight and obesity are projected to reach £9.7 billion by 2050, with wider costs to society estimated to reach £49.9 billion per year (Foresight 2007).

Sexual health and teenage pregnancy

Good sexual health forms a fundamental aspect of an individual’s general wellbeing and state of health, and is also an important public health issue - poor sexual health imposes significant social, economic, emotional and health costs. The highest burden of sexual ill health is borne by gay and bisexual men, young people and black and minority ethnic groups. Reducing the burden of HIV and STIs requires sustained approaches to support early detection, successful treatment and partner notification in conjunction with safer sex health promotion and the promotion of safer sexual behaviour.
Teenage conceptions
Rates of teenage conception in 2012 were 28.4 per 1,000 women aged 15-17 in Northumberland which is lower than the rate for the North East (35.5 per 1,000) but higher than England (27.7 per 1,000). 

Within Northumberland, there are a number of identified ‘hot spots’ based on teenage pregnancy rates within different parts of the county. Most are in the former districts of Blyth Valley and Wansbeck, although Haydon ward in Tynedale, Lesbury and Alnwick in Alnwick and Lynemouth and Chevington in Castle Morpeth also feature. There are also a number of other wards spread across Blyth Valley, Wansbeck, Castle Morpeth and Alnwick which have rates above the England average. 

The reduction of the teenage pregnancy rate has been a key target across Northumberland. Key actions have included work targeting young people in schools, and communities in teenage pregnancy ‘hot spot’ areas. The objectives are to improve access to responsive services and sex and relationship education, and to increase the use of long acting reversible contraception.

3.6 Cancer

Death rates from all cancers have decreased significantly over the last 2 decades due to a combination of early detection and the efficacy of treatment. However within Northumberland cancer remains a significant cause of premature death (death under 75 years) and health inequalities. Cancer is the commonest cause of premature death in Northumberland closely followed by cardiovascular disease. The under 75 mortality rate from cancer considered preventable is 89 per 100,000 population in Northumberland. This is similar to the England average but significantly lower than the regional average(14).

3.7 Long term conditions

Cardiovascular disease (CVD)

Cardiovascular disease (CVD) covers a number of different problems of the heart and circulatory system, such as coronary heart disease (CHD), stroke, and peripheral vascular disease (PVD). It is strongly linked with other conditions, notably obesity and diabetes, and is more prevalent in lower socio-economic and ethnic minority groups. CVD is a major contributor to health inequalities in Northumberland. The under 75 mortality rate from cardiovascular diseases considered preventable is 53.9 per 100,000 population in Northumberland. This is similar to the England average but significantly lower than the regional average(15).
Coronary heart disease (CHD)
Coronary heart disease (CHD) prevalence, as recorded for the monitoring of the Quality and Outcomes Framework (QOF) – the system for measuring quality of service in general practice – is higher than the regional and national average.

Table 5: Diagnosed CHD prevalence (all ages) 2012/13
Source: Monitoring data on QOF 2012/13, HSCIC
Hypertension
Data collected to monitor the Quality and Outcomes Framework (QOF) shows hypertension prevalence to be higher than the regional and national average, which may be partially due to better case finding. However, a prevalence model16 developed to predict the number of people with hypertension suggests that there are large numbers of people who remain undiagnosed. The 2012/13 QOF data indicate that there were 55,016 patients on Northumberland GP registers with hypertension.

Table 6: Diagnosed hypertension prevalence (all ages) 2012/13
Source: Monitoring data on QOF 2012/13, HSCIC
Diabetes
Diabetes is a chronic and progressive disease that impacts upon almost every aspect of life. It can affect infants, children, young people and adults of all ages, and is becoming more common. Diabetes can result in premature death, ill-health and disability, yet these can often be prevented or delayed by high quality care.
Preventing Type 2 diabetes (the most common form) requires prevention activities to tackle obesity and lifestyle choices about diet and physical activity.

Data collected as part of the monitoring arrangements for the QOF shows that the prevalence of diagnosed diabetes in Northumberland is higher than the regional and of people with diabetes suggests a significant gap between predicted and measured (or diagnosed) levels. 

Diabetes can remain undiagnosed for many years; people who are undiagnosed will not receive the routine care and monitoring required to optimise wellbeing and minimise long-term complications. Identifying people who are undiagnosed and providing systematic care for them is therefore a priority if diabetes is to be managed effectively.

Table 7: Diagnosed diabetes prevalence (% of population aged 17+) 2012/13
Source: Monitoring data on QOF 2012/13, HSCIC
Chronic obstructive pulmonary disease (COPD)
COPD is a chronic lung condition resulting from damage to the lung and leads to breathing difficulties. One of the main causes of COPD is smoking, so prevention of COPD is linked to smoking cessation activities, which can be provided by community pharmacies.

Table 8: Diagnosed COPD prevalence 2012/13
Source: Monitoring data on QOF 2012/13, HSCIC

The female premature mortality rate in Northumberland from respiratory disease considered preventable is 19.5 per 100,000 population. This is significantly higher than the England average but similar to the regional average18. COPD is a contributor to health inequalities. 

COPD prevalence as recorded within QOF is higher than the average for England as a whole (2.3% versus 1.5%). However, a prevalence model19 developed to predict the number of people with COPD suggests that there are significant numbers of people who have COPD but who are not on GP practice COPD registers.

3.8 Older persons

Many of the people whose lives are substantially affected by long-term illness or disability are in their eighties or nineties and have age-related conditions such as osteoarthritis, visual or sensory impairment, or Alzheimer’s disease. But there are also older people who are disabled by health problems much earlier in life, for instance people who suffer a severe stroke or early-onset dementia. 

Population projections indicate the number of persons in Northumberland, aged 65 years and over will increase to over 30% of the total population by 2035. The proportion of people aged 85 and over is projected to increase from 3% of the population to 5% by the year 203020, creating additional demands for social care, housing support and health services. Long term conditions and dementia will be among the biggest challenges faced by health services going forwards.

People with dementia require substantial amounts of care, particularly social care. Pharmacists can contribute to the care of those with dementia by reviewing their medication, and helping to ensure that patients remember to take the medicines they require by advising on and supplying appropriate support where necessary. The number of patients with dementia is expected to rise as the number of elderly people in Northumberland increases. According to the 2012-13 QOF data, there are 2,243 people recorded by Northumberland GP practices as having dementia. 

An ageing population will be associated with more harm as a result of falls, in relation to emergency hospital admissions for fractured proximal femur at all ages. Community pharmacists are in an ideal position to review medication which could contribute to dizziness and falls. 

As the population ages the proportion of people with a disability is also likely to increase creating additional demands for service provision. In a rural county like Northumberland, provision of these services will be difficult and costly due to the rural nature of the County.

Map 3: Northumberland mid-2012 population estimates – 65+ population
Data source: ONS population estimates

3.9 Mental health

Poor mental health and wellbeing in parts of the county are inextricably linked to socio-economic deprivation and vulnerability and premature mortality. People suffering from serious mental illnesses like schizophrenia or bipolar disorder have a life expectancy that can be 10 to 15 years lower than the average in the local population. 

According to the 2012-13 QOF data 0.8% of the Northumberland population have a mental health problem21. Depression in adults is higher than the England average with 6.9% of adults diagnosed with depression on practice disease registers.22 The estimated prevalence of any mental health disorder in those aged 5 to 16 years is 9.5%(23).

3.10 Learning Disability

Life expectancy for people with learning disabilities is lower than for the rest of the population. Evidence shows that people with learning disabilities are 2.5 times more likely to have health problems than other people but are less likely to receive regular health checks or to access screening programmes.

Practice registers show that 6.43 adults per 1,000 registered with a GP have a known learning disability. This is significantly higher than the England average of 4.54 per 1,000. The rate of children known to have learning difficulties is 25.19 per 1,000 pupils.(24)

3.11 Immunisation

Northumberland compares favourably with both the North East and England with regard to immunisation rates for children. It also compares favourably with regard to pneumococcal and influenza vaccine rates for the over 65s, which are 74% and 76% respectively(25).

3.12 Prison health needs

Northumberland has one prison, HMP Northumberland. It is a category C prison holding 1,348 male offenders. As in the general population, the average age of prisoners is increasing and consequently their health needs reflect this aging population.

The pharmaceutical needs of the prison population are served through an outsourced healthcare provider. The pharmaceutical needs of those within the criminal justice system who are not incarcerated are met by community services, i.e. community pharmacy. The particular needs of this population require consideration given their high incidence of mental health problems and illegal drug issues.

3.13 Holidaymakers

Northumberland attracts a significant number of holiday makers and visitors. Their health needs are usually met through community pharmacies providing self-care and emergency supply of medicines, or primary care provided by general practice when patients are registered as temporary residents.

3.14 Travellers

There is a small travelling community within Northumberland which makes infrequent but regular camps within the county. A number of travellers are now living on one of three permanent sites in Northumberland. Permanent residents will normally be registered with a GP, others will normally be treated as temporary residents or receive self-care from community pharmacies.

4.1 Definition of pharmaceutical services

The national framework for community pharmacy requires every community pharmacy to open for a minimum of 40 hours per week, and provide a minimum level of ‘essential services’ which comprise:
  • Dispensing
  • Repeat dispensing
  • Disposal of unwanted medicines
  • Promotion of healthy lifestyles e.g. public health campaigns
  • Signposting patients to other healthcare providers
  • Support for self-care
  • Clinical governance including clinical effectiveness programmes.

4.2 Advanced services

In addition to the essential services, the community pharmacy contract allows for ‘advanced services’. Advanced services are those services that require accreditation of the pharmacist providing the service and/or specific requirements to be met in regard to premises. They are commissioned by NHS England and the specification and payment is agreed nationally.

Advanced services currently include:
  • Medicine Use Reviews (MUR)
  • New Medicine Service
  • Stoma Appliance Customisation Service
  • Appliance Use Review.
MURs aim to improve patient knowledge and use of their medicines by:
  • Establishing the patient’s actual use, understanding and experience of taking their medicines
  • Identifying, discussing and resolving poor or ineffective use of their medicines
  • Identifying side effects and drug interactions which may affect medicine use
  • Improving clinical and cost effectiveness of prescribed medicines and reducing waste.
Each pharmacy can provide a maximum of 400 MURs per year and at least 70% (26) of the reviews must be with patients who fall into one of the national target groups,namely:
  • High risk medicines
  • Patients recently discharged from hospital
  • Patients taking respiratory medicines
  • Patients at risk of or diagnosed with cardiovascular disease and regularlybeing prescribed at least four medicines (from late 2014).
The New Medicines Service aims to help patients who have long term conditions get the best out of any new medicines which have been started particularly for those with the following conditions:
  • Asthma or Chronic Obstructive Pulmonary Disease
  • Type 2 diabetes
  • Antiplatelet or anticoagulant therapy
  • Hypertension.
Stoma Appliance Customisation service ensures that stoma products are individually tailored to a patient’s needs ensuring that a close fitting product is supplied. Extra training and specialisation is required to provide this service, and therefore it tends to be provided by specialist appliance companies.

The Appliance Review Service is intended to help patients make best use of their appliances, in the same way as the MUR helps make best use of medicines. Training for pharmacists to perform this service is difficult to access, and therefore when provided in a pharmacy it tends to be done by trained appliance specialists.

4.3 Locally commissioned services


Pharmacy services are currently commissioned locally by Public Health Teams, Clinical Commissioning Groups and the local area team of NHS England. Most of the services provided locally were previously commissioned by the Primary Care Trust to meet local health need. Since April 2013 responsibility for these services has moved to Local Authorities, Clinical Commissioning Groups and NHS England. 

Service reviews have been undertaken and new service specifications developed for services commissioned by the Public Health Department of Northumberland County Council. Northumberland Clinical Commissioning Group are currently reviewing the services they commission and new service specifications and contracts will be needed to replace the old PCT contracts.

Public Health currently commissions the following services from community pharmacies:
  • Supervised consumption of opiates
  • Needle exchange
  • Intermediate smoking cessation services
  • Pharmacy Direct dispensing service for smoking cessation products
  • Plan B emergency contraception
  • C.Card distribution
  • Healthy Living Pharmacies.
Northumberland CCG currently commissions the following services from community pharmacies (all currently under review):
  • Think Pharmacy First – minor ailments scheme
  • Sharpend – safe disposal of medicinal needles and sharps
  • On demand availability of specialist drugs for palliative care
NHS England currently commissions community pharmacies to provide seasonal influenza vaccines to at risk patients.

4.4 Self-care

Community pharmacies are expected to promote self-care through the sale of “over the counter” medicines and by giving advice. Support for “self-care” is an NHS essential service, and the population is encouraged to use community pharmacies to treat minor illness, reserving GP appointments for more serious conditions. Community pharmacies are able to sell a wide range of medicines which are not available through other retail outlets, and give advice on when and how to use them.

4.5 Dispensing doctors

Some rural general practices provide dispensing services to some of their patients. Dispensing doctors can provide dispensing services to patients who live in controlled localities 27 more than 1.6 kilometres (1 mile) away from a community pharmacy. 17 of Northumberland’s 46 general practices provide dispensing services to some of their patients. Some rural practices dispense from more than one of their surgery premises to provide a localised service in remote areas. In rural areas of Northumberland, dispensing doctors contribute an important element to the provision of the network of medicines supply. Maps showing designated rural areas for Northumberland are shown in Appendix 2 (Maps 4a to 4d).

4.6 Dispensing appliance contractors

Some patients may choose to have appliances supplied by appliance contractors.Although there are no dispensing appliance contractors located within Northumberland, these products are usually delivered to the patient’s home, so distance to the dispenser is not an impediment to service. However, this may limit the ability of residents to access Appliance Use Review services to ensure that they get the most out of the appliances supplied.

4.7 Hospital services

NHS hospital trusts and private hospitals do not provide the type of pharmaceutical services which are in the scope of a PNA. NHS hospitals within Northumberland work closely with community pharmacists to ensure that discharged patients get the most from their medicines.

4.8 Current provision of essential pharmaceutical services

Maps 5 and 5a identify the current provision of essential pharmaceutical services and will be used to determine any applications for new pharmacy contracts. Copies of these maps are duplicated in Appendix 1 with a key identifying all pharmacies, GP main surgeries, branch surgeries and “dispensing doctor” premises. The maps in Appendix 1 are continually updated and will be used in the determination of pharmacy applications. 

Pharmacies in Newcastle and North Tyneside which may provide services to residents of Northumberland are shown. This includes city centre pharmacies and those at Kingston Park, many of which open for extended hours. Pharmacies within Gateshead, County Durham and Cumbria have not been included due to the natural barriers of the river Tyne and rural geography. It is recognised that some patients may use the pharmacies in the Metro Centre in Gateshead due to extended opening hours and easy parking.

Map 5: GP practices and pharmacies in Northumberland, August 2014

Map 5a: GP practices and pharmacies in South East Northumberland, August 2014

There are 75 pharmacies in Northumberland, including six 100 hour pharmacies, one essential small pharmacy28 and one internet pharmacy. Pharmacies are located primarily in areas of higher population density (See Maps 5 and 5a). There is more than one pharmacy in most market towns and in urban areas, allowing patient choice. Hexham, Morpeth and Ashington have an over-provision of pharmacies during core hours Monday to Friday; however this gives additional patient choice and extra capacity to provide enhanced services. Weekend and evening provision across Northumberland is limited and mainly dependant on 100 hour pharmacies. 

Since the last PNA was written in 2010, a 100 hour pharmacy has opened in Berwick, and a 40 hour contract has opened in Widdrington. Two 100 hour pharmacies have closed in Hexham and Morpeth, and pharmacies with 40 hour contracts have closed in Hexham and Blyth.

Table 9: Average number of pharmacies per 100,000 population, August 2014
Sources: $Population Estimates Unit, Office for National Statistics (ONS) © Crown copyright; *Health
and Social Care Information Centre29; †
NHS England

* This includes the internet/distance selling pharmacy.

Table 9 shows that Northumberland is well serviced by community pharmacies, having a similar number of pharmacies per 100,000 population to the North East generally and the England average. In North and West Northumberland dispensing doctors provide additional capacity for the dispensing of prescriptions. Blyth appears to have fewer pharmacies per 100,000 population than the England average, but a pharmacy closed in Blyth in 2012 for commercial reasons. 

Table 10 shows the number of prescriptions issued by practices for each locality. These figures do not take into account prescriptions issued by dentists.

Table 10: Average number of prescription items issued per pharmacy
Data source: NHS Business Services Authority
*May 2014; **June 2013 – May 2014; $Practices have been assigned to a locality based on the
location of the main surgery

*This does not include the internet/distance selling pharmacy as patients cannot walk into this pharmacy to have a prescription dispensed.

A patient could use any of the distance selling pharmacies across the UK to have a prescription dispensed. North and West Northumberland have 26 dispensing surgeries which contribute
significantly to the dispensing of prescriptions, therefore the actual number of prescriptions which pharmacies need to dispense is lower. There are 3 dispensing practices in Central locality. Nationally, 7% of prescriptions are dispensed by GP practices; however that figure rises to 9% in Northumberland. 10% of patients in Northumberland are registered as dispensing patients.

Northumberland has an adequate number of pharmacies and dispensing doctors to meet the needs of patients who require prescriptions dispensed.

Repeat Dispensing

As part of the essential services component of the NHS contract, all pharmacies are expected to provide a repeat dispensing service for patients who are considered by their GP to have a stable long term condition. Patients are dispensed up to a year’s supply of medicines, usually in monthly instalments. 

Some GP practices identify fewer patients suitable for this service, and some have indicated that they will wait for more advanced electronic prescribing to be activated before introducing the majority of suitable patients.

Figure 4 - Question: What is the average monthly number of repeat dispensing clients?
Source: Pharmaceutical needs assessment questionnaire

4.9 Hours of provision of medical services 

The basic GP contract requires GPs to offer appointments between 8.00am and 6.30pm Monday to Friday. To improve access, GPs have been required to provide more, routine appointments outside of these core hours. Pharmacy opening hours are not always required to mirror these extended surgery hours, as most appointments are pre-booked and the need for immediate provision of medicines is rare.

Additionally, Wansbeck Primary Care Access Centre operates Monday to Friday 9am - 6pm (except bank holidays). This is a nurse led facility based next to Accident & Emergency on the Wansbeck General Hospital site. Patients are either given an FP10 (ordinary) prescription or medication by the nursing staff via a Patient Group Direction. There are also five walk in centres in Newcastle; the one on Ponteland Road operates from 8am to 8pm 7 days per week.

Northern Doctors Urgent Care provides home and centre visits between 6.30pm and 8am seven days a week, and 24 hour access at weekends and bank holidays. Patients requiring urgent medication are issued with one week’s supply of medication at the time of consultation. 

Minor Injuries Units are open 24 hours a day in Berwick and Alnwick, and Accident & Emergency Services are provided at Hexham General, Wansbeck Hospital and Rake Lane Hospital (North Tyneside). The new emergency care hospital at Cramlington is due to open in 2015 and a new hospital is planned for Berwick.

An existing surgery in Cramlington plans to relocate to the new hospital site at some future date. No other new surgeries are planned in the near future.

4.10 Pharmacy opening hours

Core hours: Each pharmacy is required to be open for 40 hours a week, unless a reduction is agreed by NHS England. These core hours are provided as an ‘essential’ pharmacy service. There are a number of 100 hour pharmacies in Northumberland, and these pharmacies must be open for at least 100 hours per week as core hours.

Supplementary hours: These are provided on a voluntary basis by the pharmacy contractor often based on patient need and business viability, i.e. they are additional to the core hours provided. Supplementary hours can be amended by giving NHS England 90 days’ notice of the intended change. 

Figures 5a to 5c show, by CCG locality, the numbers of pharmacies open outside Monday to Friday, 9am to 5pm core trading hours. Figure 5a shows pharmacies open during weekday evenings, Figure 5b shows pharmacies open on Saturdays, and Figure 5c shows pharmacies available on Sundays. Numbers are for total hours, i.e. including both core and supplementary hours.

Figures 5a – 5c: Opening Hours in Northumberland
Source: NHS England

Figure 5a: Number of pharmacies open after 5pm on weekdays (excluding internet/distance selling pharmacy)

In relation to Figure 5a, if a pharmacy's hours differed on one day of the week from the other four days this difference is ignored on the chart. For example, if a pharmacy is open four days of the week, until 6pm but closes one day at 5pm it is counted on the chart as being open until 6pm. Therefore if a pharmacy opens one evening per week to mirror a surgery’s late opening this is not reflected in these tables.

Figure 5b: Number of pharmacies open on Saturdays (excluding internet pharmacy)

Figure 5c: Number of pharmacies open on Sundays (excluding internet pharmacy)

82% of pharmacies in Northumberland open for more than the core contract hours. However, one of the pharmacies is only open for 35.5 hours per week. This pharmacy was previously an “Essential Small Pharmacy” and when the contract was reviewed by NHS England in July 2013, it was directed to open for 35.5 hours per week. This decision will be reviewed in July 2015. Table 11 illustrates how important supplementary hours are to the provision of good access to pharmaceutical services.

Table 11: Number of hours of pharmaceutical services available each week
Data source: NHS England

* excludes internet pharmacy

Access to community pharmacy across Northumberland is well provided for during core hours. Many pharmacies in town centres are open on Saturday afternoons, giving access to working residents, although it is recognised that this does rely to a large extent on the supplementary hours provided by pharmacies and the 100 hour pharmacies. 

Pharmaceutical services in north Northumberland after 6pm and at weekends are available at the 100 hour contract in Berwick. In the west of Northumberland the 100 hour pharmacy in Hexham provides access to medicines after 6pm and at the weekend. Central locality has two 100 hour pharmacies in Ashington, and although the 100 hour pharmacy in Morpeth has closed the pharmacy does provide extended evening services on weekdays. Blyth Valley locality has two 100 hour pharmacies. One of the 100 hour pharmacies in Blyth and a pharmacy in Ashington are both open until 8pm on Sundays.

Northumberland has six 100 hour pharmacies which guarantee access to pharmaceutical services in the evenings and at weekends. This is down from eight 100 hour pharmacies at the time of the last PNA. The extended opening hours provided by the 100 hour pharmacies are essential to provide guaranteed access to services outside the 40 hour core contract. In a large geographical area like Northumberland it is important to maintain a network of 100 hour pharmacies in population hubs which are known and advertised and can be accessed by those living in rural areas albeit by private car. The loss of the 100 hour pharmacy in Morpeth leaves a community (and its hinterland) without a Sunday service, with patients having to travel an extra 7 miles to Ashington. However, this is a relatively affluent community with high (over 75%) car ownership. The Sunday service was little used and therefore commercially not viable.

Figure 6: Number of hours of pharmaceutical services available each week by CCG locality
Data source: Pharmaceutical needs assessment questionnaire, July 2014

There are also pharmacies with extended opening hours in Newcastle and North Tyneside which patients in south Northumberland can conveniently access. Due to the restrictions of Sunday opening hours, access to pharmaceutical services outside the hours of 10am to 5pm is limited. Two pharmacies (one in Blyth and one in
Ashington) are open until 8pm on Sundays. Previously, in 2010, four pharmacies in Northumberland were open until 8pm on Sundays, however it was not found to be commercially viable to continue with these services.

After considering all the elements of the PNA, Northumberland County Council concludes that there is adequate provision of NHS pharmaceutical services across Northumberland., Northumberland County Council considers that the network of extended hour pharmacies are essential to meet the needs of patients by extending access to pharmaceutical services outside core hours when other pharmacies are closed.

4.11 Current Provision of Advanced Services

Consultation rooms
A consultation room is essential to provide advanced services, e.g. Medicine Use Reviews (MURs) and many locally commissioned services. Standards for consultation rooms are specified in the service specification for MURs30. They include:
  • clear designation as an area for confidential consultations
  • distinct from the general public areas of the pharmacy premises
  • an area where both the person receiving MUR services and the registered
    pharmacist providing those services are able to sit down together and talk at
    normal speaking volumes without being overheard by any other person.
Figure 7 - Question: Does your pharmacy have a consultation area?
Data source: Pharmaceutical needs assessment questionnaire, July 2014

Three pharmacies do not have a consultation area; two plan to have one and one pharmacy does not have one due to the landlord objecting to structural alterations to the building. 

Of the 71 pharmacies which had a consultation room, 56 (79%) could access hand washing facilities either in the consultation area or close to it. It is not a requirement to have hand-washing facilities within the consultation room, as these will be available in the dispensary. However, it would be advantageous to have handwashing facilities close to the consultation room for some locally commissioned services.

Figure 8 - Question: Does your pharmacy have hand washing facilities close to the
consulting room?
Data source: Pharmaceutical needs assessment questionnaire, July 2014

Medicines Use Review service

Most pharmacies (70 out of 74) provide Medicines Use Review (MUR) services; one pharmacy in West Northumberland is not able to provide the service as the premises do not have a consulting room. The pharmacy hopes that a consultation room will be available within the next 12 months. Distance selling pharmacies cannot provide this or any service which requires face to face contact with patients. As pharmacists have to gain an extra qualification to provide this service, it may be that those pharmacies intending to provide the service in the next 12 months are expecting pharmacists to qualify in the next 12 months.

Figure 9 - Question: Does the pharmacy provide Medicines Use Review?
Data source: Pharmaceutical needs assessment questionnaire, July 2014

Most pharmacies do between 21 and 40 MURs per month. This will be driven by the fact that pharmacies can be paid for doing up to 400 MURs per year. If pharmacies do more than 400 MURs per year, there is no guarantee of being paid for the extra MURs performed.

Figure 10 - Question: How many Medicines Use Reviews are performed in an average
month?
Data source: Pharmaceutical needs assessment questionnaire, July 2014

However, there is some capacity, within the current financial envelope of the scheme, to better utilise targeted MURs. Work is ongoing to identify vulnerable patients, on multiple medications, who could benefit from receiving advice on getting the most from their medicines, and reducing the risk of hospital admission.

New Medicines Services

The majority of pharmacies in Northumberland (68 out of 74 or 92%) provide this service. The MUR qualification is required to provide this service. As this service was only introduced in 2013, it would be expected that patient numbers would be less than for MURs, which are well established. Work is ongoing
with Northumbria Healthcare Trust and Newcastle Hospitals to develop systems to identify patients discharged from hospital that would benefit from this service.

Figure 11 - Question: Does the pharmacy provide the New Medicines Service (NMS)?
Data source: Pharmaceutical needs assessment questionnaire, July 2014

Figure 12 - Question: What is the average monthly number of New Medicines Service
reviews?
Data source: Pharmaceutical needs assessment questionnaire, July 2014

4.12 Appliance services

Most pharmacies in Northumberland (58 out of 75) currently supply appliances on prescription. All but one of these pharmacies dispense both dressings and appliances. Regulations which came into force in 2010 defined the essential and advanced services, which apply to pharmacies and appliance contractors who supply appliances on NHS prescriptions. This stricter service specification probably accounts for the reduction in the number of pharmacies providing this service across Northumberland. Further details of the services and the payments applicable to each service can be found in the Drug Tariff (31).

Essential services
• Home delivery service and supply of wipes and disposal bags
• Provide appropriate advice
• Dispensing referral
• Repeat dispensing service
• Urgent supply without a prescription

Advanced services

• Stoma Appliance Customisation
• Appliance Use Reviews

Training to provide the advanced appliance services has been difficult to access as there are few training providers. There are few pharmacies which provide this service and those that do tend to employ specialist nurses to provide the service. 

Nursing teams in Northumberland use dressings from stock drawn from NHS Supplies to apply at dressings changes undertaken by them. They are allowed to change a dressing up to a maximum of 4 times using their own stock, thereafter a prescription must be issued in the normal way. The scheme aims to reduce waste and ensure that a dressing is available at the first visit to the patient.

4.13 Distance Selling Pharmacies

Currently there is one distance selling pharmacy registered in Northumberland. Some pharmacies offer dispensing services which are available over the internet or by telephone. Delivery is then made by post, carrier or through a branch network. It is not known how many Northumberland residents currently use these services.

4.14 Essential Small Pharmacies

Currently there is one essential small pharmacy in Northumberland (Haydon Bridge). An essential small pharmacy was, under the previous pharmacy regulations, a small pharmacy which was essential to a (usually) rural area but was only doing a small number of prescriptions –less than 26,400 per annum. The pharmacy in Haydon Bridge is now dispensing more than 26,400 prescriptions annually and is expected to re-apply to join the Pharmaceutical list before the end of March 2015.When another rural pharmacy had its contract reviewed by NHS England in July 2013, it was directed to open for 35.5 hours per week. This decision will be reviewed
in July 2015.

4.15 Electronic Transfer of Prescriptions

Prescriptions can be sent directly from the GP’s computer to computers in community pharmacies via a secure internet link. Eventually the paper prescription which is currently given to the patient will no longer be necessary and will cease to be the legal prescription. This will streamline the transfer of prescriptions from GP
surgery to the pharmacy nominated by the patient. It will also encourage more GPs to use the repeat dispensing scheme in the future as some GPs have complained about the awkwardness of using the paper based repeat dispensing system. 

Release 1: In EPS release 1 the paper prescription form remained the legal
prescription with a parallel electronic message flow linked via a barcode on the prescription which could be used to support the processing of the paper prescription. EPS Release 1 was not intended to deliver significant direct benefits, but rather to provide a safe environment to establish the EPS infrastructure without the risk of
disruption to the supply of medicines to patients. 

Release 2: Release 2 supports the transmission of electronic prescriptions, e-repeat dispensing, patient nomination of their selected pharmacy, and the electronic submission of reimbursement claims to NHS Prescription Services. Not all GP practices in Northumberland have been Release 2 enabled.

Figure 13 - Question: Is the pharmacy EPS (Electronic Prescription Service) enabled?
Data source: Pharmaceutical needs assessment questionnaire, July 2014

Most pharmacies are able to process electronic prescriptions. Routine use of electronic prescriptions in the local health economy is largely dependent on the speed of progress of local practices. According to the Health and Social Care Information Centre (HSCIC), all pharmacies in Northumberland are now EPS R2 enabled.

Figure 14 - Question: Are you currently processing electronic prescriptions?
Data source: Pharmaceutical needs assessment questionnaire, July 2014
Since 2013, services are now commissioned from community pharmacies by several commissioners; namely Public Health departments of local councils, Clinical Commissioning Groups and NHS England. Some of these services are provided only through community pharmacies, some are part of a locality wide network of
services which use multiple providers to improve patient accessibility. The following locally commissioned services are currently being commissioned either totally or in part from community pharmacies. The first 3 services are commissioned by Northumberland Clinical Commissioning Group.

5.1 Think Pharmacy First

This is a scheme targeted at those patients who would not normally purchase selfcare medicines from their local pharmacy. These patients, and their families, are in receipt of a means tested benefit and would probably visit their surgery to have a medicine prescribed for a minor ailment because a prescription would be exempt
from prescription charges. The intention of the scheme is to reduce pressure on appointments within general practices and provide a more convenient service for patients, by providing simple remedies directly by consultation with a pharmacist. 

Maps 6 and 6a (in Appendix 3) show the pharmacies within Northumberland which provide medicines directly to patients through the Think Pharmacy First scheme, plotted against the index of multiple deprivation. 

Several pharmacies in each locality do not provide this service. Further work needs to be undertaken to understand why these pharmacies have chosen not to participate. When the previous PNA was written only one pharmacy in Northumberland was not providing this service. 

It is one of the strategic goals of the CCG to make better use of self-care and community pharmacists, reserving GP appointments for the more serious conditions which need medical input. It will therefore be important to understand which conditions are being treated in the Think Pharmacy First scheme, and which drugs are being prescribed, before making plans for any major re-launch of the scheme.

Figure 15 - Question: What is the average monthly number of clients using Think
Pharmacy First?
Data source: Pharmaceutical needs assessment questionnaire, July 2014

There are no gaps in the provision of this service in deprived areas, because most pharmacies provide the service. Those pharmacies which do not provide the service are mainly in affluent areas.

5.2 Specialist drug access service


Figure 16 - Question: What is the average monthly number of clients accessing Specialist
Drug Services?
Data source: Pharmaceutical needs assessment questionnaire, July 2014
Some drugs are not routinely stocked in pharmacies because they are prescribed infrequently. To ensure that patients and professionals can access these drugs e.g. for terminal care, a few community pharmacies are commissioned to hold them in readiness. The community pharmacies commissioned to provide this service are open for long hours and have good parking availability. Map 7 in Appendix 3, shows the geographical spread of the pharmacies which provide this service.

There is adequate provision of this service across the county with many other pharmacies willing to provide the service if commissioned.

5.3 Sharps collection service

Within Northumberland a service for the safe disposal of sharps is commissioned from community pharmacy. This allows patients who use needles for self-injecting prescribed medicines, or who use blood lancets for self-monitoring blood tests to dispose of the used sharps in a safe way. This service was originally commissioned because of the rural nature of the county and the distances patients would have to travel to leave used sharps at NHS premises for disposal. Maps 8 and 8a in Appendix 3 show the geographic spread of pharmacies providing this service.

Figure 17 - Question: What is the average monthly number of clients using the Sharps
collection service?
Data source: Pharmaceutical needs assessment questionnaire, July 2014

The majority of pharmacies (63 out of 74) provide this service and a further nine pharmacies would provide the service if they were commissioned to. Only four pharmacies stated that they did not intend to provide this service. The distance selling pharmacy cannot provide this service.

There is adequate provision of this service across the county with other pharmacies willing to provide the service if commissioned.

The following services are commissioned by the Public Health Department of
Northumberland County Council

5.4 Alcohol and drug misuse services

The aim of alcohol and drug misuse services is to reduce the harms done to patients by:
• reducing the risks associated with illegal drug use
• reducing the numbers of people who use illegal drugs
• promoting the responsible use of alcohol.
Needle exchange
The key aim of this service is to reduce the transmission of blood borne viruses and other infections caused by sharing injecting equipment. Services have been commissioned from community pharmacies and other providers, to provide needle exchange services, which encourage those who still use illegal drugs, to use them as safely as possible by providing access to clean needles and syringes. Map 9 in Appendix 3 shows the locations of these services. 

It is important that community pharmacies are linked in with Public Health commissioned services, as this will ensure the pharmacies receive information updates, alerts and professional support. Public Health currently commissions two pharmacies in Blyth Valley to provide Needle Exchange services, five in Central locality, one in North locality and three in West. Currently there is no provision in Alnwick and Morpeth; although a service would be commissioned in any locality where a client expressed a need for it . There are a number of other providers of Needle Exchange services as well as to community pharmacies. In addition, several pharmacies have expressed an interest in providing this service in the future. Detailed work will be undertaken to assess need and demand across the county for this service to ensure adequate provision.

When community pharmacy is considered with other providers of Needle Exchange services, there is potentially further scope to extend this service. A specific review of health needs will be done to ensure that there is no unmet need within Northumberland.

Supervised opioid consumption

Services have been commissioned from community pharmacies to provide a supervised consumption scheme for methadone for those individuals who have made the decision to reduce their illegal opiate use. Substance misuse services prescribe an opiate substitute, tailoring the dose to the individual’s needs. When a pharmacist supervises the patient’s consumption of the methadone in the pharmacy, it will not end up being traded on the street, or accidently being taken by children in the home. This also reduces the potential for criminal activity.

Although 57 pharmacies stated that they provide a Supervised Opioid Consumption service in their responses to the questionnaire, only 55 are commissioned to provide the service. Some confusion may have arisen as the questionnaire was completedmidway through the commissioning process. The number of pharmacies commissioned from April 2014 to provide supervised opioid consumption services in each of the localities is as follows:
  • 12 pharmacies in Blyth valley
  • 19 pharmacies in central locality (7 in Ashington)
  • 16 in North Northumberland
  • 8 in West Northumberland
Maps 10 and 10a in Appendix 3 show the locations of these services. Most of the need for this service is in Blyth Valley and Ashington. Coverage is adequate in these areas.

Figure 19 - Question: What is the average monthly number of clients using the supervised
opioid consumption services?
Data source: Pharmaceutical needs assessment questionnaire, July 2014

Most pharmacies provide this service to less than 10 clients per month. In most cases there is daily contact which allows the pharmacy staff to get to know their clients, and provides opportunities for health messages to be re-enforced. The staff may also react to other cues about the client’s health status, sign-posting to other relevant services. It is important that pharmacies providing supervised consumption services are linked into the support services offered by the Public Health team, so that the pharmacy receives relevant updates and alerts. It is also important that pharmacies serving larger numbers of clients have sufficient trained staff to serve all of the customer’s health needs.

There is adequate provision of this service across Northumberland where it is needed. In market towns and other communities there is a choice of provider.

5.5 Sexual health services

Plan B (EHC)
To meet public health targets to reduce teenage pregnancy, a locally commissioned service was developed to make emergency hormonal contraception (EHC) more readily available. Although EHC is available without prescription the retail cost (around £25) means it is unaffordable for many of the target group, and it is not licensed for women under 16. Pharmacists providing the service undergo extra training, and provide treatment against a Patient Group Direction in an attempt to reduce unintended pregnancies and subsequent terminations. 

Pathways are in place for an immediate referral to community Sexual Health Services or Primary Care for Emergency Intrauterine Contraception as the first line option in response to Emergency Contraception. Pharmacists are trained in prioritising and advising of the optimal pathway. There are also pathways that have been developed to support ongoing reliable contraception and processes that have been implemented to enable pharmacists to refer women into specialist contraceptive services for ongoing advice, treatment and support. The service also includes an option for the pharmacist to supply ulipristal (Ella One®) where clinically indicated.

Maps 11 and 11a in Appendix 3 show the locations of services which can provide emergency contraception. Known teenage pregnancy “hotspots” (areas where under 18 conception rates are at least 60 per 1,000 girls aged 15-17) are well served by pharmacies providing Plan B.

Figure 20 - Question: What is the average monthly number of clients using Plan B?
Data source: Pharmaceutical needs assessment questionnaire, July 2014

When considered with GP surgeries and other services which offer emergency contraception, the current service is adequate. Community pharmacies which are open at the weekends, and outside regular service hours during weekdays, are seen to offer a needed service.

Chlamydia screening

All pharmacists providing Plan B are expected to discuss screening for sexually transmitted infections during a consultation and provide details about the free condom scheme. Those registered as C.Card outlets supply free condoms to Young People under the age of 25 years. Postal Chlamydia screening kits are provided to pharmacies to give to those women aged 15 to 24 years who present for Plan B. However the number of clients who access this service is low, when the number who present for Plan B treatment is considered.

5.6 Stop smoking services

Northumberland Public Health team has a well-developed NHS Stop Smoking service including intermediate and specialist provision. Pharmacies provide one of the locations for intermediate level stop smoking services and complement the services provided in general practice and the community. Maps 12 and 12a in Appendix 3 show the locations of these services.

Table 12: Pharmacies providing Intermediate Stop Smoking services by CCG locality
Data source: Pharmacy claims data, 2013/14

Figure 21: Northumberland pharmacies actively providing Pharmacy Direct in 2013/14
Data source: Pharmacy claims data, 2013/14

Specialist services are provided by staff from multiple locations, but some are located in community pharmacies. The majority of Healthy Living Pharmacies provide intermediate level smoking cessation services. Northumberland also operates Pharmacy Direct, a scheme for the supply of nicotine replacement therapy products, and all pharmacies can provide this service. 

When considered with other providers of stop smoking services, coverage across Northumberland is adequate but levels of activity appear to be dropping. Pharmacies with longer opening hours have the opportunity to provide the service to the working population who may not be able to access other services in normal working hours.

5.7 Healthy Living Pharmacies

Public health activities aim to provide conditions in which people can be healthy across entire populations. There are many factors that influence public health over the course of a lifetime. Northumberland County Council’s Public Health team recognise the importance of building capacity to upscale health improvement awareness and advice to the population of Northumberland. It is a challenge to cover the wide geographical area, hence the importance of engaging Pharmacies, which should be the accessible hubs of health in local communities. 

The Healthy Living Pharmacy programme was launched by Northumberland County Council, in partnership with the Local Pharmaceutical Committee, in September 2012. The programme was set-up in response to a 2008 government white paper which suggested that pharmacies could become healthy living centres: promoting and supporting healthy living and health literacy; offering patients and the public healthy lifestyle advice and support on self-care. A national framework was developed and in Northumberland the Council Public Health team has adapted this to suit local needs. 

There are 27 pharmacies in Northumberland which have been awarded the Healthy Living Pharmacy status at Level 1. The Pharmacies are natural community hubs, which are well known and trusted sources of support and health advice. The number of applications received exceeded expectations, and currently the team are in phase three of recruitment at Level 1. The development and expansion of the programme is in progress to move successful pharmacies into level 2 and one pharmacy is currently piloting the Level 2 programme.

Map 13 in Appendix 3 shows the current spread of Healthy Living Pharmacies, by population density. Phase 3 of recruitment will see a targeted approach to ensure equity of geographical spread.

5.8 Seasonal Influenza Vaccination

This service is commissioned by NHS England to help meet national targets to immunise the over 65s and those at risk from influenza. Pharmacists undergo extra training to deliver this service, but can provide the service privately to those clients who do not qualify for NHS vaccines. Pharmacists have access to influenza vaccine over and above the vaccines ordered by GPs at the beginning of the seasonal campaign. 

As many more pharmacists have attended training sessions over the summer of 2014, it is hoped that pharmacy will contribute significantly more to the 2014 campaign, particularly in the harder to reach target groups.

Figure 22 - Question: How many NHS patients did you vaccinate against flu last winter?
Data source: Pharmaceutical needs assessment questionnaire, July 2014

5.9 Current provision of locally commissioned services

Figures 23 –27 summarise the current provision of locally commissioned services according to the Pharmaceutical needs assessment questionnaire results and Public Health commissioning data.

Figure 23: Proportion of Northumberland pharmacies that provide sexual health services by CCG locality

Figure 24: Proportion of Northumberland pharmacies that provide drug services by CCG locality

Figure 25: Proportion of Northumberland pharmacies that provide other public health services by CCG locality

Figure 26: Proportion of Northumberland pharmacies that provide other CCG commissioned services by CCG locality

Figure 27: Proportion of Northumberland pharmacies that provided seasonal influenza vaccination by CCG locality in 2013

 
Community pharmacies provide a range of services which are neither part of the core contract with the NHS, nor commissioned by Northumberland County Council, the Clinical Commissioning Group or NHS England. These services are often very valuable for special patient groups e.g. the housebound, but are provided at the discretion of the pharmacy owner.

Table 13: Non-commissioned services identified in the PNA questionnaire

As these services are not reimbursed by the NHS, the decision to provide the service is often a commercial one, especially when the service increases the pharmacy’s overhead costs. Non-commissioned services identified in the pharmaceutical needs assessment questionnaire are detailed in Table 13 above. From this table it can be seen that pharmacies offer a wide range of non NHS services. Some of the services are not aligned with the strategic priorities of the CCG or the council, but may be fulfilling a customer generated demand for non NHS services.

Collection and delivery services

Two of the services which customers find extremely useful are the prescription collection from the surgery and home delivery services. Patients are often surprised to find that these are not NHS services. 74 out of 75 pharmacies in Northumberland provide prescription collection servicesonly the distance selling pharmacy does not provide this service. As electronic prescriptions become more widely used the need for prescription collection services will diminish, as the prescriptions will be sent electronically to the pharmacy which the patient has chosen. Most pharmacies (61 out of 75) provide a prescription home delivery service.

Figure 28 - Question: Do you provide a prescription delivery service?
Data source: Pharmaceutical needs assessment questionnaire, July 2014

Some pharmacies do put a limit on this service with regard to distance, and some only provide this service to housebound patients. Pharmacists are continually trying to balance the desire of customers to have their medicines delivered to their home, with the need to personally advise patients on their medicines. The opportunity to provide this advice is reduced when medicines are delivered, as the pharmacist cannot leave the pharmacy to make the deliveries.

Monitored dosage systems

Pharmacies are expected to make suitable arrangements for patients who have disabilities which ensure that they can take their medicines as instructed by the doctor. This will sometimes require the use of monitored dosage system (MDS) cassette boxes to help patients take complicated drug regimens. 

Sometimes family or carers ask for medicines to be dispensed in MDS boxes, without any assessment of whether this is the most appropriate way of providing the help that the patient needs to safely take their medicines. Twenty eight pharmacies offer a compliance aid assessment service to ensure that the most appropriate compliance aid is recommended for that patient. 

Some pharmacies insist on an assessment by GP, social services or other suitable professional before agreeing to provide this service.

Figure 29 - Question: Which patients may access MDS boxes?
Data source: Pharmaceutical needs assessment questionnaire, July 2014

 
The CCG vision for community pharmacy is to complement dispensing medicines by the provision of a wider range of services from community pharmacies, better utilising pharmacists’ clinical skills. This is consistent with the pharmacy white paper (April 2008) (32).

Pharmacists are health professionals who have a specific expertise in the use of medicines. To date, their clinical knowledge and expertise in the use of medicines has been underutilised within community pharmacy. These skills must be harnessed to ensure that patients have the same level of pharmaceutical care in the community as they currently receive within hospital settings. This would make a step change in the long term conditions agenda. 

Pharmacies provide a convenient and less formal environment for people to access readily available professional advice and help to deal with everyday health concerns and problems. The role of pharmacies in promoting self-care will become even more important as the healthcare budget becomes stretched, and GPs have less time to spend on those with more minor health conditions. 

The pharmacy white paper quotes a survey showing that 84% of adults visit a pharmacy at least once a year. Pharmacists in Northumberland are accessible and offer extended opening times (late into the evenings or at weekends) to suit patients and customers. Furthermore, most pharmacies now have dedicated consultation areas specifically designed for private discussion.

7.1 Potential future roles

Northumberland Clinical Commissioning Group considers community pharmacists a vital element in their plan to transform primary care. The CCG principles for medicines are to ensure quality safe prescribing, reduce waste medicines, increase cost effective prescribing and ensure patient satisfaction. 

The aim is to improve access to a broader range of pharmacist services than the traditional model of dispensing and supply of medicines, for the patients and carers who live in Northumberland. The CCG wishes to use the expertise of community pharmacists to support patients with minor illness, promote health and healthy life styles, and help people avoid admission and re-admission to hospital. The CCG strive to have a medicines optimisation approach to help patients to improve their outcomes, taking their medicines correctly, avoid taking unnecessary medicines, reducing wastage of medicines and improve medicines safety.

The CCG sees pharmacists working more closely across primary, secondary and community care. The CCG vision is to have a fully integrated structured medication review system provided for the patients of Northumberland. To enable this to work effectively, shared decision making between the patient, pharmacistand clinician is key. The CCG will build upon the current IT system to ensure further integration, to allow structured medication reviews to take place in the most appropriate setting. This will involve pharmacists working outside of the pharmacy in outreach teams, residential care, hospices and General Practice, helping patients to manage their illness, provide health checks, support best use of medicines and detect early deterioration in patients’ conditions.

The Northumbria Care Home project(33) showed that pharmacists have a vital role in the structured review of prescribed medicines in the care home setting, saving money, reducing the risk of harm, and shortening drug rounds, which frees staff for more patient centred activities. This project was undertaken by hospital clinical pharmacists, but with training this model could be rolled out to community pharmacists. The second stage of the project was to ask GPs to identify patients at high risk, and then a hospital pharmacist would go and visit the patient in their own home to review their medication use. Again, this model could be developed to involve community pharmacists. 

The Local Pharmaceutical Committee is working closely with senior hospital pharmacists to develop systems which target those patients who would get maximum benefit from the New Medicines Service. This would help meet a key target of the CCG, namely reduced re-admissions to hospital.

7.2 Potential future services

There is the potential to widen the Healthy Living Pharmacy scheme. By encouraging more pharmacies to sign up there will be clear benefits around the health promotion agenda, in relation to the lifestyle challenges in Northumberland. 

The Healthy Living Pharmacy programme has a vision of a trained health promotion professional in at least one pharmacy in every community. The pharmacy would then act as a hub for health promotion activities and knowledge within that community – a one stop shop, gaining the trust and support of local residents and increasing footfall.

Development of the pharmacy workforce will build effective foundations for Public Health capacity across Northumberland. At the same time the pharmacy team will develop multidisciplinary links and positive working relationships with other health services which will improve collaborative working to improve patient care and deliver better service outcomes. 

There may also be opportunities to develop NHS health checks through pharmacy. Perhaps some of the harder to reach groups might be encouraged to attend the less formal environment of a Healthy Living Pharmacy. There may be other services that are being delivered by other providers, but are not currently reaching all the target population as has been demonstrated by the influenza campaigns. 

Community pharmacists have an important role to play in promoting the safe and effective use of medicines, in reducing inappropriate hospital admissions, and ensuring that integrated care supports patients as they move between hospital and the community. 

Community pharmacists can also use their expertise to tackle problems related to adverse effects and poor use of medicines, as well as ensure the safe disposal of unwanted medicines.
  • Between one third and one half of medicines prescribed for long term conditions are thought not to be taken as recommended
  • Between 4% and 5% of hospital admissions are thought to be due to preventable medicines related problems
  • Many GP consultations which involve minor ailments could be dealt with by pharmacists
  • Pharmacies could have a role in promoting healthy lifestyles, encouraging the responsible use of alcohol, and obesity management
  • As modelling suggests that many people suffering from CHD and diabetes have not yet been identified by general practice teams, pharmacies could have a role in reaching those who do not routinely visit their GP
  • Pharmacies could have a role in the reduction of waste, since unused medicines account for at least 1% of the primary care drug budget.
Community pharmacists in Northumberland are ideally placed, and have the potential, to make a significant contribution to the delivery of services to meet the health needs of the population of Northumberland.
There are 75 pharmacies in Northumberland, located primarily in areas of higher population density. There is more than one pharmacy in most market towns and urban areas, allowing patient choice. Hexham, Morpeth and Ashington have an over-provision of pharmacies Monday to Friday 9am to 5pm; however this gives additional patient choice and extra capacity to provide enhanced services. Weekend and evening provision across Northumberland is limited and mainly dependant on 100 hour pharmacies. Dispensing doctors make a significant contribution to the dispensing of prescriptions in very rural areas. 

With regard to the locally commissioned services provided by community pharmacies, there are no gaps in provision of the Pharmacy First scheme in deprived areas as the majority of pharmacies provide this service. 

There are no gaps in the provision of specialist medicines services, and many other pharmacies are willing to provide the service if needed. 

There are no gaps in the Sharpend scheme for safe disposal of medical sharps with more pharmacies willing to provide the service if required.

Services for drug users – needle exchange and supervised consumption - have adequate coverage in the areas where the service is needed. More pharmacies have stated that they are willing to provide this service if commissioned. Some extra provision for needle exchange may be needed in North Northumberland, particularly in Alnwick. A review will determine whether extra provision is needed. 

Plan B is available from at least 80% of the pharmacies in each locality, (62 out of 75 pharmacies across Northumberland) and all GP practices. Known teenage pregnancy “hotspots” are well served. Community pharmacies which are open at the weekends are seen to offer a valuable service. The service is considered to be adequate in each locality.

Stop smoking services are available from more than half of pharmacies across Northumberland. When considered with other providers of stop smoking services, coverage across Northumberland is adequate. Pharmacies with longer opening hours have the opportunity to provide the service to the working population who may not be able to access other services in normal working hours. 

Community pharmacists have already been commissioned to provide flu vaccine to target groups. More pharmacists have undergone training in advance of the 2014 72 campaign, and this will help Northumberland reach more of the target at risk population. 

There is the potential to widen the Healthy Living Pharmacy scheme. By encouraging more pharmacies to sign up there will be clear benefits around the health promotion agenda, in relation to the lifestyle challenges in Northumberland. There may also be opportunities to develop NHS health checks through pharmacy to target the harder to reach groups who do not attend GP surgeries.

After considering all the elements of the PNA, Northumberland County Council concludes that there is adequate provision of NHS pharmaceutical services across Northumberland. Northumberland County Council considers that the network of extended hour pharmacies are essential to meet the needs of patients by extending access to pharmaceutical services outside core hours when other pharmacies are closed. 

Services currently commissioned form pharmacies in Northumberland include emergency contraception, smoking cessation, needle exchange, supervised consumption of methadone, minor ailments, disposal of sharps and specialist palliative care drugs. There is adequate provision of all of these services except needle exchange in North Northumberland.
Map 5. GP practices and pharmacies in Northumberland

Map 5a. GP practices and pharmacies in South East Northumberland